C. Probst

Erstversorgung Schwerstverletzter am Unfallort

ZusammenfassungIn der komplexen, präklinischen Versorgung Schwerstverletzter müssen Notärzte für eine gute Prognose lebens- oder Gliedmaßen bedrohende Verletzungen schnell erkennen und behandeln. Die Zusammenarbeit mit Rettungsdienst, Feuerwehr und Polizei muss koordiniert, der Transport früh organisiert werden.Die Intubation durch Geübte bei korrekter Indikation wird, insbesondere beim Schädel-Hirn- und schweren Thoraxtrauma, unterstützt, ebenso die Thoraxdrainage beim schweren oder penetrierenden Thoraxtrauma. Kristalloide und kolloidale Lösungen bleiben erste Wahl als Volumenersatz. Die Menge wird individuell an den tastbaren Radialis-/Karotispuls beim stumpfen/penetrierenden Trauma angepasst. Als erweiterte präklinische Diagnostik konnten sich Sonographie und Nahinfrarotspektroskopie bisher nicht durchsetzen.Der Transport erfolgt frühest möglich in die nächste geeignete Klinik. Trotz längerer Einsatzzeiten durch Nachalarmierung oder umfassendere Maßnahmen beeinflussen Hubschrauber mit einem Traumazentrum als Zielklinik das Outcome positiv.AbstractLife or extremity threatening injuries have to be diagnosed and treated rapidly by emergency physicians during prehospital care for severely injured patients. The cooperation with other rescue services, the fire brigade and the police must be coordinated and early transportation has to be organized.Rapid sequence intubation by trained personnel for correct indications, such as head injury or severe chest trauma is recommended as well as prehospital chest tube placement in cases of severe or penetrating thoracic injury. Crystalloids and colloidal solutions remain the first choice for intravenous volume replacement. The amount of fluid depends on the individual response, such as palpable peripheral and central pulse for blunt or penetrating trauma. Ultrasound or near infrared spectroscopy could not be routinely implemented for extended prehospital diagnostic procedures.Transportation to the closest appropriate hospital has to be accomplished as early as possible. Helicopters show positive outcomes if the destination is a level I trauma center, even if secondary alarm calls or more extensive measures prolong the prehospital interval.

Early Total Care (ETC) im Vergleich zu Damage Control Orthopedics (DCO) bei der Behandlung polytraumatisierter Patienten mit Femurschaftfrakturen

ZusammenfassungEinleitungFemurfrakturen stellen eine häufige Verletzung polytraumatisierter Patienten dar. Das Versorgungskonzept des Damage Control Orthopedics (DCO) konkurriert mit dem des Early Total Care (ETC).Material und MethodenIn einer retrospektiven Studie (2003–2007) wurden 73 polytraumatisierte Patienten mit Femurschaftfrakturen erfasst. Das Gesamtkollektiv wurde anhand der Verletzungsschwere (Injury Severity Score [ISS], 16–24 leicht, 25–39 mittelschwer, über 40 schwer) und des Versorgungskonzepts (DCO vs. ETC) unterteilt. Beim Vergleich der beiden unterschiedlichen Therapiekonzepte wurden klinische Daten und Kostenaspekte analysiert.ErgebnisseBeim leichten Polytrauma war die Dauer von Beatmung und Intensivaufenthalt in der DCO-Gruppe verlängert, die Gesamtkosten und die Kostenunterdeckung waren in der ETC-Gruppe erniedrigt. Beim mittelschweren Polytrauma zeigte sich in der DCO-Gruppe eine geringere Inzidenz von „adult respiratory distress syndrome“ (ARDS), die Kostenanalyse erbrachte in dieser ebenfalls eine höhere Kostenunterdeckung im Vergleich zur ETC-Gruppe.SchlussfolgerungBeim leichten Polytrauma scheint die Schere zwischen Kosten und Erlösen bei Behandlung nach dem ETC-Konzept weniger stark zu klaffen. Die Behandlungsstrategie sollte anhand des Verletzungsmusters festgelegt werden. Die Kosten sollten durch das Institut für das Entgeltsystem im Krankenhaus (INEK) entsprechend abgebildet werden.AbstractIntroductionFemoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC).Patients and methodsIn a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects.ResultsIn the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group.ConclusionFrom an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).INTRODUCTION Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

Anforderungen an Traumanetzwerke in Niedersachsen

ZusammenfassungHintergrundDurch den Arbeitskreis Umsetzung Weißbuch/Traumanetzwerk (AKUT) der DGU wurde zur qualitätssichernden Versorgung schwerverletzter Patienten die Gründung regionaler Traumanetzwerke initiiert. Im Rahmen einer Befragung von Kliniken und Rettungsdiensten in Niedersachsen wurden die Anforderungen an ein Traumanetzwerk untersucht.MethodenDie (unfall-)chirurgischen Kliniken in Niedersachsen und den Grenzgebieten benachbarter Bundesländer wurden um eine Selbsteinschätzung ihrer Versorgungsstufe gebeten. Weiterhin wurden die Kliniken und die Rettungsdienste in Niedersachsen gebeten, ihre Wünsche und Anforderungen an ein Traumanetzwerk zu formulieren.ErgebnisseVon den angeschriebenen Einrichtungen schickten 70,2% der Kliniken und 11,5% der Rettungsdienste die Fragebögen zurück. Als Basisversorger stuften sich 46,9% der Kliniken ein, 50,0% als regionales Traumazentrum und 3,1% als überregionales Traumazentrum. Die Basisversorger gaben im Vergleich zu den Traumazentren signifikant häufiger den Wunsch nach einer schnellen Übernahme der Patienten an, wohingegen ein Fortbildungswunsch signifikant häufiger von den Traumazentren angegeben wurde.SchlussfolgerungDie Anforderungen der Kliniken an ein Traumanetzwerk stimmen mit den durch die AKUT formulierten Zielen überein. Dabei sind die vordringlichen Anforderungen teilweise von der Versorgungsstufe abhängig. Eine enge Kooperation mit den Rettungsdiensten ist nötig, um das bestehende Interesse an der Mitarbeit an Traumanetzwerken weiter zu verstärken.AbstractBackgroundThe German Association of Trauma Surgery has developed a concept for the quality-assured care of severely injured patients; this concept includes the establishment of trauma networks. In this study, hospitals and emergency services in Lower Saxony were asked about their demands on the Hanover regional trauma network.Materials and MethodsTrauma departments in Lower Saxony and adjoining federal states were asked to self-assess their level of trauma care. The demands of emergency services and trauma departments on the trauma network were also ascertained.ResultsResponses to the questionnaire were received from 70.2% of trauma departments and 11.5% of emergency services organizations. Of these, 46.9% of the trauma departments classified themselves as a “center of basic care”, 50.0% as a “regional trauma center”, and 3.1% as a “national trauma center”. Compared with the regional trauma centers, centers of basic care requested fast transfers of patients to a trauma center significantly more often, whereas trauma centers desired more educational activities.ConclusionThe demands of trauma centers on a trauma network correspond with the aims formulated by the German Association of Trauma Surgery. These demands depend on the level of trauma care provided. Close cooperation with emergency services is essential to strengthen collaboration within the trauma network.

Bedeutung der Hypothermie beim Polytrauma

Multiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35 degrees C, already at admission in the emergency room. As a drop of the core temperature below 34 degrees C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. Multiple trauma patients with hypothermia demonstrate a markedly increased mortality rate compared to normothermic patients with the same injury severity. Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.ZusammenfassungSchwerverletzte Patienten weisen häufig schon bei der Klinikaufnahme eine Hypothermie, definiert als ein Absinken der Körperkerntemperatur auf unter 35°C, auf. Die kritische Temperaturgrenze, ab der mit einem signifikanten Anstieg posttraumatischer Komplikationen zu rechnen ist, wird nach einem Polytrauma mit 34°C angegeben. Schwerverletzte Patienten mit einer Hypothermie weisen im Vergleich zu normothermen Patienten mit gleicher Verletzungsschwere eine deutlich erhöhte Mortalitätsrate auf. Eine effiziente Wiedererwärmung ist daher eine Voraussetzung für eine adäquate Blutstillung und hämodynamische Stabilisierung und somit einer verbesserten Überlebensrate. In wie weit eine therapeutisch induzierte Hypothermie in der frühen intensivmedizinischen Behandlung nach initialer Stabilisierung und operativer Blutungskontrolle zu einer Reduktion posttraumatischer Komplikationen und einem verbesserten Behandlungsergebnis führen kann, muss in weiteren experimentellen und klinischen Studien geklärt werden.AbstractMultiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35°C, already at admission in the emergency room. As a drop of the core temperature below 34°C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. Multiple trauma patients with hypothermia demonstrate a markedly increased mortality rate compared to normothermic patients with the same injury severity. Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.

Traumasysteme in Deutschland, USA und Australien

ZusammenfassungDurch die Entwicklung von Versorgungssystemen für Traumapatienten konnten in den letzten Jahrzehnten die Behandlungsergebnisse Schwerverletzter deutlich verbessert werden. Zusammen mit den verbesserten präklinischen Behandlungsalgorithmen, Standardisierungen der Behandlung im Schockraum sowie der frühen operativen Phasen der Traumaversorgung und Verbesserungen in der Intensivmedizin hat auch die Einführung von Traumaregistern zur Steigerung der Versorgungsqualität beigetragen. In Adaptation an die strukturellen, geographischen und demographischen Gegebenheiten haben sich unterschiedliche nationale Versorgungssysteme entwickelt. Ihre Aufrechterhaltung ist jedoch an hohe finanzielle Kosten gebunden. Bei einer gleichzeitigen finanziellen Unterdeckung in der Polytraumaversorgung sind zur Aufrechterhaltung einer bestmöglichen Versorgungsqualität massive Anstrengungen aller beteiligten Berufsgruppen notwendig. In diesem Zusammenhang können Traumaregister und die in Deutschland in Etablierung befindlichen Traumanetzwerke hilfreich sein. Zum einen tragen sie zu einer Verbesserung einer flächendeckenden Traumaversorgung bei und reduzieren dementsprechend sozioökonomische Folgekosten von Unfallverletzten, zum anderen könnten sie zur Identifikation kostenintensiver, jedoch nicht prognoseverbessernder Behandlungsstrategien dienen.AbstractDue to the development of trauma care systems the treatment results of multiply injured patients have clearly improved during the last decades. More sophisticated preclinical algorithms, standardized procedures in the emergency room, calculated surgical strategies during the early phases and the subsequent intensive care (ICU) treatment as well as the implementation of trauma registries have all contributed to an improvement in trauma care. Different national trauma care systems have been developed due to the structural, geographic and demographic differences of the compared countries. However, large financial resources are required to maintain all three trauma care systems. To cope with financial losses in multiple trauma care, huge efforts of all the personnel involved are necessary to maintain the maximum treatment quality. In this context, national trauma registries, as well as the recently established trauma networks in Germany, might be helpful. Due to improvements in comprehensive trauma care and identification of expensive, but not prognosis improving treatment strategies, costs can be reduced by trauma registries and trauma networks.Due to the development of trauma care systems the treatment results of multiply injured patients have clearly improved during the last decades. More sophisticated preclinical algorithms, standardized procedures in the emergency room, calculated surgical strategies during the early phases and the subsequent intensive care (ICU) treatment as well as the implementation of trauma registries have all contributed to an improvement in trauma care. Different national trauma care systems have been developed due to the structural, geographic and demographic differences of the compared countries. However, large financial resources are required to maintain all three trauma care systems. To cope with financial losses in multiple trauma care, huge efforts of all the personnel involved are necessary to maintain the maximum treatment quality. In this context, national trauma registries, as well as the recently established trauma networks in Germany, might be helpful. Due to improvements in comprehensive trauma care and identification of expensive, but not prognosis improving treatment strategies, costs can be reduced by trauma registries and trauma networks.

Erste Ergebnisse der multidirektional-winkelstabilen palmaren Osteosynthese der distalen Radiusfraktur

BACKGROUND The management of fractures of the distal radius continues to evolve. New operative strategies have recently been developed including the use of fixed-angle plates. This study reviews the results of 20 patients with fractures of the distal radius treated with a new multidirectional fixed angle plate. METHOD AND MATERIALS A total of 20 patients with closed Colles type fractures of the distal radius were treated with Medartis (Aptus 2.5) palmar fixed-angle plates. Surgery was performed under plexus anesthesia using the standard or extended flexor carpi radialis (FCR) approach. Patients were evaluated prospectively with a mean follow-up of 26 weeks (range 23-28 weeks). Pain, range of motion, grip strength, DASH score, modified Mayo wrist score and radiographs were obtained. The level of significance was set at 95% and the χ(2) and ANOVA tests in combination with a post hoc Tukey test were used for statistical analysis. RESULTS The average range of motion (ROM) in extension-flexion was 87° (76% of the contralateral side) and in ulnar-radial deviation 42° (88% of the contralateral side). Pain values (visual analogue scale 0-100) at follow-up were 3 (without stress) and 24 (with stress). Grip strength improved to 84% of the contralateral side, the mean DASH score was 13 points and the modified Mayo wrist score confirmed the excellent results with a mean value of 83±27 points. Radiological examination showed a satisfactory result with an ulna variance of 0.9±0.4 mm, radio-ulnar inclination of 21±5° and palmar inclination of 4±6°. CONCLUSIONS Our data show that treating unstable distal radius fractures with multidirectional palmar fixed-angle plates is reliable and effective and produces good early functional and radiological results. However, long-term results with a larger number of patients and randomized prospective studies comparing this technique with other established procedures are required.

Diagnostik und Therapie primärer Knochentumoren

Primary bone tumors can be either benign or malignant. Metastization is a characteristic feature of malignant bone tumors. Malignant tumors are characterized by a local aggressive and destructive behavior. The behavior of a tumor is dependent on its entity, the differentiation grade and localization and these factors are of decisive importance for the correct therapy. Even benign tumors can behave very aggressively. Different stages are defined. Patient history and conventional radiographs are the most powerful primary diagnostic tools. Many tumors show typical characteristics and if a malignant lesion is suspected a biopsy should be carried out. Several quality standards have to be respected when making the biopsy. The approach to malignant tumors is always interdisciplinary. Several biological as well as alloplastic reconstruction techniques exist. The treatment of primary malignant bone tumors requires a lot of experience and should only be done in specialized centers.ZusammenfassungPrimäre Knochentumoren lassen sich in maligne und benigne Läsionen unterscheiden. Die Metastasierung ist ein Merkmal maligner Tumoren. Lokal zeigen maligne Tumoren ein aggressives und destruierendes Wachstum. Dieselbe Tumorentität kann verschiedene Differenzierungsgrade aufweisen, die für die Therapie von entscheidender Bedeutung sind. Auch benigne Tumoren können sich abhängig von ihrem Stadium lokal aggressiv verhalten. Der Anamnese und dem konventionellen Röntgenbild kommt in der primären Diagnostik entscheidende Bedeutung bei. Viele Tumoren zeigen hier bereits charakteristische Merkmale. Bei Verdacht auf einen malignen Prozess ist in der Regel eine Biopsie erforderlich. Diese muss strengen Qualitätsansprüchen genügen. Die Therapie der malignen Tumoren ist interdisziplinär. Nach Resektion eines Tumors stehen verschiedene biologische und alloplastische Rekonstruktionsmöglichkeiten zur Verfügung. Speziell die Behandlung von malignen Knochentumoren bedarf einiger Erfahrung und sollte daher in ausgewählten Zentren erfolgen.AbstractPrimary bone tumors can be either benign or malignant. Metastization is a characteristic feature ofmalignant bone tumors. Malignant tumors are characterized by a local aggressive and destructive behavior. The behavior of a tumor is dependent on its entity, the differentiation grade and localization and these factors are of decisive importance for the correct therapy. Even benign tumors can behave very aggressively. Different stages are defined. Patient history and conventional radiographs are the most powerful primary diagnostic tools. Many tumors show typical characteristics and if a malignant lesion is suspected a biopsy should be carried out. Several quality standards have to be respected when making the biopsy. The approach to malignant tumors is always interdisciplinary. Several biological as well as alloplastic reconstruction techniques exist. The treatment of primary malignant bone tumors requires a lot of experience and should only be done in specialized centers.

Comparative biomechanical analysis of two techniques of radiolunate fusion: Shapiro staples vs. plate and oblique screw

The purpose of this prospective randomized comparative biomechanical study on six pairs of human cadaveric forearms was to study the mechanism of implant loosening and loss of lunate positioning and to discern whether primary stability following staple arthrodesis differs from plate fixation. Six wrists were randomly assigned to either group such that one wrist of each pair was fixed via titanium staples and the other via a mini-titanium plate with oblique screw. Under fluoroscopic guidance, passive extension and flexion of each wrist was performed using a spring balance. Traction force increased by 5 N at each step, ranging from 0 N to a maximum of 100 N. Fixation using a plate and oblique screw demonstrated greater flexibility than staple fixation. Loosening of the implant and/or the lunate occurred earlier following staple fixation in all pairs. Osteolytic rims around the staple limbs within the lunate occurred in all wrists. These were observed to be an early sign of implant loosening and fusion failure. The current investigators conclude that radiolunate fusion via miniplate and oblique screw is superior to staple fixation in terms of primary stability which is consistent with the radiological results of comparable clinical trails.

First clinical experience with a novel forearm boom

The optimal forearm boom should facilitate dynamic investigation of the wrist and approaches for wrist arthroscopy. It should be safely fixed at the operating table without any contact with the patient. It must be compatible with the arm of any patient and should be sterilisable. Repositioning of distal radius fractures, fluoroscopy and insertion of Kirschner-wires should not be restricted. According to these criteria the current investigators designed a new forearm boom which was subsequently used in 19 wrist arthroscopies and 9 distal radius fracture fixations. Twenty-eight patients with heights between 150 and 205 cm and forearm lengths between 17.5 to 37 cm were treated. Preoperatively, wrist motion was tested in those 19 wrists, that underwent wrist arthroscopy, before and after fixation by the forearm boom and any restriction due to usage of the novel device was found. The new forearm boom satisfied all of the criteria cited above. Therefore the current authors believe the new forearm boom may be valuable for the indications mentioned.

Traumatische Karotisdissektion nach Motorradunfall

Injuries of internal carotid arteries caused by high energy trauma are rare but often combined with poor outcome. Blunt trauma to the head and neck as well as the use of newer motorcycle helmets together with crash circumstances should promptly lead to a differentiated polytrauma management with expansion of radiologic diagnostics. This could lead to a reduction of overlooked dissections and an increase in promptly and correctly treated injuries.ZusammenfassungVerletzungen der hirnversorgenden Gefäße im Rahmen von Hochrasanztraumen sind seltene aber potentiell das Outcome verschlechternde Verletzungen. Ein differenziertes Schockraummanagement sowie eine Ausweitung der CT-Diagnostik können die Gefahr des Übersehens einer derartigen Verletzung reduzieren. Bei Prell- und Kontusionsmarken im Halsbereich sowie Rasanztraumen mit Krafteinwirkung auf die Halsweichteile bei angelegtem Integralhelm sollte immer an eine mögliche Gefäßverletzung gedacht werden.AbstractInjuries of internal carotid arteries caused by high energy trauma are rare but often combined with poor outcome. Blunt trauma to the head and neck as well as the use of newer motorcycle helmets together with crash circumstances should promptly lead to a differentiated polytrauma management with expansion of radiologic diagnostics. This could lead to a reduction of overlooked dissections and an increase in promptly and correctly treated injuries.