[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.

[Periprosthetic fractures-Diagnostics, classification and treatment]. / Periprothetische Frakturen ­ Diagnostik, Klassifikation und Therapie.

BACKGROUND: Due to the increase in hip and knee prosthetic as a result of the demographic changes, with raised levels of activity among older persons with geriatric comorbidities, a continuous increase in periprosthetic fractures can be observed. OBJECTIVE: The incidence and causes of periprosthetic fractures, presentation of diagnostic pathways and derivation of a recommendation according to generally accepted classifications. MATERIAL AND METHOD: Literature search of basic scientific work, recommendations of experts as well as evaluation of own patient collective. CONCLUSION: With a growing number of prosthetic interventions in combination with increasing patient age, an increase in periprosthetic fractures is to be expected. The treatment of periprosthetic fractures is complex and requires detailed analysis of the location of the fracture and its morphology as well as the recognition of possibly loosened prosthetic material. Based on this information, the correct surgical treatment can be determined and scheduled in an appropriate center of care. In geriatric patients with corresponding comorbidities, an individual holistic treatment plan should be developed.

[Medical confidentiality]. / Ärztliche Schweigepflicht.

Medical confidentiality is a fundamental prerequisite in the patient-physician relationship based on trust and goes back to the Hippocratic oath. It is clearly defined in the German Constitution as well as the medical professional code of conduct. A breach of confidentiality can result in criminal sanctions and professional consequences as well as civil claims for damages and compensation by the affected patients. In routine clinical practice situations repeatedly occur which lead to uncertainty regarding the limits of confidentiality, the right to silence and the obligation to disclosure. The purpose of this article is to explain the legal foundations of medical confidentiality, the right to silence and the obligation to disclosure and to provide practical support for critical questions in routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

Synthesis, Photophysical, and Biological Evaluation of Sulfated Polyglycerol Dendronized Perylenebisimides (PBIs)--A Promising Platform for Anti-Inflammatory Theranostic Agents?

A set of four water-soluble perylene bisimides (PBI) based on sulfated polyglycerol (PGS) dendrons were developed, their photophysical properties determined via UV/vis and fluorescence spectroscopy, and their performance as possible anti-inflammatory agents evaluated via biological in vitro studies. It could be shown that in contrast to charge neutral PG-PBIs the introduction of the additional electrostatic repulsion forces leads to a decrease in the dendron generation necessary for aggregation suppression, allowing the preparation of PBIs with fluorescence quantum yields of >95% with a considerable decreased synthetic effort. Furthermore, the values determined for L-selectin binding down to the nanomolar range, their limited impact on blood coagulation, and their minor activation of the complement system renders these systems ideal for anti-inflammatory purposes.

[Operative interventions of urologic traumata in severe injured patients in the acute phase]. / Operative Interventionen urologischer Verletzungen beim schwerverletzten Patienten in der Akutphase.

INTRODUCTION: The frequency of urological traumata and the need for interventions in severely injured patients in Germany are unknown. The aim of this study was to determine the frequency of urological traumata in about 90,000 severely injured patients (Injury Severity Score, ISS ≥ 16). MATERIALS AND METHODS: Data of 90,000 patients from the TraumaRegister DGU® were retrospectively analyzed. All patients with an ISS of ≥ 16 were included. The kind of urological traumata and the need for urological intervention within 24 hours were assessed, as well as the kind of accident, additional traumata and the clinical course. RESULTS: 48,797 patients fulfilled the inclusion criteria. Urological trauma was existent in 7.1 %, especially in men (78 %). Kidneys were affected most frequently (4.8 %) compared to ureters (0.2 %), urinary bladder (1.2 %), urethra (0.5 %) and genitals (0.4 %). Traffic accidents and falls from higher levels represented the main cause for urological traumata (> 90 %). It was associated with additional pelvis, thorax and abdomen traumata (each 7.1 %) and showed a distinct increase dependent on the abbreviated injury scale (AIS). Ureter (10.6%) and urethra (6.3%) trauma was deferred diagnosed most, this was associated with a higher rate of urological operations. The general duration of hospital stay and that in the intensive care unit were prolonged by urological traumata. DISCUSSION: The data showed the prevalence of urological trauma in severely injured patients analyzed in a huge patient cohort of the TraumaRegister DGU®. For the first time the number, degree and medical care in the reality of urological traumata in severely injured patients were available.

[Living will, durable power of attorney and legal guardianship in the trauma surgery routine : Data from a geriatric trauma center]. / Patientenverfügung, Vorsorgevollmacht und gesetzliche Betreuung im unfallchirurgischen Alltag : Zahlen aus einem alterstraumatologischen Zentrum.

BACKGROUND: Due to the increasing number of elderly patients, trauma surgeons are often confronted with end-of-life treatment decisions. Advance directives can help reduce the lack of clarity in those situations. OBJECTIVES: The aim of this study was to identify the presence of living wills, durable power of attorney, legal guardianship and appointment of guardianship in the geriatric trauma center of a university hospital. MATERIALS AND METHODS: The data of all patients treated in our geriatric trauma center from 01/01/2013 to 03/31/2014 were analyzed regarding the presence of a living will, durable power of attorney, legal guardianship and appointment of guardianship as well as the procedure of documenting those items. RESULTS: Out of 181 patients, 63 % (n = 114) had one or more of these documents. Most frequently used was the durable power of attorney in 33 % (n = 59), followed by a living will in 27 % (n = 48), legal guardianship in 20 % (n = 37) and appointment of guardianship in 7 % (n = 12). The existence of those documents was recorded in 88 % (n = 100) of patients within 24 h after admission; documentation in the medical records was found in 58 % (n = 66). CONCLUSION: A large proportion of patients had one or more of the documents named above. In this respect, standardized documentation of advance directives in the medical record is an important issue for all persons involved.

[Expectations from the TraumaNetwork DGU®: Which goals have been achieved? What can be improved?]. / Erwartungen an das TraumaNetzwerk DGU®: Welche Ziele wurden erreicht? Was kann verbessert werden?

INTRODUCTION: Following the establishment of the first trauma networks in 2009 an almost nationwide certification could be achieved. Despite the impressive number of 46 certified networks, little is known about the actual improvements and the satisfaction of the participating hospitals. OBJECTIVES: This article aims to give a first representative overview of the expectations and actual achievements. MATERIAL AND METHODS: An online survey with a total of 36 questions was conducted in 884 hospitals. The questionnaire could be filled out online, sent by post or fax to the AKUT- Office. Descriptive statistical analyses were performed with Microsoft Excel. RESULTS: With 326 responses, a response rate of 48.9% of all active hospitals was achieved. Of the participating hospitals 64.1% (209) were certified and had taken part in the project for an average of 3.9 years. The average score for satisfaction was 2.3, 72.4% (236) felt that there was a need for improvement in the care of severely injured patients and 46.6% (152) in the transfer of patients. In 47.2% (142) no improvement in cooperation with the ambulance service could be determined, 25.2% (82) documented an increase in the number of severely injured patients since participating in the trauma network (TNW-DGU) and 93.9% (306) of all hospitals wanted to participate in the trauma network in the future. DISCUSSION: It could be shown that important goals, such as simplification of patient transfer or general improvement in cooperation have been achieved. Overall there was a high level of satisfaction among the participating hospitals; however, the survey has identified some points which need to be improved by further intensive work.

[Rehabilitation of multiple injured patients in Germany: Clinic locations, structural and equipment attributes]. / Rehabilitation von Schwerverletzten in Deutschland: Klinikstandorte, Struktur- und Ausstattungsmerkmale.

BACKGROUND: In recent years, there has been an ongoing improvement in the treatment and structural aspects of acute trauma care. Because of the definition of rehabilitation as a post-acute part of the treatment of traumatic injuries, especially in multiple injured patients, there is need to improve the interaction and cooperation between acute care hospitals and rehabilitation clinics. This article gives a survey of the current state of rehabilitation in Germany. MATERIALS AND METHODS: Based on a directory of rehabilitation clinics and an internet search, all rehabilitation clinics were identified and included in the analysis for clinic location, structural and equipment attributes. RESULTS: In total 551 rehabilitation clinics with expertise in the treatment of traumatic and orthopedic injuries were identified. In detail, broad differences between the federal states could be observed. The number of rehabilitation clinics per state ranged from 1 to 136 and the number of beds from 70 to 18040. The average catchment area covered by a rehabilitation clinic is 648 km(2) (range 149-2106 km(2)) with an average of 1584 patients per clinic per year. Of the clinics 68% can treat patients with methicillin-resistant Staphylococcus aureus (MRSA) infections and 62.1% are able to deal with patients who need renal dialyses. Almost all clinics provide an x-ray facility (96.4%) while computed tomography (CT) and magnetic resonance imaging (MRI) are available in 52.6% and 50.3%, respectively. CONCLUSION: The number of rehabilitation clinics available seems to be adequate for all patients with traumatic injuries but there are enormous differences between the federal states. Because rehabilitation is important for the outcome of multiple injured patients, a further improvement of the quality and integration into the regional trauma network seem to be necessary.

[Implantable cardioverter-defibrillator at the end of life]. / Implantierbarer Kardioverter-Defibrillator am Ende des Lebens.

Brady- and tachyarrhythmias at the end of life are common observations. Implantable cardioverter-defibrillators answer with antibrady and antitachycardia pacing, which will not be associated with any complaints of the dying patient. In contrast, defibrillation and cardioversion shocks are extremely painful. Therefore shocks should be inactivated at the end of life. Family doctors, internists, emergency physicians and paramedics are unable to inactivate shocks. Deactivation of shocks at the end of life is not comparable to euthanasia or assisted suicide, but allow the patient to die at the end of an uncurable endstage disease. Deactivation of shocks should be discussed with the patient before initial implantation of the devices. The precise moment of the inactivation at the end of life should be discussed with patients and relatives. There is no common recommendation for the time schedule of this decision; therefore it should be based on the individual situation of the patient. Emergency health care physicians need magnets and sufficient information to inactivate defibrillators. The wishes of the patient have priority in the decision process and should be written in the patient's advance directive, which must be available in the final situation. However the physician must not necessarily follow every wish of the patient. As long as the laws in the European Union are not uniform, German recommendations are needed.

[Polytrauma in children and adolescents. Choice of the primary care clinic and importance of pediatric traumatology competence centers]. / Das Polytrauma von Kindern und Jugendlichen. Auswahl der primärversorgenden Klinik und Bedeutung von kindertraumatologischen Kompetenzzentren.

BACKGROUND: The number of (seriously) injured children increased again for the first time in 2011. The aim of this study was to analyse differences compared to multiple injured adults and to show the reality of daily treatment. METHODS: All cases of the DGU Trauma Registry from the years 1997 to 2010 were examined. The documented cases were divided into different the age groups. The study investigated, e.g. the mechanism of accident, injury pattern, the number of hospital and ICU days, and lethality. RESULTS: At 38.8% the largest percentage of severely injured children and adolescents belongs to the group of 16-17 year olds. The group of 0-5 year olds (15.9%) has the lowest percentage. The most common accident cause was traffic accidents (58.5%). The mechanism of accident and the injury patterns changes with age. Younger patients are often treated in supraregional trauma centers (0-5 year olds: 78.2% vs. 16-17 year olds: 73.1% vs. > 65 years: 63.2%). The average lethality rate was 14.8% (16.3% RISC). CONCLUSIONS: The percentage of severely injured children in the overall population is only 7.4%. Because the majority of patients are primarily treated in supraregional trauma centers, trauma centers with specialisation in paediatric traumatology are mandatory.

[Outcomes after operative treatment of distal radius fractures - an analysis of 721 patients]. / Ergebnisse der operativen Versorgung distaler Radiusfrakturen - eine Analyse von 721 Patienten.

AIM OF THE STUDY: Treatment strategies in distal radius fractures differ nationally and internationally. Conservative and operative treatment options compete as well as implants, postoperative therapy regimens and the necessity of implant removal. In our institution operative treatment is favoured. In the following the results of 721 surgically treated patients are presented. PATIENTS: PATIENTS who underwent operative treatment of their distal radius fractures in our institution between 2008 and 2011 were retrospectively analysed. Following patient characteristics have been surveyed regarding age, sex, location of plate osteosynthesis, operation time, time of cast immobilisation and complications like infections, tendon ruptures, need of revision surgery. RESULTS: 721 patients (mean age: 59.03 years) were retrospectively analysed. 514 of them (71.29 %) were female. Time of operation was after a mean duration of 5.48 days. In 558 (77.39 %) patients we performed palmar plate osteosynthesis. 89 (12.34 %) had dorsal plate osteosynthesis and 74 (10.3 %) cases were treated with either K-wires or screws. 18 (2.5 %) patients had concomitant traumatic carpal tunnel syndrome and a concomitant SL rupture was seen in 38 (5.27 %) patients. 40 (5.55 %) patients underwent operative revision because of posttraumatic carpal tunnel syndrome (n = 15), tendon ruptures (n = 7), malposition of screws (n = 6), loss of reduction (n = 6) and infection (n = 3). Mean duration of in-hospital stay after operation was 6.6 days. Implant removal was performed in 77 (10.7) patients; 59 (8.2 %) patients had palmar plate osteosynthesis and 18 (2.5 %) patients had dorsal plating. CONCLUSION: Because of the low complication rate after operative treatment of distal radius fractures, osteosynthesis of this fracture seems to be warranted. Regarding the patients' higher age we have seen an unexpectedly long in-hospital stay with a mean time of 6.6 days. Herein attempts should be made to reduce time of in-hospital stay. In our opinion implant removal should not be recommended routinely.

[Rehabilitation of severely injured patients in acute care hospitals: who is doing what? A nationwide survey in the Trauma Network DGU]. / Rehabilitation von schwerverletzten Patienten im Akutkrankenhaus: wer macht was? Eine bundesweite Umfrage im TraumaNetzwerk DGU.

BACKGROUND: During the treatment of severely injured patients, rehabilitation takes an important role. In this study we examined the present structures in acute care hospitals, which influence the process of rehabiliation. MATERIALS AND METHODS: The data was captured in a questionnaire. The questions deal with the personal and structural situation of acute care hospitals in Germany. The questionnaires were sent to all clinics, which are registered in the TraumaNetwork DGU. RESULTS: 424 hospitals answered the questionnaire. This is a response rate of 57.3% regarding 740 acitve clinics in the TraumaNetwork DGU. 58% have no opportunity for rehabilitation. The majority of the hospitals have a physiotherapy, (98.6%) or an occupational therapy (71.0%); 33.3% have a case management. Only 17.0% of the hospitals have rehabilitation teams which take care during the hospital stay. These teams consist mainly of internal rehabilitation physicians and physical therapists. Supraregional Trauma Center have better organized structures, as hospitals with lower level of care. Only 56.6% of all hospitals reported that they were familiar with the cooperating rehabilitation hospitals. There are special cooperations with rehabilita­tion hospitals in 34.4% of all cases. CONCLUSION: The early mobilisation of severely injured patients is an integral part of the postoperative course in German hospitals. While on the one hand a large number of hospitals have good structural conditions on the other hand these structures are little integrated in the daily treamtment. There are major gaps and uncertainties in the cooperation between acute care clincs and rehabilitation hospitals. The integra­tion of rehabilitation hospitals in the TraumaNetwork DGU could be a good chance to improve this collaboration.

[TraumaregisterTraumaNetwork DGU® und TraumaRegister DGU®. Success by cooperation and documentation]. / TraumaNetzwerk DGU® und TraumaRegister DGU®. Erfolge durch Kooperation und Dokumentation.

BACKGROUND: The TraumaNetwork DGU® (TNW) connects hospitals with different capacities for the treatment of severely injured patients who work together as superregional (STC), regional (RTC) and local trauma centres (LTC). The standards of treatment and equipment are defined on the basis of current guidelines as published in the"White book of the Treatment of Severely Injured Patients". An external audit process evaluates the organisation and structure of participating hospitals as well as the cooperation of the trauma centres within a regional TNW. RESULTS: In May 2013 a total of 618 hospitals were visited and assessed according to the White book and 39 fully certified regional TNWs covered around 85% of the area of Germany. Treatment quality in the certified TCs was analyzed on the basis of 25,249 severely injured patients in the TraumaRegister DGU® (2008-2011) and significant differences between the expected and observed mortality rates were found. These differences were most obvious in superregional and regional trauma centres. CONCLUSION: The TraumaNetwork represents an innovative, cooperative project for successfully improving the treatment of severely injured patients.

[Emergency room management : in the era of the White Paper, S3 guidelines, Advanced Trauma Life Support® and TraumaNetwork DGU® of the German Society of Trauma Surgery]. / Schockraummanagement : Im Zeitalter von Weißbuch, S3-Leitlinie, "Advanced Trauma Life Support"® und TraumaNetzwerk DGU®

The treatment of the severely injured is, just as the injury severity and combinations, often highly complex and leaves little leeway for delay, dissent or even error. In order to reduce this to a minimum, trained emergency room teams in addition to optimal technical and structural prerequisites are necessary. This must function in an interdisciplinary fashion according to fixed consensus algorithms which are known to all team members and have been agreed by all participants. The White Paper on treatment of the severely injured of the German Society of Trauma Surgery (DGU) and the recently published S3 guidelines offer evidence-based recommendations on the structural, technical, organizational and personnel prerequisites.

[The TraumaNetzwerk DGU project. Goals, conception, and successes achieved]. / Das Projekt TraumaNetzwerk DGU. Zielsetzung, Konzeption und bisher Erreichtes.

In Germany, approximately 35,000 patients with major injuries are treated per year. The treatment of patients suffering from major injuries is both a medical and a logistic challenge. Despite the high-level quality of medical care, regional differences exist due to geographical and infrastructural conditions. In addition, discrepancies in human resources and technical equipment in hospitals influence diagnostics and treatment of severely injured patients. Based on these findings trauma networks of the German Trauma Association were founded to guarantee nationwide high-quality medical care of these patients. This article provides an overview about requirements of all involved professions and establishment of trauma networks considering state-of-the-art communication technology. Moreover, characteristics of the auditing and certification process and planning of the integration of rehabilitation facilities are described.

[Arthroscopically assisted reduction of acute acromioclavicular joint separations: comparison of clinical and radiological results of single versus double TightRope™ technique]. / Die arthroskopisch unterstützte Stabilisierung der akuten AC-Gelenksprengung: Vergleich der klinischen und radiologischen Ergebnisse der Single- vs. Double-TightRope™-Technik.

BACKGROUND: The aim of this study was to compare the results of the single (STR) versus double TightRope™ (DTR) technique for stabilisation of acute separations of the AC joint with the hypothesis that DTR achieves lower CC distance. PATIENTS AND METHODS: A total of 29 consecutive patients treated operatively with the TR technique (mean age 38.1 years, n=26 male) were analysed in a cohort study with a mean follow-up of 13.3 months (12.0-21.7). Acute AC joint separations types III and V according to Rockwood (R) were included; R types I, II, IV and VI were excluded. The prospective scores determined pre-op and 3, 6 and 12 months post-op and X-rays were evaluated. RESULTS: Of the patients 12 suffered an R type III and 17 an R V separation; 14 were treated with STR and 15 with DTR. With STR, 8 R III and 6 R V injuries and with DTR 4 R III and 11 R V injuries were treated arthroscopically. STR achieved an increased CC distance >125% compared to the contralateral AC joint in five cases (36%). Two of them occurred as R V and three as R III injury. DTR achieved a CC distance >125% in two cases of an R V injury (13%). CONCLUSION: The DTR technique provides lower CC distance compared to the STR technique, without a significant difference of CC distance and scores.