Effect of coronavirus (COVID-19) pandemic on orthopedic trauma patients presenting in the emergency department of a maximum care hospital and level 1 trauma center.

INTRODUCTION: While overcrowding of emergency departments was often reported in the recent years, during the early phase of the pandemic, a reduction in patient numbers was seen. The aim of the current study was to describe the orthopedic trauma patient cohort presenting to the emergency department (ED) during the early pandemic period as compared to the cohort from the analogue time period 2019. MATERIALS AND METHODS: A single-center case-control study was performed. All the consecutive orthopedic trauma patients > 12 years presenting to the ED were included. Patients in the same time period in 2019 served as the control group. RESULTS: Compared to 2019, in 2020, 33% less patients presented in the emergency department. Patients treated in 2020 were significantly older, significantly more often brought to ED by emergency medical services and significantly more often admitted. The number of fractures and diagnoses requiring surgical treatment decreased only slightly and the proportion of these patients among all the patients was significantly higher during the pandemic than in the control period. Furthermore, a higher percentage of polytrauma patients could be found in 2020 as well. Analysis of Manchester Triage System showed significantly less not urgent patients in 2020. CONCLUSION: The present study shows a significant decline in the number of patients treated in the ED during the pandemic period but at the same time almost identical numbers of patients with fractures or diagnoses requiring surgical treatment. In the context of an overall decline in patient numbers, a stronger concentration on level 1 trauma centers seems to be evident during the pandemic.

Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary?

BACKGROUND: While several studies report on accuracy rates of pedicle screws, risk factors associated with inaccurate pedicle screw positioning in patients with thoracolumbar fractures are reported rarely. CT scan as a routine postoperative control is advocated by various authors, however its necessity remains unclear. METHODS: Two hundred forty-five patients were included in this retrospective study. Percutaneous dorsal instrumentation was most commonly performed (n = 201). Classification of Zdichavsky et al. and Rao et al. were used to classify screw misplacement and anterior perforation was further evaluated according to the extent of perforation (< 2 mm; > 2 mm). Multivariate analysis was performed to identify risk factors for misplacement of screws. RESULTS: One thousand sixty-eight pedicle screws were inserted in 245 patients. Misplacement was found in 51 screws (4.8%) in 42 patients (17.1%) according to the classification of Zdichavsky et al. and in 75 screws (7.0%) in 64 patients (26.1%) according to the classification of Rao et al.. An anterior perforation of the vertebral cortex was found in 56 screws (5.2%). Multivariate analysis showed fracture location in the upper thoracic (p = 0.048) and lumbar spine (p = 0.013) to be the only independent predictors for screw misplacement. In addition a significant correlation between pedicle diameter and the occurrence of screw malposition was found (p = 0.003). No consequences were drawn from postoperative routine CT in asymptomatic patients. CONCLUSION: An overall low rate of screw misplacement was found with fracture location in the upper thoracic and lumbar spine being the only factors independently associated with the risk of screw misplacement. No consequences were drawn from postoperative routine CT in asymptomatic patients. Therefore its use has to be discussed critically.

[Early clinical care strategy for severely injured patients with abdominal trauma]. / Frühe klinische Versorgungsstrategien für schwerverletzte Patienten mit Abdominaltrauma.

BACKGROUND: The presence of abdominal injuries has a major impact on the mortality of severely injured patients. For injuries that require surgery, laparotomy is still the gold standard for early surgical care; however, there is increasing evidence that laparoscopy may be an alternative in the early clinical care of polytrauma patients. OBJECTIVE: The present registry-based study analyzed the utilization and the outcome of laparoscopy in severely injured patients with abdominal trauma in Germany. MATERIAL AND METHODS: A retrospective analysis of 12,447 patients retrieved from the TraumaRegister DGU® (TR-DGU) was performed. The primary inclusion criteria were an injury severity score (ISS) ≥ 9 and an abbreviated injury scale (AIS) [abdomen] ≥ 1. The included patients were grouped according to early treatment management: (1) laparoscopy, (2) laparotomy and (3) non-operative management (NOM). Finally, group-specific patient characteristics and outcome were analyzed. RESULTS: The majority of patients were treated by NOM (52.4%, n = 6069), followed by laparotomy (50,6%, n = 6295) and laparoscopy (0.7%, n = 83). The majority of laparoscopies were performed in patients with an AIS [abdomen] ≤ 3 (86.7%). The ISS of the laparoscopy group was significantly lower compared to that of the laparotomy and NOM groups (ISS 23.4 vs. 34.5 vs. 28.2, respectively, p ≤ 0.001). The standardized mortality rate (SMR), defined as the ratio between observed and expected mortality, was lowest in the patients receiving laparoscopy followed by laparotomy and NOM (SMR 0.688 vs. 0.931 vs. 0.932, respectively, p-value = 0.2128) without achieving statistical significance. CONCLUSION: Despite being rarely employed the data indicate the effectiveness of laparoscopy for the early treatment of severely injured, hemodynamically stable patients with an AIS [abdomen] ≤ 3.

Hypothermia does not influence liver damage and function in a porcine polytrauma model.

BACKGROUND: Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls. RESULTS: Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well. CONCLUSIONS: Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.

Long-Term Effects of Induced Hypothermia on Local and Systemic Inflammation - Results from a Porcine Long-Term Trauma Model.

BACKGROUND: Hypothermia has been discussed as playing a role in improving the early phase of systemic inflammation. However, information on the impact of hypothermia on the local inflammatory response is sparse. We therefore investigated the kinetics of local and systemic inflammation in the late posttraumatic phase after induction of hypothermia in an established porcine long-term model of combined trauma. MATERIALS & METHODS: Male pigs (35 ± 5kg) were mechanically ventilated and monitored over the study period of 48 h. Combined trauma included tibia fracture, lung contusion, liver laceration and pressure-controlled hemorrhagic shock (MAP < 30 ± 5 mmHg for 90 min). After resuscitation, hypothermia (33°C) was induced for a period of 12 h (HT-T group) with subsequent re-warming over a period of 10 h. The NT-T group was kept normothermic. Systemic and local (fracture hematoma) cytokine levels (IL-6, -8, -10) and alarmins (HMGB1, HSP70) were measured via ELISA. RESULTS: Severe signs of shock as well as systemic and local increases of pro-inflammatory mediators were observed in both trauma groups. In general the local increase of pro- and anti-inflammatory mediator levels was significantly higher and prolonged compared to systemic concentrations. Induction of hypothermia resulted in a significantly prolonged elevation of both systemic and local HMGB1 levels at 48 h compared to the NT-T group. Correspondingly, local IL-6 levels demonstrated a significantly prolonged increase in the HT-T group at 48 h. CONCLUSION: A prolonged inflammatory response might reduce the well-described protective effects on organ and immune function observed in the early phase after hypothermia induction. Furthermore, local immune response also seems to be affected. Future studies should aim to investigate the use of therapeutic hypothermia at different degrees and duration of application.

The relationship between initial closed reduction and the surgical reconstruction of the radiocarpal joint line in distal radial fractures.

INTRODUCTION: Whilst initial closed reduction followed by definitive open fixation is widely applied in the treatment of distal radial fractures, the effect of the closed reduction on the reconstruction of the articular surface remains unclear. Our research questions were: METHODS: Palmar tilt and radiocarpal inclination of 425 patients were measured at admission, following initial closed reduction and after surgical reconstruction. RESULTS: Closed reduction increased palmar tilt by 12.1° and radial inclination by 2.7°. Open surgical reduction further corrected palmar tilt by 17.88° and radial inclination by 3.5°. Whilst there was no association between postoperative palmar tilt and initially achieved closed reduction, a significant association between radial inclination following closed reduction and surgical fixation was found. CONCLUSION: Our retrospective study challenges the existence of a relationship between the initial closed reduction and the reconstruction of the anatomic joint line in surgically treated distal radial fractures.

[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.

A porcine polytrauma model with two different degrees of hemorrhagic shock: outcome related to trauma within the first 48 h.

BACKGROUND: An animal polytrauma model was developed, including trunk and extremity injuries combined with hemorrhagic shock and a prolonged post-traumatic phase. This could be useful for the assessment of different therapeutic approaches during intensive care therapy. METHODS: A standardized polytrauma including lung contusion, liver laceration and lower leg fracture was applied in 25 pigs. They underwent controlled haemorrhage either with a blood volume loss of 45 % and a median arterial pressure (MAP) <30 mmHg/90 min (group L, n = 15) or a 50 % blood loss of and an MAP <25 mmHg/120 min (group H, n = 10). Five non-traumatized pigs served as a control (group C). Subsequently, intensive care treatment was given for an observational period of 48 h. RESULTS: Both trauma groups showed signs of shock and organ injury (heart rate, MAP and lactate). The frequency of cardiopulmonary resuscitation (CPR) and lung injury was directly related to the severity of the haemorrhagic shock (CPR-group L: 4 of 15 pigs, group H: 4 of 10 pigs; Respiratory failure-group L: 3 of 13, group H: 3 of 9. There was no difference in mortality between trauma groups. CONCLUSION: The present data suggest that our model reflects the mortality and organ failure of polytrauma in humans during shock and the intensive care period. This suggests that the experimental protocol could be useful for the assessment of therapeutic approaches during the post-traumatic period.

[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.

[Diagnosis and treatment of abdominal trauma]. / Diagnostik und Therapie des Abdominaltraumas.

Abdominal trauma represents the leading cause of haemorrhagic shock in the severely injured patient and is associated with high mortality and morbidity rates. The trauma surgeon has a central role in the multidisciplinary team addressing the specific diagnostic and therapeutic needs of patients with abdominal trauma. The management of blunt and penetrating abdominal trauma has undergone substantial changes in recent decades. Major innovations have been established in the field of diagnostic imaging and of nonoperative interventions such as angioembolization and endoscopic procedures. Another key development is the introduction of the damage control concept for the care of patients with abdominal trauma. The present manuscript comprises a review of the current management of abdominal trauma with an emphasis on diagnostic and therapeutic innovations.

Mechanism of injury and treatment of trauma-associated acute compartment syndrome of the foot.

Acute compartment syndrome (ACS) of the foot represents a rare complication following trauma of the lower extremity. Early diagnosis and treatment are necessary to prevent poor outcome. The study was conducted to describe etiology and treatment of foot ACS. In the current study, patients diagnosed with and treated for ACS between 1st December 2000 and 30th September 2007 were included. Mechanism of injury, additional injuries and treatment was analyzed. We included 31 patients (21 males) with a mean age of 33.8 ± 16.9 years. Most injuries were caused by a motor vehicle accident, while nearly 20 % occurred after a low-energy mechanism. Multiple injuries with a mean ISS of 19.5 ± 11.0 were present in 14 patients. Superficial infections occurred in 6 feet, while a deep infection only developed in one patient. Acute compartment syndrome of the foot has a low incidence. A thorough clinical examination in patients on risk is required to provide timely diagnosis and adequate surgical decompression.

[Influence of comorbidities and delay in surgical treatment on mortality following femoral neck fracture]. / Der Einfluss von Begleiterkrankungen und operativem Versorgungszeitpunkt auf die Mortalität bei Patienten mit Schenkelhalsfraktur.

BACKGROUND: Hip fractures typically occur in geriatric patients representing an increasing medical as well as socioeconomic challenge. PATIENTS AND METHODS: In order to reveal the influence of considerable comorbidities and the time of surgery in the treatment of geriatric hip fractures we analysed patients treated between 1993 and 2008 at a level I trauma centre. RESULTS: 654 patients with isolated hip fractures were included. Surgical treatment was performed with osteosynthetic stabilisation in 55.5 % (n = 363) and with endoprosthetic implants in 44.5 % (n = 291). The presence of pulmonary, psychiatric and metabolic/endocrinological comorbidities resulted in delayed treatment. If an early surgical treatment was performed within the first 12 hours after hospital admission, long-term survival was significantly improved (p = 0.02). A regression analysis revealed a statistical trend towards an increased mortality of 0.2 % per hour delay after hospital admission. The presence of considerable comorbidities and surgical treatment with endoprosthetic implants (odds ratio 1.611) were proven as independent mortality factors. CONCLUSION: The present study supports the guideline of early surgical treatment of geriatric hip fractures. Emphasising the incidence of in-hospital complications and the mortality after endoprosthetic treatment, osteosynthetic fracture stabilisation should be considered in the presence of considerable morbidity and pre-surgical immobilisation.

[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.

Effects of accidental hypothermia on posttraumatic complications and outcome in multiple trauma patients.

INTRODUCTION: Accidental hypothermia seems to predispose multiple trauma patients to the development of posttraumatic complications, such as Systemic Inflammatory Response Syndrome (SIRS), sepsis, Multiple Organ Dysfunction Syndrome (MODS), and increased mortality. However, the role of accidental hypothermia as an independent prognostic factor is controversially discussed. The aim of the present study was to evaluate the incidence of accidental hypothermia in multiple trauma patients and its effects on the development of posttraumatic complications and mortality. PATIENTS AND METHODS: Inclusion criteria for patients in this retrospective study (2005-2009) were an Injury Severity Score (ISS) ≥16, age ≥16 years, admission to our Level I trauma centre within 6h after the accident. Accidental hypothermia was defined as body temperature less than 35°C measured within 2 h after admission, but always before first surgical procedure in the operation theatre. The association between accidental hypothermia and the development of posttraumatic complications as well as mortality was investigated. Statistical analysis was performed with χ(2)-test, Student's t-test, ANOVA and logistic regression. Statistical significance was considered at p<0.05. RESULTS: 310 multiple trauma patients were enrolled in the present study. Patients' mean age was 41.9 (SD 17.5) years, the mean injury severity score was 29.7 (SD 10.2). The overall incidence of accidental hypothermia was 36.8%. The overall incidence of posttraumatic complications was 77.4% (SIRS), 42.9% (sepsis) and 7.4% (MODS), respectively. No association was shown between accidental hypothermia and the development of posttraumatic complications. Overall, 8.7% died during the posttraumatic course. Despite an increased mortality rate in hypothermic patients, hypothermia failed to be an independent risk factor for mortality in multivariate analysis. CONCLUSIONS: Accidental hypothermia is very common in multiply injured patients. However, it could be assumed that the increase of mortality in hypothermic patients is primarily caused by the injury severity and does not reflect an independent adverse effect of hypothermia. Furthermore, hypothermia was not shown to be an independent risk factor for posttraumatic complications.

Both column fractures of the acetabulum: epidemiology, operative management and long-term-results.

PURPOSE OF THE STUDY: Both column fractures, defined as an acetabular fracture with no articular fragment in connection with the axial skeleton account for approximately 20% of all acetabular fractures. The typical type of a both column acetabular fracture is the C1.2 fracture with a multifragmentary anterior column fracture extending to the iliac crest and a large posterior column fragment in more than half of the patients. MATERIAL AND METHODS: The analysis of 135 surgically treated patients with both column fractures showed that more than half of these patients had associated injuries. The mean age was 40 years, and two thirds of these patients were male. A high energy trauma was the trauma mechanism in 87.4%. The mean ISS was 14.2 points. The mean articular fracture displacement was 14.8 mm. 65.9% of the patients showed a central femoral head dislocation. An associated posterior wall fracture was present in 34.8% and an acetabular roof comminution in 34.1%. 8.9% of patients had a fracture related nerve damage. RESULTS: Osteosynthesis was performed 9.6 days after trauma. Several approaches were used for stabilization with a combination of plate and screw fixation in 71.9%. The mean operative time was 287 minutes with a blood loss of 1796 ml. Post operatively the hip joint was congruent in 94.7% with anatomical or near-anatomical joint reconstruction in 75.6%. Iatrogenic nerve injury occurred in 12 patients (8.9%). 89 patients (66.4%) could be followed after a mean of 54.6 months. The average subjective Visual Analog Scale pain score was 27.6. Mild or no pain was seen in 60.7%. The mean Merle d'Aubigné score was 15 with 60.7% of patients having a functionally perfect or good result. 61.8% had no post-traumatic osteoarthritic changes of their hip joint. A joint failure was diagnosed in 25.8% of the patients. DISCUSSION: Analysing only patients with anatomically reconstructed hip joints patients had better results with 69,8% having no or mild pain and a good or excellent functional result. Post-traumatic arthrotic changes occued in only 17.5% of these patients. A joint failure was present in 25.4%. In this group, a joint failure was significantly more likely to be present with an additional lesion of the femoral head and severe primary articular fracture displacement. CONCLUSIONS: In contrast to other acetabular fracture types, both column fractures show worser results regarding joint reconstruction, and functional and radiological long-term results. The optimal results can be achieved with anatomic joint reconstruction.

[Accidental hypothermia in multiple trauma patients]. / Akzidentelle Hypothermie beim Polytrauma.

BACKGROUND: Hypothermia, defined as a body core temperature below 35 °C, could be divided into an endogeneous, therapeutic and accidental hypothermia. At admission in the emergency room multiple trauma patients show a hypothermic core temperature in up to 66 %. A core temperature below 34 °C seems to be critical in these patients as this temperature limit has been demonstrated to be associated with an increased risk for post-traumatic complications and a decreased survival. In polytraumatised patients with a core temperature below 32 °C a mortality rate of 100 % has been described. MATERIAL AND METHODS: The main pathophysiological effects of hypothermia concern the haemo-dynamic, coagulatory and immune systems. Mild hypothermia (35-32 °C) leads to a vasoconstriction, tachycardia and increased cardiac output. After an increasing arrhythmia and bradycardia severe hypothermia (< 32 °C) finally results in a cardiac arrest. Hypothermia-induced coagulopathy comprises a dysfunction of the cellular and plasmatic coagulation with an increased blood loss. Due to the attenuation of the post-traumatic, pro-inflammatory immune response and enhancement of anti-inflammatory reactions, hypothermia counteracts an overwhelming systemic inflammation, concomitantly resulting in an increased susceptibility for infectious complications. RESULTS: Because of the negative effects of the -accidental hypothermia, effective rewarming is essential for adequate bleeding control and successful resuscitation. As aggressive rewarming (> 0.5 °C / h) has been reported to be associated with an increased mortality during the further course, this procedure should only be applied in hypothermic multiple trauma patients with haemorrhagic shock. CONCLUSION: Accidental hypothermia represents a serious problem in multiple trauma patients due to its frequency and negative pathophysiological effects. Therefore, early and effective re-warm-ing is essential in the treatment of hypothermic trauma patients. Possible protective effects of a therapeutic hypothermia in the treatment of trauma patients after initial resuscitation and operative bleeding control have to be clarified in further experimental and clinical studies.

Productive capacity of alveolar macrophages and pulmonary organ damage after femoral fracture and hemorrhage in IL-6 knockout mice.

Alveolar macrophages (AM) play an important role in the pathogenesis of posttraumatic pulmonary failure, and have been identified as major source of pulmonary cytokines. The effects of locally generated IL-6 as well as femoral fracture on the pulmonary inflammatory response and organ damage have not been fully elucidated. In the present study we evaluated the influence of femoral fracture, isolated or in combination with hemorrhage, on the immune function of AM and remote lung injury, and investigated the role of pulmonary IL-6 within this setting. 18 wild type (WT) and 18 IL-6 knockout mice (IL-6(-/-)) underwent standardized femoral fracture, isolated or in combination with volume-controlled hemorrhage, followed by fluid resuscitation and splint fixation of the fracture. Animals were sacrificed 4h after induction of fracture and hemorrhage. Animals were randomly assigned to three study groups (each consisting of six animals). Besides sham groups, experimental groups included animals with isolated femoral fracture or in combination with hemorrhagic shock. Cytokine release of AM was determined by flow cytometry. Pulmonary damage in terms of interstitial thickening and lung neutrophil infiltration was assessed by histology and immunohistology. The productive capacity of AM for pro-inflammatory cytokines was increased after isolated femoral fracture in WT and IL-6(-/-) mice. An additional hemorrhagic insult resulted in a further enhancement of pro-inflammatory cytokine release and an increased MCP-1 secretion in WT and IL-6(-/-) animals. MCP-1 and pro-inflammatory cytokine production of AM was attenuated in IL-6(-/-) mice compared to the respective WT groups. Interstitial thickening and lung neutrophil infiltration was only observed after femoral fracture combined with hemorrhagic shock with an attenuation of the pulmonary organ damage in IL-6(-/-) compared to WT animals. These results support the role of IL-6 as a therapeutic target for posttraumatic immune modulation. With an increased pro-inflammatory mediator release, already an isolated femoral fracture seems to influence the immune response of AM.

[Jehova's Witnesses and severe injury with impending hemorrhaging : how complex is the treatment?]. / Zeugen Jehovas und Schwerverletzung mit drohender Hämorrhagie : Wie komplex ist die Behandlung?

Hemorrhage is frequently seen during the early phases of polytrauma management and intensive care treatment of the severely injured. Traumatic coagulopathy as well as the sometimes overlooked hyperfibrinolysis may lead to further complications. Therefore, transfusion of blood products and coagulation factors is often crucial. Jehova's Witnesses reject transfusions of blood and blood products due to religious convictions. In this case report a therapeutic approach of a multiple trauma patient suffering from traumatic brain injury, blunt chest trauma and liver laceration is described, who has been treated without blood products. As one main focus, ethical as well as legal aspects are discussed. Beside therapeutic concepts, such as the administration of coagulation factors, recombinant erythropoietin and iron, ethical and legal aspects remain part of the controversial discussion.

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]. / Early Total Care (ETC) im Vergleich zu Damage Control Orthopedics (DCO) bei der Behandlung polytraumatisierter Patienten mit Femurschaftfrakturen: Nutzen und Kosten.

INTRODUCTION: Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS: In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS: In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION: From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).