[Diagnosis and immediate therapeutic management of limb injuries. A systematic review of the literature]. / Diagnostik und sofortige Therapiemassnahmen bei Verletzungen der Extremitäten. Eine systematische Literaturübersicht.

OBJECTIVE: Limb injuries are often underestimated in the diagnostic procedures initiated in the resuscitation room. Missed diagnosis is therefore a frequent consequence in this issue. A systematic analysis of evidence-based procedures was therefore investigated in this paper. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Following admission of a multiple trauma patient vital functions have to be established in first priority. After stabilization a systematic clinical investigation and consecutive specific radiological procedures should rule out extremity injuries. These are the only evidence-based criteria leading to a complete detection of all limb injuries. All other aspects are only based on clinical experience or the opinion of expert committees. CONCLUSION: The quality of shock room management is mostly dependent on the experience of the " trauma team" (and especially of the trauma leader). Guidelines and specific trauma algorithms can provide a helpful instrument in this issue.

Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

[Analysis of the incidence and causes of mass casualty events in a southern Germany medical rescue area]. / Analyse der Inzidenz und Ursachen von Grossschadensereignissen in einem süddeutschen Rettungsdienstbereich.

UNLABELLED: The growing number of mass casualty events during the early 1990s led, in January 1996, to the foundation of an honorary group of specially trained emergency physicians for dealing primarily with the management of large-scale emergency events and mass casualties. The incidence and quantity of these casualties was analysed in order to be better prepared for such events in the future. METHODS: All calls prospectively registered by the Augsburg Rescue Co-ordination Centre (ARCC) in the 5 years from July 1997 to June 2002 were analysed, distinguishing between the different types of damage, number of patients involved, and time of occurrence (time of day/season). The area served by the ARCC includes the city of Augsburg with its surrounding counties. An estimated 850,000 inhabitants live in this area of 4,100 square kilometers (1,600 square miles). Since 1998, more than 145,000 calls a year have been dealt with of which 28,000 were covered by emergency physicians. In the 5 year period discussed here, 75 large-scale-calls were registered, giving an average incidence of 1.25 calls/month. Most of the calls were fire alarms, followed by car accidents. In total, we were able to serve more than 800 patients. The lowest number per event was two people during an emergency landing of a sport aircraft; the largest number was about 150 patients during a large open-air event in the city. While there was no difference in the time of day at which the event happened, most occurred in November and December. Taking these results into account, the authors, supported by the members of the emergency physician team of the German Trauma Society, developed an algorithm describing the optimal procedure for mass casualty events. This is presented here. In mass casualty or large-scale emergency events, an experienced emergency physician is necessary to co-ordinate the rescue brigades on site.

[Emergency treatment of penetrating, combined thoracic- and abdominal injury. Pre-hospital i.v. fluid therapy]. / Erstversorgung einer penetrierenden 2-Höhlen-Verletzung Diskussion des präklinischen Managements der Volumentherapie.

We report the rare case of a penetrating, combined thoracic- and abdominal injury as a consequence of a farm work accident. During the recent years, a "treat and run" approach has been increasingly advocated as a time-saving way of treating penetrating injuries, constituting a compromise between the existing strategies of "scoop and run" (used mainly in the USA) and "stay and treat" (preferred in Central Europe). A prolonged rescue response time makes the treat and run approach impossible here. Immediate treatment at the accident site requires an appropriate provision of i.v. fluids. We examine the course of pre-hospital treatment of a trauma patient to illustrate the various approaches to i.v. fluid therapy in relation to rescue response time. However there are only a few studies with a real evidence. If "treat and run" is not possible, the outcome of patients with penetrating trauma can be influenced positively by moderate fluid therapy under continuous monitoring after having reached a constant, low mean arteria pressure (so called permissive hypotension).

[Ventilation according to the "open lung" concept of multiple trauma patients]. / Beatmung nach dem "open-lung"-Konzept bei polytraumatisierten Patienten.

OBJECTIVE: The ventilation mode clearly influences the course of patients with multiple trauma on the ICU. Ventilation according the "open lung" approach rapidly opens up atelectatic lung regions. Generation of an adequate intrinsic PEEP enables to keep the lung open. We studied the consequences of the "open lung" approach on the lung function and monitored its side effects on patients with multiple trauma. METHODS: 18 consecutive patients with multiple trauma and additional thoracic trauma were routinely ventilated according the "open lung" approach between May and November 1999. We were mainly interested in data of lung mechanics, oxygenation and ventilation. Side effects on other organ systems and consequence for the infection rate were monitored. RESULTS: Ventilation according the "open lung" approach enables early sufficient oxygenation and ventilation of patients with severe multiple trauma and accompanying thoracic trauma. The ventilation mode helps to prevent baro-, volu- and atelectrauma and thus fulfils the requirements for a present-day ventilation mode. An immediate complete healing of the lung damages was not found. Nevertheless, as a trend the length of ventilation support seems short. Even extensive osteosynthesis at multiple fractures was possible without delay. Side effects of the high opening pressure on the lung or other organs as well as sequels of the high intrinsic PEEP on liver, kidney or intestine were not found. The infection rate was low, therapeutic doses of antibiotics were necessary only in less than half of the ICU-stay. CONCLUSION: Ventilation according the "open lung" approach is a very effective and safe way to ventilate patients after severe multiple trauma with accompanying thoracic trauma.