Hagen Andruszkow

Physical and psychological long-term outcome after traumatic brain injury in children and adult patients.

BackgroundSeveral studies have indicated that younger age is associated with worse recovery after pediatric traumatic brain injury (TBI) compared to elder children. In order to verify this association between long-term outcome after moderate to severe TBI and patient’s age, direct comparison between different pediatric age groups as well as an adult population was performed.MethodsThis investigation represents a retrospective cohort study at a level I trauma center including patients with moderate to severe, isolated TBI with a minimum follow-up of 10xa0years. According to their age at time of injury, patients were divided in pre-school (0–7xa0years), school (8–17xa0years) and adult (18–65xa0years) patients. Physical examination and standardized questionnaire on physical and psychological aspects (Glasgow Outcome Scale, Barthel Index, Impact of Event Scale, Hospital Anxiety and Depression Scale, short form 12) were performed.Results135 traumatized patients were included. Physical and psychological long-term outcome was associated with injury severity but not with patients’ age at time of injury. Outcome recovery measured by Glasgow Outcome Scale was demonstrated with best results for pre-school aged children (pu2009=u20090.009). According to the Hospital Anxiety and Depression Scale an increased incidence of anxiety (pu2009=u20090.010) and depression (pu2009=u20090.026) was evaluated in older patients.ConclusionLong-term outcome perceptions after moderate to severe TBI presented in this study question current views of deteriorated recovery for the immature brain. The sustained TBI impact seemed not to reduce the child’s ability to overcome the suffered impairment measured by questionnaire based psychological, physical and health related outcome scores. These results distinguish the relevance of rehabilitation and family support in the long term.

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs].

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).INTRODUCTIONnFemoral 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).nnnPATIENTS AND METHODSnIn 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.nnnRESULTSnIn 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.nnnCONCLUSIONnFrom 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).

Ten years of helicopter emergency medical services in Germany: Do we still need the helicopter rescue in multiple traumatised patients?

BACKGROUNDnHelicopter emergency medical service (HEMS) has been established in the preclinical treatment of multiple traumatised patients despite an ongoing controversy towards the potential benefit. Celebrating the 20th anniversary of TraumaRegister DGU(®) of the German Trauma Society (DGU) the presented study intended to provide an overview of HEMS rescue in Germany over the last 10 years analysing the potential beneficial impact of a nationwide helicopter rescue in multiple traumatised patients.nnnPATIENTS AND METHODSnWe analysed TraumaRegister DGU(®) including multiple traumatised patients (ISS ≥ 16) between 2002 and 2012. In-hospital mortality was defined as main outcome. An adjusted, multivariate regression with 13 confounders was performed to evaluate the potential survival benefit.nnnRESULTSn42,788 patients were included in the present study. 14,275 (33.4%) patients were rescued by HEMS and 28,513 (66.6%) by GEMS. Overall, 66.8% (n=28,569) patients were transported to a level I trauma centre and 28.2% (n=12,052) to a level II trauma centre. Patients rescued by HEMS sustained a higher injury severity compared to GEMS (ISS HEMS: 29.5 ± 12.6 vs.nnnISS GEMSn27.5 ± 11.8). Helicopter rescue teams performed more on-scene interventions, and mission times were increased in HEMS rescue (HEMS: 77.2 ± 28.7 min. vs. GEMS: 60.9 ± 26.9 min.). Linear regression analysis revealed that the frequency of HEMS rescue has decreased significantly between 2002 and 2012. In case of transportation to level I trauma centres a decrease of 1.7% per year was noted (p<0.001) while a decline of 1.6% per year (p<0.001) was measured for level II trauma centre admissions. According to multivariate logistic regression HEMS was proven a positive independent survival predictor between 2002 and 2012 (OR 0.863; 95%-CI 0.800-0.930; Nagelkerkes-R(2) 0.539) with only little differences between each year.nnnCONCLUSIONSnThis study was able to prove an independent survival benefit of HEMS in multiple traumatised patients during the last 10 years. Despite this fact, a constant decline of HEMS rescue missions was found in multiple trauma patients due to unknown reasons. We concluded that HEMS should be used more often in case of trauma in order to guarantee the proven benefit for multiple traumatised patients.

Interleukin-6 as inflammatory marker referring to multiple organ dysfunction syndrome in severely injured children

BackgroundDespite the suggestion that the inflammatory response in traumatized children is functionally unique, prognostic markers predicting pediatric multiple organ failure are lacking. We intended to verify whether Interleukin-6 (IL-6) displays a pivotal role in pediatric trauma similar to adults.MethodsTraumatized children less than 18xa0years of age with an Injury Severity Score >9 points and consecutive admission to the hospital’s pediatric intensive care unit were included. Organ function was evaluated according to the score by Marshall et al. while IL-6 levels were measured repetitively every morning.Results59 traumatized children were included (8.4u2009±u20094.4xa0years; 57.6% male gender). Incidence of MODS was 11.9%. No differences were found referring to age, gender, injury distribution or overall injury severity between children with and without MODS. Increased IL-6 levels during hospital admission were associated with injury severity (Spearman correlation: ru2009=u20090.522, pu2009<u20090.001), while an inconsistent association towards the development of MODS was proven at that time point (Spearman correlation: ru2009=u20090.180, pu2009=u20090.231; Pearsons correlation: ru2009=u20090.297, pu2009=u20090.045). However, increased IL-6 levels during the first two days were no longer associated with the injury severity but a significant correlation to MODS was measured.ConclusionsThe presented prospective study is the first providing evidence for a correlation of IL-6 levels with injury severity and the incidence of MODS in traumatized children.

Impact of Helicopter Emergency Medical Service in Traumatized Patients: Which Patient Benefits Most?

Introduction The Helicopter Emergency Medical Service (HEMS) was established for the prehospital trauma care of patients. Improved rescue times and increased coverage areas are discussed as specific advantages of HEMS. We recently found evidence that HEMS exerts beneficial effects on outcomes for severely injured patients. However, it still remains unknown which group of trauma patients might benefit most from HEMS rescue. Consequently, the unique aim of this study was to reveal which patients might benefit most from HEMS rescue. Methods Trauma patients (ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2002 and 2012 were analysed using the TraumaRegister DGU. A multivariate regression analysis was used to reveal the survival benefit between different trauma populations. Results The study included 52u2005281 trauma patients. Of these, 68.8% (35u2005974) were rescued by GEMS and 31.2% (16u2005307) by HEMS. HEMS patients were more severely injured compared to GEMS patients (ISS: HEMS 24.8±13.5 vs. GEMS 21.7±18.0) and more frequently suffered traumatic shock (SBP sys <90mmHg: HEMS 18.3% vs. GEMS 14.8%). However, logistic regression analysis revealed that HEMS rescues resulted in an overall survival benefit compared to GEMS (OR 0.81, 95% CI [0.75–0.87], p<0.001, Nagelkerkes R squared 0.526, area under the ROC curve 0.922, 95% CI [0.919–0.925]). Analysis of specific subgroups demonstrated that patients aged older than 55 years (OR 0.62, 95% CI [0.50–0.77]) had the highest survival benefit after HEMS treatment. Furthermore, HEMS rescue had the most significant impact after ‘low falls’ (OR 0.68, 95% CI [0.55–0.84]) and in the case of minor severity injuries (ISS 9–15) (OR 0.66, 95% CI [0.49–0.88]). Conclusions In general, trauma patients benefit from HEMS rescue with in-hospital survival as the main outcome parameter. Focusing on special subgroups, middle aged and older patients, low-energy trauma, and minor severity injuries had the highest survival benefit when rescued by HEMS. Further studies are required to determine the potential reasons of this benefit.

Displaced intra-articular calcaneal fractures: is there a consensus on treatment in Germany?

AbstractIntroductionOpen reduction in displaced intra-articular calcaneal fractures entails a high rate of wound healing deficits and infections as well as an uncertain outcome, which leads to remaining ambiguity in treatment preferences.MethodsBetween January and July 2011, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 31–question web-based survey regarding three broad domains: fracture classification, surgical treatment algorithms and risk factors for wound healing deficits.ResultsThe response rate was 47xa0%. With an incidence of 77xa0%, open reduction via an extended lateral approach and plate fixation was the main treatment option for displaced intra-articular fractures of the joint-depression-type (Sanders II or III). Percutaneous techniques were only preferred in individual cases, with mainly precarious wound situations (59xa0%) as well as in patients with a reduced general health condition (ASA 3 and 4; 41xa0%). The re-operation rate due to infections and wound healing deficits after an extended lateral approach was reported with a percentage of 0-5xa0% by 88xa0% of the respondents. Participants stated that especially a poor microcirculation of the foot, disregard of soft tissue conserving techniques, overall condition of the patient, smoking, long time-to-surgery and operation time are the main reasons for wound healing deficits.ConclusionGiven the extended lateral approach as the preferred treatment option, we found minimally invasive techniques and primary arthrodesis of the lower ankle joint play a minor role in treating intra-articular calcaneal fractures in Germany. Ninety percent of our respondents stated less than 5xa0% of patients required re-operations due to infections and wound healing deficits.n Level of Evidence Level V, expert opinion.

Impact of age on the clinical outcomes of major trauma

PurposeIn view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing.xa0We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients.MethodsReview of the literature.ResultsDue to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality.ConclusionThe impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Post-traumatic thrombo-embolic complications in polytrauma patients

IntroductionThrombo-embolic events after trauma are considered to be life-threatening complications. Our aim was to determine the incidence of arterial and venous thrombo-embolic events (TE) in severely-injured trauma patients, and its associated risk factors by using a large trauma registry.MethodsPatients data from the TraumaRegister DGU® (TR-DGU) were screened for TE (DVT [symptomatic deep vein thrombosis], PE [symptomatic pulmonary embolism], MI [myocardial infarction], and stroke) through the clinical course of severely injured adult trauma patients from January 2005 to December 2012. Univariate analysis was used to compare the clinical outcomes (endpoints: mortality, ICU and hospital length of stay, ventilator days), and a multivariate regression analysis was used to assess the independent risk factors associated with each TE event.ResultsFrom a cohort of 40,846 trauma patients, 1122 (2.8xa0%) patients developed a TE during their post-traumatic clinical course (313, 0.8xa0% DVT; 425, 1.0xa0% PE; 160, 0.4xa0% MI and 231, 0.6xa0% stroke). ICU length of stay [LOS], total LOS, days on mechanical ventilation, and incidence of multiple organ failure (MOF) and sepsis were significantly increased in patients with TE complications. Injury severity, major pelvic injury, and one or more operations were found to be independent risk factors for the development of DVT. Ageu2009≥u200960xa0years, male gender, and more than one operation were risk factors for PE development. For MI age was the only significant risk factor. The occurrence of a stroke is increased in patients with an ageu2009≥u200960xa0years, major head injury (AIS headu2009≥u20093), and more than one operation. Finally, mortality rates were significantly higher in the TE group when compared to the non-TE cohort (21.8xa0% vs. 12.7xa0%; pu2009<u20090.001).ConclusionTE complications were associated with longer ICU and hospital stay as well as a higher mortality. Overall, age and repeated operations were the most important risk factors for the development of TE events.

Development of a scoring system based on conventional parameters to assess polytrauma patients: PolyTrauma Grading Score (PTGS).

BACKGROUNDnThe impact of conventional laboratory data to identify polytrauma patients at risk of complications is established. However, it has not been assessed in terms of prognostic accuracy for systemic complications (ARDS, organ failure). We therefore assessed the most predictive parameters for systemic complications and developed a scoring system for early grading of polytrauma patients.nnnMETHODSnA population based trauma registry was used.nnnINCLUSION CRITERIAnage >16 years, Abbreviated Injury Score (AIS) of the abdomen or chest ≥ 3 points and treatment in an intensive care unit, or Injury Severity Score (ISS) ≥ 16 points. The primary endpoint was hospital mortality. Patients were graded according their risk of death: low risk of death (5-14% mortality), intermediate risk patients (15-39% mortality) and high risk (>40%). Routine clinical and laboratory parameters on admission were assessed to determine their specific relevance to describe the risk profile of the patient. Based on these data, a scoring system for the description of the clinical status was developed. Statistical analysis included uniand multivariate analysis.nnnRESULTSn11.436 patients were included, the mean ISS was 22.7 ± 11.2 points, 73% were male, and 95.6% had blunt injuries. The most sensitive parameters were found to be the following ones: systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered. The multivariate analysis revealed the following threshold levels: BP 76-90 mmHg: r = 0.249, OR 1.283: Base deficit 8-10 r = 0.474, OR 1.606; INR 1.4-2 r = 0.160, OR 1.174; NISS 35-39 r = 0.9, OR 2.46; pBRC 3-14: r = 0.671, OR 1.957. The following ranges of score values were found to be associated with different patient status: <6 points: stable patients; 6-11 points: borderline condition; >11 points: unstable patients. When using this score, 80.6% were stable, 14.6% in a borderline condition and 4.8% unstable.nnnCONCLUSIONnWe developed a scoring system to discriminate polytrauma patients on admission that are at risk of systemic complications. Systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered are able to provide a prognosis of patients at risk of posttraumatic complications. Further prospective studies should be performed to verify this new scoring system.

Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion

External fixation has become an important tool in orthopedic surgery. Technology has improved the design and material as well as the construct of the fixator. As most patients are converted from external fixation to definite stabilization during later clinical course, prevention of complications such as infection is of high importance. Based on the current literature, principles of temporary external fixation were summarized. We focused on minimizing the risk of infection and introduce a standardized algorithm how to proceed when converting from external to internal fixation, which also was examined for effectiveness.