Care for traumatic injuries continues to face significant challenges in modern healthcare systems [...].

With the aging population, the number of geriatric trauma patients continues to rise, posing significant challenges for emergency care and trauma management. Structured trauma team activation (TTA) protocols aim to provide timely and adequate treatment for severely injured patients. However, evidence suggests that current triage criteria may inadequately address the specific needs of geriatric patients, potentially leading to undertriage and worse outcomes. The prospective, multicentre observational cohort study analysed trauma team activation and triage practices for patients aged ≥ 70 years across 12 Level 1 trauma centres across rural and urban regions in Germany and Switzerland. Data were prospectively collected from December 2020 to February 2021, following the STROBE guidelines. Triage decisions were compared with the TAcTIC (Trauma Team Activation and Trauma/Injury Care) consensus criteria to assess undertriage and overtriage rates. Key outcomes included trauma team activation rates, injury severity, transport characteristics, and early mortality. Among 3,753 trauma patients, 1,371 (36.5%) were geriatric (≥ 70 years). Trauma team activation was significantly lower in the geriatric group (15.8%) compared to younger patients (31.8%), despite similar injury severity. Post-hoc analysis revealed that 53.8% of geriatric patients requiring trauma care were undertriaged. Head injuries (47.7%) and pelvic fractures (5.7%) were more common in geriatric patients in comparison to the younger cohort. Mortality within 48 h was more than three times as high in geriatric patients (1.8% vs. 0.5%). A significant undertriage rate (53.8%) was identified among geriatric trauma patients, contributing to delayed care and increased mortality. Undertriage of geriatric trauma patients remains a critical issue, reflecting the insufficiency of current trauma activation protocols. Tailored triage criteria that even more consider age-related physiological differences, comorbidities, and frailty are urgently needed. Future updates to trauma guidelines should aim to reduce undertriage and improve outcomes for this vulnerable population. Not applicable.

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.

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

Multiple trauma patients with severe chest trauma are at increased risk for tracheostomy. While the risk factors associated with the need for tracheostomy are well established in the general critical care population, they have not yet been validated in a cohort of patients suffering severe thoracic trauma. This retrospective cohort study analysed data on patients aged 18 years or older who were admitted to one of the six participating academic level I trauma centres with multiple injuries, including severe thoracic trauma (AISThorax ≥ 3) between 2010 and 2014. A multivariable binary regression was used to identify predictor variables for tracheostomy and to develop the Tracheostomy in Thoracic Trauma Prediction Score (T3P-Score). The study included 1019 adult thoracic trauma patients, of whom 165 underwent tracheostomy during their intensive care unit (ICU) stay. Prehospital endotracheal intubation (adjusted OR [AOR]: 2.494, 95% CI [1.412; 4.405]), diagnosis of pneumonia during the ICU stay (AOR: 4.374, 95% CI [2.503; 7.642]), duration of mechanical ventilation (AOR: 1.008/hours of intubation, 95% CI [1.006; 1.009]), and an AISHead ≥ 3 (AOR 1.840, 95% CI [1.039; 3.261]) were independent risk factors for tracheostomy. Patients with sepsis had a lower risk of tracheostomy than patients without sepsis (AOR 0.486, 95% CI [0.253; 0.935]). The T3P-Score had high predictive validity for tracheostomy (ROCAUC = 0.938, 95% CI [0.920, 0.956]; Nagelkerke's R2 was 0.601). The T3P-Score's specificity was 0.68, and the sensitivity was 0.96. The severity of thoracic trauma did not predict the need for tracheostomy. Follow-up studies should validate the T3P-Score in external data sets and study the reasons for the reluctant use of tracheostomy in patients with severe thoracic trauma and subsequent sepsis.Trial registration: The study was applied for and registered a priori with the respective ethics committees.

Einleitung und Fragestellung Für den Nachweis und den Ausschluss einer Fraktur ist das Röntgenbild der Standard. Nur wenige klinische Untersuchungen sind dazu geeignet, Frakturen sicher auszuschließen, um die Anzahl angefertigter Röntgenbilder zu reduzieren. Durch Ultraschall lassen sich Frakturen als Kortikalisunterbrechungen gut darstellen. Ziel dieses Studiendesigns ist es, die Sensitivität und Spezifität der Fraktursonografie in ausgewählten Frakturentitäten zu untersuchen und die Effektivität einer niedrigschwellige Anwenderschulung zu evaluieren.

Abstract Background Second medical opinions (SOs) can assist patients in making informed treatment decisions and improve the understanding of their diagnosis. In Germany, there are different approaches to obtain a structured SO procedure: SO programs by health insurers and SOs according to the SO Directive. Through a direct survey of the population, we aimed to assess how structured SOs should be provided to fulfil patients’ needs. Methods A stratified sample of 9990 adults (≥18 years) living in the federal states of Berlin and Brandenburg (Germany) were initially contacted by post in April and sent a reminder in May 2020. The survey results were analyzed descriptively. Results Among 1349 participants (response rate 14%), 56% were female and the median age was 58 years (interquartile range (IQR) 44–69). Participants wanted to be informed directly and personally about the possibility of obtaining an SO (89%; 1201/1349). They preferred to be informed by their physician (93%; 1249/1349). A majority of participants would consider it important to obtain an SO for oncological indications (78%; 1049/1349). Only a subset of the participants would seek an SO via their health insurer or via an online portal (43%; 577/1349 and 16%; 221/1349). A personally delivered SO was the preferred route of SO delivery, as 97% (1305/1349) would (tend to) consider this way of obtaining an SO. Participants were asked to imagine having moderate knee pain for years, resulting in a treatment recommendation for knee joint replacement. They were requested to rate potential qualification criteria for a physician providing the SO. The criteria rated to be most important were experience with the recommended diagnosis/treatment (criterion (very) important for 93%; 1257/1349) and knowledge of the current state of research (criterion (very) important for 86%; 1158/1349). Participants were willing to travel 60 min (median; IQR 60–120) and wait 4 weeks (median; IQR 2–4) for their SO in the hypothetical case of knee pain. Conclusion In general, SOs were viewed positively. We found that participants have clear preferences regarding SOs. We propose that these preferences should be taken into account in the future design and development of SO programs.

Nach mehr als zwei Jahrzehnten Erfahrung mit der computerassistierten Navigation in der Knieendoprothetik liegen für diese Technik weitreichende Erfahrungen und Studiendaten vor, die eine umfassende Bewertung ermöglichen. Zweifelsfrei ist für die navigationsgestützte Technik eine sehr hohe Präzision für die Implantatpositionierung und Achsrekonstruktion bewiesen. Damit stellt diese Technik den derzeitigen Goldstandard sowohl für eine neutrale Implantatausrichtung als auch für jegliche individualisierte Ausrichtung („kinematic alignment“, „adjusted mechanical alignment“ und weitere) dar, um sicher unbeabsichtigte Ausreißer der Implantatlage zu vermeiden. Für das funktionelle Ergebnis und die Patientenzufriedenheit konnten frühere Studien keine wesentlichen Unterschiede aufzeigen. Die Metaanalysen der letzten 10 Jahre zeigen jedoch relevante Vorteile der Navigation, was sowohl auf Weiterentwicklungen der softwareunterstützen Weichteilbalancierung als auch feineren Bewertungsmethoden der Nachuntersuchungen basieren könnte. Auch für die Bewertung des Langzeitergebnisses zeigen internationale Register Vorteile der Navigation. Insbesondere im Australischen Register wird eindrücklich eine deutlich niedrigere Rate an Revisionen aufgrund von aseptischen Lockerungen/Osteolysen für die Gruppe der navigierten Operationen über einen Zeitraum von bis zu 17 Jahren beschrieben. Vorteile der Navigation wurden bereits ab dem 6. Monat nach Operation ermittelt. Trotz der nachgewiesenen Vorteile konnte sich die Technik bisher nicht in der täglichen Routine durchsetzen und zeigt regional große Unterschiede der Verbreitung. Neuere Entwicklungen, wie die Robotik, die zum großen Teil auf der Technik der Navigation basieren, werden aktuell mit großem Engagement angeboten. Aber auch diese neue Technik muss im Spannungsfeld zwischen Kosten und Nutzen ihre enormen Zusatzkosten rechtfertigen und vermeintliche Vorteile im Vergleich zur Navigation erst beweisen. Dieses erscheint zurückblickend auf die Entwicklung der Navigation ein schwieriger Weg.

OBJECTIVES:Detailed and decisive information about the patients' coagulation status is important in various emergency situations. Conventional global coagulation testing strategies are often used to provide a quick overview, but several limitations particularly in the trauma setting are well described. With the introduction of direct oral anticoagulations (DOACs), a milestone for several disease entities resulting in overall improved outcomes could be reached, but at the same time providing new diagnostic challenges for the emergency situation.DESIGN:As an alternative to conventional coagulation tests, there is increasing clinical and scientific interest in the use of early whole blood strategies to provide goal-directed coagulation therapies (GDCT) and hemostatic control in critically ill patients. Viscoelastic hemostatic assays (VHAs) were therefore introduced to several clinical applications and may provide as a bedside point-of-care method for faster information on the underlying hemostatic deficiency.CONCLUSION:The use of VHA-based algorithms to guide hemostatic control in emergency situations now found its way to several international guidelines for patients at risk of bleeding. With this qualitative review, we would like to focus on VHA-based GDCT and review the current evidence for its use, advantages, and challenges in the two different clinical scenarios of trauma and intracerebral bleeding/stroke management.

Purpose Uncontrolled hemorrhage is still the major cause of preventable death after trauma and is aggravated by trauma-induced coagulopathy (TIC). The underlying pathophysiology of TIC is still elusive, but several key effectors such as the thrombin-generation capacity, the protein C (PC) pathway, and the fibrinolytic activity could be identified. The aim of this prospective observational study was to investigate plasma coagulation markers attributed to reflect the course of TIC and to identify the mechanisms being responsible for the coagulopathy after major trauma. Methods Seventy-three consecutive patients after major trauma and admission to a level-1-trauma unit were included to the study. During early trauma management, extended coagulation testing including the measurement of circulating thrombin markers and activated PC (APC) was performed and correlated with standard shock parameters and the patients’ clinical course and outcome. Results In contrast to standard coagulation parameters, thrombin markers and APC were found to be increased in correlation with injury severity. Even in patients with lower impact mechanisms, early endogenous accumulation of thrombin markers and APC (ISS < 16: 0.5 ng/ml; ISS ≥ 16–26: 1.5 ng/ml; ISS > 26: 4.1 ng/ml) were observed. Furthermore, APC showed ISS- and injury-dependent patterns while ROC curve analysis revealed that especially APC plasma levels were predictive for coagulopathy and general patient outcome. Conclusion Increased levels of APC and thrombin markers in patients after major trauma were positively correlated with injury severity. APC showed an ISS- and injury-dependent kinetic and might serve as candidate biomarker to identify patients at risk for developing TIC.

INTRODUCTION:Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of ROTEM has been described as being efficient and associated with positive outcomes in several studies. OBJECTIVE:The effect of ROTEM use was assessed on three different outcome variables: (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality in severely injured patients. METHODS AND MATERIAL:A retrospective analysis of a large data set of severely injured patients collected into the TraumaRegister DGU® between 2009 and 2016 was conducted. The data of 7461 patients corresponded to the inclusion criteria and were subdivided into ROTEM-using and ROTEM-non-using groups. Both groups were analysed regarding (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality. RESULTS:A lower mortality rate in ROTEM-using groups was observed (p = 0.043). Furthermore, more patients received haemostatic medication when ROTEM was used. In ROTEM-using groups, there was a statistically relevant higher application of massive transfusion. CONCLUSIONS:In this retrospective study, the use of ROTEM was associated with reduced mortality and an increased application of haemostatics and RBC transfusions. Prospective evidence is needed for further evidence-based recommendations.

Objective Assessment of the anticoagulant effect of direct oral anticoagulants (DOACs) still is a challenge for various medical disciplines, especially in patients needing immediate care in a medical emergency. Aside from severe bleeding and thrombotic events, evaluation of the coagulation status is important for urgent indication of fracture care or administration of a specific antidot. An assay that screens for the absence of a DOAC might help accelerate treatment in these situations. The goal of this study is to evaluate the use of a qualitative POC Method (DOAC Dipstick, DOASENSE®) in an emergency setting.

Das Schockraummanagement ist eine interdisziplinäre und interprofessionelle Teamleistung, die geprägt ist von klarer Kommunikation und eintrainierten Algorithmen. Der Schockraum ist das Bindeglied zwischen präklinischer Initialstabilisierung und definitiver Therapie. Hier müssen wichtige und richtungsweisende Entscheidungen bezüglich Diagnostik und Therapie unter Zeitdruck getroffen werden. Die Qualität der Schockraumversorgung hat somit einen wesentlichen Einfluss auf das Behandlungsergebnis des Patienten.

Purpose Trauma-induced coagulopathy (TIC) is recognised as an own clinical entity which includes all components of haemostasis following rapidly tissue injury, hypoperfusion and shock. Microparticles (MP) are known to be released in large quantities from different cell types after trauma. The present study aimed to perform a phenotypic MP profiling after major trauma and to elucidate potential procoagulative function of MP under simulated conditions of lethal triad. Methods For MP isolation, 20 trauma patients (median ISS 24) were included. To produce a Standard MP Phenotype Profile after trauma, samples were pooled, extracted and concentrated by using an ultracentrifuge protocol. Specific cell surface markers were measured by flow cytometry. Our Standard MP Phenotype Profile was subsequently added in high and low concentration to an in vitro lethal triad assay, simulating coagulopathy via induced hypothermia, dilution and acidosis. A comprehensive analysis of coagulation function was performed. Results Within our Standard MP Phenotype Profile, PDMP (56%) were found as predominant phenotype followed by EDMP (33%) and MDMP (11%). EDMP characterized by CD144, CD62E and Annexin were determined most frequently but also EDMP expressing CD62P. In addition, tissue factor (TF) was expressed on all MP entities (EDMP 63%, PDMP 30%, MDMP 7%). Within our lethal triad simulation assay, the addition of low and high concentrated MP did not cause any significant alteration in standard coagulation assays, coagulation initiation, clot kinetics or stability. Addition of high concentrated MP increased platelet function and P-selectin expression significantly. Conclusion Our data confirm the assumption that there is a characteristic MP phenotype pattern in trauma, which may alter haemostatic capacity at least in part mediated via augmenting in primary haemostasis resulting in an improved contribution of platelets to clot formation. There are indications that expression of selectins on MP surface is involved in this activation process, but this pathway needs to be investigated in more detail.

Background: Aggressive trauma management and other external factors lead to hypothermia, acidosis and hemodilution (defined as Lethal Triad, LT) contributing to coagulopathy after trauma (Trauma-induced coagulopathy, TIC) that worsens patients’ outcomes. Procoagulative microparticles (MP) are crucial players at the interface of cellular and plasmatic coagulation. However, their functions remain largely unexplored. This study aimed to characterize effects of MP subtypes and concentrations on functional coagulation under in vitro simulated conditions. Methods: Blood from eleven volunteers were collected to simulate in vitro conditions of haemodilution (HD) and LT, respectively. HD was induced by replacing a blood volume of 33% by crystalloids and for LT, samples were further processed by reducing the temperature to 32 °C and lowering the pH to 6.8. MP were obtained either from platelet concentrates (platelet-derived MP, PDMP) or from cell culture (ECV304 cells for endothelial-derived MP, EDMP) by targeted stimulation. After introducing MP to in vitro conditions, their concentration-dependent effects (1.000, 10.000 and 15.000 MP/µl blood) on coagulation compared to whole blood (WB) were characterized by flow cytometric platelet activation and by quantification of fibrin clot propagation and spontaneous clotting using Thrombodynamics ® technology. Results: MP originated from platelets and endothelial cells affected blood coagulation in a concentration-dependent manner. Particularly, high PDMP quantities significantly induced platelet activation and fibrin clot growth and size in HD conditions. In LT conditions, the highest PDMP concentration enhanced platelet activation, clot growth and size. In contrast, EDMP supplementation did not affect platelet activation, but resulted in enhanced formation of spontaneous clots, irrespective of simulated condition. With increasing EDMP concentration, the time until the onset of spontaneous clotting decreased in both HD and LT conditions. Discussion: The study demonstrates an essential role of MP within the coagulation process under simulated coagulopathic conditions. While PDMP affected platelets promoting clot formation likely by providing a surface enlargement, EDMP presumably affected clotting factors of the plasmatic coagulation resulting in an increased formation of spontaneous fibrin clots. Conclusion: The diverse effects of in vitro generated MP from different cellular origin indicate a divergent mechanism of action exhibiting distinct functions within the coagulation process.

BackgroundAggressive fluid therapy of patients following a major trauma may result in hypothermia, acidosis and haemodilution that deteriorates even further towards a trauma-induced coagulopathy. The combination of these three factors is referred as lethal triad (LT) and a progressive course of LT is associated with a worsening or complete failure of haemodynamics and coagulative function. Within the process of coagulation, microparticles (MP) are crucial players at the interface of cellular and plasmatic coagulation. This study aimed at the characterization of coagulative effects originating from MP with different cellular origin and concentration under in vitro simulated traumatic conditions of haemodilution (HD) and LT.MethodsHD was induced by replacing a blood volume of 33% by crystalloids and for LT, samples were further processed by reducing the temperature to 32 °C and lowering the pH to 6.8. MP were obtained either from platelet concentrates (platelet-derived MP, PDMP) or from cell culture (ECV304 cells for endothelial-derived MP, EDMP) by targeted stimulation. Effects of MP on coagulation depending on concentrations (1.000, 10.000 and 15.000 MP/µl blood) were characterized by flow cytometric platelet activation and by quantification of fibrin clot propagation and spontaneous clotting using Thrombodynamics® technology.ResultsMP originated from platelets and endothelial cell culture affected blood coagulation in a concentration-dependent manner. Particularly, high PDMP quantities significantly induced platelet activation and fibrin clot growth and size in HD conditions. In LT conditions, the highest PDMP concentration enhanced platelet activation, clot growth and size. In contrast, EDMP supplementation did not affect platelet activation, but resulted in enhanced formation of spontaneous clots, irrespective of simulated condition. With increasing EDMP concentration, the time until the onset of spontaneous clotting decreased in both HD and LT conditions.DiscussionThe study demonstrates the essential role of MP within the coagulation process in the simulated traumatic conditions. While PDMP affected platelets promoting clot formation likely by providing a surface enlargement, EDMP presumably affected clotting factors of the plasmatic coagulation resulting in an increased formation of spontaneous fibrin clots.ConclusionThe diverse effects of in vitro generated MP from different cellular origin indicate a divergent mechanism of action exhibiting distinct functions within the coagulation process.

Abstract Background Aggressive fluid therapy of patients following a major trauma may result in hypothermia, acidosis and haemodilution that deteriorates even further towards a trauma-induced coagulopathy. The combination of these three factors is referred as lethal triad (LT) and a progressive course of LT is associated with a worsening or complete failure of haemodynamics and coagulative function. Within the process of coagulation, microparticles (MP) are crucial players at the interface of cellular and plasmatic coagulation. This study aimed at the characterization of coagulative effects originating from MP with different cellular origin and concentration under in vitro simulated traumatic conditions of haemodilution (HD) and LT. Methods HD was induced by replacing a blood volume of 33% by crystalloids and for LT, samples were further processed by reducing the temperature to 32 °C and lowering the pH to 6.8. MP were obtained either from platelet concentrates (platelet-derived MP, PDMP) or from cell culture (ECV304 cells for endothelial-derived MP, EDMP) by targeted stimulation. Effects of MP on coagulation depending on concentrations (1.000, 10.000 and 15.000 MP/µl blood) were characterized by flow cytometric platelet activation and by quantification of fibrin clot propagation and spontaneous clotting using Thrombodynamics® technology. Results MP originated from platelets and endothelial cell culture affected blood coagulation in a concentration-dependent manner. Particularly, high PDMP quantities significantly induced platelet activation and fibrin clot growth and size in HD conditions. In LT conditions, the highest PDMP concentration enhanced platelet activation, clot growth and size. In contrast, EDMP supplementation did not affect platelet activation, but resulted in enhanced formation of spontaneous clots, irrespective of simulated condition. With increasing EDMP concentration, the time until the onset of spontaneous clotting decreased in both HD and LT conditions. Discussion The study demonstrates the essential role of MP within the coagulation process in the simulated traumatic conditions. While PDMP affected platelets promoting clot formation likely by providing a surface enlargement, EDMP presumably affected clotting factors of the plasmatic coagulation resulting in an increased formation of spontaneous fibrin clots. Conclusion The diverse effects of in vitro generated MP from different cellular origin indicate a divergent mechanism of action exhibiting distinct functions within the coagulation process.

Trauma remains a leading cause of mortality and morbidity in youth. The Prevent Alcohol and Risk Related Trauma in Youth (P.A.R.T.Y.) program is an injury prevention program. The aim of the study was to analyze the influence on risk-taking behaviors and risk awareness on young road users by a pre–post-questionnaire.

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 < 0.001) from 2006 to 2015. The use of Benzodiazepines increased slightly, while the utilization rate of Barbiturates remained constant. In patients with Shock Index > 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.

Over the last decade, the pivotal role of trauma-induced coagulopathy has been described and principal drivers have been identified. We hypothesized that the increased knowledge on coagulopathy of trauma would translate into a more cautious treatment, and therefore, into a reduced overall incidence rate of coagulopathy upon ER admission.