Uli Schmucker

The definition of polytrauma revisited: An international consensus process and proposal of the new 'Berlin definition'

BACKGROUND The nomenclature for patients with multiple injuries with high mortality rates is highly variable, and there is a lack of a uniform definition of the term polytrauma. A consensus process was therefore initiated by a panel of international experts with the goal of assessing an improved, database-supported definition for the polytraumatized patient. METHODS The consensus process involved the following:1. Expert panel. Multiple meetings and consensus discussions (members: European Society for Trauma and Emergency Surgery [ESTES], American Association for the Surgery of Trauma [AAST], German Trauma Society [DGU], and British Trauma Society [BTS]).2. Literature review (original articles before June 8, 2014).3. A priori assumptions by the expert panel. The basis for a new definition should include the Injury Severity Score (ISS) based on the Abbreviated Injury Scale (AIS); “A patient classified as polytraumatized should have a mortality rate of approximately 30%, twice above the established mortality of ISS > 15.”4. Database-derived resources. Deductive calculation of parameters based on a nationwide trauma registry (TraumaRegister DGU) with the following inclusion criteria: multiple injuries and need for intensive care therapy. RESULTS A total of 28,211 patients in the trauma registry met the inclusion criteria. The mean (SD) age of the study cohort was 42.9 (20.2) years (72% males, 28% females). The mean (SD) ISS was 30.5 (12.2), with an overall mortality rate of 18.7% (n = 5,277) and an incidence of 3% of penetrating injuries (n = 886). Five independent physiologic variables were identified, and their individual cutoff values were calculated based on a set mortality rate of 30%: hypotension (systolic blood pressure ⩽ 90 mm Hg), level of consciousness (Glasgow Coma Scale [GCS] score ⩽ 8), acidosis (base excess ⩽ −6.0), coagulopathy (international normalized ratio ≥ 1.4/partial thromboplastin time ≥ 40 seconds), and age (≥70 years). CONCLUSION Based on several consensus meetings and a database analysis, the expert panel proposes the following parameters for a definition of “polytrauma”: significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one or more additional variables from the five physiologic parameters. Further validation of this proposal should occur, favorably by mutivariate analyses of these parameters in a separate data set.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

Background: Contrast-enhanced whole-body computed tomography (also called “pan-scanning”) is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. Methods: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. Results: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7–490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%–8.0%). Interpretation: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Not all that glistens is gold: civilian white phosphorus burn injuries

White phosphorus is an incendiary agent used in particular types of ammunition. Exposure to phosphorus-containing compounds may cause severe burn injuries. Systemic effects may be fatal for the casualty even though only a small surface of the body is burned. We report 4 cases of white phosphorus burn injuries due to an exceptional accident mechanism. All casualties were holidaymakers in a coastal area at the Baltic Sea and confused white phosphorus ammunition residues with amber on a beachwalk. The supposed treasure was taken into the pants pocket. The phosphorus substances ignited spontaneously when they dried because of the body heat. Injury patterns combined simultaneous full thickness burn injuries of both hands with a burn injury of one thigh or the abdominal region. The acute treatment and the controversy surrounding decontamination of such patients are discussed. In addition, pathology of tissue damage and systemic injury are elucidated.

Not another 4th of July report: uncommon blast injuries to the hand

Objectives: Blast injuries to the hand are rare during peacetime and are mainly caused by fireworks. The injury patterns combine a variety of tissue destruction (laceration, dissemination, avulsion, blast, crush and burns). Emergency department staff play a key role in identifying the cause of injury, recognising the full extent of the lesion and referring patients for appropriate treatment. A review was undertaken to examine specificities in emergency department diagnosis and treatment of a separate subgroup of blast injuries. Methods: The diagnosis and treatment of patients admitted with work-related blast injuries of the hand were retrospectively reviewed. Demographic, clinical and diagnostic data were evaluated and treatment algorithms were analysed. Results: Treatment algorithms of 14 patients suffering blast injuries of the hand due to a vole captive bolt device were analysed. The non-homogeneous injury pattern showed complex multistructural lesions. Relatively innocent-looking superficial wounds mask extensive deep tissue damage, the full extent of which could only be recognised after rigorous surgical exploration. All patients but one were treated by immediate surgery, debridement of tissue necrosis and lavage. A delay before surgery resulted in phlegmonous infection in one case. Conclusion: Emergency staff must be aware of the potential dangers of this subgroup of blast injuries and the worsening effect of delay before surgery. Only knowledge of the underlying mechanism of the accident enables the emergency physician to understand the complexity and full extent of the injury pattern and to refer patients early for appropriate surgical management. Conservative treatment is inappropriate, dangerous and may become a focus of negligence claims.

Road traffic crashes in developing countries

Road traffic crashes pose a major threat to individuals and national health systems. Developing countries account for 48% of motorized vehicles, but for 91% of the 1.3 million fatalities per annum. While ranked ninth among the causes of disabilities adjusted life years lost in 2004, crash injuries are projected to rise to third position by 2030. This article reviews current prognoses of deaths and disabilities, the characteristics of crashes in low and middle income countries and evidence-based road safety interventions. This article is considered a wake-up call for trauma, orthopaedic, and emergency surgeons in high-income countries to join the global community in fighting the neglected yet potentially curable epidemic named road traffic injuries.

Real-world car-to-pedestrian-crash data from an urban centre

BackgroundPedestrians are at a high risk for crash and injury. This study aims at comparing data from real world crashes with data gathered from experimental settings.MethodsIMPAIR (In-Depth Medical Pedestrian Accident Investigation and Reconstruction) was a prospective, observational study performed in a metropolitan area. Data was collected on-scene, from clinical records, and interviews. Data comprise crash data, details on injury pattern and injury severity.ResultsThirty-seven pedestrians (of which 19 males) with a mean 37.1 years of age were included in the study. The mean collision speed was 49.5 km/h (SD 13.7, range, 28 - 93). The mean ISS (31.0, SD 25.4) and the 24% fatality rate indicate a substantial trauma load. The most common AIS 4+ injuries were to the head (23 subjects), followed by chest (8), pelvis (4), and abdomen (2). An association of impact side and injury side (right/left) was found for abdominal, chest, pelvic, and upper limb injuries. Primary head impacts were documented on the windscreen (19 subjects), hood (10), A-pillar (2), and edge of the car roof (2). With bivariate analysis, a significant increase of MAIS 4+ head injury risk was found for collision speeds of >40 km/h (OR 9.00, 95% CI 1.96-41.36).ConclusionThe real-world data from this study is in agreement with previous findings from biomechanical models and other simulations. This data suggest that there may be reason to include further pedestrian regulations in EuroNCAP.

Humane killers, human injury: functional outcome of vole captive bolt injuries.

BACKGROUND High-pressure blast injuries to the hand due to vole captive bolt devices are serious injuries that are to a great extent unknown to emergency care operators and trauma surgeons. There is no study on the functional outcome of these patients. METHODS We assessed the functional outcome of patients with injuries inflicted by vole captive bolt devices. Therefore, a protocol consisting of a physical examination and an assessment of static muscle power (grip and pinch strength) was performed. To capture the subjective experience of patients regarding their injury related disability and impairment, the DASH follow-up questionnaire was used. Based on clinical/radiologic findings and outcome, a classification of this unique subgroup of blast injuries was developed. RESULTS The functional outcome of 34 patients suffering hand injuries due to captive bolt devices between 2004 and 2007 was assessed. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed. Fourteen patients lost a digit. Average time lost from work was 5.4 weeks. CONCLUSION Vole captive bolt device-related hand injuries are followed by deterioration of hand function. The present observations alarmed national authorities. The manufacturers were required to take engineering and teaching measures to rule out handling errors that were identified as leading cause of injury.

A new approach and first steps to strengthen trauma management and road safety in North Vietnam.

BackgroundIn Vietnam, the number of road traffic accidents increased dramatically which is a major threat for the national health system. Reliable data on the magnitude of traffic accidents as well as the current management of victims is missing. Our multistep international cooperation project aims to (1) identify local needs and knowledge related to trauma management, to (2) assess basic behavioural patterns and attitudes of road users in order to (3) establish a school-based educational programme and trauma courses for doctors.Methods and resultsAs part of a European Union co-financed cooperation, two European and one Vietnamese university set up three action lines (Trauma and Emergency Courses, school-based education programs, public awareness campaigns). Specific contents of the activities were derived from a literature search, a questionnaire pilot-study and by panel consensus technique. After adjustment to local capabilities (equipment, infrastructure, etc.) these were implemented within a professional network of hospitals, schools, public and media institutions.The literature research and questionnaire results from 1 000 young road users indicates that for pedestrian and two-wheelers accidents, low compliance with traffic regulations and high prevalence of risk-taking behaviour dominate Vietnams road traffic environment. A school-based educational program (4 hrs/month) was set up using teachers who were trained on road safety issues. Also, major parts of the public awareness campaigns (i.e. broadcasts, media conferences) reflected these topics. From panel discussions and Delphi-technique, diagnosis and early treatment of severe head trauma and internal haemorrhage were identified as topics of highest interest for doctors therefore representing key topics of the Trauma and Emergency Courses.ConclusionKnowledge on behaviour and attitudes of road users in Vietnam as well as on local infrastructure and effective networks is essential to establish sustainable and effective countermeasures. Our approach might serve as guideline for future small scale projects as it proved to be feasible, cost-effective but provided scientific base for immediate on spot activities.

Notärztliche Einschätzung der Verletzungsschwere am Unfallort

ZusammenfassungHintergrundTechnische Unfallparameter werden häufig im Rahmen der ersten notärztlichen Behandlung Schwerverletzter erfasst. Ihre Vorhersagekraft zur Diskriminierung zwischen moderat und lebensgefährlich verletzten Patienten wurde bisher nur unzureichend untersucht.Material und MethodeIn einem mehrstufigen Experiment wurden 3 erfahrene Notärzte aufgefordert, auf der Basis technischer Datenfragmente von 100 realen Pkw-Verkehrsunfällen aus einem regionalen Unfallforschungsprojekt die Verletzungsschwere des Pkw-Fahrers (mittlerer ISS=23,6±26,9) zu bestimmen. Die Verletzungskategorien wurden anhand der ISS-Werte zwischen leicht bis schwer (ISS≤ 8–15) und lebensgefährlich bis tödlich (ISS ≥16) dichotomisiert. Vorgelegt wurden in zufälliger Reihenfolge einfache Routineparameter, erweiterte Parameter sowie eine Fotodokumentation des Unfallortes. Berechnet wurden die Übereinstimmung der Teilnehmer im Hinblick auf die eingeschätzte Verletzungsschwere jenseits des Zufalls (Kappa-Statistik) sowie die diagnostische Testgüte (Sensitivität, Spezifität, Fläche unter der ROC-Kurve, Likelihood-Ratios).ErgebnisseDie Beobachterübereinstimmung der Verletzungsschwere unter Kenntnis einfacher, erweiterter und Bildparameter lag bei Kappa-Werten von 0,42, 0,65 und 0,61. Die Sensitivität schwankte zwischen den Beobachtern und unterschiedlicher Informationsmenge zwischen 18 und 80%, die Spezifität zwischen 41 und 89%. Durch die Präsentation von Fotos vom Unfallort ließ sich eine Steigerung der Sensitivität erzielen. Die Verschiebung der Vortestwahrscheinlichkeit von 50% für eine lebensbedrohliche Verletzung betrug im Falle negativer technischer Befunde maximal 40%, im positiven Fall 67%.SchlussfolgerungWeder anhand von isolierten technischen Parametern, die in der Regel am Unfallort leicht ersichtlich sind, noch durch zusätzliche technische Informationen oder eine Fotodokumentation gelingt es dem Notarzt, robuste Rückschlüsse auf die Verletzungsschwere eines verunfallten Pkw-Fahrers zu ziehen. Die Ergebnisse dieser Studie sollten durch eine Folgeuntersuchung mit einer größeren Stichprobe untermauert werden.AbstractBackgroundTechnical parameters of road traffic crashes are routinely documented by emergency physicians on scene. It is, however, unclear whether this information contributes to the estimation of injury severity of vehicle drivers.Materials and methodsIn this study, three experienced emergency physicians were asked to predict the injury severity of vehicle drivers [categorized according to Injury Severity Score (ISS) values of <16 and ≥16 as moderate to severe or life-threatening] based on increasingly complex technical crash information, ranging from routine variables to photo documentation of the crash scene. A sample of 100 cases (mean ISS 23.6±26.9) was obtained from the prospective database of an in-depth technical and medical car crash research project conducted in the northeastern part of Germany. Statistical analysis comprised inter-rater agreement beyond chance (kappa values) and indicators of diagnostic test accuracy (i.e. sensitivity, specificity and so on).ResultsThe inter-rater agreement of injury severity based on technical crash information was moderate to substantial (kappa 0.42–0.66). Amongst the three observers and various amounts of technical data, sensitivity ranged between 18 and 80%, and specificity ranged between 41 and 89% in predicting the presence of major trauma. Presentation of photographs from the crash scene increased diagnostic accuracy. Still, the presented information led to a shift from a 50% prior probability of life-threatening injuries to a maximum of 40% in the negative and 67% in the positive case.ConclusionNeither basic technical parameters that are easy to obtain after a car crash nor additional technical information markedly contribute to the emergency physician’s estimation of a vehicle driver’s injury severity. The presented results should be supported by a subsequent study including a larger sample.BACKGROUND Technical parameters of road traffic crashes are routinely documented by emergency physicians on scene. It is, however, unclear whether this information contributes to the estimation of injury severity of vehicle drivers. MATERIALS AND METHODS In this study, three experienced emergency physicians were asked to predict the injury severity of vehicle drivers [categorized according to Injury Severity Score (ISS) values of <16 and ≥16 as moderate to severe or life-threatening] based on increasingly complex technical crash information, ranging from routine variables to photo documentation of the crash scene. A sample of 100 cases (mean ISS 23.6±26.9) was obtained from the prospective database of an in-depth technical and medical car crash research project conducted in the northeastern part of Germany. Statistical analysis comprised inter-rater agreement beyond chance (kappa values) and indicators of diagnostic test accuracy (i.e. sensitivity, specificity and so on). RESULTS The inter-rater agreement of injury severity based on technical crash information was moderate to substantial (kappa 0.42-0.66). Amongst the three observers and various amounts of technical data, sensitivity ranged between 18 and 80%, and specificity ranged between 41 and 89% in predicting the presence of major trauma. Presentation of photographs from the crash scene increased diagnostic accuracy. Still, the presented information led to a shift from a 50% prior probability of life-threatening injuries to a maximum of 40% in the negative and 67% in the positive case. CONCLUSION Neither basic technical parameters that are easy to obtain after a car crash nor additional technical information markedly contribute to the emergency physicians estimation of a vehicle drivers injury severity. The presented results should be supported by a subsequent study including a larger sample.

Welcome to a decade of action that can make a change

The Journal of Trauma Management and Outcomes welcomes the launch of the UN Decade of Action for Road Safety 2011–2020. More than 100 countries around the world will kick off the first global Decade of Action for Road Safety 2011–2020, a decade that we believe can make a change!