Management einer chronischen vorderen, verhakten Schulterluxation während des COVID-19-Lockdowns

<jats:title>Zusammenfassung</jats:title><jats:p>In diesem Beitrag wird der Fall einer chronisch verhakten vorderen Schulterluxation bei einem 25-jährigen, geistig retardierten Patienten geschildert, welcher während des ersten COVID-19-Lockdowns eine verspätete orthopädisch-fachärztliche Versorgung erhielt. Die Therapie bestand in der offenen Reposition mittels Tuberculum-minus-Osteotomie, einer Auffüllung des Hill-Sachs-Defekts sowie einer knöchernen Glenoidaugmentation, jeweils mit autologem trikortikalem Beckenkammspan. Die hierzulande seltene Verletzung zeigt in Ländern mit erschwertem Zugang zum Gesundheitssystem eine höhere Inzidenz mit hochgradiger Funktionseinschränkung.</jats:p&gt

Pre-hospital emergent intubation in trauma patients: the influence of etomidate on mortality, morbidity and healthcare resource utilization

BackgroundDue to its favorable hemodynamic characteristics and by providing good intubation conditions etomidate is often used for induction of general anesthesia in trauma patients. It has been linked to temporary adrenal cortical dysfunction. The clinical relevance of this finding after a single-dose is still lacking appropriate evidence.MethodsThis retrospective multi-centre study is based on merged data from a German Helicopter Emergency Medical Service (HEMS) database and a large trauma patient registry. All trauma patients who were intubated prior to hospital admission with a documented Injury Severity Score9 between 2008 and 2012 were eligible for analysis. The primary endpoint was hospital mortality. Other outcome measures were organ failures, sepsis, length of ventilation, as well as length of stay in hospital and ICU.ResultsOne thousand six hundred ninety seven patients were enrolled into the study. Seven hundred sixty two patients received etomidate and 935 patients received other induction agents. The in-hospital mortality was similar in both groups (18.9% versus 18.2%; p=0.71). Incidences of organ failures and sepsis were not increased in the etomidate group. However, health care resource utilization parameters were prolonged (after adjusting: +1.3days for ICU length of stay, p=0.062; +0.8days for length of ventilation, p=0.15; +2,7days for hospital length of stay, p=0.034). A multivariable logistic regression analysis did not identify etomidate as an independent predictor of hospital mortality (OR: 1.10, 95% CI: 0.77-1.57; p=0.60).ConclusionsThis is the largest trial investigating outcome data for trauma patients who had received a single-dose of etomidate for induction of anesthesia. The use of etomidate did not affect mortality. The influence on morbidity and health care resource utilization remains unclear

Schwerverletztenversorgung durch Notärzte aus unterschiedlichen Fachgebieten

Background and objective!#!The level 3 guidelines on treatment of patients with severe/multiple injuries provide a defined framework for an appropriate treatment of these patients. It is presumed that prehospital diagnostic and therapeutic decisions are affected by the clinical expertise and the medical disciplines of the emergency physicians.!##!Methods!#!Retrospective, multicenter study based on data from the ADAC Air Recue Service and the TraumaRegister DGU®. In the study period 2011-2015, a total of 11,019 seriously injured patients were included. They were treated by emergency physicians from the following disciplines: anesthesiology (ANÄ), internal medicine (INN) and surgery (CHIR).!##!Results!#!Of the patients 81.9% were treated by ANÄ, 7.6% by INN and 10.5% by CHIR. Preclinically, 40.5% of patients were intubated (ANÄ 43.0%, INN 31.2%, CHIR 28.3%; p < 0.001), 5.5% received pleural decompression (ANÄ 5.9%, INN 4.2%, CHIR 2.8%; p = 0.004),and 10.8% were treated with catecholamines (ANÄ 11.3%, INN 8.3%, CHIR 8.3%; p = 0.022). Unconscious patients were intubated in 96.0% (ANÄ 96.1%, INN 97.7%, CHIR 93.9%; p = 0.205). The mortality was not influenced by the medical specialty of the emergency physician.!##!Conclusion!#!In this air rescue cohort differences in indications for invasive procedures were observed between the groups. This may be caused by their clinical background. Using the example of intubation, it has been shown that guideline recommendations were closely followed irrespective of the medical specialty of the emergency physician

Changes in anaesthetic use for trauma patients in German HEMS – a retrospective study over a ten-year period

Abstract Background Airway management and use of intravenous anaesthetics to facilitate tracheal intubation after major trauma remains controversial. Numerous agents are available and used for pre-hospital rapid-sequence induction (RSI). The aim was to investigate usage and potential changes in administration of intravenous anaesthetics for pre-hospital RSI in trauma patients over a ten-year period. Methods Based on a large helicopter emergency medical service (HEMS) database in Germany between 2006 and 2015, a total of 9720 HEMS missions after major trauma leading to RSI on scene were analysed. Administration practice of sedatives and opioids were investigated, while neuromuscular blocking agents were not documented in the database. Results With respect to administration of sedatives, independent from trauma mechanism and specific injury patterns the use of Etomidate decreased dramatically (52 to 6%) in favour of a more frequent use of Propofol (3 to 32%) and Ketamine (9 to 24%; all p  1 at initial contact, the administration rate of Etomidate dropped significantly as well. This decline was mainly substituted by Ketamine and particularly Propofol. In patients with GCS ≤ 8 upon initial contact, a similar distribution compared to the general trauma population could be observed. With respect to opioids, mainly Fentanyl has been administered for RSI in trauma patients (2006: 69,6% to 2015: 60.2%; p < 0.001), while the use of sufentanyl showed a significant increase (0.2 to 8.8%; p < 0.001). Conclusions This large study analysed prehospital administration of anaesthetics in trauma patients, showing a substantial change from 2006 to 2015 despite the lack of any high-level evidence. Etomidate has shifted from the main sedative substance to virtual absence, indicating that the recommendation of an established national guideline was transferred into clinical practice, although based on weak evidence as well. The pre-hospital use of Propofol showed a particular increase. Fentanyl has been the main opioid drug for RSI in trauma, however Sufentanyl has become increasingly popular. The mechanisms and advantages of the different substances still have to be elucidated, especially in head injury and bleeding trauma

Alcohol and trauma: the influence of blood alcohol levels on the severity of injuries and outcome of trauma patients - a retrospective analysis of 6268 patients of the TraumaRegister DGU®

Background!#!Blood alcohol level (BAL) has previously been considered as a factor influencing the outcome of injured patients. Despite the well-known positive correlation between alcohol-influenced traffic participation and the risk of accidents, there is still no clear evidence of a positive correlation between blood alcohol levels and severity of injury. The aim of the study was to analyze data of the TraumaRegister DGU!##!Methods!#!Datasets from 11,842 trauma patients of the TR-DGU from the years 2015 and 2016 were analyzed retrospectively and 6268 patients with a full dataset and an AIS ≥ 3 could be used for evaluation. Two groups were formed for data analysis. A control group with a BAL = 0 ‰ (BAL negative) was compared to an alcohol group with a BAL of ≥0.3‰ to &amp;lt; 4.0‰ (BAL positive). Patients with a BAL &amp;gt;  0‰ and &amp;lt;  0.3‰ were excluded. They were compared with regard to various preclinical, clinical and physiological parameters. Additionally, a subgroup analysis with a focus on patients with a traumatic brain injury (TBI) was performed. A total of 5271 cases were assigned to the control group and 832 cases to the BAL positive group. 70.3% (3704) of the patients in the control group were male. The collective of the control group was on average 5.7 years older than the patients in the BAL positive group (p &amp;lt; .001). The control group showed a mean ISS of 20.3 and the alcohol group of 18.9 (p = .007). In terms of the injury severity of head, the BAL positive group was significantly higher on average than the control group (p &amp;lt;  0.001), whereas the control group showed a higher AIS to thorax and extremities (p &amp;lt;  0.001). The mean Glasgow Coma Scale (GCS) was 10.8 in the BAL positive group and 12.0 in the control group (p &amp;lt;  0.001). Physiological parameters such as base excess (BE) and International Normalized Ratio (INR) showed reduced values ​​for the BAL positive group. However, neither the 24-h mortality nor the overall mortality showed a significant difference in either group (p = 0.19, p = 0.14). In a subgroup analysis, we found that patients with a relevant head injury (AIS: Abbreviated Injury Scale head ≥3) and positive BAL displayed a higher survival rate compared to patients in the control group with isolated TBI (p &amp;lt; 0.001).!##!Conclusions!#!This retrospective study analyzed the influence of the blood alcohol level in severely injured patients in a large national dataset. BAL positive patients showed worse results with regard to head injuries, the GCS and to some other physiological parameters. Finally, neither the 24-h mortality nor the overall mortality showed a significant difference in either group. Only in a subgroup analysis the mortality rate in BAL negative patients with TBI was significantly higher than the mortality rate of BAL positive patients with TBI. This mechanism is not yet fully understood and is discussed controversially in the literature

Arthroscopic Transosseous Suture Button Fixation Technique for Treatment of Large Anterior Glenoid Fracture

To date, several open and arthroscopic surgical procedures are available for the treatment of anterior glenoid fractures after anterior shoulder dislocation. Open approaches require extensive soft-tissue dissection and are associated with poorer outcomes. Arthroscopic screw fixation techniques are technically challenging and related to complications as well, for example, risk of brachial plexus injury or hardware impingement. Alternative arthroscopic fixation techniques use suture anchors placed along the fracture rim with sutures passed around the fragment. However, these techniques require an intact capsulolabral complex and cannot be used effectively for large fracture fragments. This article describes a safe interfragmentary, transosseous, all-arthroscopic procedure using a double–cortical button fixation technique. This method can be used to achieve anatomic reduction and stable fixation of intermediate to large anterior glenoid fractures while minimizing the difficulties associated with previously described arthroscopic or open approaches