The purpose of this study was to assess severe abdominal injury in child passengers of different ages of motor vehicle accidents and analyze the concomitant pattern of injury regarding injury severity, trauma management and outcome. Data acquisition from Trauma Register DGU® (TR-DGU) in a 10-years period (2010–2020) of seriously injured children (max. AIS 2+ / intensive care) 0–15 years of age, as motor vehicle passengers (cMVP) (n = 1,035). Primarily treated in or transferred to a German Trauma Center. Matched pairs analysis with adult severely injured motor vehicle passengers (aMVP) (age 20–50 years, n = 26,218), matching 1:4 (child: adult), was performed to identify causes of mortality. The study group (cMVP) included 1,035 children. The mean age was 9.5 years, 50.5

BACKGROUND:The provision of specialized trauma teams for the care of severely injured patients is mandatory according to the requirements of the S3 guidelines polytrauma and the composition is determined by the White Book Medical Care of the Severely Injured (Weißbuch Schwerverletztenversorgung). In each level of care the basic resuscitation room team is composed of four disciplines: orthopedics and trauma surgery, anesthesia, radiology and emergency medicine in the emergency department. MATERIAL AND METHODS:A prospective, multicenter observational study was conducted in 12 supraregional trauma centers in Germany and Switzerland, where a total of 3753 patients were treated in the emergency department following accidents. Amongst them 964 patients (26%) were treated after prior trauma team activation. RESULTS:In 94.7% of the trauma room care instances all 4 required disciplines were present, with an average of 6.6 individuals involved in the trauma room care. The 48‑h mortality rate was 3% among patients receiving trauma room care. In all deceased patients, all four disciplines were present during the trauma room care. At least one or more high-risk criteria for serious injuries were present in 40.8% of the patients. In these cases, a complete team consisting of all 4 disciplines was involved in 97.7% of the care instances. CONCLUSION:In nearly 98% of cases where high-risk criteria for serious injuries (category A activation criteria) all 4 required disciplines were present in the trauma room for patient care. This was associated with an average resource commitment of 6.6 individuals. The absence of one or more disciplines in trauma room care does not appear to significantly affect early mortality in the severely injured.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Background: Thromboelastometry like ROTEM® is a point-of-care method used to assess the coagulation status of patients in a rapid manner being particularly useful in critical care settings, such as trauma, where quick and accurate assessment of coagulation can guide timely and appropriate treatment. Currently, this method is not yet comprehensively available with sparse data on its effectiveness in resuscitation rooms. The aim of this study was to assess the effect of early thromboelastometry on the probability of mass transfusions and mortality of severely injured patients. Methods: The TraumaRegister DGU® was retrospectively analyzed for severely injured patients (2011 until 2020) with information available regarding blood transfusions and Trauma-Associated Severe Hemorrhage (TASH) score components. Patients with an estimated risk of mass transfusion >2% were included in a matched-pair analysis. Cases with and without use of ROTEM® diagnostic were matched based on risk categories for mass transfusion. A total of 1722 patients with ROTEM® diagnostics could be matched with a non-ROTEM® patient with an identical risk category. Adult patients (≥16) admitted to a trauma center in Germany, Austria, or Switzerland with Maximum Abbreviated Injury Scale severity ≥3 were included. Results: A total of 83,798 trauma victims were identified after applying the inclusion and exclusion criteria. For 7740 of these patients, the use of ROTEM® was documented. The mean Injury Severity Score (ISS) in patients with ROTEM® was 24.3 compared to 19.7 in the non-ROTEM® group. The number of mass transfusions showed no significant difference (14.9% ROTEM® group vs. 13.4% non-ROTEM® group, p = 0.45). Coagulation management agents were given significantly more often in the ROTEM® subgroup. Mortality in the ROTEM® group was 4.1% less than expected (estimated mortality based on RISC II 34.6% vs. observed mortality 30.5% (n = 525)). In the non-ROTEM® group, observed mortality was 1.6% less than expected. Therefore, by using ROTEM® analysis, the expected mortality could be reduced by 2.5% (number needed to treat (NNT) 40; SMR of ROTEM® group: 1:0.88; SMR of non-ROTEM® group: 1:0.96; p = 0.081). Conclusions: Hemorrhage is still one of the leading causes of death of severely injured patients in the first hours after trauma. Early thromboelastometry can lead to a more targeted coagulation management, but is not yet widely available. This study demonstrated that ROTEM® was used for the more severely injured patients and that its use was associated with a less than expected mortality as well as a higher utilization of hemostatic products.

Medizinische Datenregister sind ein zentrales Instrument der Versorgungsforschung und ein wertvolles Werkzeug der medizinischen Qualitätssicherung. Die strukturierte, plausibilitätsgeprüfte Erfassung von großen Fallzahlen auf einer longitudinal ausgerichteten Zeitachse mit unterschiedlichen Zeitpunkten der Datenerhebung lässt Aussagen zu zahlreichen relevanten Outcomes – nicht nur der Mortalität von Patienten – zu. Für Ereignisse außerhalb der täglichen unfallchirurgischen Versorgungsroutine wie Naturkatastrophen, Unglücke mit vielen Betroffenen und die nichtmilitärische Versorgung der Bevölkerung im Inland im Verteidigungsfall, können solche Register datenbasierte Handlungsempfehlungen geben. Diese hauptsächlich aus der traumatologischen Routineversorgung gewonnenen Daten ermöglichen bei oben genannten Ereignissen, die mit einem Massenanfall von Verletzten (MANV) einhergehen, die gerichtete Ressourcensteuerung. Durch die Nutzung von Registern aus dem militärischen Bereich oder aus internationalen Registern wird die Perspektive im Hinblick auf Versorgungsstrategien und Verletzungsmuster zusätzlich erweitert. Ob für die oben skizzierten Register auch im konkreten Katastrophenfall in geeigneter Weise Daten generiert werden und einen direkten Erkenntnisgewinn aus dem Ereignis liefern können, muss kritisch diskutiert werden. Die Pflege der Registerdatensätze ist aufwendig und unterliegt spätestens seit Mai 2018 – dem Inkrafttreten der EU-Datenschutz-Grundverordnung (EU-DSGVO) – einer verschärften Regulierung. Das künftige Registergesetz in Deutschland wird hoffentlich deutliche Erleichterungen bei der Dokumentation von Routinedaten schaffen.

Rettungsmittel zur Behandlung schwer verletzter Patienten können notärztlich (NA) oder mit Rettungsdienstfachpersonal (RD) besetzt sein. Ziel dieser Studie war es festzustellen, ob sich die präklinische Sichtung durch NA oder RD und deren Auswirkungen für eine Schockraumalarmierung (SRA) unterscheiden. Daten eines dreimonatigen Beobachtungszeitraums aus 12 Notaufnahmen wurden analysiert. Eingeschlossen wurden 3753 Traumapatienten. Dokumentiert wurden SRA-Kriterien sowie präklinische Parameter und Daten zur Behandlung in Notaufnahme (ZNA) oder Schockraum (SR). Unterschieden wurden SRA-kriterien der S3-Leitlinie Polytrauma (Version 2016) mit den Empfehlungsgraden GoR A und GoR B. Die Notwendigkeit einer Behandlung in der ZNA oder einer SR-Behandlung wurde retrospektiv anhand festgelegter Kriterien bewertet. Alle Daten wurden den Gruppen NA oder RD zugeteilt. SRA war bei NA häufiger als bei RD (64

The third revision of the S3 guideline on polytrauma/severe injury treatment was conducted under the leadership of the German Society for Trauma Surgery (DGU) by a total of 26 scientific medical professional societies and organizations. It represents a comprehensive update of the recommendations for the care of severely injured patients, based on new scientific findings and studies. The guideline comprises 332 core recommendations with varying levels of recommendation and corresponding explanations, which consider expert knowledge and over 2400 cited references, thus meeting the highest level (S3) of guideline quality. The changes, particularly regarding trauma team activation, are of particular importance to emergency medical services. Two new chapters with recommendations for haemorrhage control and pain management in pre-hospital care have been added. Overall, the guideline remains an important standard for decision-making in the diagnosis and treatment of severely injured patients.

Die Bereitstellung spezialisierter Schockraumteams zur primären Schwerverletztenversorgung ist nach heutigem Standard auch unter Inkaufnahme eines hohen Ressourcenaufwandes obligat. Insbesondere die Nutzung von Alarmierungskriterien nach dem Unfallhergang führt vermehrt zur Übertriage. Ziel der Studie ist die Bewertung von Kriterien nach dem Unfallhergang hinsichtlich ihrer Eignung für eine bedarfsgerechte Schockraumalarmierung. Bei der vorliegenden Studie handelt es sich um eine prospektive, multizentrische, nichtinterventionelle Querschnittstudie. Die Datenerhebung erfolgte in 12 überregionalen Traumazentren in Deutschland und der Schweiz über einen papierbasierten Erhebungsbogen mit anschließender anonymisierter Zusammenfassung in einer webbasierten Datenbank. Als Referenz zur Analyse der Notwendigkeit einer Schockraumaktivierung wurden die neu definierten NIS-Post-hoc-Konsensuskriterien (TAcTIC-Kriterien) genutzt. Von den Schockraumalarmierungskriterien der S3-Leitlinie 2016 für ein moderates Risiko schwerer Verletzungen (MRSI), Grad-B-Kriterien, hatten „Sturz aus über drei Metern Höhe“ („positive predictive value“, PPV 32

Medical data registers are a key instrument of medical care research and a valuable tool for medical quality assurance. The structured plausibility tested documentation of large case numbers on a longitudinally oriented time axis with different points in time of data acquisition enables statements to be made on numerous relevant outcomes, not only the mortality of patients. For incidents outside the daily routine care in trauma surgery, such as natural disasters, accidents with multiple casualties and nonmilitary treatment of the domestic population in defence situations, such registers can provide data-based recommendations for action. These data, mainly obtained from routine traumatological treatment, enable a targeted resource management in the abovenamed incidents, which are associated with mass casualties. Due to the utilization of registers from the military field or from international registers, the perspective is additionally extended with respect to treatment strategies and injury patterns. Whether data can also be generated in a suitable manner for the abovenamed registers in specific disaster situations and can provide a direct gain of knowledge from the incident, must be critically discussed. The maintenance of the register datasets is time-consuming and has been subjected to a more stringent regulation at least since May 2018, when the European Union General Data Protection Regulation (EU-GDPR) came into force. The future Register Act in Germany will hopefully achieve greater simplification in the documentation of routine data.

Die 3. Überarbeitung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung wurde unter der Federführung der Deutschen Gesellschaft für Unfallchirurgie (DGU) von insgesamt 26 Fachgesellschaften und Organisationen durchgeführt und stellt eine umfassende Aktualisierung der Handlungsempfehlungen zur Schwerverletzten-Versorgung auf Basis neuer wissenschaftlicher Erkenntnisse und Studien dar. Die Leitlinie enthält 332 Kernempfehlungen unterschiedlicher Empfehlungsgrade und dazugehörige Erläuterungen, die Expertenwissen und über 2400 zitierte Literaturstellen berücksichtigen und somit das höchste Niveau (S3) einer Leitlinie erfüllen. Die Änderungen, insbesondere zur Schockraumalarmierung, sind für den Rettungsdienst von besonderer Bedeutung. Zwei neue Kapitel mit Empfehlungen für die Blutstillung und Schmerzbehandlung in der prähospitalen Versorgung wurden hinzugefügt, insgesamt bleibt die Leitlinie ein wichtiger Standard für Entscheidungsfindungen bei Diagnostik und Therapie von Schwerverletzten.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

Purpose Comparison of access times to CT and surgical/radiological bleeding control between two European military trauma centers. Methods Retrospective and observational study conducted in two military level 1 trauma centers in Toulon (France) and Koblenz (Germany) between 2013 and 2018. Inclusion of severe trauma patients with ISS > 15 with clinical and biological criteria of bleeding. Results Inclusion of 607 patients (318 in Toulon and 289 in Koblenz). Mean ISS 30. Median access time to CT significantly lower for Koblenz, 14 vs. 30 min; p < 0.001. Median access time to the emergency bleeding control lower in Toulon 84 min vs. 92 ( p = 0.114). No impact on mortality at 24 h 9% in Koblenz and 11% in Toulon. Mortality at 28 days identical 17%. Conclusion The organizational innovation at the military hospital in Koblenz saves time in the injury assessment. However, it has no impact on the access time to the scanner and on the mortality at 24 and 28 days. This fight against hemorrhage is a management bundle including delays, transfusion, and team training. Clinical trial registration 2,002,878 v 0.

IntroductionEmergency medical services (EMS) treating critically injured patients can be staffed by emergency physicians (P-EMS) or by paramedics (EMT). The aim of this study was to determine whether P-EMS or EMT triage affect trauma team alerting (TTA). MethodsData from a 3-month observation period from 12 emergency departments were analyzed. Included were 3753 trauma patients referred by the EMS. TTA criteria, preclinical parameters, and data on treatment in the emergency department or trauma room were documented. A distinction was made between high-risk criteria for severe injuries (HRSI) and moderate-risk criteria for severe injuries (MRSI) defined in the national trauma guideline (2016 version) as recommendation grades GoR A and GoR B. The need for treatment in the emergency department or trauma room was assessed retrospectively. All data were assigned to the P-EMS or EMT group. ResultsTTA was more frequent in P-EMS than in EMT (64% vs. 6%). Activation of the shock room occurred in 46% in the P-EMS group due to HRSI criteria (14% in EMT) and in 25% due to MRSI criteria (44% in EMT), while 31% of TTA were initiated without a specific criterion. The positive predictive value (ppV) for a TAA by the EMS was 50.3%, with 49.7% of cases being overtriaged and 35.9% of cases under-triaged. In the P-EMS group, overtriage was 44.5% and undertriage was 15.6%. In the EMT group, we found significantly more undertriage (84.5%) despite a significantly higher overtriage rate of 76.6%. ConclusionThere is potential for optimization in prehospital triage of trauma patients by both P-EMS and EMT personnel. The current triage practice leads to a pronounced misuse of expensive hospital resources. In the future, in addition to the pure medical training of emergency physicians and paramedics, greater attention should be paid to the knowledge and correct application of established triage criteria. Appropriate prehospital triage depends on the quality of the triage criteria and the associated risks for the presence of severe injuries. HRSI-based TTA shows a better positive predictive value.

The purpose of this study was to identify predictive factors for peri-pelvic vascular injury in patients with pelvic fractures and to incorporate these factors into a pelvic vascular injury score (P-VIS) to detect severe bleeding during the prehospital trauma management. To identify potential predictive factors, data were taken (1) of a Level I Trauma Centre with 467 patients (ISS ≥ 16 and AISPelvis ≥ 3). Analysis including patient’s charts and digital recordings, radiographical diagnostics, mechanism and pattern of injury as well as the vascular bleeding source was performed. Statistical analysis was performed descriptively and through inference statistical calculation. To further analyse the predictive factors and finally develop the score, a 10-year time period (2012–2021) of (2) the TraumaRegister DGU® (TR-DGU) was used in a second step. Relevant peri-pelvic bleeding in patients with AISPelvis ≥ 3 (N = 9227) was defined as a combination of the following entities (target group PVITR-DGU N = 2090; 22.7