Survival among patients with severe high cervical spine injuries - a TraumaRegister DGU® database study.

BACKGROUND: Trauma is a significant cause of death and impairment. The Abbreviated Injury Scale (AIS) differentiates the severity of trauma and is the basis for different trauma scores and prediction models. While the majority of patients do not survive injuries which are coded with an AIS 6, there are several patients with a severe high cervical spinal cord injury that could be discharged from hospital despite the prognosis of trauma scores. We estimate that the trauma scores and prediction models miscalculate these injuries. For this reason, we evaluated these findings in a larger control group. METHODS: In a retrospective, multi-centre study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) to select patients with a severe cervical spinal cord injury and an AIS of 3 to 6 between 2002 to 2015. We compared the estimated mortality rate according to the Revised Injury Severity Classification II (RISC II) score against the actual mortality rate for this group. RESULTS: Six hundred and twelve patients (0.6%) sustained a severe cervical spinal cord injury with an AIS of 6. The mean age was 57.8 ± 21.8 years and 441 (72.3%) were male. 580 (98.6%) suffered a blunt trauma, 301 patients were injured in a car accident and 29 through attempted suicide. Out of the 612 patients, 391 (63.9%) died from their injury and 170 during the first 24 h. The group had a predicted mortality rate of 81.4%, but we observed an actual mortality rate of 63.9%. CONCLUSIONS: An AIS of 6 with a complete cord syndrome above C3 as documented in the TR-DGU is survivable if patients get to the hospital alive, at which point they show a survival rate of more than 35%. Compared to the mortality prognosis based on the RISC II score, they survived much more often than expected.

[Algorithm for flexible decision-making in the intra-hospital management of patients with the changing requirements of the SARS-CoV-2 pandemic]. / Flexibler Entscheidungsalgorithmus zum innerklinischen stationären Patient*innen-Management unter wechselnden Anforderungen der SARS-CoV-2-Pandemie.

After the initial fulminant outbreak, the SARS-CoV­2 pandemic has now taken a more protracted course which, nevertheless, challenges hospitals in returning to a "normal" mode and in preparing for a worst-case scenario of a second wave. Not only the organization of the first contact with the patient and the admission in the emergency department but also the admission as an in-patient and the subsequent management requires both flexibility and clear directions of action for the medical personnel involved. The aim of the algorithm was to develop a structured, easy to implement and easy to follow guideline while simultaneously preserving resources. The algorithm covers some key points of decision making such as clinical signs, first contact, admission for in-patient treatment, consequences of swab and computed tomography (CT) results, and allocation and isolation measures within the hospital. The algorithm is not intended to guide diagnostics, decisions and treatment in the narrower medical sense but to provide more general instructions for the management of in-patients considering specific aspects of SARS-CoV­2.

[Unplanned admission or readmission to the intensive care unit : Avoidable or fateful?] / Ungeplante Aufnahmen oder Rückverlegungen auf die Intensivstation : Vermeidbar oder schicksalhaft?

BACKGROUND: Unplanned admissions or readmissions to the intensive care unit lead to a poorer outcome and present medical, logistic and economic challenges for a clinic. How often and what are the reasons for readmission to the intensive care unit? Which strategies and guidelines to avoid readmission are recommended. MATERIAL AND METHODS: Analysis and discussion of available studies and recommendations of national and international societies. RESULTS: Many studies show that unplanned admissions and readmissions to the intensive care unit represent an independent risk factor for a poor outcome for patients. Different factors that increase the probability of readmission can be identified. Structural changes concerning the normal wards, intensive care unit or the clinic internal emergency service could positively effect readmission rates and/or patient outcome while other studies failed to show any effect of these arrangements. CONCLUSION: Patient transition from the intensive care unit to a lower level of care is a critical point of time and has to be accompanied by a high quality handover. Unstable patients on normal wards have to be identified and treated as soon as possible but effects of standardized medical emergency teams are controversial.

Effective and rapid treatment of wound botulism, a case report.

BACKGROUND: The latest news shows several cases of contaminated heroin that is found in different parts all over Europe. This information can be helpful for the emergency doctors to find the correct diagnosis of wound botulism in patients who are intravenous drug users. CASE PRESENTATION: We describe a case of a 40-year-old man who presented to the emergency department in 2016. He suffered from mild dysarthria, diplopia, dysphagia and ptosis since two days. The CT-scan of the cerebrum and the liquor were without any pathological results. We found out that the patient is an intravenous drug user and the clinical examination showed an abscess in the left groin. So we treated him with the suspected diagnosis of wound botulism. In the emergency operation we split the abscess, made a radical debridement and complementary treated him with a high dose of penicillin g and two units of botulism antitoxin. The suspected diagnosis was confirmed a few days later by finding the Toxin B in the abscess and in the patient's serum. In the following days the neurological symptoms decreased and the wound healing was without any complications. The patient left the hospital after nine days; the antibiotic therapy with penicillin g was continued for several days. In a following examination, 14 days after the patient's discharge of the hospital, no further symptoms were found and the abscess was treated successfully without any problems. CONCLUSION: Because wound botulism is a very rare disease it can be challenging to the attending physician. This case shows a fast treatment with full recovery of the patient without any further disabilities, which can be used for the future.

[Intramedullary stabilization of bilateral femur fractures with pulmonary artery embolism]. / Intramedulläre Stabilisierung beidseitiger Femurfrakturen bei Polytrauma mit primärer Lungenembolie.

This is a case report of a 31-year-old motorcyclist who was admitted to our emergency department with severe multiple injuries and an ISS score of 38 points.There were bone injuries on all 4 extremities, fractures of both proximal femurs, both radii, a great soft tissue injury of the lower limb, stable fractures of the spine and a blunt thoracic injury. A bone fragment compressed femoral vein and artery on the right side with consecutive thrombus in the inferior caval vein and thrombembolism of the central lung artery. The proximal femur fractures were treated initialy with gamma-nails after implanting a cava-filter because of the high-risk constellation for further thrombembolism. Operation was monitored with transesophageal echocardiography.The cava filter could be delivered on 2nd postoperative day without complication. The patient was ventilated for 1 day, stayed on ICU for 9 days and left hospital in a good condition after 28 days. It was the strategic and logistic great achievement of an interdisciplinary trauma center to implant cava filter and decide for intramedullar osteosythesis without delay.