The trauma patient in hemorrhagic shock: How is the C-priority addressed between emergency and ICU admission?

BACKGROUND: Trauma is the leading cause of death in young people with an injury related mortality rate of 47.6/100,000 in European high income countries. Early deaths often result from rapidly evolving and deteriorating secondary complications e.g. shock, hypoxia or uncontrolled hemorrhage. The present study assessed how well ABC priorities (A: Airway, B: Breathing/Ventilation and C: Circulation with hemorrhage control) with focus on the C-priority including coagulation management are addressed during early trauma care and to what extent these priorities have been controlled for prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock. METHODS: A retrospective analysis of data documented in the TraumaRegister of the ‘Deutsche Gesellschaft für Unfallchirurgie’ (TR-DGU®()) was conducted. Relevant clinical and laboratory parameters reflecting status and basic physiology of severely injured patients (ISS ≥ 25) in either moderate or severe shock according to base excess levels (BE -2 to -6 or BE < -6) as surrogate for shock and hemorrhage combined with coagulopathy (Quick’s value <70%) were analyzed upon ER arrival and ICU admission. RESULTS: A total of 517 datasets was eligible for analysis. Upon ICU admission shock was reversed to BE > -2 in 36.4% and in 26.4% according to the subgroups. Two of three patients with initially moderate shock and three out of four patients with severe shock upon ER arrival were still in shock upon ICU admission. All patients suffered from coagulation dysfunction upon ER arrival (Quick’s value ≤ 70%). Upon ICU admission 3 out of 4 patients in both groups still had a disturbed coagulation function. The number of patients with significant thrombocytopenia had increased 5-6 fold between ER and ICU admission. CONCLUSION: The C-priority including coagulation management was not adequately addressed during primary survey and initial resuscitation between ER and ICU admission, in this cohort of severely injured patients

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries

STUDY DESIGN Retrospective database analysis. OBJECTIVE Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome. METHODS The TraumaRegister DGU$^{®}$ was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined. RESULTS 12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%). CONCLUSIONS The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery

Discrimination and calibration of a prediction model for mortality is decreased in secondary transferred patients: a validation in the TraumaRegister DGU

INTRODUCTION The Revised Injury Severity Classification II (RISC II) score represents a data-derived score that aims to predict mortality in severely injured patients. The aim of this study was to assess the discrimination and calibration of RISC II in secondary transferred polytrauma patients. METHODS This study was performed on the multicentre database of the TraumaRegister DGU. Inclusion criteria included Injury Severity Score (ISS)≥9 points and complete demographic data. Exclusion criteria included patients with 'do not resuscitate' orders or late transfers (>24 hours after initial trauma). Patients were stratified based on way of admission into patients transferred to a European trauma centre after initial treatment in another hospital (group Tr) and primary admitted patients who were not transferred out (group P). The RISC II score was calculated within each group at admission after secondary transfer (group Tr) and at primary admission (group P) and compared with the observed mortality rate. The calibration and discrimination of prediction were analysed. RESULTS Group P included 116 112 (91%) patients and group Tr included 11 604 (9%) patients. The study population was predominantly male (n=86 280, 70.1%), had a mean age of 53.2 years and a mean ISS of 20.7 points. Patients in group Tr were marginally older (54 years vs 52 years) and a had slightly higher ISS (21.5 points vs 20.1 points). Median time from accident site to hospital admission was 60 min in group P and 241 min (4 hours) in group Tr. Observed and predicted mortality based on RISC II were nearly identical in group P (10.9% and 11.0%, respectively) but predicted mortality was worse (13.4%) than observed mortality (11.1%) in group Tr. CONCLUSION The way of admission alters the calibration of prediction models for mortality in polytrauma patients. Mortality prediction in secondary transferred polytrauma patients should be calculated separately from primary admitted polytrauma patients

Age-Dependent Patient and Trauma Characteristics and Hospital Resource Requirements-Can Improvement Be Made? An Analysis from the German Trauma Registry

Background and objectives: The burden of geriatric trauma patients continues to rise in Western society. Injury patterns and outcomes differ from those seen in younger adults. Getting a better understanding of these differences helps medical staff to provide a better care for the elderly. The aim of this study was to determine epidemiological differences between geriatric trauma patients and their younger counterparts. To do so, we used data of polytraumatized patients from the TraumaRegister DGU$^{®}$. Materials and Methods: All adult patients that were admitted between 1 January 2013 and 31 December 2017 were included from the TraumaRegister DGU$^{®}$. Patients aged 55 and above were defined as the elderly patient group. Patients aged 18-54 were included as control group. Patient and trauma characteristics, as well as treatment and outcome were compared between groups. Results: A total of 114,169 severely injured trauma patients were included, of whom 55,404 were considered as elderly patients and 58,765 younger patients were selected for group 2. Older patients were more likely to be admitted to a Level II or III trauma center. Older age was associated with a higher occurrence of low energy trauma and isolated traumatic brain injury. More restricted utilization of CT-imaging at admission was observed in older patients. While the mean Injury Severity Score (ISS) throughout the age groups stayed consistent, mortality rates increased with age: the overall mortality in young trauma patients was 7.0%, and a mortality rate of 40.2% was found in patients >90 years of age. Conclusions: This study shows that geriatric trauma patients are more frequently injured due to low energy trauma, and more often diagnosed with isolated craniocerebral injuries than younger patients. Furthermore, utilization of diagnostic tools as well as outcome differ between both groups. Given the aging society in Western Europe, upcoming studies should focus on the right application of resources and optimizing trauma care for the geriatric trauma patient

Does the time of the day affect multiple trauma care in hospitals? A retrospective analysis of data from the TraumaRegister DGU®

Results Fewer patients were admitted during the night (6.00 pm-11.59 pm: 18.8% of the patients, 0.00-5.59 am: 4.6% of the patients) than during the day. Patients who arrived between 0.00 am-5.59 am were younger (49.4 ± 22.8 years) and had a higher injury severity score (ISS) (21.4 ± 11.5) and lower Glasgow Coma Scale (GCS) score (11.6 ± 4.4) than those admitted during the day (12.00 pm-05.59 pm; age: 55.3 ± 21.6 years, ISS: 20.6 ± 11.4, GCS: 12.6 ± 4.0). Time in the trauma department and time to an emergency operation were only marginally different. Time to imaging was slightly prolonged during the night (0.00 am-5.59 am: X-ray 16.2 ± 19.8 min; CT scan 24.3 ± 18.1 min versus 12.00 pm- 5.59 pm: X-ray 15.4 ± 19.7 min; CT scan 22.5 ± 17.8 min), but the delay did not affect the outcome. The outcome was also not affected by level of the trauma center. There was no relevant difference in the Revised Injury Severity Classification II (RISC II) score or mortality rate between patients admitted during the day and at night. There were no differences in RISC II scores or mortality rates according to time period. Admission at night was not a predictor of a higher mortality rate. Conclusion The patient population and injury severity vary between the day and night with regard to age, injury pattern and trauma mechanism. Despite the differences in these factors, arrival at night did not have a negative effect on the outcome

Traumatic Hip Dislocations in Major Trauma Patients: Epidemiology, Injury Mechanisms, and Concomitant Injuries

Introduction: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and associated injuries to identify patients at risk. Methods: For this study based on the TraumaRegister DGU&reg; (January 2002&ndash;December 2017), the inclusion criterion was an Injury Severity Score (ISS) &ge;9 points. Exclusion criteria were an isolated head injury and early transfer to another hospital. The THD group was compared to a control group without hip dislocation. The ISS and New ISS were used for injury severity and the Abbreviated Injury Scale for associated injuries classification. Univariate and logistic regression analyses were performed. Results: The final study cohort comprised n = 170,934 major trauma patients. We identified 1359 individuals (0.8%) with THD; 12 patients had sustained bilateral hip dislocations. Patients with THD were predominantly male (79.5%, mean age 43 years, mean ISS 22.4 points). Aortic injuries (2.1% vs. 0.9%, p &le; 0.001) were observed more frequently in the THD group. Among the predictors for THDs were specific injury mechanisms, including motor vehicle accidents (odds ratio (OR) 2.98, 95% confidence interval (CI) 2.57&ndash;3.45, p &le; 0.001), motorcycle accidents (OR 1.99, 95% CI 1.66&ndash;2.39, p &le; 0.001), and suicide attempts (OR 1.36, 95% CI 1.06&ndash;1.75, p = 0.016). Despite a lower rate of head injuries and a comparable level of care measured by trauma center admission, both intensive care unit and total hospital stay were prolonged in patients with THD. Conclusions: Since early diagnosis, as well as timely and sufficient treatment, of THDs are of high relevance for long-term outcomes of severely injured individuals, knowledge of patients at risk for this injury pattern is of utmost importance. THDs are frequently related to high-energy mechanisms and associated with severe concomitant injuries in major trauma patients

Nerve injury in severe trauma with upper extremity involvement: evaluation of 49,382 patients from the TraumaRegister DGU® between 2002 and 2015

Abstract Background Peripheral nerve injury (PNI) as an adjunct lesion in patients with upper extremity trauma has not been investigated in a Central European setting so far, despite of its devastating long-term consequences. This study evaluates a large multinational trauma registry for prevalence, mechanisms, injury severity and outcome characteristics of upper limb nerve lesions. Methods After formal approval the TraumaRegister DGU® (TR-DGU) was searched for severely injured cases with upper extremity involvement between 2002 and 2015. Patients were separated into two cohorts with regard to presence of an accompanying nerve injury. For all cases demographic data, trauma mechanism, concomitant lesions, severity of injury and outcome characteristics were obtained and group comparisons performed. Results About 3,3% of all trauma patients with upper limb affection (n = 49,382) revealed additional nerve injuries. PNI cases were more likely of male gender (78,6% vs.73,2%) and tended to be significantly younger than their counterparts without nerve lesions (mean age 40,6 y vs. 47,2 y). Motorcycle accidents were the most frequently encountered single cause of injury in PNI patients (32,5%), whereas control cases primarily sustained their trauma from high or low falls (32,2%). Typical lesions recognized in PNI patients were fractures of the humerus (37,2%) or ulna (20,3%), vascular lacerations (arterial 10,9%; venous 2,4%) and extensive soft tissue damage (21,3%). Despite of similar average trauma severity in both groups patients with nerve affection had a longer primary hospital stay (30,6 d vs. 24,2 d) and required more subsequent inpatient rehabilitation (36,0% vs. 29,2%). Conclusion PNI complicating upper extremity trauma might be more commonly encountered in Central Europe than suggested by previous foreign studies. PNI typically affect males of young age who show significantly increased length of hospitalization and subsequent need for inpatient rehabilitation. Hence these lesions induce extraordinary high financial expenses besides their impact on health related quality of life for the individual patient. Further research is necessary to develop specific prevention strategies for this kind of trauma