M. Raum

Association between injury pattern of patients with multiple injuries and circulating levels of soluble tumor necrosis factor receptors, interleukin-6 and interleukin-10, and polymorphonuclear neutrophil elastase.

BACKGROUND Our knowledge about the bidirectional interactions between brain and whole organism after trauma is still limited. It was the purpose of this prospective clinical study to determine the influence of severe head trauma (SHT) as well as trauma in different anatomic injury regions on posttraumatic inflammatory mediator levels from patients with multiple injuries. METHODS Thirty-five healthy controls, 33 patients with an isolated SHT, 47 patients with multiple injuries without SHT, and 45 patients with both SHT and multiple injuries were studied. The posttraumatic plasma levels of soluble tumor necrosis factor receptors p55 and p75, interleukin (IL)-6, IL-10, and polymorphonuclear neutrophil (PMN) elastase were monitored using enzyme-linked immunosorbent assay technique. The influence of head injuries as well as thorax, abdomen, and extremity injuries on the mediator release from patients with multiple injuries was investigated by multivariate linear regression models. RESULTS The soluble tumor necrosis factor receptor p55/p75 ratio was significantly elevated within 3 hours of trauma in all three injury groups and returned to reference ratios after 12 hours. The lowest increase was found in patients suffering from an isolated SHT. Lowest mediator levels in this patient population were also found for IL-6, IL-10, and PMN elastase during the first 36 hours after trauma. Additional injuries to the head, thorax, abdomen, and extremity modulated mediator levels to a different degree. No specific effect was found for SHT when compared with other injury groups. Thorax injuries caused the quickest rise in mediator levels, whereas abdominal injuries significantly increased PMN elastase levels 12 to 24 hours after trauma. CONCLUSION Traumatic injuries cause the liberation of various mediators, without any specific association between anatomic injury pattern and the pattern of mediator release.

Prognoseabschätzung des Schwerverletzten – Eine Analyse von 2069 Patienten des Traumaregisters der DGU

ZusammenfassungZum Zeitpunkt der Krankenhausaufnahme werden zahlreiche Variablen beim schwerverletzten Patienten erhoben. Die Wertigkeit dieser Variablen in Bezug auf ihre Fähigkeit der Prognoseabschätzung wird unterschiedlich beurteilt. Ziel ist es, bei Krankenhausaufnahme eine initiale Abschätzung des Outcomes schwerverletzter Patienten vornehmen zu k¨nnen. Dazu wurde ein multivariates Prognosemodell auf der Grundlage des Traumaregisters der DGU entwickelt. Patienten und Methode. Zum Zeitpunkt der Krankenhausaufnahme werden durch das DGU-Traumaregister mehr als 30 Variable prospektiv erfasst. Im 1. Schritt der zentral anonymisierten Auswertung wurden zur Vermeidung multipler statistischer Vergleiche diejenigen Variablen ausgewählt, die aufgrund der Literatur als klinische Prädiktoren für das Outcome angesehen werden. Im 2. Schritt erfolgte eine univariate Analyse dieser Variablen. Für alle primären Variablen mit univariater Signifikanz der Outcomevorhersage wurde im 3. Schritt, eine multivariate logistische Regression durchgeführt und ein multivariates Prognosemodell entwickelt. Ergebnisse. Vom 01.01.1993 bis 31.12.1997 wurden 2069 Patienten aus 20 Kliniken im Traumaregister prospektiv erfasst (Alter 39±19 Jahre; m.: 70,0%; ISS 22±13; 18,6% verstorben). Aus mehr als 30 bei Aufnahme erhobenen Variablen zeigten sich das Alter, der GCS, der ISS, der Base-Excess (BE) und der Quick-Wert als wichtigste Prognosefaktoren zur Abschätzung der Wahrscheinlichkeit zu versterben [P(Tod)]. Folgendes Prognosemodell wurde entwickelt: P(Tod)=1/1+e{−[k+β1(Alter)+β2(GCS)+β3(ISS)+β4(BE)+β5(Quick)]} wobei: k=−0,1551, β1=0,0438 mit p<0,0001, β2=−0,2067 mit p<0,0001, β3=0,0252 mit p=0,0071, β4=−0,0840 mit p<0,0001 und β5=−0,0359 mit p−0,0001.Jedes der 5 Variablen trägt signifikant zu dieser multifaktoriellen Gleichung bei. Schlussfolgerungen. Diese Daten zeigen, dass initiales Alter, GCS, ISS, Base-Excess und Quick-Wert frühzeitig verfügbare und potentiell wichtige Prädiktoren sind, um Traumapatienten mit einer hohen Sterbenswahrscheinlichkeit zu identifizieren. Mit Hilfe von Base-Excess und Quick-Wert, als einzige beeinflussbare Variablen dieser multifaktoriellen Gleichung, kann möglicherweise die frühzeitige, aggressive Therapie besser gesteuert werden.AbstractOn hospital admission numerous variables are documented from multiple trauma patients. The value of these variables to predict outcome are discussed controversially. The aim was the ability to initially determine the probability of death of multiple trauma patients. Thus, a multivariate probability model was developed based on data obtained from the trauma registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU). Patients and methods. On hospital admission the DGU trauma registry collects more than 30 variables prospectively. In the first step of analysis those variables were selected, that were assumed to be clinical predictors for outcome from literature. In a second step a univariate analysis of these variables was performed. For all primary variables with univariate significance in outcome prediction a multivariate logistic regression was performed in the third step and a multivariate prognostic model was developed. Results. 2069 patients from 20 hospitals were prospectively included in the trauma registry from 01.01.1993–31.12.1997 (age 39±19 years; 70.0% males; ISS 22±13; 18.6% lethality). From more than 30 initially documented variables, the age, the GCS, the ISS, the base excess (BE) and the prothrombin time were the most important prognostic factors to predict the probability of death (P(death)). The following prognostic model was developed: P(death)=1/1+e{−[k+β1(age)+β2(GCS)+β3(ISS)+β4(BE)+β5(prothrombin time)]} where: k=minus;0.1551, β1=0.0438 with p<0.0001, β2=−0.2067 with p<0.0001, β3=0.0252 with p=0.0071, β4=−0.0840 with p<0.0001 and β5=−0.0359 with p<0.0001. Each of the five variables contributed significantly to the multifactorial model. Conclusions. These data show that the age, GCS, ISS, base excess and prothrombin time are potentially important predictors to initially identify multiple trauma patients with a high risk of lethality. With the base excess and prothrombin time value, as only variables of this multifactorial model that can be therapeutically influenced, it might be possible to better guide early and aggressive therapy.

Incidence and Outcome of Traumatic Brain Injury in an Urban Area in Western Europe over 10 Years

Introduction: Valid epidemiological data on incidence and outcome of traumatic brain injury (TBI) show great variability. A study on incidence, severity and outcome of TBI was conducted in an urban area of one million inhabitants. Materials and Methods: 130,000 prehospital emergencies were screened for TBI. Inclusion criteria: Glasgow Coma Scale (GCS) score ≤8 and/or Abbreviated Injury Scale for head injuries (AIShead) score ≧2 with confirmed TBI via appropriate diagnostics. Results: Annual incidence was 7.3/100,000. Overall mortality rate was 45.8%: 182 (28%) were prehospital deaths, 116 (17.8%) patients died in hospital. Two hundred and fourteen of 352 (60.8%) surviving patients were sufficiently rehabilitated at discharge [Glasgow Outcome Scale (GOS) score = 1], but 138 patients (39.2%) survived with persisting deficits. GOS was associated with initial GCS and AIShead. Conclusion: The incidence of TBI was lower compared to the literature. The overall mortality was high, especially prehospital and early in-hospital mortality rates.

Systematische Entwicklung eines Messinstruments zur Erfassung der gesundheitsbezogenen Lebensqualität beim polytraumatisierten Patienten Die Polytrauma-Outcome- (POLO-)Chart

ZusammenfassungPolytraumatisierte Patienten leiden häufig noch Jahre nach dem Trauma unter dessen Spätfolgen. Diese bestehen – wie zahlreiche Studien belegen – nicht nur aus körperlichen Funktionseinschränkungen, sondern auch aus Schmerzen, sozialen und psychischen Beeinträchtigungen. Obwohl mit der Meran-Konsensuskonferenz (1990) eine Operationalisierung des Konstrukts Lebensqualität in der Chirurgie erarbeitet wurde, existiert bis heute noch kein Messinstrument, das alle relevanten Komponenten der gesundheitsbezogenen Lebensqualität zur Bewertung des Outcome polytraumatisierter Patienten ausreichend valide erfassen kann.Gegenstand der vorliegenden Arbeit ist die Darstellung der systematischen Entwicklung eines einheitlichen, modular aufgebauten Messinstruments zur Erfassung der gesundheitsbezogenen Lebensqualität polytraumatisierter Patienten.Innerhalb von 3 Phasen (Phase I: Itempoolerstellung; Phase II: Itemreduktion; Phase III: Vortest an 70 Polytrauma- und 70 Kontrollpatienten) wurde ein Outcome-Instrument entwickelt, welches mit 57 Items (Fragen) die relevanten Lebensqualitätskomponenten polytraumatisierter Patienten nach Klinikentlassung erfassen soll. Zusammen mit der Glasgow Outcome Scale (GOS), dem EUROQOL und dem SF-36 zur Erfassung der globalen Lebensqualität soll dieses Instrument u. a. als den Bogen E (POLytrauma Outcome Chart, POLO-Chart) des DGU-Traumaregisters dienen.Die POLO-Chart soll in einer abschließenden Studie (Phase IV: Überprüfung der Testgütekriterien, Normierung) an 5 verschiedenen unfallchirurgischen Kliniken (Celle, Essen, Hannover, Köln und München) validiert werden.AbstractEven years after having sustained multiple injuries patients often suffer from its sequelae. These comprise restrictions in physical function, but also pain, social and psychological impairments.Although the Meran Consensus Conference in 1990 defined the contents of “quality of life” (QoL) measures in surgery, still no instrument is available for the valid assessment of all relevant QoL domains in multiple injured patients.This paper describes the systematic development of a modular instrument for the assessment of health related QoL. Within three phases (phase I: generation of items, phase II: item reduction, phase III: pre-testing in 70 multiple injured and control patients) a questionnaire of 57 items was developed, which measures all relevant trauma-related aspects of QoL after acute hospital care. In combination with the Glascow Outcome Scale (GOS), the EUROQOL and the SF-36, the newly developed instrument builds the Polytrauma Outcome Chart (POLO-Chart) which will also be used as “Part E” for outcome assessment within the “Trauma registry” of the German Society for Trauma Surgery.In phase IV, the POLO-Chart will finally be validated in five trauma centres (Celle, Essen, Hanover, Cologne und Munich).

Emergency trauma score: an instrument for early estimation of trauma severity.

Objectives:Early estimation of the mortality risk of severely injured patients is mandatory. To estimate the seriousness of the condition of patients with trauma, we developed the emergency trauma score (EMTRAS) for ease of use, with simple parameters that are available within 30 minutes. Design:Prospective analysis of the German Trauma Registry of multitrauma patients. Setting:EMTRAS was derived from data from 1993 through 2003. Potential parameters that were prognostic for mortality in univariate analysis were evaluated by multivariate binary logistic regression. Selected parameters were then assigned a subscore that varied from 0 to 3. The EMTRAS score was a simple addition of these subscores. EMTRAS was compared with other scores’ receiver operating characteristic curves. After completion, EMTRAS was validated in patients from 2004 and 2005. Patients:A total of 11,533 patients were to be used for developing the score and 3314 patients for validating it. Main Results:The strongest predictors of mortality were age, prehospital Glasgow Coma Scale, base excess (mmol/L), and prothrombin time (% of reference). These parameters were categorized in subscores of 0 through 3. Age: <40, 40 through 60, 61 through 75, and >75 scored 0, 1, 2, and 3, respectively. Glasgow Coma Scale: 13 through 15, 10 through 12, 6 through 9, and 3 through 5 scored 0, 1, 2, and 3, respectively. Base excess: >−1, −5 through −1, −10 through −5.1, and <−10 scored 0, 1, 2, and 3, respectively. Prothrombin time: <80%, 80% through 50%, 49% through 20%, and >20% received a score of 0, 1, 2, and 3, respectively. In the validation dataset, the area under the receiver operating characteristic curve for EMTRAS was 0.828. Conclusions:EMTRAS combines four early parameters from the emergency room and accurately predicts mortality. Knowledge of the anatomical injuries is not necessary. The determination of the EMTRAS will inform caregivers of the seriousness of patients with trauma at an early stage.

The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis.

IntroductionSeveral studies have recently questioned whether routine radiographic screening for pelvic fractures is necessary in the initial evaluation of blunt trauma patients. Therefore, we assessed how sensitive and specific the clinical examination is in detecting fractures of the pelvis.MethodsWe extensively searched various medical databases for studies that reported on the accuracy of pelvic examination in severely injured adults or children. Individual study results were summarized in a receiver operating characteristics (ROC) curve and pooled in a meta-analysis.ResultsTwelve studies with a total of 5454 patients met our inclusion criteria and provided data in sufficient detail. Pooled sensitivity and specificity were 0.90 (95% confidence interval: 0.85–0.93) and 0.90 (0.84–0.94), respectively. Results were better in those studies which excluded neurologically impaired patients [e.g., Glasgow Coma Scale (GCS) <13]. Among the 49 false negative cases whose fractures went undetected on clinical examination, the majority of patients had either altered consciousness or minor pelvic fracture only. Only 3 clinically relevant pelvic fractures were missed among 441 patients with fracture within a total population of 5235 patients.ConclusionIn stable and alert trauma patients, a thorough clinical examination will detect pelvic fractures with nearly 100% sensitivity, thus rendering initial radiography unnecessary in this group of patients.

Das schwere Schädel-Hirn-Trauma bei Mehrfachverletzten Eine Bestandsaufnahme zur Interaktion lokaler und systemischer Mediatorwirkungen

ZusammenfassungDas isolierte oder mit weiteren Verletzungen kombinierte Schädel-Hirn-Trauma (SHT) ist ein Hauptprognosefaktor für Morbidität und Mortalität nach einem Unfallereignis. Die Prognose des Patienten ist sowohl von der primären, mechanischen Hirnschädigung als auch von der Entwicklung sekundärer Hirnschäden abhängig. Als Ursachen einer sekundären Hirnschädigung werden neben der intrakraniellen Raumforderung aufgrund posttraumatischer Blutungen und Ödembildungen, sowie der daraus resultierenden Ischämie, Entzündungsprozesse diskutiert. Sowohl beim isolierten SHT als auch nach Polytrauma mit und ohne Hirnschädigung kann eine inflammatorische “Systemreaktion” (SIRS) unter der Beteiligung von Zytokinen und anderen Entzündungsmediatoren zu einem Ein- oder Multiorganversagen (MOF) führen. Dabei sind einzelne Verletzungskomponenten und Funktionsstörungen meistens überlebbar, können jedoch in Ihrer Kombination und Kumulation tödlich enden. Hypermetabolische Zustände nach einem SHT werden auch als Interaktionen des ZNS mit dem Gesamtorganismus unter Beteiligung der neuroendokrinen Achse aufgefaßt. Diesen Auswirkungen eines SHT auf den übrigen Organismus ist der Einfluß multipler Verletzungen eines polytraumatisierten Verletzten auf die Hirnfunktion gegenüberzustellen, wobei schockbedingte Perfusionsstörungen eine prognoselimitierende Hypoxie des Gehirns verursachen können. Darüber hinaus beeinflußt die generalisierte “Ganzkörperentzündungsreaktion” Blutgerinnung, Stoffwechsel und Frakturheilung. Die Kenntnisse der traumainduzierten, bidirektionalen, inflammatorischen Interaktionen zwischen Gehirn und Gesamtorganismus, sowie der Einfluß der derzeit angewendeten Therapiemaßnahmen sind bisher noch unzureichend und bedürfen weiterer Aufklärung. Letztendlich muß aus dieser Sicht auch die Wahl des richtigen Zeitpunktes für sekundäre Eingriffe, die nicht unmittelbar der Lebenserhaltung dienen und zu einer zusätzlichen Belastung des Patienten durch das Operationstrauma führen, überdacht werden. Diese Arbeit versucht wichtige Aspekte auf diesem Gebiet zusammenzufassen.SummaryIsolated severe head trauma (SHT) or SHT in combination with multiple injuries are important factors for the prognosis of morbidity and mortality in patients suffering from the consequences of accidents. The prognosis mainly depends on the presence of primary mechanic brain injury and the development of secondary brain damage. Causes for the development of secondary brain damage are the intracranial space demand after traumatic injury and edema formation which may result in iscemia, as well as inflammatory processes. Both isolated SHT and polytrauma with or without brain damage may result in a systemic inflammatory response syndrome (SIRS) due to the synthesis of cytokines and other inflammatory mediators which may cause a single or multiple organ failure (MOF). Often the organism is able to survive isolated traumatic injuries and functional disturbances, but in combination or cumulation they may be lethal. The hypermetabolism after SHT is often regarded as an interaction between the central nervous system and the whole organism by the activation of the neuroendocrine axis. In contrast to the consequences of SHT for the whole organism, multiple injuries after polytrauma may affect brain functions, such as the shock dependent disturbance of the brain perfusion accompanied by brain hypoxia which may lead to an aggravated prognosis. Moreover, coagulation, metabolism and fracture healing are influenced by the onset of SIRS as well. Our knowledge about the bidirectional inflammatory interaction between brain and whole organism is still limited. In this context, the effects of secondary surgical interventions which may additionally stress a traumatized body have to be considered and are the subject for actual clinical discussions and experimental studies. This article tries to summarize some important aspects on this topic.

Plasma Levels of Procalcitonin and Neopterin in Multiple Trauma Patients with or without Brain Injury

Clinical and experimental evidence suggests that traumatic brain injury (TBI) leads to a systemic immune response. To examine whether TBI causes a release of procalcitonin (PCT) or neopterin (NT) into the circulation, we compared plasmatic mediator levels among multiple injured patients with or without TBI. In total, 98 trauma patients (24 with TBI only, 39 with extracranial injuries excluding TBI, and 35 with combined injuries) and 35 healthy volunteers were studied. Blood was sampled at 15 predefined time points within 132 h after injury and analysed for NT and PCT. Multivariate statistical comparisons were adjusted for different severity of head, thorax, abdomen and extremity injuries, as quantified by the Abbreviated Injury Scale (AIS). PCT was normal 3 h after trauma, but 24 h after extracranial injuries a massive release (median 3 ng/mL) was observed. Significant positive associations between injury severity and posttraumatic PCT levels were found for abdominal and extremity, but not for cranial or thoracic injuries. Only modest changes of marginal statistical significance were detected for NT. The maximum increase per AIS point was 9% (95% confidence intervals [CI]: 3-16%). The effect of TBI on NT release was significant only at 108 h posttrauma with a 5% (95% CI: 1-10%) increase per AIS point. TBI induces a release of PCT and NT into the plasma, but this effect seems to be smaller for intra- than for extracranial injuries, probably due to more extensive surgery for abdominal and extremity injuries.

The Prognostic Value of Prothrombin Time in Predicting Survival after Major Trauma: a Prospective Analysis of 1,351 Patients from the German Trauma Registry

Background: Early assessment of the individual trauma load in major trauma patients is difficult. A simple and reliable prognostic factor already available in the emergency room would help the emergency physician to make appropriate therapeutic decisions, e. g., when and how to operate on major fractures. The aim of the study was to evaluate the prognostic value of prothrombin time (PT). Patients and Methods: The German Trauma Registry is a prospective, standardized and anonymous documentation of severely injured patients. 3,814 patients were included in the registry. 1,351 patients with an Injury Severity Score (ISS) ≤ 16 and complete data for specific variables (PT, Trauma Score + Injury Severity Score [TRISS], survival until discharge) were included in the study. The PT was measured on the patients arrival in the emergeny room. Three different analyses were performed. 1. According to clinical judgment, three groups of patients were compared (PT ≥ 60%, PT 40–59%, PT < 40%). A univariate analysis compared therapeutic interventions and outcome variables between the three groups. 2. A receiver-operator-characteristic (ROC) curve analysis compared the performance of PT with the prognostic standard TRISS. 3. A multivariate logistic regression was performed in order to evaluate PT as an independent prognostic variable. Results: PT values showed a good inverse correlation with the severity of injury and the level of therapeutic interventions. The ROC analysis as well as the regression revealed PT as a significant prognostic factor although it showed a slightly worse performance compared to TRISS. Conclusions: As PT, in contrast to TRISS, is readily available already in the emergency room, it can be used as a screening variable for the assessment of a patients trauma load and thereby help in the decision-making for further operative treatment of major trauma patients.

Systematische Literatursuchen in der Erstellung klinischer Leitlinien am Beispiel der prä- und frühklinischen Versorgung polytraumatisierter Patienten

ZusammenfassungFragestellung. Inwieweit findet die unfallchirurgische Literatur über medizinische Datenbanken den Weg in internationale Polytraumaleitlinien? Methodik. Wir suchten in verschiedenen Datenbanken nach Leitlinien zum frühen Polytraumamanagement und analysierten die in den Leitlinien berichteten Literatursuchen und -bewertungen. Als Zweites wurden über Bibliothekskataloge alle relevanten Zeitschriften zum Thema der präklinischen Traumaversorgung identifiziert. Zuletzt wurde für eine Anzahl nicht in Medline indexierter deutscher Zeitschriften eine Handsuche nach Studien mit wahrscheinlich randomisiert-kontrolliertem Design (RCT) durchgeführt. Ergebnisse. Es wurden 22 Leitlinien gefunden. Die Qualität der für die Leitlinien durchgeführten Literatursuchen variierte stark, wobei die amerikanischen Leitlinien am besten bewertet wurden. Von den 38 inhaltlich relevanten Zeitschriften waren 21 (55%) in Medline, weitere 6 aber nur in Embase und 11 in keiner Datenbank indexiert. Dennoch fanden sich in der Handsuche solch nicht-indexierter deutscher Zeitschriften fast 200 RCTs. Schlussfolgerungen. Der Informationsfluss zwischen klinischer Forschung und der Entwicklung klinischer Leitlinien ist noch schwierig, sodass aufwändige Literatursuchen für Leitlinien notwendig bleiben.AbstractQuestion. To what extent does the scientific literature have an impact on current clinical practice guidelines (CPGs) in trauma surgery? Methods. We searched for CPGs on the initial management of multiply injured patients and assessed the quality of literature search and appraisal within these CPGs. Secondly, we compiled a list of all medical journal with relevance to prehospital trauma care. Lastly, we performed a handsearch for randomised controlled trials (RCTs) in some of the German not in Medline indexed traumatological journals. Results. We identified 22 CPGs of varying methodological quality. The American guidelines scored highest. Only 21 of the 38 journals (55%) in the field of prehospital trauma surgery were indexed in Medline, while 6 were covered only by Embase and 11 were indexed in neither of both databases. Handsearching four non-indexed German journals identified nearly 200 RCTs. Conclusion. Information flow between clinical research and CPG development remains difficult. Thoroughly performed literature searches have an important role in CPG development.