C.T. Buschmann

Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin.

BACKGROUND Despite continuous innovation in trauma care, fatal trauma remains a significant medical and socioeconomic problem. Traumatic cardiac arrest (tCA) is still considered a hopeless situation, whereas management errors and preventability of death are neglected. We analyzed clinical and autopsy data from tCA patients in an emergency-physician-based rescue system in order to reveal epidemiologic data and current problems in the successful treatment of tCA. MATERIAL AND METHODS Epidemiological and autopsy data of all unsuccessful tCPR cases in a one-year-period in Berlin, Germany (n=101, Group I) and clinical data of all cases of tCPR in a level 1 trauma centre in an 6-year period (n=52, Group II) were evaluated. Preventability of traumatic deaths in autopsy cases (n=22) and trauma-management failures were prospectively assessed. RESULTS In 2010, 23% of all traumatic deaths in Berlin received tCPR. Death after tCPR occurred predominantly prehospital (PH;74%) and only 26% of these patients were hospitalized. Of 52 patients (Group II), 46% required tCPR already PH and 81% in the emergency department (ED). In 79% ROSC was established PH and 53% in the ED. The survival rate after tCPR was 29% with 27% good neurological outcome. Management errors occurred in 73% PH; 4 cases were judged as potentially or definitive preventable death. CONCLUSION Trauma CPR is beyond routine with the need for a tCPR-algorithm, including chest/pericardial decompression, external pelvic stabilization and external bleeding control. The prehospital trauma management has the highest potential to improve tCPR and survival. Therefore, we suggested a pilot prehospital tCPR-algorithm.

Emergency medicine techniques and the forensic autopsy

Emergency medicine measures often have to be carried out under suboptimal conditions in emergency situations and require invasive patient treatment. In the case of a fatal outcome these measures have to be evaluated at autopsy, regarding indications, correct implementation and possible complications. As well, alongside the more familiar procedures—such as endotracheal intubation, insertion of chest drains, external cardiac massage and cannulation of central and peripheral veins—there are alternative techniques being increasingly applied, that include new tools for the management of hemorrhagic shock, drug delivery and alternative airway management devices. On the one hand, all of these measures are essential for the survival and appropriate treatment of the injured and/or sick patient, but on the other hand they can damage the patient and thus contain a significant risk of both medical and forensic relevance for the patient and the physician. In the following review we provide an overview of established, new and alternative techniques for emergency airway management, administration of drugs and management of hemorrhagic shock. The aim is to facilitate the understanding and autopsy evaluation of current emergency medicine techniques.

Preventive pathology: the interface of forensic medicine and trauma surgery for pre-hospital trauma management.

We read Professor Byard’s editorial on preventive pathology with great interest [1]. We agree with the statements he made and report on the interdisciplinary collaboration between trauma surgery and forensic medicine in Berlin. The ‘‘look over the edge of the dish’’ (as we say in Germany) in terms of interdisciplinary research is a key point for the future of forensic medicine. The need to continuously evaluate medical algorithms is evident. Emergency medical research is subject to special conditions, i.e., patients who are considered to be unable to give their own consent. This results in sparse data, compared with clinical studies. After unsuccessful resuscitation decedents are often subject to forensic examination, especially in cases of traumatic death. The gold standard for medical quality control is the autopsy, and forensic pathologists must recognize emergency medical artifacts, distinguish them from other findings, and assess their indication and implementation as well as possible complications. Non-implementation of feasible and life-saving emergency measures must also be questioned [2]. Additionally, clinicians should know the definitive causes of their patients’ death to contingently adjust treatment strategies. Due to low autopsy rates in Germany, clinicians are often left with no resolution as to why a patient died. Contact between forensic medicine and emergency medicine arises through a successive and contiguous interaction with the same patient, bearing a significant scientific potential—not only in individual cases, but also in terms of a systematic interdisciplinary analysis and mortality conferences. Our appraisal of trauma management in Berlin revealed, beneath the critical care phase, that most mortality occurs prior to admission to hospital, demonstrating that the main causes of traumatic death are not complications of implemented medical measures performed hospitals, but severe injury patterns, and—in a relevant proportion—omitted therapy on-scene [3, 4]. Nevertheless, we regularly experience that patients with traumatic cardiac arrest are treated analogous to patients with disease-related cardiac arrest—although the identified invasive measures could save lives. Illustrating the fertile collaboration of forensic medicine and trauma surgery, we developed an algorithm for traumatic resuscitation including neglected invasive measures [5]. Study networks will gain growing importance in emergency medicine research in the future. Interdisciplinary collaboration of forensic medicine and trauma surgery has a high educational potential in individual cases and a significant scientific innovation potential with the retrospective evaluation of pre-hospital trauma care. It aids forensic scientists in understanding emergency medicine at autopsy and encourages emergency physicians to question existing guidelines based on autopsy findings. We can learn a lot from each other.

Abschiedsbrief auf dem Körper nach genitaler Selbstbeschädigung

ZusammenfassungDer Suizid eines 29-jährigen Mannes, der sich atypisch erhängte, nachdem er sich zuvor selbst partiell zirkumzidiert hatte, wird beschrieben. Dieser stand vermutlich im Zusammenhang mit der bei dem Suizidenten langjährig bestehenden, aktuell akut exazerbierten hebephrenen Schizophrenie mit halluzinatorisch-wahnhaften Symptomen. Im Rahmen der Obduktion fielen neben den Befunden des atypischen Erhängens auf den gesamten Körper mit Filzstift aufgemalte, teils auch oberflächlich eingeritzte abschiedsähnliche Zeilen und Satzfragmente auf. Die Suizidalität wurde hier in wahnhafter Form thematisiert. Dies wurde von rechtsmedizinischer Seite in engem zeitlichen Zusammenhang mit dem Tod gesehen. Die außergewöhnlichen Befunde werden in Ergänzung zum Schrifttum vorgestellt und diskutiert.AbstractThe case of suicide of a 29-year-old schizophrenic male who hanged himself in an atypical manner following partial circumcision is described and discussed. This was probably in the context of a long-lasting but currently acute exacerbated hebephrenic schizophrenia with hallucinatory-delusional symptoms. At autopsy, apart from the signs of atypical hanging, sentences and fragments of sentences resembling those of a suicide note were found written with a felt-tip pen and also superficially scratched on the skin over the entire body. The sentences were on the subject of suicide in a delusional form and were thus considered as having been written in close chronological connection with death. The unusual findings are presented and discussed as a supplement to the current literature.

Ansätze zur prähospitalen Gerinnungstherapie

ZusammenfassungBlutungen sind typische Traumafolgen. Ein Verbluten ist für rund 50 % der Todesfälle innerhalb der ersten 6 h nach Trauma verantwortlich. Zur adäquaten Blutungs- und Gerinnungstherapie zählt daher ein ineinandergreifendes Konzept, bestehend aus lokaler Blutstillung durch Druck, Kompression und ggf. Tourniquet, Wärmeerhalt, Verhinderung von Acidose und Hypokalzämie. Weiterhin wird bei geeigneten Patienten eine permissive Hypotension akzeptiert und Tranexamsäure frühzeitig eingesetzt. Zahlreiche Untersuchungen zeigen, dass die prähospitale Transfusion von Blutprodukten (z. B. Erythrozytenkonzentraten, gefrorenes Frischplasma) oder Gerinnungspräparaten (z. B. Fibrinogen) sicher und möglich, aber nur bei <5 % aller zivilen polytraumatisierten Patienten notwendig ist.AbstractSevere bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.Severe bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.

Calcified myocardial necrosis in pediatric patients after cardiopulmonary resuscitation

We report three autopsy cases of wide-spread myocardial necrosis with calcification in pediatric patients after temporary generalized hypoxia and initially successful cardiopulmonary resuscitation, but subsequent in-hospital death. Autopsy and histological workup in all three cases showed multiple circumscribed calcified and necrotic areas in progressive stages of organization within the myocardium. We conclude that these macro- and microscopic autopsy features appear to be related to reperfusion injuries in children as a consequence of hypoxic-ischemic changes occurring in the peri- and postresuscitation period.

Notfallmedizin up2date@@@Emergency medicine update: Obduktionsbefunde@@@Autopsy findings

ZusammenfassungPräklinische Notfallmaßnahmen erfordern invasive iatrogene Manipulationen am Patienten, die bei der Obduktion hinsichtlich ihrer Indikation, ihrer korrekten Durchführung und möglicher Komplikationen zu beurteilen sind. Da in diesem Bereich neben bekannten Prozeduren wie endotrachealer Intubation, Anlage von Thoraxdrainagen, externer Herzdruckmassage sowie der Punktion zentraler und peripherer Venen auch zunehmend alternative Techniken angewandt werden, wird im Folgenden eine Übersicht über etablierte, neue und alternative technische Möglichkeiten des präklinischen „airway management“, der Applikation von Medikamenten und der Beherrschung des hämorrhagischen Schocks gegeben, um das Verständnis und die autoptische Evaluation aktueller Notfallmedizintechniken zu ermöglichen.AbstractOut-of-hospital emergency medicine procedures require invasive iatrogenic manipulations on the patient, which are to be evaluated at autopsy regarding medical indications, correct execution and possible complications. Within this field of medicine, alternative techniques apart from the well-known procedures, e.g. endotracheal intubation, chest drain insertion, external chest compression and cannulation of central and peripheral veins are also increasingly being applied. This article gives an overview of established, new and alternative technical possibilities of emergency airway management, the administration of drugs and the management of hemorrhagic shock to permit understanding and the post-mortem evaluation of current emergency medicine techniques.

Spannungspneumomediastinum und -pneumothorax nach Trachealperforation während Reanimation

Tension pneumothorax can occur at any time during cardiopulmonary resuscitation (CPR) with external cardiac massage and invasive ventilation either from primary or iatrogenic rib fractures with concomitant pleural or parenchymal injury. Airway injury can also cause tension pneumothorax during CPR. This article presents the case of a 41-year-old woman who suffered cardiopulmonary arrest after undergoing elective mandibular surgery. During CPR the upper airway could not be secured by orotracheal intubation due to massive craniofacial soft tissue swelling. A surgical airway was established with obviously unrecognized iatrogenic tracheal perforation and subsequent development of tension pneumomediastinum and tension pneumothorax during ventilation. Neither the tension pneumomediastinum nor the tension pneumothorax were decompressed and accordingly resuscitation efforts remained unsuccessful. This case illustrates the need for a structured approach to resuscitate patients with ventilation problems regarding decompression of tension pneumomediastinum and/or tension pneumothorax during CPR.ZusammenfassungEs wird über den Todesfall einer 41-jährigen Patientin nach einer elektiven Unterkieferoperation berichtet. Die Patientin war nach einem endotrachealen Absaugmanöver reanimationspflichtig geworden. Bei operativ versorgtem Unterkiefer und postoperativer Gesichtsweichteilschwellung misslang die orotracheale Intubation, sodass ein chirurgischer Atemwegszugang geschaffen werden musste. Hierbei perforierte die eingeführte Trachealkanüle offenbar unbemerkt die Hinterwand der Trachea, und unter laufender Beatmung entwickelte sich ein Spannungspneumomediastinum mit Spannungspneumothorax. Diese wurden während der Reanimation nicht entlastet; die Reanimation blieb erfolglos. Der dargestellte Fall verdeutlicht die Notwendigkeit eines strukturierten Vorgehens bei Patienten mit Beatmungsproblemen unter kardiopulmonaler Reanimation, insbesondere hinsichtlich der Entlastung eines Spannungspneumomediastinums bzw. eines Spannungspneumothorax.AbstractTension pneumothorax can occur at any time during cardiopulmonary resuscitation (CPR) with external cardiac massage and invasive ventilation either from primary or iatrogenic rib fractures with concomitant pleural or parenchymal injury. Airway injury can also cause tension pneumothorax during CPR. This article presents the case of a 41-year-old woman who suffered cardiopulmonary arrest after undergoing elective mandibular surgery. During CPR the upper airway could not be secured by orotracheal intubation due to massive craniofacial soft tissue swelling. A surgical airway was established with obviously unrecognized iatrogenic tracheal perforation and subsequent development of tension pneumomediastinum and tension pneumothorax during ventilation. Neither the tension pneumomediastinum nor the tension pneumothorax were decompressed and accordingly resuscitation efforts remained unsuccessful. This case illustrates the need for a structured approach to resuscitate patients with ventilation problems regarding decompression of tension pneumomediastinum and/or tension pneumothorax during CPR.

Overall Distribution of Trauma-Related Deaths in Berlin 2010: The Weakest Links of the Chain of Survival are Emergency Medicine and Critical Care: Reply

Dear Editor,We are very happy to have received such a greatresponse since the publication of our article about trau-matic deaths in Berlin 2010 [1]. Furthermore, we expectmore controversy and scientific discussion after publicationof the second part, preventable trauma deaths (article inreview, World Journal of Surgery).In our opinion, the major finding of our first study is theunderestimation of the importance of preclinical trauma man-agement. The results of our second study will clarify that thequalityofpreclinicaltraumamanagementisoverestimated,andtherefore the significance and potential to reduce traumaticdeaths is not recognized. With the primary focus on advance-ments in critical care, one of the two ‘‘hot spots’’ of traumamanagement, the main problem, preclinical trauma manage-ment,isdisregarded[2].Inarecentstudy,werevealedtheneedfor individualized preclinical treatment of trauma patients withinvasive preclinical measures, e .g., intubation and chest tubing[3]. Therefore, we conclude that the education of paramedicsand emergency physicians, and the active contribution oftrauma surgeons to preclinical trauma management are crucialfactors for improving the quality of national trauma manage-ment, and that adding these components has the potential tosignificantly lower mortality after severe trauma. All organi-zational, structural, and management efforts (national traumanetwork, trauma registry, national interdisciplinary guideline)rely on effective preclinical trauma management. Thus, wehave to secure the preclinical treatment of trauma patients andadvocate for their needs.Referring to the letter from Brambillasca et al. [4]wetotally agree with their striving for structures and nationalprotocols necessary for a modern trauma system, but thebasis of all is an intact chain of survival. The weakest link isalways crucial, and in our study, preclinical trauma care wasthe weakest link. Therefore, we recommend advancingpreclinical trauma management further by educating para-medics and emergency physicians in the administration ofsafe and effective preclinical treatment of patients aftersevere trauma. Self-evidently there are regional or nationaldifferencesdemandingananalysisoflocaltraumasystemstoreveal their weakest link(s). To our minds, the new bimodaltemporal distribution of traumatic deaths is not only aregional phenomenon but also the logical consequence ofcontinuous advancement in the treatment and logistics oftraumapatientsrevealingthetwohotspots,orweakest links:preclinicaltraumamanagementandintensivecaremedicine.References

Internal patterned injuries in trauma

Patterned bruising of the internal organs is unusual. In these cases a cutaneous pattern of bruising is not observed but the underlying tissue may show unusual injuries that may even be recognizable as a tramline pattern. We report the suicide of a 23-year-old man by jumping off a bridge. At autopsy, an unusual finding was “tramline” bruising of the right liver lobe. The “blunt objects” that inflicted the bruising were determined to be the right ribs which were pushed against the liver capsule as a consequence of the extensive thoracic and vertebral trauma after a fall from a height with intermediate impact.