Thorsten Hammer

Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review

IntroductionThis systematic review is focused on the in-hospital mortality and neurological outcome of survivors after prehospital resuscitation following trauma. Data were analyzed for adults/pediatric patients and for blunt/penetrating trauma.MethodsA systematic review was performed using the data available in Ovid Medline. 476 articles from 1/1964 - 5/2011 were identified by two independent investigators and 47 studies fulfilled the requirements (admission to hospital after prehospital resuscitation following trauma). Neurological outcome was evaluated using the Glasgow outcome scale.Results34 studies/5391 patients with a potentially mixed population (no information was found in most studies if and how many children were included) and 13 paediatric studies/1243 children (age ≤ 18 years) were investigated. The overall mortality was 92.8% (mixed population: 238 survivors, lethality 96.7%; paediatric group: 237 survivors, lethality 86.4% = p < 0.001).Penetrating trauma was found in 19 studies/1891 patients in the mixed population (69 survivors, lethality: 96.4%) and in 3 pediatric studies/91 children (2 survivors lethality 97.8%).44.3% of the survivors in the mixed population and 38.3% in the group of children had a good neurological recovery. A moderate disability could be evaluated in 13.1% in the mixed population and in 12.8% in children. A severe disability was found in 29.5% of the survivors in the mixed patients and in 38.3% in the group of children. A persistent vegetative state was the neurological status in 9.8% in the mixed population and in 10.6% in children.For each year prior to 2010, the estimated log-odds for survival decreased by 0.022 (95%-CI: [0.038;0.006]). When jointly analyzing the studies on adults and children, the proportion of survivors for children is estimated to be 17.8% (95%-CI: [15.1%;20.8%]). The difference of the paediatric compared to the adult proportion is significant (p < 0.001).ConclusionsChildren have a higher chance of survival after resuscitation of an out-of-hospital traumatic cardiac arrest compared to adults but tend to have a poorer neurological outcome at discharge.

Influence of Arm Positioning on Radiation Dose for Whole Body Computed Tomography in Trauma Patients

BACKGROUND Multislice whole body computed tomography is regarded as the method of choice for primary investigation of hemodynamically stable patients with multiple injuries. However, a disadvantage of this method is the high level of radiation to which the patient is exposed. Various recommendations on how to position the patients arms during whole body computed tomography have been given in the literature, but conclusive data are missing. Therefore, the aim of our study was to investigate the relationship between different arm positions and radiation dose in patients undergoing whole body computed tomography. METHODS In a retrospective analysis of available data derived from former whole body computed tomography screening of patients with multiple injuries, we calculated the effective radiation dose and scanning time for different arm positions (both arms up, both arms at sides, right arm up, and left arm up). Statistical analysis was performed using the independent t test with 95% confidence intervals. Statistical significance was set at 0.05. RESULTS The data evaluated had been recorded for 956 patients during a period of 18 months. Of these patients, 710 were included in the study. In 487 cases (68%), both arms were up; in 82 cases (12%), down by the sides; in 90 cases (13%), the right arm was up; and in 44 cases (6%), the left arm was up. Overall, the radiation dose was statistically significantly higher with both arms at sides (24.69 mSv ± 6.91 mSv) than with both arms up (19.18 mSv ± 4.99 mSv; p < 0.0000001). Statistically significant differences in effective radiation dose were not found for either the right arm up (23.52 mSv ± 5.23 mSv; p = 0.211) or the left arm up (22.53 mSv ± 5.4 mSv; p = 0.076) compared with both arms down at sides. Comparison of scan lengths for the thorax or abdomen did not yield any significant differences between arms down and any other arm position. Analysis of scanning times did not reveal any significant differences for whole body computed tomography with both arms down (07:31 minutes ± 02:53 minutes) compared with both arms up (07:30 minutes ± 02:04 minutes; p = 0.94), right arm up (07:15 minutes ± 01:43 minutes; p = 0.582), or left arm up (07:18 minutes ± 01:24 minutes; p = 0.707). CONCLUSION Based on our retrospective investigation, it can be recommended with reference to whole body computed tomography screening that the arms should be in the arms-up position during thorax or abdomen scanning of a severely injured patient, provided there are no clear clinical indications of shoulder injury. For the patient, this position is associated with a significantly reduced radiation dose without noticeable loss of time.

Lawinennotfall und akzidentelle Hypothermie

ZusammenfassungSowohl präklinisch als auch klinisch stellt die Rettung und Behandlung von Lawinenopfern eine Herausforderung dar.Obwohl die Hypothermie in der Gesamtmortalität der Lawinenopfer initial eine eher untergeordnete Rolle spielt, ist die regelrechte Behandlung von unterkühlten Patienten präklinisch wie auch klinisch für das Überleben entscheidend. Hierbei ist eine gute Zusammenarbeit sowohl des Rettungspersonals als auch der weiterbehandelnden Klinik notwendig.Dazu gehört die Durchführung einer Triage durch den erfahrenen Notarzt sowie die Behandlung der Hypothermie durch eine geeignete Klinik, die auch strukturell in der Lage ist,unterkühlte Patienten adäquat zu therapieren.Obwohl Lawinenopfer im Südschwarzwald eher selten sind, überlebte zuletzt im Frühjahr 2002 ein ganzverschüttetes Lawinenopfer nach 70 min Verschüttungsdauer und einer Verschüttungstiefe von 200 cm einen Lawinenabgang am Feldberg.Durch eine Übersicht der aktuellen Literatur wollen wir einerseits einen Algorithmus gemäß den Richtlinien des IKAR (Internationale Kommission für Alpines Rettungswesen) für das Rettungspersonal/Notarzt wiedergeben, zum anderen den aktuellen Stand der adäquaten Behandlung einer akzidentellen Hypothermie entsprechend den verschiedenen Stadien aufzeigen.AbstractThe importance of emergency medical treatment for avalanche victims in the pre-clinical and clinical sector is still actual.Based on new investigations, guidelines for triage have been endorsed by the International Commission of the Alpine Rescue Services (ICAR) to reduce secondary deaths following the successful extrication of victims from the avalanche mass.Although hypothermia plays a secondary role in the total mortality of avalanche victims, the most important task if extrication lasts 35 min or more is the professional treatment of hypothermia.Avalanche emergencies in the southern part of the Black Forest are quite rare. In February 2002 one avalanche victim in this region survived despite a statistically bad prognosis.Based on the current literature,we provide an algorithm which conforms with the ICAR guidelines for emergency personnel and describe the possibilities and standard stage dependent treatment in cases of accidental hypothermia.

Lower Health-Related Quality of Life in Polytrauma Patients: Long-Term Follow-Up After Over 5 Years

AbstractAlthough trauma-associated mortality has fallen in recent decades, and medical care has continued to improve in many fields, the quality of life after experiencing polytrauma has attracted little attention in the literature. This group of patients suffer from persisting physical disabilities. Moreover, they experience long-term social, emotional, and psychological effects that limit/lower considerably their quality of life.We analyzed retrospective data on 147 polytraumatized patients by administering written questionnaires and conducting face-to-face interviews 6 ± 0.8 years after the trauma in consideration of the following validated scores: Glasgow Outcome Scale, European Quality of Life Score, Short Form-36, Trauma Outcome Profile, and Beck Depressions Inventory II.Our analysis of these results reveals that polytraumatized patients suffer from persistent pain and functional disabilities after >5 years. We also observed changes in their socioeconomic situation, as well as psychological after-effects.The rehabilitation of this particular group of patients should not only address their physical disabilities. The psychological after-effects of trauma must be acknowledged and addressed for an even longer period of time.

Outcome and predictors for successful resuscitation in the emergency room of adult patients in traumatic cardiorespiratory arrest.

BackgroundData of the TraumaRegister DGU® were analyzed to derive survival rates, neurological outcome and prognostic factors of patients who had suffered traumatic cardiac arrest in the early treatment phase.MethodsThe database of the TraumaRegister DGU® from 2002 to 2013 was analyzed. The main focus of this survey was on different time points of performed resuscitation.Descriptive and multivariate analyses (logistic regression) were performed with the neurological outcome (Glasgow Outcome Scale) and survival rate as the target variable. Patients were classified according to CPR in the prehospital phase and/or in the emergency room (ER). Patients without CA served as a control group. The database does not include patients who required prehospital CPR but did not achieve ROSC.ResultsA total of 3052 patients from a total of 38,499 cases had cardiac arrest during the early post-trauma phase and required CPR in the prehospital phase and/or in the ER. After only prehospital resuscitation (n = 944) survival rate was 31.7 %, and 14.7 % had a good/moderate outcome. If CPR was required in the ER only (n = 1197), survival rate was 25.6 %, with a good/moderate outcome in 19.2 % of cases. A total of 4.8 % in the group with preclinical and ER resuscitation survived, and just 2.7 % had a good or moderate outcome. Multivariate logistic regression analysis revealed the following prognostic factors for survival after traumatic cardiac arrest: prehospital CPR, shock, coagulopathy, thorax drainage, preclinical catecholamines, unconsciousness, and injury severity (Injury Severity Score).ConclusionsWith the knowledge that prehospital resuscitated patients who not reached the hospital could not be included, CPR after severe trauma seems to yield a better outcome than most studies have reported, and appears to be more justified than the current guidelines would imply. Preclinical resuscitation is associated with a higher survival rate and better neurological outcome compared with resuscitation in the ER. If resuscitation in the ER is necessary after a preclinical performed resuscitation the survival rate is marginal, even though 56 % of these patients had a good and moderate outcome. The data we present may support algorithms for resuscitation in the future.

β-Tricalcium phosphate for bone replacement: Stability and integration in sheep

Implants of microporous β-tricalcium phosphate (β-TCP) were developed for primarily stable supply of bone defects. A consistent stability over the healing period should be retained in sheep. β-TCP cylindrical shaped implants, with 7 mm diameter, 25 mm length, medium pore diameter 5 μm and 40% porosity were developed. Fresh bone defects of 21 sheep in the medial femur condyle were filled with the implants. At time zero, after 6, 12 and 24 weeks the knees of each 7 animals were studied. Specimens were investigated radiologically, followed by biomechanical and histological analysis. Radiological analysis showed progressive resorption. 6 weeks after surgery results of the indentation test were slightly lower, after 12 and 24 weeks higher than on the healthy opposite knee. At 6 weeks a phagocyte reaction overbalanced. After 12 weeks bone regeneration around the implant was seen. After 24 weeks a highly advanced resorption of TCP implant was realized. The trabecular structure of the new bone increased after 24 weeks. Using microporous β-TCP implants continuous stable filling of bone defects can be reached in sheep. Microporous β-TCP implants are resorbed and replaced by bone.

Emergency radiological examination of the externally stabilized pelvis – there is a catch to it: lessons learned from two cases with symphyseal disruption despite initial inconspicuous computed tomography

BackgroundPreclinical and early clinical external pelvic stabilization using commercially available devices has become common in trauma patient care. Thus, in the emergency department an increasing number of patients will undergo radiographic evaluation of the externally stabilized pelvis to exclude injuries. While reports exist where injuries to the pelvis were elusive to radiological examination due to the pelvic immobilization we elaborate on an algorithm to remove an external pelvic stabilizing device, prevent delayed diagnosis of pelvic disruption and thus increase patient safety.Case presentationWe report on two patients with external pelvic stabilization presenting with an inconspicuous pubic symphysis on initial pelvic computed tomography scans. The first patient was an otherwise healthy 51-year old male being run over by his own car. He received external pelvic stabilization in the emergency department. The second patient was a 36-year old male falling from a ladder. In this patient external pelvic stabilization was performed at the scene. In the first patient no pelvic injury was obvious on computed tomography. In the second patient pelvic fractures were diagnosed, yet the presentation of the pubic symphysis appeared normal. Nevertheless, complete symphyseal disruption was diagnosed in both of them upon removal of the external pelvic stabilization and consequently required internal fixation.ConclusionBased on our experience we propose an algorithm to “clear the initially immobilized pelvis” in an effort to minimize the risk of missing a serious pelvic injury and increase patient safety. This is of significant importance to orthopedic trauma surgeons and emergency physicians taking care of injured patients.

Complications after surgical management of distal lower leg fractures

BackgroundOsseous healing of distal lower leg fractures can be prolonged and is often associated with wound healing problems because of the marginal soft - tissue and vascular supply in this area. Postoperative complications are frequent, and according to the literature, open reduction and plate fixation is thought to be associated with higher complication rates. The objective of this study was to evaluate the most common postoperative complications following intramedullary nailing or plate osteosynthesis of distal lower leg injuries with a focus on combined tibio-fibular fractures. The outcomes of patients with and without complications associated the two surgical techniques were compared.MethodsDuring a 5-year period, all surgically treated distal tibiofibular fractures were retrospectively collected from the clinical database and were evaluated for the presence of postoperative complications which included compartment syndrome, wound infection, delayed union and non-union, synostosis and rotational malalignment. Postoperative complications were reviewed and correlated with patient risk factors.ResultsA total of 199 patients were included in the study, and 75 complications were reported. The majority of complications were associated with closed fracture types treated with intramedullary nailing, delayed union being the most frequent. For open fractures, surgical treatment with plate fixation had a complication rate of 12% compared with 25% after intramedullary nailing.DiscussionIn general, distal lower leg fractures are associated with a high risk of postoperative complications. Distal diaphyseal tibial fractures that have been treated with intramedullary nailing devices have a higher risk of delayed union or non - union.ConclusionPlate fixation in distal metaphyseal fractures has a higher risk of problems related to wound healing and postoperative wound infections.

[Radiological comparison between two procedures for ventral spondylodesis: autologous iliac crest bone graft vs bovine bone graft].

BACKGROUND The objective of this study was the radiological evaluation of osseous integration of autologous iliac crest graft and bovine bone graft after spondylodesis based on a standardized score. MATERIAL AND METHODS Spondylodesis was performed on 18 sheep, divided into 2 groups, 1 with an autologous iliac crest graft and the other with a bovine bone graft. Computed tomography was performed 12 and 24 weeks postoperatively. The osseous integration was assessed by the Tübinger Score. RESULTS The evaluation of the CT scans demonstrated a significantly better osseous integration of the autologous iliac crest graft compared to the bovine bone graft. CONCLUSIONS Based on our results, the bovine bone graft as a transplant for spondylodesis is inadvisable.

Radiologischer Vergleich zweier Verfahren zur ventralen Spondylodese@@@Radiological comparison between two procedures for ventral spondylodesis: Autologer trikortikaler Beckenkammspan vs. boviner Spongiosablock@@@Autologous iliac crest bone graft vs bovine bone graft

BACKGROUND The objective of this study was the radiological evaluation of osseous integration of autologous iliac crest graft and bovine bone graft after spondylodesis based on a standardized score. MATERIAL AND METHODS Spondylodesis was performed on 18 sheep, divided into 2 groups, 1 with an autologous iliac crest graft and the other with a bovine bone graft. Computed tomography was performed 12 and 24 weeks postoperatively. The osseous integration was assessed by the Tübinger Score. RESULTS The evaluation of the CT scans demonstrated a significantly better osseous integration of the autologous iliac crest graft compared to the bovine bone graft. CONCLUSIONS Based on our results, the bovine bone graft as a transplant for spondylodesis is inadvisable.