Simultaneous Casualty Admissions-Do they Affect Treatment in the Receiving Trauma Center?

BACKGROUND: Simultaneous trauma admissions expose medical professionals to increased workload. The impact of simultaneous trauma admissions on hospital allocation, therapy, and outcome is currently unclear. We hypothesized that multiple admission-scenarios impact the diagnostic pathway and outcome. METHODS: The TraumaRegister DGU® was utilized. Patients admitted between 2002-2015 with an ISS ≥ 9, treated with ATLS®- algorithms were included. Group ´IND´ included individual admissions, two individuals that were admitted within 60 min of each other were selected for group ´MULT´. Patients admitted within 10 min were considered as simultaneous (´SIM´) admissions. We compared patient and trauma characteristics, treatment, and outcomes between both groups. RESULTS: 132,382 admissions were included, and 4,462/3.4% MULTiple admissions were found. The SIM-group contained 1,686/1.3% patients. The overall median injury severity score was 17 and a mean age of 48 years was found. MULT patients were more frequently admitted to level-one trauma centers (68%) than individual trauma admissions were (58%, p < 0.001). Mean time to CT-scanning (24 vs. 26/28 min) was longer in MULT / SIM patients compared to individual admissions. No differences in utilization of damage control principles were seen. Moreover, mortality rates did not differ between the groups (13.1% in regular admissions and 11.4%/10,6% in MULT/SIM patients). CONCLUSION: This study demonstrates that simultaneous treatment of injured patients is rare. Individuals treated in parallel with other patients were more often admitted to level-one trauma centers compared with individual patients. Although diagnostics take longer, treatment principles and mortality are equal in individual admissions and simultaneously admitted patients. More studies are required to optimize health care under these conditions.

Unmatched Type O RhD+ Red Blood Cells in Multiple Injured Patients.

BACKGROUND: Immediate supply of red blood cell (RBC) concentrates is crucial in the initial treatment of exsanguinating patients in the emergency room. General shortage of RhD- RBCs has led to protocols in which patients with unknown blood groups are initially transfused with group O, RhD+ RBCs. Limited data are available regarding the safety of such an approach. METHODS: Transfusion protocols for all multiple injured patients from the regional polytrauma database were retrospectively analyzed over a period of 5 years. Data on side effects were retrieved from the local safety update registry. Follow-up data were obtained from patients with identified RhD-incompatible transfusions. RESULTS: In total, 823 patients were registered as multiple injured in the database. An immediate transfusion of 259 units (mean number of units 4, range 1-6) group O, RhD+ RBCs was initiated in 62 of them. 14 of these patients were RhD- and received 60 units of RhD-incompatible RBCs in the emergency room. In the later course RhD- patients received additional 185 incompatible transfusions (13; 1-31). The overall seroconversion rate was 50%. No adverse outcome due to incompatible transfusion was observed. CONCLUSIONS: Initial supply with group O, RhD+ RBCs in multiple injured patients appears to be safe. Significant numbers of RhD- units can be saved for use in other patients.

A Consensus-Based Criterion Standard for the Requirement of a Trauma Team.

BACKGROUND: Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team. METHODS: A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria. RESULTS: Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period. CONCLUSIONS: The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria.

Association of an In-House Blood Bank with Therapy and Outcome in Severely Injured Patients: An Analysis of 18,573 Patients from the TraumaRegister DGU®.

INTRODUCTION: Hemorrhagic shock remains one of the most common causes of death in severely injured patients. It is unknown to what extent the presence of a blood bank in a trauma center influences therapy and outcome in such patients. MATERIAL AND METHODS: We retrospectively analyzed prospectively recorded data from the TraumaRegister DGU® and the TraumaNetzwerk DGU®. Inclusion criteria were Injury Severity Score (ISS) ≥ 16, primarily treated patients, and hospital admission 2 years before or after the audit process. RESULTS: Complete data sets of 18,573 patients were analyzed. Of 457 hospitals included, 33.3% had an in-house blood bank. In trauma centers with a blood bank (HospBB), packed red blood cells (PRBCs) (21.0% vs. 17.4%, p < 0.001) and fresh frozen plasma (FFP) (13.9% vs. 10.2%, p <0.001) were transfused significantly more often than in hospitals without a blood bank (Hosp0). However, no significant difference was found for in-hospital mortality (standard mortality ratio [SMR, 0.907 vs. 0.945; p = 0.25). In patients with clinically apparent shock on admission, no difference of performed transfusions were present between HospBB and Hosp0 (PRBCs, 51.4% vs. 50.4%, p = 0.67; FFP, 32.7% vs. 32.7%, p = 0.99), and no difference in in-hospital mortality was observed (SMR, 0.907 vs. 1.004; p = 0.21). DISCUSSION: In HospBB transfusions were performed more frequently in severely injured patients without positively affecting the 24h mortality or in-house mortality. Easy access may explain a more liberal transfusion concept.

Two-Incision Minimally Invasive Approach for the Treatment of Anterior Column Acetabular Fractures.

INTRODUCTION: We describe an alternative to the Letournel ilioinguinal approach for anterior column acetabular fractures that is performed with a unique retraction device that decreases the rate of soft-tissue complications. STEP 1 POSITION THE PATIENT AND IDENTIFY THE SITES FOR THE INCISIONS: Identify the sites for both incisions with the help of an image intensifier. STEP 2 MAKE THE FIRST INCISION TO EXPOSE THE ANTERIOR COLUMN AND THE LINEA TERMINALIS PELVIC BRIM: Make the first incision to expose the central area of the fracture. STEP 3 MAKE THE SECOND INCISION TO EXPOSE THE SYMPHYSIS AND THE IPSILATERAL PUBIC BONE: Make the second incision to expose the area for the distal plate fixation. STEP 4 MAINTAIN EXPOSURE OF THE LINEA TERMINALIS USING A SOFT-TISSUE RETRACTION SYSTEM: For better visualization, use a soft-tissue retraction system. STEP 5 REDUCE THE FRACTURE: Clean and reduce the fracture through the first incision. STEP 6 FIX THE FRACTURE: Perform temporary and definitive fixation according to the standards for anterior acetabular fracture fixation. STEP 7 CLOSE THE WOUND: After radiographic documentation in three views, close the wound. RESULTS: We reported the results of a case-control study of the first twenty-six patients operated on with the two-incision minimally invasive technique.IndicationsContraindicationsPitfalls & Challenges.

Numbers of Severely Injured Patients in Germany. A Retrospective Analysis From the DGU (German Society for Trauma Surgery) Trauma Registry.

BACKGROUND: Persons who sustain severe traumatic injury, i.e., those with an Injury Severity Score (ISS) of 16 or above, go on to suffer major physical, emotional, and socio-economic consequences. It is important to know the incidence of severe trauma so that these patients can be cared for optimally. METHODS: Data from the year 2012 on severely injured persons with an ISS of 16 or above were obtained from the trauma registry of the German Society for Trauma Surgery (DGU) and analyzed. Further information was obtained from the database of the DGU trauma network. The annual incidence of severe trauma was estimated from these data in three different ways. RESULTS: An extrapolation of hospital-based data to the German population yielded a figure of 16 742 severely injured persons per year. A population-based estimate from the German federal state of Bavaria yielded a figure of 16 514/year, while an area-based extrapolation using data from 17 established networks yielded a figure of 16 554/year. We added 10% to each of these figures as a correction for assumed underreporting. We conclude that the number of persons who sustained a severe traumatic injury in Germany in 2012 lay between 18 209 (95% confidence interval [CI]: 17 751-18 646) and 18 416 (95% CI: 18 156-18 695). This corresponds to an incidence of 0.02% per year. CONCLUSION: Data from a prospectively maintained nationwide trauma registry were used for the first time to calculate the annual incidence of severe traumatic injury in Germany: the expected number of severely injured persons per year is 18 200-18 400. Previous extrapolations yielded values in the range of 32 500-35 300. A high variability of documentation practices among supraregional trauma centers may have distorted the estimate, along with other factors. The figures were not normalized for age or sex.

Effect of the localisation of the CT scanner during trauma resuscitation on survival -- a retrospective, multicentre study.

INTRODUCTION: Whole-body computed tomography (WBCT) is increasingly becoming the standard diagnostic technique during the resuscitation of severely injured patients. However, little is known about the ideal localisation of the CT scanner within the emergency setting. We intended to analyse the potential effect of the localisation of the CT scanner on outcome. PATIENTS AND METHODS: In a retrospective multicentre cohort study involving 8004 adult blunt major trauma patients out of 312 hospitals, we analysed the effect of the distance of the trauma room to the CT scanner on the outcome. Three groups were built: 1. CT in the trauma room 2. CT equal or less than 50 m away and 3. CT more than 50 m away. Using data derived from the 2007-2011 version of TraumaRegister DGU(®) and the structure data bank of the TraumaNetzwerk DGU(®) (trauma network, TNW; German Trauma Society, DGU) we determined the observed and predicted mortality and calculated the standardised mortality ratio (SMR) as well as logistic regressions. RESULTS: n=8004 patients fulfilled the inclusion criteria: their mean age was 46.4 ± 21.0 years. 72.8% of them were male and the mean injury severity score (ISS) was 28.6 ± 11.8. The overall mortality rate was 16.0%. The mean time from hospital admission to whole-body CT was 17.1 ± 12.3 min for group 1, 22.7 ± 15.5 min for group 2 and 27.7 ± 17.1 min for group 3, p<0.001. Risk adjusted SMR was 0.74 (CI 95% 0.67-0.81) in group 1, 0.81 (CI 95% 0.76-0.87) in group 2, and 0.88 (CI 95% 0.79-0.98) in group 3. SMR group 1 vs. SMR group 2: p=0.130. SMR group 2 vs. SMR group 3: p=0.170. SMR group 1 vs. SMR group 3: p=0.016. SMR groups 1+2 vs. SMR group 3: p=0.046. Comparable data were found for the subgroup analysis of Level-I trauma centres only. Logistic regression confirmed the positive effect of a close localisation of the CT to the trauma room. The odds ratio (OR) was lowest for the localisation of the CT in the trauma room (OR 0.68, CI 95% 0.54-0.86, p<0.001). CONCLUSIONS: It was proven for the first time that a close distance of the CT scanner to the trauma room has a significant positive effect on the probability of survival of severely injured patients. The closer the CT is located to the trauma room, the better the probability of survival. Distances of more than 50 m had a significant negative effect on the outcome. If new emergency departments are planned or rebuilt, the CT scanner should be placed less than 50 m away from or preferably in the trauma room.

TraumaNetzwerk DGU(®): optimizing patient flow and management.

PURPOSE: Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals. METHODS: To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU(®) (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU(®) documentation. RESULTS: By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country's surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU(®) documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes. CONCLUSIONS: The TraumaNetzwerk DGU(®) project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system.

[In-hospital trauma management - damage control]. / Innerklinisches Traumamanagement - Damage Control - Die Mutter vieler Strategien.

Damage Control is a strategy for the initial treatment phase in severely injured patients. The aim is to avoid time consuming surgical procedures thereby reducing secondary damage and to improve patients' outcome. Once the patient is haemodynamically stabilized on the intensive care unit, definitive therapy - i. e. osteosynthesis, bowel/urinary tract reconstruction etc. - can be performed after a time interval of 5-10 days. Thus Damage Control is a quick and focused but preliminary treatment strategy in the initial emergency phase in critically injured patients.

Implementation of a nationwide trauma network for the care of severely injured patients.

BACKGROUND: Regional differences in the care of severely injured patients remain problematic in industrial countries. METHODS: In 2006, the German Society for Trauma Surgery initiated the foundation of regional networks between trauma centers in a TraumaNetwork (TNW). The TNW consisted of five major elements as follows: (a) a whitebook on the treatment of severely injured patients; (b) evidence-based guidelines (S3); (c) local audits; (d) contracts of interhospital cooperation among all participating hospitals; and (e) TraumaRegister documentation. TNW hospitals are classified according to local audit results as supraregional (STC), regional (RTC), or local (LTC) trauma centers by criteria concerning staff, equipment, admission capacity, and responsibility. RESULTS: Five hundred four German trauma centers (TCs) were certified by the end of December 2012. By then, 37 regional TNWs, with a mean of 13.6 TCs, were established, covering approximately 80% of the country's territory. Of the hospitals, 92 were acknowledged as STCs, 210 as RTCs, and 202 as LTCs.In 2012, 19,124 patients were documented by the certified TCs. Fifty-seven percent of the patients were treated in STCs, 34% in RTCs, and 9% in LTCs. The mean (SD) Injury Severity Score (ISS) was highest in STCs (21 [13]), compared with 18 (12) in RTCs and 16 (10) in LTCs. There were differences in expected mortality (based on Revised Injury Severity Classification) according to the differences in the severity of trauma among the different categories, but in all types, the expected mortality was significantly higher than the observed mortality (differences in STCs, 1.8%; RTCs, 1.4%; LTCs, 2.0%). CONCLUSION: According to our findings, it is possible to successfully structure and standardize the care of severely injured patients in a nationwide trauma system. Better outcomes than expected were observed in all categories of TNW hospitals. LEVEL OF EVIDENCE: Epidemiologic study, level III. Therapeutic/care management study, level IV.

A comparison of the treatment of severe injuries between the former East and West German States.

BACKGROUND: The annual number of persons killed in road-traffic accidents in Germany declined by 36% from 2001 to 2008, yet official traffic statistics still reveal a marked difference in fatalities between the federal states of the former East and West Germany twenty years after German reunification. METHODS: We retrospectively analyzed data from the Trauma Registry of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; TR-DGU). Patients receiving primary treatment that had an Injury Severity Score (ISS) of 9 or above were analyzed separately depending on whether they were treated in the former East Germany or the former West Germany. RESULTS: Data were obtained from a total of 26 866 road-accident trauma cases. With Berlin excluded, 2597 cases (10.2%) were from the former East Germany (EG), and 22 966 (89.9%) were from the former West Germany (WG). The percentage of the population living in these two parts of the country is 16.7% and 83.3%, respectively. The two groups did not differ significantly in either the mortality of injuries (EG 15.8%, WG 15.7%) or in the standardized mortality rate (0.89 [EG] vs. 0.88 [WG]). Over the years 2002-2008, the mean time to arrival of the emergency medical services on the scene was 19 minutes (EG) vs. 17 minutes (WG), and the mean time to arrival in hospital was 76 minutes (EG) vs. 69 minutes (WG). CONCLUSION: Among the hospitals whose cases are included in the TR-DGU, there is no significant difference between the former East and West Germany with respect to mortality or any other clinically relevant variable. Hypothetically, the higher rate of death from road-traffic accidents in the former East Germany, as revealed by national traffic statistics, might be attributable to a difference in the quality of care received by trauma patients, but no such difference was found. Other potential reasons for it might be poorer road conditions, more initially fatal accidents, and lower accessibility of medical care in less densely populated areas.