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Purpose Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries. Methods In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed. Results In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053). Conclusion Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey. Level of evidence Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).

Background Serum biomarker S100B has been explored for its potential benefit to improve clinical decision-making in the management of patients suffering from traumatic brain injury (TBI), especially as a pre-head computed-tomography screening test for patients with mild TBI. Although being already included into some guidelines, its implementation into standard care is still lacking. This might be explained by a turnaround time (TAT) too long for serum S100B to be used in clinical decision-making in emergency settings. Methods S100B concentrations were determined in 136 matching pairs of serum and lithium heparin blood samples. The concordance of the test results was assessed by linear regression, Passing Pablok regression and Bland-Altman analysis. Bias and within- and between-run imprecision were determined by a 5 × 4 model using pooled patient samples. CT scans were performed as clinically indicated. Results Overall, S100B levels between both blood constituents correlated very well. The suitability of S100B testing from plasma was verified according to ISO15189 requirements. Using a cut-off of 0.105 ng/ml, a sensitivity and negative predictive value of 100% were obtained for identifying patients with pathologic CT scans. Importantly, plasma-based testing reduced the TAT to 26 min allowing for quicker clinical decision-making. The clinical utility of integrating S100B in TBI management is highlighted by two case reports. Conclusions Plasma-based S100B testing compares favorably with serum-based testing, substantially reducing processing times as the prerequisite for integrating S100B level into management of TBI patients. The proposed new clinical decision algorithm for TBI management needs to be validated in further prospective large-scale studies., Highlights • Plasma-based S100B testing reduces turnaround time to 26 minutes and thus enables its use in the emergency department. • Plasma- and serum-based S100B testing demonstrate commutability of results. • Clinical cases demonstrate the benefit of elevated S100B levels as an indicator for second-look CT re-evaluation.

In Germany, among patients with minor head injury (MHI), the incidence of coexisting alcohol intoxication is indicated up to 50%. The neurological symptoms of patients with MHI may be caused or altered by alcohol intoxication, this could mislead to further, potential harmful, diagnostic steps or to misinterpretation of the symptoms and to non-execution of necessary treatments. In order to decide which patients need further diagnostics by CCT, S100B has been proposed as a potential selection criterion. On the other hand, studies have hypothesized that alcohol intoxication may lead to elevated S100B serum levels. Therefore, the present study aims to investigate the relationship between the blood ethyl alcohol concentration and the S100B serum concentration in an experimental setting in young human adult volunteers.In a cohort of 58 healthy volunteers, serum S100B concentration and blood ethyl alcohol concentration were measured before and after liberately drinking alcohol. The study was approved by the local Ethics Committee of the Medical Faculty Mannheim (Ethics Committee II, AZ 2012-272 N-MA). Instantaneous analysis of the samples was carried out using state-of-the art automated measuring systems. (Analyzer Cobas e411, Roche and Analyzer Dimension Vista 1500, Siemens).After drinking, alcohol levels ranged from 0,23 to 1,92 g/l. The S100B value ranged from to 0,021 to 0,115 µg/l after alcohol consumption (S100B standard value 0,11 µg/l). By calculating the Pearson correlation of empirical correlation after drinking alcohol with r = 0.01181, a correlation between serum S100B concentration and ethyl alcohol concentration is not probable. The S100B concentrations were independent on the alcohol intake in low to medium alcohol levels.A relevant alcohol blood concentration (~ 1 g/l), in otherwise healthy volunteers, does not affect the serum concentration of S100B. S100B may be a useful brain injury marker in low to moderate drunken patients.In Deutschland wird bei Patienten mit leichtem Schädel-Hirn-Trauma (SHT) die Häufigkeit der koexistenten Alkoholintoxikation mit bis zu 50% angegeben. Die neurologischen Symptome von Patienten mit leichtem SHT können durch die Alkoholintoxikation verursacht oder verändert werden. Weitere, potenziell schädliche diagnostische Schritte oder Fehlinterpretation der Symptome mit Nichtdurchführung der notwendigen Behandlungen können die Folge sein. Um zu entscheiden, welche Patienten eine weitere Diagnostik durch cCT benötigen, wurde S100B als potenziell gehirnspezifischer Serumbiomarker vorgeschlagen. Auf der anderen Seite lassen Studien vermuten, dass die Alkoholintoxikation selbst zu einem erhöhten Serumgehalt von S100B führen kann. Die vorliegende Studie zielt daher darauf ab, den Zusammenhang zwischen der Blutethylalkoholkonzentration und der S100B-Serumkonzentration in einem experimentellen Rahmen bei jungen Freiwilligen für Erwachsene zu untersuchen.In einer Kohorte von 58 gesunden Freiwilligen wurden vor und nach dem moderaten Alkoholkonsum die Serumkonzentration von S100B und die Blutethylalkoholkonzentration gemessen. Die Studie wurde vom örtlichen Ethikausschuss der Medizinischen Fakultät Mannheim (Ethikausschuss II, AZ 2012-272 N-MA) genehmigt. Die sofortige Analyse der Proben wurde mit modernsten automatisierten Messsystemen durchgeführt. (Analyzer Cobas e411, Roche und Analyzer Dimension Vista 1500, Siemens).Nach dem moderaten Alkoholkonsum lag der Alkoholgehalt der Probanden zwischen 0,23 und 1,92 g/l im Blut. Der S100B-Wert reichte von 0,021 bis 0,115 µg/l nach Alkoholkonsum (S100B-Standardwert 0,11 µg/l). Durch die Berechnung der Korrelation nach Alkoholkonsum mit r = 0,01181 ist ein Zusammenhang zwischen Serum-S100B-Konzentration und Ethylalkoholkonzentration nicht wahrscheinlich. Die S100B-Konzentrationen ist damit unabhängig von der Alkoholeinnahme bei moderatem Alkoholkonsum.Eine relevante Blutalkoholkonzentration (~ 1 g/l), bei ansonsten gesunden Freiwilligen, wirkt sich nicht auf die Serumkonzentration von S100B aus. S100B kann daher ein nützlicher Biomarker bei moderat betrunkenen Patienten sein.

The correct timing of urgent surgery in the field of orthopedic and trauma surgery is under constant discussion. The authors of this review like to present a scientific based recommendation for the timing of acute care surgery using the TACS-classification for the description of urgency. The timing and priority of the indicated procedure is deduced only from the expected mortality and disability caused by a potential delay. A proposal for a nomenclature is given to be integrated in the clinical practice and to be completed.Das Review versucht, aus der Sicht des Versorgungsspektrums in Orthopädie und Unfallchirurgie, wissenschaftlich belegbare Einordnungen spezieller Eingriffe in eine zeitlich geordnete Klassifikation vorzunehmen. Dabei wird die TACS-Klassifikation der Dringlichkeitsbeschreibung genutzt. Die Zuordnung einer OP-Indikation zur jeweiligen Dringlichkeitskategorie erfolgt anhand wissenschaftlicher Belege ausschließlich aufgrund der ansonsten zu erwartenden Mortalität oder bleibenden Behinderungen. Es wird vorgeschlagen, die Dringlichkeitsterminologie im klinischen Alltag zu übernehmen und die angebotenen Beispiele von OP-Indikationen begründet zu ergänzen.