[Treatment regimen for deep sternal wound infections after cardiac surgical interventions in an interdisciplinary approach]. / Behandlungsregime tiefer sternaler Wundinfektionen nach kardiochirurgischen Eingriffen im interdisziplinären Ansatz.

The aim of this article is to present the importance of a structured and situation-adapted approach based on the diagnostic and therapeutic strategy in the interdisciplinary treatment of 54 patients with deep sternal wound infections (DSWI) after cardiac surgical interventions and the results achieved. The patients were 41 men and 13 women with an average age of 65.1 years, who developed a DSWI after a cardiac surgical intervention during the period 2003-2016. The treatment strategy included a thorough debridement including the removal of indwelling foreign material, the reconstruction with a stable re-osteosynthesis after overcoming the infection and if necessary, situation-related surgical flaps for a defect coverage with a good blood supply and mandatory avoidance of dead spaces. A total of 146 operations were necessary (average 2.7 operations/patient, range 1-7 operations). In 24.1 % of the cases a one-stage approach could be carried out. In 41 patients negative pressure wound therapy (NPWT) with programmed sponge changing was used for wound conditioning (mean 5 changes, standard deviation, SD±â€¯5.6 changes over 22 days, SD±â€¯23.9 days, change interval every 3-4 days in 40.7% of the cases). In 33 patients a bilateral myocutaneous pectoralis major flap was used, in 4 patients a vertical rectus abdominis myocutaneous (VRAM) flap and in 7 patients both were carried out. A total of 43 osteosynthesis procedures were carried out on the sternum with fixed-angle titanium plates. Of the patients 7 died during intensive care unit treatment (total mortality 13 %, n = 5, 9.3 % ≤ 30 days) or in the later course. Of the patients 47 (87.1 %) could be discharged with a cleansed infection. In 2 patients the implant was removed after 2 years due to loosening.

[Calcaneoplasty with radiofrequency cementing following balloon reduction]. / Kalkaneoplastie mit Radiofrequenzzementierung nach Ballonaufrichtung.

The standard surgical procedure for complex calcaneal fractures is open reduction, internal reduction and internal stable angle plate osteosynthesis via a lateral approach. More recently, options for minimally invasive and percutaneous surgical strategies have been presented [4, 7]. As a possible procedural alternative for a covered, surgical treatment of calcaneal fractures, calcaneoplasty is discussed and applied in this context [5]. In this case series of five complex calcaneal fractures presented here, a balloon catheter was used for percutaneous reduction to restore the alignment of the calcaneus.This was followed by placement of PMMA cement in radiofrequency application and osteosynthesis using percutaneous cannulated screws. This Vicenti technique allows stable reduction and retention with early partial weight bearing with an overall low complication rate [17].

Evaluation of the interhospital patient transfer after implementation of a regionalized trauma care system (TraumaNetzwerk DGU®) in Germany.

Purpose: The aim of the study was to evaluate how many patients are being transferred between trauma centers and and their characteristics in the 2006 initiated TraumaNetzwerk DGU® (TNW). We further investigated the time point of transfer and differences in outcome, compared to patients not being transferred. We wanted to know how trauma centers judged the performance of the TNW in transfer. Method: (1) We analyzed the data of the TraumaRegister DGU® (TR-DGU) from 2014-2018. Included were patients that were treated in German trauma centers, maximum AIS (MAIS) >2 and MAIS 2 only in case of admission on ICU or death of the patient. Patients being transferred were compared to patients who were not. Characteristics were compared, and a logistic regression analysis performed to identify predictive factors. (2) We performed a survey in the TNW focussing on frequency, timing and communication between hospitals and improvement through TNW. Results: Study I analyzed 143,195 patients from the TR-DGU. Their mean ISS was 17.8 points (SD 11.5). 56.4% were admitted primarily to a Level-I, 32.2% to a Level-II and 11.4% to a Level-III Trauma Center. 10,450 patients (7.9%) were transferred. 3,667 patients (22.7%) of the admitted patients of Level-III Center and 5,610 (12.6%) of Level-II Center were transferred, these patients showed a higher ISS (Level-III: 18.1 vs. 12.9; Level-II: 20.1 vs. 15.8) with more often a severe brain injury (AIS 3+) (Level-III: 43.6% vs. 13.1%; Level-II: 53.2% vs. 23.8%). Regression analysis showed ISS 25+ and severe brain injury AIS 3+ are predictive factors for patients needing a rapid transfer. Study II: 215 complete questionnaires (34%) of the 632 trauma centers. Transfers were executed within 2 h after the accident (Level-III: 55.3%; Level-II: 25.0%) and between 2-6 h (Level-III: 39.5%; Level-II: 51.3%). Most trauma centers judged that implementation of TNW improved trauma care significantly (Level III: 65.0%; Level-II: 61.4%, Level-I: 56.7%). Conclusion: The implementation of TNW has improved the communication and quality of comprehensive trauma care of severely injured patients within Germany. Transfer is mostly organized efficient. Predictors such as higher level of head injury reveal that preclinical algorithm present a potential of further improvement.

[Trauma team activation-Who should be alerted for which patients?] / Schockraumaktivierung ­ Bei welchen Patienten alarmieren wir wen?

INTRODUCTION: It is estimated that in total almost 10 million people are injured in accidents in Germany every year, most of which are in the household milieu and leisure sector. It is estimated that of these more than 32,000 seriously injured patients are admitted to the emergency room every year. It is recommended that the decision of the prehospital treatment team or the first examiner in the hospital as to whether a potentially severely injured patient should be admitted via the emergency room of the hospital should be based on a catalogue of criteria. MATERIAL AND METHOD: Against the background of the update of the S3 guidelines on the treatment of multiple trauma/severely injured patients and on the basis of the current literature, an overview with respect to the composition of the team and the criteria for which an emergency room team is or should be activated is given. RESULTS: Alerting the emergency room team is still recommended if a certain injury pattern is present or if a prehospital intervention is necessary. The B­criteria based on the course of the accident or mechanism, which have recently been the subject of increasing criticism, have been adapted. Recommendations for geriatric patients could also be formulated. DISCUSSION: Compared to the S3 guidelines from 2016 the emergency room alarm criteria could be revised on the basis of new literature and have been included in the revised guidelines. There is no doubt that further optimization. e.g., based on prehospital algorithms or using point of care diagnostics, are possible and desirable in the future.

Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma-A Matched-Pairs Analysis of the German Trauma Registry.

Purpose: In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay. Methods: Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS) ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3-10 days after trauma. Results: After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226). Conclusions: We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

[Differences in injury patterns in motorcycle accidents involving children and adolescents]. / Unterschiede der Verletzungsmuster bei Motorradunfällen von Kindern und Jugendlichen.

BACKGROUND: Traffic accidents and the traumatic injury consequences are frequent causes of mortality and irreversible damage in children and young adults. In motorcycle accidents the injury patterns differ depending on the age of the patient. OBJECTIVE: The aim of this study was to describe the typical injury patterns after motorcycle accidents involving children and adolescents as these can have a decisive influence on the prevention and the adequate treatment in the respective patient groups. MATERIAL AND METHODS: The study included 22,923 patients from the years 2002-2018 which were extracted from the TraumaRegister DGU®. Injury patterns of 4 age categories were analyzed: group 1 (4-15 years), group 2 (16-17 years), group 3 (18-20 years) and group 4 (21-50 years). RESULTS: In both younger age groups, limb injuries mostly of the lower extremities, showed the highest incidence. Moreover, younger patients with traumatic brain injury showed better outcomes despite of initially poor conditions. Ribcage, abdominal, pelvic and spinal injuries are the least frequent in younger patients. In terms of diagnostics, children are less likely to undergo whole-body computed tomography (CT) diagnostics than adults. CONCLUSION: The study revealed age-specific differences with respect to injury patterns in patients involved in motorcycle accidents, either as drivers or co-drivers. Furthermore, the analysis of preclinical and in-hospital treatment elucidated the relevance of preventive and protective measures.

[Implications of prehospital estimation of trauma patients for the treatment pathway-An evaluation of the TraumaRegister DGU®]. / Implikationen der prähospitalen Einschätzung des Traumapatienten auf den Behandlungsverlauf ­ Eine Auswertung aus dem TraumaRegister DGU®.

BACKGROUND: In the prehospital acute treatment phase of severely injured patients, the stabilization of the vital parameters is paramount. The rapid and precise assessment of the injuries by the emergency physician is crucial for the initial treatment and the selection of the receiving hospital. OBJECTIVE: The aim of this study was to determine whether the prehospital emergency medical assessment has an influence on prehospital and emergency room treatment. MATERIAL AND METHODS: Data from the TraumaRegister DGU® between 2015 and 2019 in Germany were evaluated. The prehospital emergency medical assessment of the injury pattern and severity was recorded using the emergency physician protocol and compared with the in-hospital documented diagnoses using the abbreviated injury scale. RESULTS: A total of 47,838 patients with an average injury severity score (ISS) of 18,7 points (SD 12.3) were included. In summary, 127,739 injured body regions were documented in the hospitals. Of these, a total of 87,921 were correctly suspected by the emergency physician Thus, 39,818 injured body regions were not properly documented. In 42,530 cases a region of the body was suspected to be injured without the suspicion being confirmed in the hospital. Traumatic brain injuries and facial injuries were mostly overdiagnosed (13.5% and 14.7%, respectively documented by an emergency physician while the diagnosis was not confirmed in-hospital). Chest injuries were underdocumented (17.3% missed by an emergency physician while the diagnosis was finally confirmed in-hospital). The total mortality of all groups was very close to the expected mortality calculated with the revised injury severity classification II(RISC II)-score (12.0% vs. 11.3%). CONCLUSION: In the prehospital care of severely injured patients, the overall injury severity is often correctly recorded by the emergency physician and correlates well with the derived treatment, the selection of the receiving hospital as well as the clinical course and the patient outcome; however, the assessment of injuries of individual body regions seems to be challenging in the prehospital setting.

[Measurability of the quality of care of the severely injured]. / Messbarkeit der Qualität in der Schwerverletztenversorgung.

The care of severely injured patients is characterized by the heterogeneity of the clinical picture and the time-critical aspects of many forms of treatment in the acute phase, so that quality measurement and assessment is always complex. In order to be able to operate a meaningful and structured quality management the quality must be validly measured and it must be defined what quality is. To handle this complex picture the quality of care for the severely injured is divided into three levels: structural quality, process quality and outcome quality. With respect to structural quality there are clear guidelines for personnel and structural equipment of hospitals for the optimal care of severely injured patients. This is regularly checked in Germany through trauma center certification as part of the TraumaNetzwerk DGU®. Process quality can also be measured in the care of severely injured patients. With the TraumaRegister DGU® annual report in 2017, 14 newly developed quality indicators were introduced. Due to the comprehensive participation of hospitals in the TraumaRegister DGU® structured external quality assurance is possible in addition to internal process analysis. With respect to the quality of the outcome patient reported outcome measures (PROM) have become increasingly more important in addition to the mortality. The PROMs that are used to assess the consequences of injuries are typically multidimensional and capture not only aspects of physical health but also enable self-assessment of the mental health status by the patient.

Penetrating injuries in Germany - epidemiology, management and outcome an analysis based on the TraumaRegister DGU®.

BACKGROUND: The management of penetrating wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. In Germany, penetrating injuries are reported to occur in 4-5 % of the severely injured patients who are enrolled in the TraumaRegister DGU® (trauma registry of the German Trauma Society). They include gunshot injuries, knife stab injuries, which are far more common, and penetrating injuries of other origin, for example trauma caused by accidents. The objective of this study was to assess the epidemiology and outcome of penetrating injuries in Germany, with a particular focus on the level of care provided by the treating trauma centre to gain more understanding of this trauma mechanism and to anticipate the necessary steps in the initial treatment. MATERIALS AND METHODS: Since 2009, the TraumaRegister DGU® has been used to assess not only whether a trauma was penetrating but also whether it was caused by gunshot or stabbing. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2018. Excluded were patients with a maximum abbreviated injury scale (MAIS) score of 1 with a view to obtaining a realistic idea of this injury entity, which is rare in Germany. RESULTS: From 2009 to 2018, there were 1123 patients with gunshot wounds, corresponding to a prevalence rate of 0.5 %, and 4333 patients with stab wounds (1.8 %), which were frequently caused by violent crime. The high proportion of intentionally self-inflicted gunshot wounds to the head resulted in a cumulative mortality rate of 41 % for gunshot injuries. Stab wounds were associated with a lower mortality rate (6.8 %). Every fourth to fifth patient with a gunshot or stab wound presented with haemorrhagic shock, which is a problem that is seen during both the prehospital and the inhospital phase of patient management. Of the patients with penetrating injuries, 18.3 % required transfusions. This percentage was more than two times higher than that of the basic group of patients of the TraumaRegister DGU®, which consists of patients with a MAIS ≥ 3 and patients with a MAIS of 2 who died or were treated on the intensive care unit. CONCLUSIONS: In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicides. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required in order to provide the basis for evaluating the long-term quality of the management of patients with stab or gunshot wounds.

[Development of a new module for the TraumaRegister DGU® : Better collation of the sequelae of severe injuries during pregnancy]. / Entwicklung eines neuen Moduls für das TraumaRegister DGU® : Folgen schwerer Verletzungen während der Schwangerschaft besser erfassen.

BACKGROUND: Life-threatening injuries during pregnancy are a rare occurrence. The TraumaRegister DGU® (TR-DGU) has been recording whether seriously injured women were pregnant since 2016. This information is not sufficient to enable a differentiated assessment of the quality of care because parameters, such as gestational age, state of pregnancy at discharge and survival of the child are missing. The TraumaRegister working group of the committee on emergency medicine, intensive care and severe trauma management (section NIS) of the German Trauma Society (DGU) therefore came to the conclusion that the fetal outcome or the intactness of the pregnancy after acute treatment is an important measure of the quality of care of pregnant women. They commissioned a task force to work out a suitable data set for a better analysis of such cases. This article presents the so-called fetus module in detail. METHODS: The data set was developed in an interdisciplinary process together with accredited experts from the German Society for Gynecology and Obstetrics (DGGG), the German Society for Perinatal Medicine (DGPM) and the Society for Neonatology and Pediatric Intensive Care Medicine (GNPI). RESULTS: The fetus module comprises 20 parameters describing the pregnancy, the condition of the mother and child on admission and discharge. CONCLUSION: The fetus module will provide important data to make the process and outcome quality of care of severely injured pregnant women measurable and to develop prognostic instruments with which predictions about high-risk constellations for the outcome of mother and child can be made.

[Empirical evaluation of quality indicators for severely injured patients in the TraumaRegister DGU®]. / Empirische Überprüfung der Qualitätsindikatoren für Schwerverletzte im TraumaRegister DGU®.

BACKGROUND AND OBJECTIVE: A systematic assessment of the quality of medical treatment by using key indicators has been required in Germany for many years. These quality indicators (QI) have to satisfy many requirements. Besides an expert review an empirical data-based evaluation is also necessary. The TraumaRegister DGU® (TR-DGU) has reported QI in the annual reports from the beginning. The objective of this study was to validate 40 QI for the treatment of severely injured patients reviewed by experts using data from the TR-DGU. MATERIAL AND METHODS: The association of the 40 QI with hospital mortality was verified using healthcare data from the TR-DGU from a 5­year period (2012-2016). Of these 26 QI consider events while the remaining 14 QI are key indicators, such as time spent in the trauma room. To compensate differences in injury severity, adjusted mortality rates were calculated using the revised injury severity classification (RISC) II score. For this two different approaches were chosen: the hospital-based approach classifies all hospitals into three categories and analyzes the grade of fulfilment of the indicator. The indicator-based approach considers the adjusted mortality depending on the grade of fulfilment of the indicator. RESULTS: The analysis was based on 111,656 cases documented in the TR-DGU (mean age 50 years; 70 % male). The data analysis showed an obvious correlation with mortality for half of the QI, including only three procedural times. A clear correlation in both approaches was shown for two QI: prehospital capnometry in intubated patients and sonography used for patients without whole body computed tomography (CT) scans. Of the 20 QI with a positive result 15 were also positively rated by the experts. Of the 14 QI reported annually since 2017 in the TR-DGU report, 8 (57%) showed a clear correlation with mortality. CONCLUSION: There is no doubt regarding the necessity of scientifically assessing QI. Approximately half of the evaluated QI showed an empirical association with mortality. Interventions and events showed better results than measurements of procedural times; however, many QI may require a refined definition. The interpretation of the results is still challenging due to differences in the patient groups. Secondary endpoints, such as hospital length of stay and quality of life after trauma were not considered here.

[ATLS® and TDSC®: how it fits together : A treatment concept for mass casualty and terrorist-related mass casualty situations, life-threatening and special scenarios]. / ATLS® und TDSC®: How it fits together : Ein Behandlungskonzept für MANV und TerrorMANV, lebensbedrohliche oder besondere Lagen.

Terrorist-related mass casualty incidents represent a medical and organizational challenge for all hospitals. The main reasons are the special patterns of injuries, the onset and development of the scenario, the lack of information at the beginning, the overall number of casualties and the number of uninjured but involved patients presenting at the hospital.Due to these circumstances and the high percentage of penetrating injuries with a permanent risk of uncontrollable bleeding and other life-threatening complications, a strategic and tactical initial surgical care is necessary.For these special terrorist-related mass casualty (MasCal) situations, the Terror and Disaster Surgical Care (TDSC®) course was developed and imparts special medical and surgical knowledge as well as a scenario-based training in surgical decision-making. The TDSC® course focusses on the scenario-related provision of surgical care and distribution of the limited resources to enable survival for as many patients as possible.To improve individualized trauma care course formats, such as the Advanced Trauma Life Support (ATLS®) were established and are nowadays widespread in Germany. It could be shown that standardized approaches and algorithm-based treatment could improve the outcome of trauma victims. Faced with the present day permanent risk of a possible terrorist-related MasCal situation, the question arises how and to what extent elements and principles of both course formats (TDSC® and ATLS®) could be used to improve and organize the initial care in a terrorist-linked MasCal incident.For the first time it is shown that the key elements of both courses (primary survey of the ATLS® and the TDSC® principles: categorization, prioritization, disposition and realization) could be established and integratively used to structure the initial intrahospital medical and surgical care.

Guidelines for using animal models in blast injury research.

Blast injury is a very complex phenomenon and frequently results in multiple injuries. One method to investigate the consequences of blast injuries is with the use of living systems (animal models). The use of animals allows the examination and evaluation of injury mechanisms in a more controlled manner, allowing variables such as primary or secondary blast injury for example, to be isolated and manipulated as required. To ensure a degree of standardisation across the blast research community a set of guidelines which helps researchers navigate challenges of modelling blast injuries in animals is required. This paper describes the guidelines for Using Animal Models in Blast Injury Research developed by the NATO Health Factors and Medicine (HFM) Research Task Group 234.

[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]. / Optimierung der Kriterien zur Schockraumalarmierung : Vermeidung von Über- und Untertriage.

INTRODUCTION: Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system. MATERIAL AND METHODS: In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC. RESULTS: This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage. CONCLUSION: Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).

[Resuscitative endovascular balloon occlusion of the aorta : Option for incompressible trunk bleeding?] / "Resuscitative endovascular balloon occlusion of the aorta" : Option für nichtkomprimierbare Körperstammblutungen?

Hemorrhage is the single largest cause of avoidable death in trauma patients, whereby in civil emergency medicine in Europe most life-threatening hemorrhages occur in the abdomen and the pelvis. This is one reason why endovascular balloon occlusion of the aorta (EBOA), a procedure especially established in vascular surgery, is increasingly propagated for rapid bleeding control in these patients. This review article provides a comprehensive overview of the technique, indications, contraindications and complications of resuscitative endovascular balloon occlusion of the aorta (REBOA). Additionally, outcomes reported in in the currently available literature are summarized and discussed. From this practical and user-oriented consequences for future successful introduction of REBOA in the field of emergency medicine are deduced.

[Update on gunshot wounds to extremities]. / Update zu Schussverletzungen der Extremitäten.

Due to recent rampage and terror attacks in Europe, gunshot wounds have become a focus of attention even though they are still rare in Europe. Approximately 50% of gunshot wounds affect the extremities and to understand the sequelae, a basic knowledge of wound ballistics is indispensable. The energy transmitted from the bullet to the tissue is responsible for the severity of the injury and is dependent on the type of weapon and ammunition. A differentiation is made between low-energy injuries caused, e.g. by pistols and high-energy injuries mostly caused by rifles. The higher energy transfer to the tissue in high-energy injuries, results in a temporary wound cavity in addition to the permanent wound channel with extensive soft tissue damage. High-energy gunshot fractures are also more extensive compared to those of low energy injuries. Debridement seems to be necessary for almost all gunshot wounds. Fractures should be temporarily stabilized with an external fixator due to contamination.

[Preclinical and intrahospital management of mass casualties and terrorist incidents]. / Prä- und innerklinisches Management bei MANV und Terroranschlag.

Due to the recent terrorist attacks in Paris, Brussels, Ansbach, Munich, Berlin and more recently Manchester and London, terrorism is realized as a present threat to our society and social life, as well as a challenge for the health care system. Without fueling anxiety, there is a need for sensitization to this subject and to familiarize all concerned with the special kind of terrorist attack-related injuries, the operational priorities and tactics and the individual basic principles of preclinical and hospital care. There is a need to adapt the known established medical structure for a conventional mass casualty situation to the special requirements that are raised by this new kind of terrorist threat to our social life. It is the aim of this article, from a surgical point of view, to depict the tactics and challenges of preclinical care of the special kind of terrorist attack-related injuries from the site of the incident, via the advanced medical post or casualty collecting point, to the triage point at the hospital. The special needs of medical care and organizational aspects of the primary treatment in the hospital are highlighted and possible decisional options and different approaches are discussed.

[Treatment strategies for mass casualty incidents and terrorist attacks in trauma and vascular surgery : Presentation of a treatment concept]. / Versorgungsstrategien beim MANV/TerrorMANV in der Unfall- und Gefäßchirurgie : Darstellung eines Versorgungskonzeptes.

The treatment of patients in the context of mass casualty incidents (MCI) represents a great challenge for the participating rescue workers and clinics. Due to the increase in terrorist activities it is necessary to become familiar with this new kind of threat to civilization with respect to the medical treatment of victims of terrorist attacks. There are substantial differences between a "normal" MCI and a terrorist MCI with respect to injury patterns (blunt trauma vs. penetrating/perforating trauma), the type and form of the incident (MCI=static situation vs. terrorist attack MCI= dynamic situation) and the different security positions (rescue services vs. police services). This article is concerned with question of which changes in the surgical treatment of patients are made necessary by these new challenges. In this case it is necessary that physicians are familiar with the different injury patterns, whereby priority must be given to gunshot and explosion (blast) injuries. Furthermore, altered strategic and tactical approaches (damage control surgery vs. tactical abbreviated surgical care) are necessary to ensure survival for as many victims of terrorist attacks as possible and also to achieve the best possible functional results. It is only possible to successfully counter these new challenges by changing the mindset in the treatment of terrorist MCI compared to MCI incidents. An essential component of this mindset is the acquisition of a maximum of flexibility. This article would like to make a contribution to this problem.