[Trauma-associated bleeding in the severely injured. Relevance, risk stratification and current therapy approaches]. / Traumaassoziierte Blutung beim Schwerverletzten. Relevanz, Risikostratifizierung und aktuelle Therapieansätze.

Of all trauma-related deaths 40% are due to exsanguination. The causes for acute, hemorrhaging are uncontrolled bleeding sources and the development of acute posttraumatic coagulopathy. Clinical observations and recent research results emphasize the key role of this disorder in acute trauma care. The present synopsis summarizes the results from different analyses based on datasets from severely injured patients derived from the Trauma Register of the German Trauma Society (DGU) on frequency, potential triggers and strategies to manage acute posttraumatic coagulopathy. In an extension to this work a clinical scoring system for early identification of patients at high risk for ongoing bleeding is presented. High risk patients seem to benefit from a more balanced transfusion regimen.

[Imaging in the emergency room]. / Bildgebung im Schockraum.

In order to reduce mortality in severely injured patients, a rapid radiologic diagnosis is essential. Sonography plays a role only as a focused assessment with sonography for trauma (FAST) to clarify free intraperitoneal fluid immediately on admittance. Today, whole-body multislice helical computed tomography (CT) has become increasingly important as a diagnostic tool. Based on the results of the CT scan, patients can be referred for laparotomy or safely classified for "wait and see" treatment. Although the reduction in injury-related mortality would outweigh the risk of radiation dose, the indiscriminate use of CT for patients with minor injuries is not justified and must be avoided.

[Application of the pelvic C-clamp]. / Die Anlage der Notfall-Beckenzwinge.

Unstable pelvic girdle injury combined with severe pelvis related haemorrhage has a high mortality rate. This prognosis can be improved by using the C-clamp according to Ganz. This can be applied while the life saving measures are in progress, and should, if necessary, be combined with a pelvic tamponade. Due to the limited number of patients, trauma centres have the most experience with this technique. In this contribution, we present our standardised application technique, which allows the use of the procedure through well defined clinically recognisable orientation points in the emergency room.

Predicting the need for laparotomy in pediatric trauma patients on the basis of the ultrasound score.

BACKGROUND: It is possible to quantify the amount of hemoperitoneum seen on focused assessment with sonography for trauma (FAST) using a simple scoring system that had previously been shown to correlate with the need for subsequent laparotomy in adults. A score of 3 or greater was shown to be highly accurate in predicting the need for laparotomy. We hypothesized that this scoring system might also predict the need for laparotomy in pediatric trauma patients. METHODS: We retrospectively reviewed all records for patients 15 years and younger who underwent FAST after blunt trauma. A "positive" ultrasound examination was defined as one containing free intraperitoneal fluid with or without solid organ injury. The ultrasound score (USS) was defined as the depth of the deepest pocket of fluid collection measured in centimeters plus the number of additional spaces where fluid was seen. RESULTS: Thirty-eight (19.6%) of 193 patients who had FAST performed had positive ultrasound examinations. Thirty-seven patients with complete records were analyzed. There were no differences between patients with a USS < or = 3.0 and those with a USS > 3.0 in terms of admission pulse, Glasgow Coma Scale score, Injury Severity Score, or the proportion of patients who were initially hypotensive. One of 22 patients with a USS < or = 3.0 required therapeutic laparotomy versus 8 of 15 patients with a USS > 3.0 ( = 0.002). For a USS > 3.0, sensitivity, specificity, and accuracy in predicting therapeutic laparotomy were 89%, 75%, and 78%, respectively. CONCLUSION: Ultrasound quantification of hemoperitoneum by a simple scoring system may serve as a useful adjunct to traditional clinical parameters in predicting the need for subsequent laparotomy in pediatric patients. Prospective validation with a larger study is required.

Hemoperitoneum score helps determine need for therapeutic laparotomy.

PURPOSE: Sonography provides a fast, portable, and noninvasive method for patient assessment. However, the benefit of providing real-time ultrasound (US) imaging and fluid quantification shortly after patient arrival has not been explored. The objective of this study was to prospectively validate a US hemoperitoneum scoring system developed at our institution and determine whether sonography can predict a therapeutic operation. METHODS: For 12 months, prospective data on all patients undergoing a trauma sonogram were recorded. All sonograms positive for free fluid were given a hemoperitoneum score. The US score was compared with initial systolic blood pressure and base deficit to assess the ability of sonography to predict a therapeutic laparotomy. RESULTS: Forty of 46 patients (87%) with a US score > or = 3 required a therapeutic laparotomy. Forty-six of 54 patients with a US score < 3 (85%) did not need operative intervention. The sensitivity of sonography was 83% compared with 28% and 49% for systolic blood pressure and base deficit, respectively, in determining the need for therapeutic operation. CONCLUSION: We conclude that the majority of patients with a score > or = 3 will need surgery. The US hemoperitoneum scoring system was a better predictor of a therapeutic laparotomy than initial blood pressure and/or base deficit.

[Non-operative/conservative treatment of hemoperitoneum in children]. / Le traitement non-opératoire/conservatoire de l'hémopéritoine chez l'enfant.

The authors present 34 cases of the traumatic hemoperitoneum with nonoperative/conservative treatment followed up in the past five years. The cases of hemoperitoneum are divided into three categories: hemorrhagic shock; stable clinic status; unstable clinic status. The first category included the cases of operational emergency, the other two categories were treated in the intensive care unit; the most of them needed no operation. The punction and punction-lavage of the peritoneum was systematically carried out and it was a therapeutic step of draining out the blood and appreciating the importance of hemoperitoneum. If laparotomy was requested initially or later on, a conservative surgery was used: spleen-hepatorrhaphy, partial splenectomy, selective arterial ligations, splenic replantation.