H. Wyen

Serum procalcitonin levels in patients with multiple injuries including visceral trauma.

Procalcitonin (PCT) is known to be a reliable biomarker of sepsis and infection. Elevation of serum or plasma PCT has also been observed after major surgery or trauma. The association of PCT with the severity or location of injury in multiple traumatized (polytrauma) patients has not been clearly established, to date. The aim of this study was therefore to evaluate the sensitivity of PCT as a biomarker for the diagnosis of abdominal trauma. In a prospective clinical study, PCT, interrleukin-6, and C-reactive protein were measured in blood (serum) samples obtained in the emergency room (D0) from 74 patients with multiple injuries and in serum samples obtained on the 2 days after trauma (D1, D2). PCT significantly increased during the first two posttraumatic days in patients with severe multiple injuries (n = 24, day 1: 3.37 ng/mL +/- 0.92 ng/mL; day 2: 3.27 ng/mL +/-0.97 ng/mL) as compared with patients with identical Injury Severity Score but without abdominal injury (day 1: 0.6 ng/mL +/- 0.18 ng/mL; 0.61 ng/mL +/- 0.21 ng/mL). Interrleukin-6 and C-reactive protein serum levels were not able to discriminate between patients with and without abdominal injury during the 2-day posttrauma observation period. In a specific evaluation of the abdominal injury pattern, a significant increase of serum PCT concentrations was observed on day 1 after trauma of the liver (4.04 ng/mL +/- 0.99 ng/mL) and the gut (4.63 ng/mL +/- 1.12 ng/mL) compared with other abdominal lesions (0.62 ng/mL +/- 0.2 ng/mL). Markedly elevated PCT concentrations were also evident after severe multiple injuries, including the liver/spleen in combination with thorax trauma (9.37 ng/mL +/- 2.71 ng/mL). Assessment of serum PCT seems to be significantly increased after abdominal trauma in severe multiple traumatized patients and may serve as a useful biomarker to support other diagnostic methods including ultrasound and CT scan. Although elevated levels of PCT during the first 2 days after trauma are more likely to be indicative of traumatic impact than of an ongoing status of sepsis, multiple events such as surgery, massive transfusion, and intensive care therapy might influence the PCT concentration.

The golden hour of shock - how time is running out: prehospital time intervals in Germany--a multivariate analysis of 15, 103 patients from the TraumaRegister DGU(R).

Objectives Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals. Methods We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST. Results 15 103 datasets were included in this study. Based on the mean OST of 32.7 (±18.6) min and a constant absolute term of 16.2 (±1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3±0.8 min) and being a car occupant (8.0±0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤8 (−4.5±0.7 min) and cardiopulmonary resuscitation (−2.8±1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0±24.6 min) compared with Level I (70.0±28.5 min) and II (66.8±27.4 min) trauma centres. Conclusions This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.

Interventional emergency embolization for severe pelvic ring fractures with arterial bleeding. Integration into the early clinical treatment algorithm

OBJECTIVE Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding. METHOD Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding. RESULTS Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14-80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3-5) and a total severity of injury with the ISS of 37 points (21-66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2-12.4) and an average transfusion requirement of 6 red blood cell units (4-13). The time until the TAE was started was on average 62 min (25-115) with a duration period of the TAE of 25 min (15-67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%. CONCLUSION Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.

Veränderungen in der Alterstraumatologie

The increasing average age in the industrialized nations is leading to an increasing number of elderly traumatized patients. Against this background, an analysis of the age-specific characteristics of geriatric traumatized patients is necessary. In this study, 14,869 patients > or = 18 years were analysed, who were prospectively documented in the registry of the German Trauma Society (DGU) between 1996 and 2005. Patients between 18 and 59 years were defined as the control group; their proportion declined from 81.1% in 1996-2000 to 75.4% in 2001-2005. The average age rose from 41.0 years (1996) to 45.3 years (2005). With increasing age a significant increase in severe head injuries of up to 58.9% (> or = 80 years) could be observed. Older patients stayed for a significantly shorter time in hospital and on the ICU. With a comparable injury severity, the lethality after trauma increased with age (18-59 years 13.8%, 60-69 years 24.1%, 70-79 years 35.5%, > or = 80 years 43.6%). The multiply traumatized geriatric patient is different from the normal group in regard to type of injury, therapy and outcome and should therefore be treated taking this fact into consideration.

Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung

OBJECTIVE Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding. METHOD Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding. RESULTS Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14-80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3-5) and a total severity of injury with the ISS of 37 points (21-66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2-12.4) and an average transfusion requirement of 6 red blood cell units (4-13). The time until the TAE was started was on average 62 min (25-115) with a duration period of the TAE of 25 min (15-67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%. CONCLUSION Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.

Distribution of spinal and associated injuries in multiple trauma patients

Injury to the spinal column and cord are often part of life-threatening multiple trauma. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of 590 multiple traumatized patients admitted within a 4-year-period. Patients suffering from injuries of the spinal column were analysed regarding mechanism and distribution of their injuries to all body regions. Thirty-one percent (n = 183) of polytraumatized patients displayed a spine injury. Distribution analysis showed peaks in the cervical spine and the thoraco-lumbar junction. The risk of relevant associated injuries is mainly influenced from anatomical vicinity to the injured spinal segment. Injuries to the spinal column are frequent in the multiple trauma patients population. Diagnosed injuries to distinct body regions should make the trauma team suspicious of injury to the nearby spinal column. Appropriate treatment includes thorough assessment of all injuries to clarify the damage and carry on special protection of these spinal regions preventing from deterioration.

Prehospital and Early Clinical Care of Infants, Children, and Teenagers Compared to an Adult Cohort

Background:Although the incidence of pediatric patients in emergency services is as low as 5–10%, trauma remains one of the leading causes of death during childhood. Only a few reports exist about the quality of the initial treatment of pediatric trauma patients. Therefore, we tested the hypothesis of whether prehospital treatment and emergency management in pediatric trauma patients is similar to the treatment that is provided for adult patients.Materials and Methods:We performed a retrospective data analysis of the German Trauma Registry of the DGU from January 1993 to December 2007. Exclusion criteria were missing information about injury severity and/or age and patients older than 50 years. All pediatric patients were subdivided into five groups (infants 0–1 year, toddlers 2–5 years, children 6–9 years, pupils 10–13 years, teenagers 14–17 years) with regard to their age and were compared with the adult cohort (18–50 years). From 24,396 patients, 2,961 were below 18 years of age, thus, about 12% of the whole population of injured patients below the age of 50 years.Results:66.4% of infants sustained relevant head injuries (Abbreviated Injury Scale [AIS] ≥3), and this rate declined with increasing age. The mean Injury Severity Score (ISS) increased from 21.0 (±11.6) in the group of infants to 26.7 (±13.9) in the adult cohort. In all groups, the majority of patients were male. The injury pattern differed according to age, with predominant traumatic brain injury (TBI) in infants. During the preclinical treatment, infants were less often intubated and this was contrasted by a higher rate of cardiopulmonary resuscitation in this group (infants 16.2%, toddlers 6.8%, adults 3.1%). Diagnostic multislice computed tomography (CT) examination was less often performed in infants as compared to the other groups (infants 57.1%, toddlers 77.2%, adults 77.8%). Mortality and quality indicators such as timelines show no significant differences between children and adults.Conclusion:We observed typical age-dependent differences regarding the injury pattern and severity and differences referring to the preclinical and initial treatment. With respect to the high rate of serious TBI in the infants and toddlers age groups, a more focused education and training of emergency physicians and paramedics should be considered.

Standardisierte Dokumentation im Schockraum mit dem Kerndatensatz „Notaufnahme“ der DIVI

In Germany the documentation of every prehospital emergency medical treatment has been standardized since 1997 based on the core data-set MIND (minimal emergency physician data-set). Against this background it is very surprising that there is still no standardized data-set implemented for the documentation of early inhospital emergency care. In order to create such a data-set the current state of documentation in many different hospitals all over the country was scrutinized. In addition existing registries and international requirements were taken into consideration. Finally, a modular data-set was created using a Delphi process. This data-set was tested, clinically validated and finally ratified by the executive committee of the DIVI (German Interdisciplinary Association of Critical Care Medicine). The modular data-set was designed in such a way that a basic module forms the foundation for every patient. Process-oriented modules (e.g. surveillance) and symptom-oriented modules (e.g. trauma, neurology) were added if necessary. Along with this data-set a set of six modules was created for graphical representation when required. This high level of standardization not only allows an internal and external quality assessment but also provides a sophisticated documentation system especially to the trauma team in the emergency department. In terms of content major parameters of interhospital quality management are recorded and important factors of process management, such as MTS (Manchester triage system), ATLS (advanced trauma life support) and EWS (early warning score) have been implemented. The data-set includes all necessary information for transfers between physicians and non-academic staff as well as between physicians and could also be used as a fundamental discharge letter. Moreover, this new core data-set is the implementation of items required by existing registries into the daily routine documentation in order to reduce unnecessarily time-consuming and error-prone secondary data acquisition. For example, all items of the preclinical and emergency room documentation for the TraumaRegister DGU® (documentation phase S, A and B of the standard and QM form) have been included. This is sufficient for participation as a TraumaNetzwerk DGU® member as far as the early clinical treatment of multiple injured patients is concerned.

[Changes in geriatric traumatology. An analysis of 14,869 patients from the German Trauma Registry].

The increasing average age in the industrialized nations is leading to an increasing number of elderly traumatized patients. Against this background, an analysis of the age-specific characteristics of geriatric traumatized patients is necessary. In this study, 14,869 patients > or = 18 years were analysed, who were prospectively documented in the registry of the German Trauma Society (DGU) between 1996 and 2005. Patients between 18 and 59 years were defined as the control group; their proportion declined from 81.1% in 1996-2000 to 75.4% in 2001-2005. The average age rose from 41.0 years (1996) to 45.3 years (2005). With increasing age a significant increase in severe head injuries of up to 58.9% (> or = 80 years) could be observed. Older patients stayed for a significantly shorter time in hospital and on the ICU. With a comparable injury severity, the lethality after trauma increased with age (18-59 years 13.8%, 60-69 years 24.1%, 70-79 years 35.5%, > or = 80 years 43.6%). The multiply traumatized geriatric patient is different from the normal group in regard to type of injury, therapy and outcome and should therefore be treated taking this fact into consideration.

Pre-hospital rescue times and actions in severe trauma. A comparison between two trauma systems: Germany and the Netherlands.

INTRODUCTION The aim of this study was to compare the effect of national pre-hospital rescue strategies on the status of severely injured patients at the time of admission to a Trauma Center (TC) in Germany or the Netherlands. PATIENTS AND METHODS This retrospective database analysis based on the TraumaRegister DGU(®) (TR-DGU) of the German Trauma Society compares the pre-hospital trauma system of Germany with three Trauma Centers (TCs) from the Netherlands. It comprises trauma patients from 2009 to 2012 admitted to a Level I TC, all patients aged 16-80 years primarily admitted with an ISS ≥ 16 and data available for mode of transport, pre-hospital measures and total pre-hospital time. Additionally three subgroups were formed by mode of transportation and involved personnel: Ambulance/Physician, Helicopter/Physician, Ambulance/EMT. Primary endpoint is the patients status at the time of admission to the trauma room. Secondary endpoint is hospital mortality. RESULTS A total of 12,168 patients met the inclusion criteria. Major differences in the injury patterns, pre-hospital rescue time, transport strategy and actions are documented. The mean ISS in the German overall group was 28.6 ± 12.2 compared to 27.4 ± 12.8 in the Dutch overall group. In the subgroups the highest injury severity with 29.8 ± 12.7 for German patients and 31.0 ± 14.6 for Dutch patients was found in the Helicopter/Physician subgroups and the lowest in patients transported by ambulance under emergency medical technician (EMT) care i.e. 24.2 ± 8.9 for German patients and 23.6 ± 10.3 for Dutch patients. The mean total pre-hospital time for patients admitted to Dutch TCs of 53.8 ± 28.7 min was 15.1 min shorter than for patients transported to German TCs 68.7 ± 28.6 min. The overall mean pre-hospital volume replacement of 1103 ± 821 ml for German patients was about twice as high as for Dutch patients (541 ± 700 ml). In physician led subgroups in the Netherlands higher rates of intubation, catecholamine administration and chest tubes are recorded. The basic vital signs from on-scene to hospital admission did not show relevant changes. Additional parameters available in the trauma room revealed a lower mean Base Excess (BE) for Dutch patients and a diminished mean prothrombin ratio for German patients. No reliable evidence was found that differences in the mortality analysis resulted from different national pre-hospital strategy. CONCLUSIONS Many differences in the national pre-hospital strategy were demonstrated but the effect on patients status at the time of admission to trauma room remains unclear. A follow-up study, which mitigates the now known injury patterns has to be initiated to further substantiate the findings of this study.