C. Zeckey

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).

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.

Die Damage-control-Strategie

ZusammenfassungDas Konzept des „damage control“ (DC) stellt eine Behandlungsstrategie zur Reduktion der Belastung polytraumatisierter Patienten durch die operative Versorgung dar. Das DC-Konzept ist zur chirurgischen Kontrolle abdomineller Blutungen vollständig akzeptiert. Im Rahmen der Behandlung von Femurfrakturen sollte die primäre definitive Versorgung bei polytraumatisierten Patienten in einem stabilen Zustand erfolgen. Für schwerverletzte Patienten in einem instabilen Zustand mit einem hohen Risiko posttraumatischer Komplikationen scheint das DC-Konzept die am besten geeignete Behandlungsstrategie zu sein. Bei polytraumatisierten Patienten in unklarem klinischem Zustand wird das optimale Vorgehen im Rahmen der operativen Erstversorgung weiterhin kontrovers diskutiert. Im Falle dieser Patienten sollte der präoperative Zustand sorgfältig begutachtet werden, um die bestmögliche initiale Versorgungsstrategie festzulegen. Anatomische, physiologische und inflammatorische Parameter können genutzt werden, um das Ausmaß der operativen Erstversorgung festzulegen.AbstractThe concept of “damage control” (DC) is a treatment strategy for multiple trauma patients in order to reduce the impact of the initial surgical treatment. The DC concept is well accepted for the surgical control of abdominal bleeding. For the treatment of femoral fractures, primary definitive stabilization should be performed in stable multiple trauma patients. The DC concept seems to be the treatment of choice for patients with severe multiple trauma in an unstable condition and at high risk for developing systemic complications. For multiple trauma patients in an uncertain condition the timing of definitive surgical treatment of major fractures is still being controversially discussed. In these patients, the preoperative condition should be considered carefully when deciding on the type of initial fixation to perform. Anatomical, physiological as well as inflammatory parameters can be used to tailor the amount of surgery that is performed to the clinical condition of the patient.

Entwicklung einer Notfallkarte zum Umgang mit Airbagwesten bei Reitunfällen

BeiUnfällen imAutomobilbereich, indenen nicht alle Airbags ausgelöst wurden, müssen beim Einsatz von hydraulischen Rettungsgeräten fahrzeugspezifische Sicherheitsmaßnahmen getroffen werden. Es sind bestimmte Regeln zu beachten, damit für die Rettungskräfte keine Gefährdung auftritt. Für viele Fahrzeuge wird auch einNotfallleitfaden (oder auch Rettungskarte genannt) zur Verfügung gestellt. Dieser wird im Fahrzeug mitgeführt und zeigt nebenanderen relevanten Gefährdungen die Lage von Airbags und Gasgeneratoren. Derzeit sind Airbagwesten und ihr protektiver Nutzen Gegenstand der Forschung. Im Reitsport etabliert sich das Tragen von Airbagwesten immer mehr, und zwar nicht nur im Profi-Reitsport. Daher wird es für Rettungsdienstpersonal und Notärzte wahrscheinlicher, bei

Unfälle im Reitsport

BACKGROUND Equestrian sports are one of the most popular forms of sport in Germany, while also being one of the most accident-prone sports. Furthermore, riding accidents are frequently associated with a high degree of severity of injuries and mortality. Nevertheless, there are insufficient data regarding incidences, demographics, mechanisms of accidents, injury severity and patterns and outcome of injured persons in amateur equestrian sports. Accordingly, it was the aim of the present study to retrospectively analyze these aspects. METHODS A total of 503 patients were treated in the emergency room of the Hannover Medical School because of an accident during recreational horse riding between 2006 and 2011. The female gender was predominantly affected with 89.5 %. The mean age of the patients was 26.2 ± 14.9 years and women (24.5 ± 12.5 years) were on average younger than men (40.2 ± 23.9 years). A special risk group was girls and young women aged between 10 and 39 years. The overall injury severity was measured using the injury severity score (ISS). RESULTS Based on the total population, head injuries were the most common location of injuries with 17.3 % followed by injuries to the upper extremities with 15.2 % and the thoracic and lumbar spine with 10.9 %. The three most common injury locations after falling from a horse were the head (17.5 %), the upper extremities (17.4 %), the thoracic and lumbar spine (12.9 %). The most frequent injuries while handling horses were foot injuries (17.2 %), followed by head (16.6 %) and mid-facial injuries (15.0 %). With respect to the mechanism of injury accidents while riding were predominant (74 %), while accidents when handling horses accounted for only 26 %. The median ISS was 9.8 points. The proportion of multiple trauma patients (ISS > 16) was 18.1 %. Based on the total sample, the average in-hospital patient stay was 5.3 ± 5.4 days with a significantly higher proportion of hospitalized patients in the group of riding accidents. Fatal cases were not found in this study but the danger of riding is not to be underestimated. The large number of sometimes severe injuries with ISS values up to 62 points can be interpreted as an indication that recreational riding can easily result in life-threatening situations. CONCLUSION Girls and young women could be identified as a group at particular risk. It has been demonstrated in this study that the three most common injury locations after falling from a horse were the head, the upper extremities, the thoracic and lumbar spine. The most frequent injury locations while handling horses were foot injuries, followed by head and mid-facial injuries.

[Jehova's Witnesses and severe injury with impending hemorrhaging : how complex is the treatment?].

ZusammenfassungWährend der Initialversorgung und im weiteren Verlauf auf den Intensivstationen kommt es bei polytraumatisierten Patienten häufig zu relevanten Blutverlusten. Die traumatische Koagulopathie sowie die oft unerkannte Hyperfibrinolyse können hierbei die Hämorrhagie weiter verkomplizieren. Die Applikation von Erythrozytenkonzentraten und anderen Blutprodukten sowie Gerinnungsfaktoren ist daher regelhaft Bestandteil der Therapie. Zeugen Jehovas lehnen aufgrund ihres Glaubens häufig die Transfusion von Blut und Blutbestandteilen ab, was zu Verunsicherung und dramatischen Entscheidungsprozessen innerhalb des behandelnden Teams führen kann. Der in dieser Kasuistik beschriebene Fall zeigt die Behandlung einer jungen polytraumatisierten Patientin mit Schädel-Hirn-Trauma, Thoraxtrauma und einer Leberlazeration, die blutfrei therapiert wurde. Besonderer Stellenwert soll bei der hier beschriebenen Kasuistik den ethischen und rechtlichen Grundlagen beigemessen werden. Die möglichen therapeutischen Konzepte unter Einsatz von Gerinnungsprodukten, Erythropoietin und Eisen bleiben ebenso wie die ethische und rechtliche Situation weiter im Fokus der Diskussionen.AbstractHemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehova’s Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.Hemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehovas Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.

Zeugen Jehovas und Schwerverletzung mit drohender Hämorrhagie@@@Jehova’s Witnesses and severe injury with impending hemorrhaging: Wie komplex ist die Behandlung?@@@How complex is the treatment?

ZusammenfassungWährend der Initialversorgung und im weiteren Verlauf auf den Intensivstationen kommt es bei polytraumatisierten Patienten häufig zu relevanten Blutverlusten. Die traumatische Koagulopathie sowie die oft unerkannte Hyperfibrinolyse können hierbei die Hämorrhagie weiter verkomplizieren. Die Applikation von Erythrozytenkonzentraten und anderen Blutprodukten sowie Gerinnungsfaktoren ist daher regelhaft Bestandteil der Therapie. Zeugen Jehovas lehnen aufgrund ihres Glaubens häufig die Transfusion von Blut und Blutbestandteilen ab, was zu Verunsicherung und dramatischen Entscheidungsprozessen innerhalb des behandelnden Teams führen kann. Der in dieser Kasuistik beschriebene Fall zeigt die Behandlung einer jungen polytraumatisierten Patientin mit Schädel-Hirn-Trauma, Thoraxtrauma und einer Leberlazeration, die blutfrei therapiert wurde. Besonderer Stellenwert soll bei der hier beschriebenen Kasuistik den ethischen und rechtlichen Grundlagen beigemessen werden. Die möglichen therapeutischen Konzepte unter Einsatz von Gerinnungsprodukten, Erythropoietin und Eisen bleiben ebenso wie die ethische und rechtliche Situation weiter im Fokus der Diskussionen.AbstractHemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehova’s Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.Hemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehovas Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.

Early Total Care (ETC) im Vergleich zu Damage Control Orthopedics (DCO) bei der Behandlung polytraumatisierter Patienten mit FemurschaftfrakturenComparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures

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).

Verletzung der Aa. subclavia und vertebralis im Kindesalter nach stumpfem Trauma

Injuries of great vessels, such as the subclavian or vertebral arteries in childhood are rare. More frequent and therefore better described are dissections of the vertebral artery, which frequently occur following low energy trauma. The combination of dissection of the vertebral and subclavian arteries described in this case study led to sensory affections of the left arm. Therapeutic anticoagulation is the therapy of choice to avoid possible ischemic insults. The therapeutic approach of injuries to the subclavian artery remains unclear and is in the focus of discussions.

Zeugen Jehovas und Schwerverletzung mit drohender Hämorrhagie

ZusammenfassungWährend der Initialversorgung und im weiteren Verlauf auf den Intensivstationen kommt es bei polytraumatisierten Patienten häufig zu relevanten Blutverlusten. Die traumatische Koagulopathie sowie die oft unerkannte Hyperfibrinolyse können hierbei die Hämorrhagie weiter verkomplizieren. Die Applikation von Erythrozytenkonzentraten und anderen Blutprodukten sowie Gerinnungsfaktoren ist daher regelhaft Bestandteil der Therapie. Zeugen Jehovas lehnen aufgrund ihres Glaubens häufig die Transfusion von Blut und Blutbestandteilen ab, was zu Verunsicherung und dramatischen Entscheidungsprozessen innerhalb des behandelnden Teams führen kann. Der in dieser Kasuistik beschriebene Fall zeigt die Behandlung einer jungen polytraumatisierten Patientin mit Schädel-Hirn-Trauma, Thoraxtrauma und einer Leberlazeration, die blutfrei therapiert wurde. Besonderer Stellenwert soll bei der hier beschriebenen Kasuistik den ethischen und rechtlichen Grundlagen beigemessen werden. Die möglichen therapeutischen Konzepte unter Einsatz von Gerinnungsprodukten, Erythropoietin und Eisen bleiben ebenso wie die ethische und rechtliche Situation weiter im Fokus der Diskussionen.AbstractHemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehova’s Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.Hemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehovas Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.