Steffen Ruchholtz

Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.

BACKGROUND Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.

Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.

Mortality in severely injured elderly trauma patients - When does age become a risk factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) ≥ 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46–55 years of age) to 13.0% (patients ages 56–65 years) in patients with ISS 16–24; from 23.8% to 32.1% in those with ISS 25–50; and from 62.2% to 82.1% in those with ISS 51–75 (P ≤ 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P ≤ 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P ≤ 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma—an increase that was independent of trauma severity.

Reduction in mortality of severely injured patients in Germany.

INTRODUCTION The trauma registry of the German Society of Trauma Surgery is a multicentric prospective record of the treatment of severely injured patients. METHODS The present study examines the effect of a quality management system on key processes and outcomes, in hospitals included in the trauma registry. The study is based on data of 11 013 severely injured patients (injury severity score = 16) who were treated in 105 hospitals between 1993 and 2005. A variety of parameters relating to early diagnosis and treatment were considered. Outcome quality was measured by a comparison between observed and calculated mortality (revised injury severity classification). RESULTS During the 13 year long study period mortality could be significantly reduced from 22.8% to 18.7%. The time to initial radiological and ultrasound diagnosis was reduced, the use of computed tomography increased, the time until emergency operations in hemorrhagic shock was reduced, and damage limiting orthopedic interventions were performed more frequently. DISCUSSION The German Trauma Registry records processes and treatment results in severely injured patients. This information is fed back to participating hospitals. The continuous data feedback is associated with a continuous improvement of process and outcome quality in the treatment of severely injured patients.

Quality management in the early treatment of patients with multiple injuries. II. Quality improvement guidelines

SummaryTo enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988–12/1993 (A; n = 126) and 1/1994–6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97 % vs. 92 % of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5 % vs. 24 %; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3 % vs. 12 %. The lethality rates of each collective were assessed after subdivision in three groups (I–III) with middle (ISS: 18–24), high (ISS: 25–49) and extreme (ISS: 50–75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0 % vs. 20 % (P < 0.05); group II, 8 % vs. 24 % (P < 0.05); and group III, 40 % vs. 71 %, not significant because of the small group in B (n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.ZusammenfassungZur Optimierung der Akutversorgung Polytraumatisierter erfolgte im Jahre 1994 die Einführung von problem- und prioritätenorientierten Behandlungsleitlinien (Polytraumaalgorithmus) in der eigenen Klinik. Die Bedeutung dieser Behandlungsleitlinien wurde vergleichend für 2 prospektiv erfaßte Kollektive 4/1988–12/1993 (A;n = 126) und 1/1994–6/1996 (B;n = 74) analysiert. Anhand neun definierter Parameter wurde der Versorgungsablauf der frühklinischen Polytraumabehandlung beurteilt. Für alle 9 Beurteilungsparameter zeigten sich Verbesserungen nach Einführung des Algorithmus (Kollektiv B) gegenüber der Kontrollgruppe: 1. Vollständige radiologische und sonographische Basisdiagnostik bei 97 vs. 91 % der Patienten; 2. Dauer von 38 vs. 55 min bis zum kraniellen CT bei schwerem SHT (GCS < 10); 3. Reduktion verzögert diagnostizierter Läsionen auf 5 vs. 32 %; 4. Dauer von 16 vs. 20 min bis zur Intubation; 5. Dauer von 23 vs. 30 min bis zur Thoraxdrainage; 6. Dauer von 18 vs. 32 min bis zur Transfusion bei Schock; 7. Dauer von 79 vs. 98 min bis zur Notoperation bei Schock; 8. Dauer von 95 vs. 124 min bis zur Trepanation; 9. Operationsrate innerhalb von 24 h nach ICU-Aufnahme von 3 vs. 11 %. Die Letalitätsraten der Kollektive wurden nach Unterteilung in 3 Gruppen (I–III) mit mittlerer (ISS: 18–24), hoher (ISS: 25–49) und sehr hoher (ISS: 50–75) Verletzungsschwere gegenübergestellt. ISS-Werte, Alter, initiale Bewußtlosigkeit und Schock waren in allen Gruppen für beide Kollektive vergleichbar (mit Ausnahme einer höheren Verletzungsschwere von Kollektiv B in Gruppe I). In allen Gruppen zeigte sich ein deutlicher Rückgang der Letalität für das Kollektiv B. Gruppe I: 0 vs. 20 %, (p < 0,05); Gruppe II: 8 vs. 24 %, (p < 0,05); Gruppe III 40 vs. 71 %, aufgrund niedriger Fallzahl (n = 5) in B nicht signifikant. Durch Behandlungsleitlinien konnten Versorgungsabläufe optimiert und Behandlungsergebnisse verbessert werden. Um solche Leitlinien in ihrer Gültigkeit und Praktikabilität regelmäßig zu überprüfen, sowie gleichzeitig die Qualität weiter zu optimieren, ist eine kontinuierliche Überprüfung der Behandlung im Sinne eines Qualitätsmanagementsystems zu fordern.

Standardized outcome evaluation after blunt multiple injuries by scoring systems: A clinical follow-up investigation 2 years after injury

OBJECTIVE The objective of this study was to evaluate the state of rehabilitation in patients with blunt multiple injuries 2 years after their initial injuries, using several standardized scales and a recently described comprehensive scoring system, by means of a prospective clinical multicenter study. METHODS Two years after the initial injury, patients with blunt multiple injuries (Injury Severity Score > or = 16) underwent a clinical follow-up in 5 German Level I trauma centers. The reassessment included a complete head-to-toe examination of the musculoskeletal system and a neurologic examination. The following patient-assessed health status scores were used to determine the quality of life: Short-Form 12, Functional Independence Measurement, and Musculoskeletal Function Assessment. Moreover, a comprehensive scoring system developed in our department (Hannover Score for Polytrauma Outcome [HASPOC]) was used that includes provider-report (physicians examination) and self-report (score systems) criteria. RESULTS Two hundred fifty-four of 312 patients who had been injured between January 1995 and July 1996 were reexamined between January 1, 1997, and July 1, 1998. Among the remaining 58 patients, 9 had died by the time of follow-up, and 49 patients had not accepted the invitation. The mean age of those patients who underwent reexamination was 36 +/- 13 years, the mean Injury Severity Score was 24 +/- 6, and the mean initial Glasgow Coma Scale score was 11 +/- 4 (Abbreviated Injury Scale (AIS) head score of 3.3 +/- 1.1; AIS face, 1.4 +/- 0.1; AIS chest, 3.0 +/- 0.8; AIS abdomen, 1.7 +/- 0.6; and AIS extremities, 3.4 +/- 0.8). The general outcome (Short-Form 12) was as follows: grade I, 9%; grade II, 25%; grade III, 29%; grade IV, 25%; grade V, 6%; and grade VI, 6%. The outcome of the injured extremity demonstrated moderate or severe restrictions according to the Musculoskeletal Function Assessment in 41% of injuries of the lower extremity and in 16% of injuries of the upper extremity. Among patients with injuries to the lower extremity, 52% experienced pain or impaired ability to walk related to an injury of the foot or ankle, 31% indicated pain after a knee or thigh injury, and 27% indicated pain after a femoral or hip injury. The most severe deficits in the range of motion occurred in the foot and the ankle region (13.4% deficit of range of motion < 20% of normal range, p < 0.05 to other injuries). The results of the outcome obtained by self-report correlated with the clinical examination when a scoring system was used that was described recently, the HASPOC. CONCLUSION In a standardized multicenter reexamination of patients with blunt multiple injuries, the general outcome was usually fair or good. Both the complaints and the objective results of specific extremity areas demonstrated that most limitations were because of injuries below the knee. These results were adequately reflected by a comprehensive scoring system, combining self-report and provider report (HASPOC).

Stellenwert der Computertomographie in der frühen klinischen Behandlung schwer verletzter Patienten

AbstractBackground. The availability of newer, faster computed tomography (CT) technology has engendered discussion about whole-body CT-scanning for primary radiological diagnostics of seriously injured patients. Method. Within a quality management system, the scaled, priority-oriented scheme of conventional radiological and CT-diagnostics used in each institution was analysed and compared with the possible benefit of whole-body CT-scanning. Every patient with severe trauma admitted directly from the scene of an accident, underwent basic radiological and sonographic diagnostics in the emergency room (ER). According to the findings, patients in a stable vital condition had CT-scans when indicated by the guidelines of the particular institution. Results. From 5/1998 until 12/2000, a total of 832 patients were treated in the ER. Of those, 480 patients (average ISS 20) were admitted directly from the scene of the accident. Basic radiological – sonographic diagnostics (radiographs of cervical spine, chest, and abdomen, as well as abdominal sonography) took 15±8 min. Twenty-two (5%) of the patients in hemorrhagic shock needed emergency operations after 57±43 min. The remaining patients underwent further radiological diagnostics (spine, extremities etc.) after 44±27 min. In 79% (379) of patients, CT was indicated. Cranial CT for traumatic brain injury prevailed clearly with 74% of cases. Spine (24%), chest (18%), abdomen (5%) and pelvis (5%) were indicated comparatively less frequently. The incidence of delayed diagnoses (after ICU-admission) was 4% (22). In 2% (nine) of patients the lesions possibly could have been detected by a primary CT-scan. In the three cases with thoracic lesions, there was a deviation from the indication guidelines for thoracic CT as normally used in the institution. There were three cases of delayed diagnoses in both the cerebral (small contusion haematomas) region and the abdominal region. The abdominal lesions were detected by sonographic control examinations. No patient died because of a delayed diagnosis. The average X-ray dose was five times lower with the scaled diagnostic management comprising indicated CT when compared to the doses calculated for routine whole-body CT. Conclusion. While 74% of patients had cranial CT, only 25% needed CT for the trunk regions. Delayed diagnoses were rare and without severe consequences for the patient. Considering the five times higher X-ray doses combined with the possible time loss in patients with unstable conditions, primary whole-body CT-scanning should not be performed routinely when serious injury is suspected.ZusammenfassungHintergrund. Aufgrund neuerer Computertomographie- (CT-)Geräte wird die Ganzkörper-CT-Untersuchung als primäre Diagnostik schwer verletzter Patienten diskutiert. Methode. Im Rahmen eines Qualitätsmanagementsystems wurde ein abgestufter, prioritätenorientierter Ablauf der konventionellen radiologischen und computertomographischen Diagnostik analysiert und dem möglichen Nutzen einer primären Ganzkörper-CT gegenübergestellt. Jeder Patient, der nach stumpfen Trauma primär vom Unfallort zuverlegt wurde, wurde im Schockraum einer radiologisch-sonographischen Basisdiagnostik unterzogen. Je nach Befund wurde nach klinikinternen Leitlinien die Indikation zur Computertomographie gestellt. Ergebnisse. Von 5/1998 bis 12/2000 wurden 832 Patienten im Schockraum behandelt. Vom Unfallort wurden 480 Schwerverletzte (ISS 20) zuverlegt. Die Basisdiagnostik (Röntgen-HWS, -Thorax, -Becken und Abdomensonographie) erfolgte innerhalb von 15±8 min. Im Blutungsschock mussten 5% (22) der Patienten notfallmäßig nach 57±43 min operiert werden. Bei allen anderen erfolgte die weitere radiologische Diagnostik (Wirbelsäule etc.) nach 44±27 min. Bei 79% (379) wurde die Indikation zur Computertomographie gestellt. Die kraniale CT bei Schädel-Hirn-Trauma stand mit 74% der Patienten im Vordergrund. CT-Untersuchungen der Wirbelsäule (24%), des Thorax (18%), des Abdomens (5%) und des Beckens (5%) waren wesentlich seltener indiziert. Die Rate verzögert diagnostizierter Läsionen betrug 4% (22). Bei 2% (9) der Patienten hätten die Läsionen möglicherweise durch eine primäre CT diagnostiziert werden können. Bei den 3 Fällen mit thorakalen Läsionen wurde jeweils von den Diagnostikleitlinien abgewichen. Im Bereich des Schädels (kleine Kontusionen) fanden sich ebenso wie im Abdomen je 3 Fälle mit verzögerten diagnostizierten Verletzungen. Die abdominalen Läsionen konnten durch Kontrollsonographien aufgezeigt werden. Kein Patient verstarb aufgrund der verzögert diagnostizierten Läsionen. Die durchschnittliche Strahlenbelastung lag bei abgestuftem Diagnostikablauf um ein Fünffaches unter den Werten die bei routinemäßiger Ganzkörper-CT erreicht worden wären. Schlussfolgerung. Im Gegensatz zum Schädel wurde die Indikation zur CT im Bereich des Rumpfes nur bei einem Viertel der Patienten gestellt. Verzögert diagnostizierte Läsionen waren trotzdem selten und ohne wesentliche Folgen. Aufgrund der erhöhten Strahlenbelastung und des möglichen Zeitverlusts bei instabilen Patienten sollte die primäre Ganzkörper-CT nicht routinemäßig bei allen Patienten mit Verdacht auf eine Mehrfachverletzung durchgeführt werden.

Prehospital intubation in severe thoracic trauma without respiratory insufficiency: a matched-pair analysis based on the Trauma Registry of the German Trauma Society.

OBJECTIVE On the basis of the data of a multicenter study, the impact of prehospital intubation and ventilation in the therapy of severe thoracic trauma without manifest respiratory insufficiency was analyzed. METHODS Data were collected prospectively in the Trauma Registry of the German Trauma Society. In a matched-pair analysis, patients with severe thoracic trauma (Abbreviated Injury Scale score of 4) with and without prehospital intubation were compared. Patients were paired with respect to age, injury severity, and prognosis (according to the TRISS method). RESULTS From a total of 3,814 patients, two groups (with/without prehospital intubation) of 44 matched patients each with comparable average age (36 vs. 36 years), Injury Severity Score (29 vs. 29), and TRISS (95.2 vs. 95.3) were identified. No patient was unconscious at the scene (all Glasgow Coma Scale scores > or = 8) or presented with severe respiratory insufficiency (all > or = 10 breaths/min). Time between injury and hospital admission was significantly longer (73 minutes; p < 0.05) in the group with prehospital intubation compared with the nonintubated group (47 minutes). Furthermore, fluid requirements in the prehospital period were significantly higher in the intubated patients (3,000 mL vs. 1,000 mL). In the prehospital intubation group, the number of patients with mass transfusion (9 vs. 4) as well as with emergency operations (10 vs. 4) were not significantly different from the nonintubated group. The prehospital intubation group showed a similar incidence of lung failure (17 vs. 14), kidney failure (6 vs. 2), and circulation failure (13 vs. 5). Except for two of the primarily nonintubated patients, all were intubated during their stay in the emergency room or on the intensive care unit. Days of ventilation (median, 7 days) as well as the length of stay on the ICU (median, 11 days) were comparable in both groups. Mortality in the prehospital intubation group was not significantly different between groups (six vs. two deceased). CONCLUSION Prognosis with respect to organ failure, treatment time, and mortality is not adversely affected in the German trauma system, if patients with severe thoracic trauma without manifest respiratory insufficiency and without other indications for intubation are not treated with prehospital intubation.

[Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU].

ZusammenfassungDie Qualität der Schwerverletztenversorgung in Deutschland ist – bedingt durch geographische Unterschiede zwischen den Bundesländern, unterschiedliche Ressourcenallokation und Behandlungskonzepte – in den einzelnen Krankenhäusern sehr inhomogen. Um die Behandlungsqualität zu sichern und weiter zu entwickeln erscheint es sinnvoll, ein strukturiertes, qualitätsgesichertes Netzwerk von Kliniken zu knüpfen, die regelhaft mit unterschiedlichem Versorgungsauftrag an der Schwerverletztenversorgung teilnehmen.Die Voraussetzungen für ein derartiges Netzwerk auf regionaler Ebene sowie für die mit der Schwerverletztenversorgung betrauten Kliniken wurden im Weißbuch „Schwerverletztenversorgung – Empfehlungen zur Struktur und Organisation von Einrichtungen zur Behandlung von Schwerverletzten in der Bundesrepublik Deutschland“ zusammengefasst.Ziel dieser Maßnahmen ist es, jedem Schwerverletzten in Deutschland rund um die Uhr die bestmögliche Versorgung unter standardisierten Qualitätsmaßstäben zu gewährleisten. Dies setzt fachliche Kompetenz und die Bereitschaft aller Beteiligten – Leistungserbringer, Kosten- und Krankenhausträger – voraus, bestehende Versorgungskonzepte gemeinsam weiter zu entwickeln.Die DGU hat als logische Konsequenz langjähriger Erfahrung und wissenschaftlicher Erkenntnisse ein Konzept zur Einrichtung von, an die örtlichen Gegebenheiten angepassten, regionalen Traumanetzwerken von Kliniken zur Schwerverletztenversorgung entwickelt. Die daran teilnehmenden Einrichtungen übernehmen entsprechend ihrer Ausstattung und Struktur unterschiedliche Aufgaben in diesem Netzwerk.Die einzelnen Schritte zur Einrichtung und Organisation eines Netzwerks werden im Rahmen des Artikels aufgezeigt.AbstractThe quality of care in Germany for seriously injured patients varies greatly in individual hospitals due to geographic variations among States and differences in resource allocation and treatment concepts. To assure and enhance treatment quality it seems sensible to establish a structured, quality assured network of clinics, which participate in the management of seriously injured patients according to different specified assignments.The conditions necessary for this type of network on a regional scale and for the clinics charged with the care of the seriously injured were summarized in the White Paper entitled “Management of the Seriously Injured—Recommendations for the Structure and Organization of Facilities in Germany for the Treatment of Seriously Injured Persons.”The goal of this action is to ensure that every seriously injured person in Germany receives the best possible round-the-clock care in adherence to standardized quality criteria. This requires specialized expertise and the willingness of all involved parties—care providers, cost bearers, and hospital owners—to cooperate in further improving existing treatment concepts.As a logical consequence of long years of experience and scientific knowledge, the German Association of Trauma Surgery has developed a concept for establishing a regional trauma network of clinics, adapted to local conditions, for management of seriously injured patients. The participating facilities assume different responsibilities in the network depending on their equipment and structure.This article describes the individual steps toward establishing and organizing a network.

The value of computed tomography in the early treatment of seriously injured patients

AbstractBackground. The availability of newer, faster computed tomography (CT) technology has engendered discussion about whole-body CT-scanning for primary radiological diagnostics of seriously injured patients. Method. Within a quality management system, the scaled, priority-oriented scheme of conventional radiological and CT-diagnostics used in each institution was analysed and compared with the possible benefit of whole-body CT-scanning. Every patient with severe trauma admitted directly from the scene of an accident, underwent basic radiological and sonographic diagnostics in the emergency room (ER). According to the findings, patients in a stable vital condition had CT-scans when indicated by the guidelines of the particular institution. Results. From 5/1998 until 12/2000, a total of 832 patients were treated in the ER. Of those, 480 patients (average ISS 20) were admitted directly from the scene of the accident. Basic radiological – sonographic diagnostics (radiographs of cervical spine, chest, and abdomen, as well as abdominal sonography) took 15±8 min. Twenty-two (5%) of the patients in hemorrhagic shock needed emergency operations after 57±43 min. The remaining patients underwent further radiological diagnostics (spine, extremities etc.) after 44±27 min. In 79% (379) of patients, CT was indicated. Cranial CT for traumatic brain injury prevailed clearly with 74% of cases. Spine (24%), chest (18%), abdomen (5%) and pelvis (5%) were indicated comparatively less frequently. The incidence of delayed diagnoses (after ICU-admission) was 4% (22). In 2% (nine) of patients the lesions possibly could have been detected by a primary CT-scan. In the three cases with thoracic lesions, there was a deviation from the indication guidelines for thoracic CT as normally used in the institution. There were three cases of delayed diagnoses in both the cerebral (small contusion haematomas) region and the abdominal region. The abdominal lesions were detected by sonographic control examinations. No patient died because of a delayed diagnosis. The average X-ray dose was five times lower with the scaled diagnostic management comprising indicated CT when compared to the doses calculated for routine whole-body CT. Conclusion. While 74% of patients had cranial CT, only 25% needed CT for the trunk regions. Delayed diagnoses were rare and without severe consequences for the patient. Considering the five times higher X-ray doses combined with the possible time loss in patients with unstable conditions, primary whole-body CT-scanning should not be performed routinely when serious injury is suspected.ZusammenfassungHintergrund. Aufgrund neuerer Computertomographie- (CT-)Geräte wird die Ganzkörper-CT-Untersuchung als primäre Diagnostik schwer verletzter Patienten diskutiert. Methode. Im Rahmen eines Qualitätsmanagementsystems wurde ein abgestufter, prioritätenorientierter Ablauf der konventionellen radiologischen und computertomographischen Diagnostik analysiert und dem möglichen Nutzen einer primären Ganzkörper-CT gegenübergestellt. Jeder Patient, der nach stumpfen Trauma primär vom Unfallort zuverlegt wurde, wurde im Schockraum einer radiologisch-sonographischen Basisdiagnostik unterzogen. Je nach Befund wurde nach klinikinternen Leitlinien die Indikation zur Computertomographie gestellt. Ergebnisse. Von 5/1998 bis 12/2000 wurden 832 Patienten im Schockraum behandelt. Vom Unfallort wurden 480 Schwerverletzte (ISS 20) zuverlegt. Die Basisdiagnostik (Röntgen-HWS, -Thorax, -Becken und Abdomensonographie) erfolgte innerhalb von 15±8 min. Im Blutungsschock mussten 5% (22) der Patienten notfallmäßig nach 57±43 min operiert werden. Bei allen anderen erfolgte die weitere radiologische Diagnostik (Wirbelsäule etc.) nach 44±27 min. Bei 79% (379) wurde die Indikation zur Computertomographie gestellt. Die kraniale CT bei Schädel-Hirn-Trauma stand mit 74% der Patienten im Vordergrund. CT-Untersuchungen der Wirbelsäule (24%), des Thorax (18%), des Abdomens (5%) und des Beckens (5%) waren wesentlich seltener indiziert. Die Rate verzögert diagnostizierter Läsionen betrug 4% (22). Bei 2% (9) der Patienten hätten die Läsionen möglicherweise durch eine primäre CT diagnostiziert werden können. Bei den 3 Fällen mit thorakalen Läsionen wurde jeweils von den Diagnostikleitlinien abgewichen. Im Bereich des Schädels (kleine Kontusionen) fanden sich ebenso wie im Abdomen je 3 Fälle mit verzögerten diagnostizierten Verletzungen. Die abdominalen Läsionen konnten durch Kontrollsonographien aufgezeigt werden. Kein Patient verstarb aufgrund der verzögert diagnostizierten Läsionen. Die durchschnittliche Strahlenbelastung lag bei abgestuftem Diagnostikablauf um ein Fünffaches unter den Werten die bei routinemäßiger Ganzkörper-CT erreicht worden wären. Schlussfolgerung. Im Gegensatz zum Schädel wurde die Indikation zur CT im Bereich des Rumpfes nur bei einem Viertel der Patienten gestellt. Verzögert diagnostizierte Läsionen waren trotzdem selten und ohne wesentliche Folgen. Aufgrund der erhöhten Strahlenbelastung und des möglichen Zeitverlusts bei instabilen Patienten sollte die primäre Ganzkörper-CT nicht routinemäßig bei allen Patienten mit Verdacht auf eine Mehrfachverletzung durchgeführt werden.