Abstract Background Hypothermia is a significant and independent predictor of mortality in patients with severe trauma and constitutes a key component of the trauma-related lethal triad, along with acidosis and coagulopathy. While the prognostic impact of hypothermia at isolated time points is well established, the clinical relevance of dynamic body temperature changes during the early in-hospital phase remains poorly understood. This study aims to evaluate the association between body temperature trajectories from emergency department (ED) admission to intensive care unit (ICU) transfer and clinical outcomes in major trauma patients. Methods Retrospective data from the TraumaRegister DGU® (TR-DGU) for the period 2015–2023 were analysed. Inclusion criteria comprised an Injury Severity Score (ISS) ≥ 9, ICU admission following ED care, and documented core body temperatures at both ED and ICU. Hypothermia was defined as a body temperature ≤ 35 °C. Patients were stratified into four groups based on the presence or absence of hypothermia at each time point. Further subgroup analysis assessed temperature trends (decreasing vs. stable/increasing) and their associations with mortality, coagulopathy, transfusion requirements, and sex distribution. Results A total of 34,877 patients met the inclusion criteria (mean age 54.2 ± 20.9 years; 71.6% male; mean ISS 22.8 ± 11.5). Hypothermia was present in 10.7% upon ED admission and 9.7% of patients at ICU transfer. Persistent hypothermia was associated with the highest mortality (43.5%), coagulopathy (28.2%), and transfusion rates (31.8%). New onset of hypothermia in the ICU was also linked to poor prognosis (mortality 31.9%). Patients with a temperature decrease (11.2%) had significantly higher injury severity and mortality compared to those with stable or rising temperatures. Female patients were disproportionately represented in hypothermic ICU groups (38%). Conclusion Hypothermia—particularly when persistent or newly acquired—emerges as a strong predictor of adverse outcomes in trauma patients. Dynamic temperature monitoring between ED and ICU provides critical prognostic insights that extend beyond static measurements. Early identification and management of thermal dysregulation, including sex-specific considerations, should be integral components of contemporary trauma care protocols.

Intensive Bemühungen und interdisziplinäre Zusammenarbeit haben die Mortalität mehrfach schwer verletzter Patienten deutlich gesenkt. Qualitativ hochwertige Leitlinienempfehlungen, die die prähospitale Phase, das Schockraummanagement und die erste operative Phase behandeln, werden regelmäßig aktualisiert. Der vorliegende Beitrag referiert den Teil einer neuen Leitlinie auf S3-Niveau, der die Behandlung polytraumatisierter und intensivmedizinisch betreuter Patienten nach der ersten operativen Phase fokussiert. Diese Patienten benötigen besondere Aufmerksamkeit u. a. hinsichtlich Monitoring, Schmerztherapie, Beatmungsstrategie, Ernährung etc. und müssen regelhaft noch der definitiven chirurgischen ihrer Verletzungen zugeführt werden. Der Beitrag fasst die aktuelle Literatur zusammen und gibt Empfehlungen hinsichtlich der frühen definitiven Versorgung polytraumatisierter Patienten, v. a. mit Blick auf ihren besten Zeitpunkt.

The treatment of polytraumatized patients is challenging. Intensive efforts and interdisciplinary teamwork have improved survival rates of severely injured patients over the last decades. High quality guideline recommendations focusing on the prehospital setting, emergency room management and also the initial surgical phase have been published and are frequently updated. The current manuscript is part of new guidelines on an S3 level that focuses on treatment of polytraumatized patients who were transferred to the intensive care unit after initial emergency treatment. These patients have special needs, especially with respect to monitoring, pain management, ventilation strategy, nutrition etc. and most often require definitive surgical stabilization of injuries to the thorax, abdomen, pelvis and extremities. This article summarizes the current literature and gives recommendations with respect to early definitive treatment of patients with multiple trauma and particularly with a view to the best possible timing of the definitive treatment.

Validation and Reliability of the Tracheostoma Well-Being Score (TWBS) in critically ill patients. Prospective observational study involving tracheotomized patients of a tertiary university referring center. Sixty-five tracheotomized patients completed the TWBS on at least two or more days. External assessments of probable problems with the inserted cannula for each patient were provided by the nurse treating that patient on the respective day. The test-retest reliability demonstrated a stable response pattern over repeated measurements. Criterion validity revealed a limited agreement between external assessment by healthcare providers and patients’ self-reported experience, highlighting discrepancies in symptom perception. The 12-Item-TWBS appears to be reliable. The results further underline the necessity of using a validated self-reporting tool to assess patient comfort, as external assessment appears to have shortcomings. The TWBS might be a valuable tool to more accurately appraise patient comfort with the indwelling tracheostomy cannula.

In Deutschland ist seit dem letzten Deutschen Ärztetag im Mai 2024 eine Diskussion über die Verkürzung der Facharztweiterbildung und eine Verlagerung von Inhalten einer Zusatzweiterbildung in die bisherige Facharztweiterbildung entstanden. Dies betrifft auch die Intensivmedizin, mit der Perspektive, einen Facharzt für fachgebietsspezifische Intensivmedizin (z. B. Facharzt für chirurgische Intensivmedizin) zu schaffen. Die damit einhergehende Reduktion allgemeiner, fachgebietsspezifischer Inhalte halten wir aus mehreren Gründen für nicht sachgerecht: Die Kenntnis der fachgebietsspezifischen Auslösefaktoren („Foci“) einer kritischen Erkrankung (Organdysfunktion) sowie die Kenntnis der jeweiligen, auslösefaktorenspezifischen Symptomatik, Diagnostik und Abläufe zur Einleitung einer kausalen Therapie sind entscheidend für die Prognose. Neueste Erkenntnisse weisen darauf hin, dass bei septischen Foci eine Zeitspanne zwischen Diagnosestellung und Fokustherapie von ca. 6 h nicht überschritten werden sollte, um eine Verschlechterung der Prognose zu vermeiden. Um die Zeit zwischen Symptombeginn und effektiver Therapie der Auslösefaktoren nicht zu lang werden zu lassen, ist eine vertiefte fachspezifische Kompetenz im gesamten Prozess erforderlich. Diese Kompetenz ist unabhängig von der intensivmedizinischen Qualifikation und kann nur im Rahmen einer ausreichenden, fachgebietsspezifischen Weiterbildung (mit darauffolgender, intensivmedizinischer Zusatzweiterbildung) erworben werden. Fachgebietsspezifische Kenntnisse sind Voraussetzung für eine effektive Therapie kritisch kranker Patient*innen. Die Beibehaltung der bisherigen fachgebietsspezifischen Weiterbildung und der damit verbundene Erwerb spezifischer Kenntnisse im jeweiligen Fachgebiet ermöglichen es ferner, Fachärzt:innen im Klinikbetrieb breiter einsetzen zu können sowie diagnostische und therapeutische Ressourcen schonender zu verwenden. Die intensivmedizinische Zusatzweiterbildung sollte nicht zulasten fachgebietsspezifischer Inhalte gehen und muss in der nächsten Änderung der Weiterbildungsordnung weiter von allen Facharztqualifikationen des Gebietes Chirurgie heraus erreichbar bleiben. Aufgrund des unumgänglichen Umfangs kann die intensivmedizinische Zusatzweiterbildung selbst nur hauptberuflich und die gesamte Arbeitszeit einnehmend erfolgen.

Die Intensivmedizin in Deutschland hat sich im Kontext des medizinischen Fortschritts und veränderter Behandlungsansprüche grundlegend verändert. Ursprünglich aus chirurgischen Pionierleistungen hervorgegangen, sind intensivmedizinische Einrichtungen heute entscheidende Kostentreiber in der Patientenversorgung. Frühere Modelle, etwa aus den 1930er-Jahren, wurden durch die Spezialisierung und interdisziplinäre Zusammenarbeit abgelöst. Vor diesem Hintergrund untersucht die vorliegende Studie den aktuellen Versorgungsstand, die Weiterbildungsstrukturen sowie den Einsatz von chirurgischen Intensiv- und Intermediate-Care (IMC)-Stationen. Zwischen dem 27.02.2023 und 08.05.2023 wurde mittels einer anonymen Onlineumfrage auf einem deutschen Webserver (lamapoll.de) eine Stichprobe von 1106 Intensivstationen erstellt, wobei 181 vollständige Antworten ausgewertet wurden. Die Umfrage umfasste 42 Fragen, die neben der demografischen Erfassung auch die personelle Ausstattung, Führung und Weiterbildungsmodalitäten sowohl auf eigenständigen chirurgischen Intensivstationen als auch interdisziplinären operativen Intensivstationen (IOI) und IMC abfragten. Etwa 17

Background Tracheotomy is common in patients requiring long-term ventilation or neurological care. Managing these patients is challenging, as urgent cannula exchanges (CE) carry potentially life-threatening risks. To improve safety and standardize care, we implemented quality measures comprising a standardized bedside information sheet and mandatory staff training. This retrospective study evaluates their impact on complications in long-term tracheotomized patients. Methods A retrospective comparison study was conducted with the previous prospective cohort (pre) as a control and an intervention cohort (post) after implementing the stated quality measures. A chart review of adult tracheotomized patients treated between 2018 and 2020 in a 22-bed surgical ICU at a level 1 trauma center was performed. Each CE was documented with regard to its indications and complications, and descriptive and comparative analyses were performed. Results The study included 122 patients (pre: 49; post: 73). The post-group experienced fewer CEs per 100 days (2.65 vs. 4.58) and longer intervals between CEs (18 vs. seven days), with fewer planned exchanges. Although the post-group experienced higher tube occlusion and overall complications (pre 7.5% vs. post 8.5%), accidental decannulations were slightly lower. Respiratory complications were more common in the pre-group, while cardiocirculatory events predominated in the post-group. Conclusion Managing tracheotomized patients remains a significant clinical challenge. A standardized cannula information sheet and mandatory training may reduce the frequency of CEs and enhance patient safety.

Adverse medical conditions can involve present and expected future restrictions as a double burden: mechanically ventilated patients with spinal cord injury (SCI), on the one hand, face pain and communication restrictions. On the other hand, they are confronted with significant changes in their future life perspective. While past research on emotion and appraisals has studied SCI patients alone or in comparison with healthy controls, the current work disentangles the potential impact of (a) the adverse current state and (b) expected future restrictions by comparing mechanically ventilated intensive care unit (ICU) patients with vs. without SCI in eye-tracking-based self-reports on emotions and appraisals. Results suggest that patients of either group could provide faceted accounts of their current state, such as feeling trapped and insecure. However, the feedback that SCI and other ICU patients gave was similar, suggesting that current adversities dominate self-reports.

Der Tertiary Survey dient der vollständigen Erfassung von Verletzungsfolgen in den Stunden und Tagen nach dem Eintritt eines Polytraumas. Ein strukturierter Prozess führt erwiesenermaßen zu einer hohen Rate bis dahin übersehener zusätzlicher Diagnosen und zu daraus folgenden Änderungen des weiteren Prozedere. Dennoch gibt es für den Tertiary Survey bisher keine konkreten praktischen Empfehlungen oder Durchdringung in deutschen Traumazentren. Wir empfehlen eine sehr frühzeitige erstmalige Durchführung des Tertiary Survey auf der Intensivstation, gefolgt von ggf. häufigen Wiederholungen, wenn sich der klinische Zustand des Patienten/der Patientin verändert. Wir empfehlen, den Tertiary Survey zusätzlich als strukturierte Reevaluation des Patienten/der Patientin über die körperliche Untersuchung hinaus zu nutzen. Dabei sollen psychische Belastung evaluiert, bildgebende und konsiliarische Befunde auf Vollständigkeit überprüft sowie zusätzliche Informationen zu Unfall und Fremdanamnese eingeholt werden. Nach der Zusammentragung aller Informationen soll das weitere Prozedere evaluiert bzw. festgelegt werden. Die Sektion Trauma der DIVI entwickelt einen frei verfügbaren Bogen für den Tertiary Survey, der einer kontinuierlichen Optimierung unter wissenschaftlicher Begleitung unterliegt. Langfristig soll dadurch ein Instrument zur standardisierten Implementierung in die lokalen Verfahrensanweisungen der jeweiligen Traumazentren, das klinikinterne und übergeordnete Qualitätsmanagement sowie in die digitale Notfallkette geschaffen werden.

Since the last meeting of the German Medical Association in May 2024, there has been a discussion in Germany about the shortening of primary specialty training and a transfer of the contents of additional supra-specialty training to the existing primary specialty training. This also affects intensive care medicine, with the prospect of creating a subspecialty for subspecialties in intensive care medicine (e.g., a specialty in surgical intensive care medicine). We consider the associated reduction of general specialty-specific contents to be inappropriate for several reasons. Knowledge of the specialty-specific trigger factors (foci) of a critical illness (organ dysfunction) as well as knowledge of the respective trigger factor-specific symptoms, diagnostics and pathways for initiating a causal treatment, are decisive for the prognosis. Recent evidence suggests that in the case of septic foci a time span between making the diagnosis and treatment of the focus should not exceed ca. 6h in order to avoid a worsening of the prognosis. To ensure that the time between symptom onset and effective treatment of the causal factors is not too long, an in-depth expertise in the primary specialty is required throughout the process. This expertise is independent of training in intensive care medicine and can only be acquired through adequate training in the specialty, followed by additional training in intensive care medicine. Expertise in the primary specialty is a prerequisite for the effective treatment of critically ill patients. Maintaining the training specific to the primary specialty and the associated acquisition of specific knowledge in the respective specialty also enables a wider deployment of specialists in clinical practice and a more economical use of diagnostic and therapeutic resources. The additional training in intensive care medicine (supraspecialty) should not be at the expense of content specific to the primary specialty and must remain accessible to all surgical specialties in the field of surgery in the next revision of the training regulations. Due to the unavoidable extent, the additional training in intensive care medicine can itself only be provided on a full-time basis.

Undetected and untreated mental disorders following severe trauma can significantly affect the healing and recovery of severely injured patients. After polytrauma every patient should be screened for psychological stress in the intensive care unit. The screening should be conducted early, after the patient has been awake, oriented, sufficiently attentive and not (no longer) delirious for 48 h. The Freiburg Screening Questionnaire (FSQ) should be used for the screening. No psychological specialist is required for this. The screening should be documented in the discharge report. In cases of abnormal screening results (red) a psychological specialists should be involved early in the patient's treatment. A psychopharmacological treatment is not recommended for acute psychological stress.

The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for temporary bleeding control in severely injured patients remains controversial. Epidemiological data from Germany, Austria and Switzerland are lacking. The objective of this study was therefore to collect data on the use of REBOA intervention and the characteristics of the affected patient population. A retrospective analysis of the TraumaRegister DGU® between January 2020 and December 2022 was conducted to evaluate the frequency of REBOA interventions, injury patterns, injury severity, epidemiology and additional therapies received by patients treated with REBOA. Between 2020 and 2022, 95,510 patients were documented in Germany, Austria and Switzerland (DACH), of whom 62 received REBOA. 44 of 62 patients (71

INTRODUCTION:Intensive care medicine in Germany has fundamentally developed in the context of medical progress and changed treatment requirements. Originally preceded by pioneer work in surgery, intensive medical care facilities are nowadays decisive cost drivers in patient care. Earlier models from around the 1930s were replaced by specialization and interdisciplinary cooperation. Against this background the present study investigated the current state of care, the structures for continuing education and the implementation of surgical intensive and intermediate care (IMC) wards. MATERIAL AND METHODS:Between 27 February 2023 and 8 May 2023, a representative sample of 1106 intensive care wards was pooled using an anonymous online survey on a German web server (lamapoli.de) and 181 complete replies could be evaluated. The survey incorporated 42 questions, which in addition to the demographic acquisition also requested data on the resources, leadership and continuing education modalities of personnel on independent surgical intensive care wards as well as interdisciplinary surgical intensive care wards (IOI) and IMCs. RESULTS:Approximately 17% of the hospitals surveyed had their own surgical intensive care ward, predominantly in university hospitals. These units are characterized by a high presence of the specialist discipline and qualified personnel with additional qualifications in intensive care medicine. In contrast, interdisciplinary intensive care wards were used in facilities with a lower level of care, frequently managed by anesthesiology departments. The continuing education times for assistant surgeons were in most cases longer than 6 months, which promotes an intensive transfer of knowledge and interdisciplinary cooperation. The IMC wards are also an integral component of surgical care even though they are personnel intensive and more economically challenging. The study shows that surgical intensive care medicine has a well-structured, discipline-specific care and training, especially at university locations. In facilities with lower levels of care interdisciplinary models dominate, which also enable an adequate training. Nevertheless, the debate on the retention of discipline-specific knowledge in intensive care medicine remains a current topic in order to ensure a high quality of perioperative care.

The tertiary survey serves to identify injuries and their consequences in the hours and days following polytrauma. A structured process has been proven to result in a high rate of previously missed additional diagnoses, leading to subsequent changes in patient management; however, to date there are no concrete practical recommendations or widespread implementation of the tertiary survey in German trauma centers. We recommend performing the tertiary survey for the first time as early as possible in the intensive care unit, followed by repeated assessments as needed when the patient´s clinical condition changes. Furthermore, we recommend utilizing the tertiary survey as a structured re-evaluation of the patient beyond physical examination. This should include the assessment of psychological stress, a thorough review of imaging and consultative findings and the collection of additional information regarding the accident and the patient´s medical history. After compiling all information further treatment plans should be evaluated and defined. The Trauma Section of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) is developing a freely available tertiary survey form, which will undergo continuous optimization supported by scientific evaluation. In the long term, the goal is to provide a standardized tool for integration into local standard operating procedures of trauma centers, quality management systems and digital emergency care pathways.

Unerkannte und unbehandelte psychische Störungen nach schwerem Trauma können die Heilung und Rekonvaleszenz schwer verletzter Patienten deutlich beeinflussen. Jeder Patient nach Polytrauma sollte auf der Intensivstation auf psychische Belastung gescreent werden. Das Screening sollte frühzeitig erfolgen, nachdem der Patient 48 h wach, orientiert, ausreichend aufmerksam und nicht (mehr) delirant ist. Zum Screening sollte der Freiburger Screening-Fragebogen (FSQ) genutzt werden. Dafür ist kein psychologisches Fachpersonal notwendig. Das Screening sollte im Entlassbericht dokumentiert sein. Bei auffälligem Screening (rot) soll frühzeitig psychologisches Fachpersonal zur Mitbehandlung des Patienten hinzugezogen werden. Für die akute psychische Belastung wird eine psychopharmakologische Behandlung nicht empfohlen.

AIMS:To examine whether eye-tracking (ET) enables reliable self-report of pain in intubated patients with spinal cord injury (SCI) and to explore associations between pain and psychological self-appraisals. METHODS:In this prospective observational study, 75 mechanically ventilated ICU patients (46 SCI, 29 non-SCI) completed pain assessments using a Tobii Dynavox ET device. Pain was measured via the Numeric Rating Scale (NRS) and the EQ-5D-5L pain dimension. Self-esteem, anxiety, and depression were measured with the Visual Analogue Self-Esteem Scale (VASES). RESULTS:NRS and EQ-5D pain ratings showed strong correlation (r = 0.78, p < 0.001). Pain intensity did not differ significantly between SCI and non-SCI groups. No significant associations were observed between pain and self-esteem, anxiety, or depression. A Bland - Altman plot confirmed agreement between NRS and EQ-5D pain scores. CONCLUSIONS:ET enables reliable pain self-report in intubated ICU patients with severely limited communication. Pain ratings were independent of psychological self-appraisals, suggesting ET offers a feasible, patient-centered tool for assessing pain in this population.

Background The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools. Methods Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest. Results Data was collected from 75 patients. Neither the NRS nor the EQ-Pain ( r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated ( r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results. Conclusions Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered. Trial registration German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

STUDY DESIGN:Observational study. OBJECTIVES:To evaluate the perceptions of patients requiring a tracheostomy tube and to identify possible different perceptions in critically ill patients with tracheostomy tubes who have acute (ASCI) or chronic spinal cord injuries (CSCI). SETTING:Medical and surgical intensive care units (ICU) and intermediate care unit of the BG University Hospital Bergmannsheil Bochum, Germany. METHODS:Patients who met the inclusion criteria completed a 25-item questionnaire on two consecutive days regarding their experiences and perceptions in breathing, coughing, pain, speaking, swallowing, and comfort of the tracheostomy tube. RESULTS:A total of 51 persons with ASCI (n = 31) and CSCI (n = 20) were included with a mean age of 53 years. Individuals with ASCI reported significantly more frequent pain and swallowing problems as compared to individuals with CSCI (p ≤ 0.014) at initial assessment. There were no differences between ASCI and CSCI reported with respect to speaking and overall comfort. CONCLUSIONS:It is necessary to regularly assess the perceptions of critically ill patients with tracheostomy tubes with ASCI or CSCI in the daily ICU care routine. We were able to assess these perceptions in different categories. For the future, evaluating the perception of individuals with SCI and a tracheostomy should be implemented to their daily routine care. TRIAL REGISTRATION:DRKS00022073.

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

We thank Shi and Mao for their interest in our recently published article on The ageadjusted Reverse Shock Index multiplied by the Glasgow Coma Scale (rSIG/A) in prehospital assessment of trauma patients and their allocation to trauma centres or trauma team activation. The authors point out some shortcomings in our manuscript. We would like to take the opportunity to address them. While we agree with Shi and Mao that considering site of trauma in general is an important contributor in advanced prediction model, we feel the need to emphasise that the aim was not to determine the best possible prediction model, but to find a reasonable compromise between fast and easy applicability in combination with a high prediction accuracy. Wellestablished tools for risk adjustment like the Injury Severity Score, the Trauma and Injury Severity Score (TRISS) or the Revised Injury Severity Classification V.2 (RISC2) consider the site of trauma but can only be applied knowing all relevant injuries or blood results. The calculations are complex and therefore not feasible in the prehospital setting. However, RISC2 and the TRISS were used as reference scores to evaluate the performance of simple indices to predict mortality, including but not limited to rSIG/A. In addition, we would like to point out that especially head injuries seem to be covered in sufficient manner, using the GCS as important contributor of rSIG/A. With regard to calibration, we would like to refer to figure 3, where rSIG based on prehospital data is plotted against observed mortality. It shows that the prediction fits both high and low values, indicating that the projected probabilities are indeed consistent with the observed frequencies of the events under consideration, even though calibration models based on calculation were not performed. We agree that Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) provides excellent guidance for developing or validating a multivariable prediction model and it would be advisable to include the TRIPOD statement in general. However, it remains somewhat unclear how the TRIPOD statement would have improved our study, as recommendations for ‘validation’ of the TRIPOD checklist were considered. Finally, rSIG/A was not designed as a ‘onesizefitsall strategy’ but proposed as a useful adjunct for the prehospital evaluation of trauma patients. Sven Frieler , Rolf Lefering, Julius Gerstmeyer, Niklas Drotleff, Thomas A Schildhauer, Christian Waydhas, Uwe Hamsen, the TraumaRegister DGU Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany Ruhr University Bochum, Bochum, Germany Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, Wetter, Germany Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany Medical Faculty University DuisburgEssen, Essen, Germany Correspondence to Dr Sven Frieler, Department of Orthopaedics and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany; sven. frieler@ bergmannsheil. de