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Terrorist-related mass casualty incidents represent a medical and organizational challenge for all hospitals. The main reasons are the special patterns of injuries, the onset and development of the scenario, the lack of information at the beginning, the overall number of casualties and the number of uninjured but involved patients presenting at the hospital.Due to these circumstances and the high percentage of penetrating injuries with a permanent risk of uncontrollable bleeding and other life-threatening complications, a strategic and tactical initial surgical care is necessary.For these special terrorist-related mass casualty (MasCal) situations, the Terror and Disaster Surgical Care (TDSC®) course was developed and imparts special medical and surgical knowledge as well as a scenario-based training in surgical decision-making. The TDSC® course focusses on the scenario-related provision of surgical care and distribution of the limited resources to enable survival for as many patients as possible.To improve individualized trauma care course formats, such as the Advanced Trauma Life Support (ATLS®) were established and are nowadays widespread in Germany. It could be shown that standardized approaches and algorithm-based treatment could improve the outcome of trauma victims. Faced with the present day permanent risk of a possible terrorist-related MasCal situation, the question arises how and to what extent elements and principles of both course formats (TDSC® and ATLS®) could be used to improve and organize the initial care in a terrorist-linked MasCal incident.For the first time it is shown that the key elements of both courses (primary survey of the ATLS® and the TDSC® principles: categorization, prioritization, disposition and realization) could be established and integratively used to structure the initial intrahospital medical and surgical care.

Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system.In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC.This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage.Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).

Since its founding in 1993 the TraumaRegister DGU® has become one of the largest registries especially in terms of data diversity. Since the introduction of the TraumaNetzwerk DGU®, the TraumaRegister DGU® has enabled a quasi-nationwide picture of the quality of care of severely injured patients in Germany. The register is subject to constant development, under the guidance of the working groups of the German Society for Trauma Surgery (DGU). The first modular expansion of special injury entities (craniocerebral trauma and complex hand injuries) is currently taking place. The future developments will involve the extension of the register to certain injury patterns. The existing registry will also be supplemented with other recorded qualities (from the supplementary serum database up to the quality of life). This makes the TraumaRegister DGU® a tool for quality assurance and science which is well prepared for the future.

Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured.Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis.The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset.The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.

Patients with severe thoracic trauma often receive continuous lateral rotational bed therapy (CLRT) for the treatment of lung contusions. In this study, the effects of CLRT on mortality, morbidity and length of stay (LOS) in the intensive care unit (ICU) and in the hospital were evaluated.Retrospective data from the TraumaRegister DGU® were analysed, focusing on patients with severe thoracic trauma. Patients treated with CLRT were compared to a control group with comparable trauma severity who had received conventional therapy.A total of 1476 patients (239 with CLRT, 1237 without CLRT) were included in this study. Both groups were similar for demographic characteristics. The median CLRT duration was 6 (4-10) days. Patients receiving CLRT were ventilated for 17 (10-26) days compared to 14 (8-22) days (p = 0.001) in the control group. The ICU length of stay differed significantly (CLRT: 23 [14-32] days; control: 19 [13-28] days; p = 0.002). Also, organ failure occurred more frequently in patients treated with CLRT (CLRT: 76.6%, control: 67.6%; p = 0.006). No differences could be detected regarding mortality rates, multiple organ failure and hospital LOS.The results of this retrospective analysis fail to detect a benefit for CLRT therapy in trauma patients. Considering inherent limitations of retrospective studies, caution should be exerted when interpreting these results. Further research is warranted to confirm these findings in a prospective trial.

To compare the treatment and survival of trauma patients in Germany and Southern Finland. Data from Helsinki University Hospital trauma registry (TR-THEL) and TraumaRegister DGU® (TR-DGU) were compared in a period from 2006 until 2011. From TR-DGU level-one trauma centers treating annually >50 injury severity score (ISS) >15 patients were included. The inclusion criterion was ISS >15. Patients under 16 years with penetrating trauma without head injury and transferred in with isolated head injury were excluded. The compared parameters were age, sex, pre-injury ASA, injury scoring, injury pattern, mechanism of injury, injury distribution, pre-hospital timings, transportation method, pre-hospital intubation, treatment at hospital, discharge destination, and 30-day hospital mortality. Expected mortality was defined with the Revised Injury Severity Classification score (RISC). Eighty-five German level-one trauma centers were included. A total of 15,306 and 1,274 patients were included in the outcome analysis from TR-DGU and TR-THEL, respectively. The difference between the observed and expected mortality of all patients was −4.1 % (standardized mortality ratio [SMR] 0.82) at German hospitals and −4.0 % (SMR 0.79) in Helsinki. Differences in the pre- and in-hospital treatment between the two countries were noted (transportation method, intubation rate, intensive care unit treatment, ventilation time, length of stay). The overall outcome results of the Helsinki University Hospital trauma unit were similar to those of the German level-one trauma centers. Registry comparison is a feasible method of quality control in a trauma centre.

Severe brain, thoracic and intrapelvic injuries, as well as heavy bleeding, are the main causes of death in patients with major trauma. Unstable pelvic ring fractures can cause this bleeding and the so-called "C problem". This is usually due to haemorrhagic shock caused by the loss of large volumes of blood from the presacral venous plexus, iliac vessels and the fracture surfaces. Many clinical studies have shown that, in the preclinical setting, unstable pelvic ring injuries are often underestimated. The application of a non-invasive external pelvic ring stabilisation (pelvic binder) is therefore recommended if a pelvic fracture is possible. Several circumferential pelvic binders have been developed and their prehospital use is increasing. Clinical and biomechanical studies have demonstrated that there is a favourable haemodynamic effect in unstable fractures, due to rapid closure of the pelvic ring. It is unclear whether the pelvic binder can be safely removed in a presumably haemodynamically stable patient. A correctly placed pelvic binder leads to anatomical closure of the pelvic ring. Therefore unstable pelvic ring fractures may be clinically and radiologically overlooked. This is a particular problem in unconscious patients. Furthermore, the real severity of the injury may then be underestimated in the diagnostic evaluation. Unconsidered opening of the pelvic binder can thus provoke renewed deterioration of the circulatory situation, especially if the injury was adequately treated by the binder and the C problem was controlled. The aim of this article is to describe procedures for handling pelvic binders, particularly as to how to deal with an already applied pelvic binder and how to "clear the pelvic region" while reducing the risk of haemodynamic instability. A detailed analysis of the literature and a Delphi-like discussion among several experts were performed. The following points were raised: 1) Assessment of the clinical situation, including trauma kinematics. 2) Assessment of the haemodynamic status. 3) Check of the need to open the pelvic binder for diagnostic/therapeutic measures before completing all diagnostic tests. 4) Assessment of the radiology diagnostic testing and release of the pelvic region. The result is a so-called "clear the pelvis algorithm" which describes a structured approach according to specific criteria and which specifies the circumstances under which the pelvic binder can be opened. Additional studies are necessary to analyse the applicability and safety of this algorithm in a clinical context. Our advice is not to "clear" the pelvis if no X-rays or CT scans of the pelvis have been carried out without (or with an opened) pelvic binder.

The German Trauma Registry DGU® started in 1993 as an initiative of five dedicated trauma centers and has evolved significantly since then. Data were obtained at four points of time from the site of the accident until discharge from hospital. In the first year (1993), the registry collected data of 260 patients from 5 hospitals. In 2015 more than 38.000 were included from 640 hospitals.This paper focusses on the impact of the trauma registry on the treatment of severely injured patients. Several authors could show that the data can be used by hospitals for benchmarking. This can help to detect problems in individual hospitals and to find solutions that can be implemented into the process of care and its subsequent reevaluation. Due to structural and process-related changes, the time necessary for the management in the emergency room could be reduced significantly. Various scientific analyses of the Trauma Registry DGU® data were implemented in the treatment of severely injured patients. In the prehospital treatment, this changed the criteria for intubation and led to a reduction of volume replacement. In the hospital setting, the analysis influenced the radiologic work-up and the treatment of coagulopathy of severely injured patients. Moreover, the risk-adjusted mortality of severely injured patients in Germany could be continuously reduced over the past 20 years.

Der fortgeschriebene Minimale Notfalldatensatz MIND3 ist ein Kerndatensatz, der eine definierte und von der DIVI autorisierte Menge an Merkmalen und Merkmalsbeschreibungen enthalt, die zur Dokumentation der prahospitalen Notfallrettung durch Rettungs- und Notarztdienst erforderlich sind. Der modulare Aufbau ermoglicht eine situations- und einsatzgerechte Dokumentation auf einem Basismodul-DIVI-Notfalleinsatzprotokoll und entsprechenden Zusatzmodulen. Mit einer IT-gestutzten Datenerfassung werden die Grundlagen fur ein medizinisches Qualitatsmanagement gelegt.

Background The Trauma Associated Severe Haemorrhage (TASH)-Score has been recognized as an easy-to-calculate scoring system to predict the probability for massive transfusion (MT) as a surrogate for life-threatening haemorrhage after injury. Changes with respect to management and outcome of these patients over time prompted a revalidation and an update of the TASH-Score. Methods The performance of the TASH-Score developed from the 1993–2003 TR-DGU database (Trauma Registry Deutsche Gesellschaft fur Unfallchirurgie/German Trauma Society) was revalidated on 5834 datasets from the 2004–2007 TR-DGU database with respect to discrimination, precision and calibration. The performance of the TASH-Score applied onto the 2004–2007 TR-DGU database was compared to its initial performance, and the logistic function to calculate the probability for MT was modified for score adjustment. Results/Conclusions When the original TASH-Score was applied onto the 2004–2007 TR-DGU database, a slight increase in discrimination was observed while precision was considerably lower. The predicted rate for MT within the development dataset was 13·9% while the observed incidence was 14·1%. In contrast, the predicted rate for MT within the revalidation dataset was 11·7%, while the observed rate was 8·4%. The logistic function to calculate MT probability was modified, and the TASH-Score was again evaluated against the most recent TR-DGU 2004–2007 database. The high performance of the score was not only restored but enhanced reflected by an increased ROC/AUC of 0·905. The score can be calculated quickly upon arrival of the patient in the emergency department and may be supportive to correct coagulopathy, to activate logistics and for research.

The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing. There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not.In a retrospective, multicentre study, we used the data recorded in the trauma registry of the German Trauma Society to calculate the probability of survival according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardised mortality ratio (SMR, ratio of recorded to expected mortality) for 4621 patients with blunt trauma given whole-body or non-whole-body CT.1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42.6 years (SD 20.7), 3364 (73%) were men, and mean injury-severity score was 29.7 (13.0). SMR based on TRISS was 0.745 (95% CI 0.633-0.859) for patients given whole-body CT versus 1.023 (0.909-1.137) for those given non-whole-body CT (p0.001). SMR based on the RISC score was 0.865 (0.774-0.956) for patients given whole-body CT versus 1.034 (0.959-1.109) for those given non-whole-body CT (p=0.017). The relative reduction in mortality based on TRISS was 25% (14-37) versus 13% (4-23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p/= 0.002). The number needed to scan was 17 based on TRISS and 32 based on RISC calculation.Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma. Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma.None.

Background To test whether an acute transfusion practice of packed red blood cells (pRBC) : fresh-frozen plasma (FFP) 1 : 1 would be associated with reduced mortality in acute bleeding multiply injury. Methods Retrospective analysis using the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie 2002–2006) on primary admissions with substantial injury (Injury Severity Score > 16) and massive transfusion (> 10 pRBCs). Seven hundred thirteen patients were divided into three groups according to the pRBC : FFP ratio transfused, that is, (i) pRBC : FFP > 1·1; (ii) pRBC : FFP 0·9–1·1 (1 : 1); and (iii) pRBC : FFP 1·1, 114 with pRBC : FFP 0·9–1·1 (1 : 1), and 115 with pRBC : FFP 1·1, pRBC : FFP 0·9–1·1 (1 : 1), and pRBC : FFP

In order to ensure adequate treatment and to avoid complications, care bundles are increasingly being implemented. These are comprehensive and evidence-based procedures for the treatment of individual diseases or injuries which should be carried out for every patient. The aim of this study was to define a care bundle for the prehospital treatment of severely injured patients.The scientific contents of the bundle were gathered from the interdisciplinary evidence-based S3 guidelines for the treatment of severely injured patients by the German Trauma Society. The ABCDE scheme suggested by the prehospital trauma life support (PHTLS®) and the advanced trauma life support (ATLS®) functioned as a matrix for the individual elements in the bundles. The identified elements were finalized by a consensus process.A bundle of six elements was suggested and a comprehensive summary of key items during prehospital management of severely injured patients was identified. In a next step the effectiveness of the care bundle should be evaluated in a clinical trial.

In der vorliegenden Studie werden die Behandlungsergebnisse der offenen transthorakalen und der endoluminalen stentgestutzten Versorgung bei polytraumatisierten Patienten mit traumatischer Aortenruptur hinsichtlich der Versorgungsqualitat (Dauer bis zur Operation, Dauer der Operation, Transfusionsbedarf) und Letalitat dargestellt. Die Datenauswertung erfolgte retrospektiv auf Grundlage des Traumaregisters der Deutschen Gesellschaft fur Unfallchirurgie (DGU) zwischen 1993 und 2002. Anhand des „Abbreviated Injury Score-“(AIS-)Codes wurden zunachst alle polytraumatisierten Patienten mit einer Aortenruptur ermittelt und in die Analyse [“Injury Severity Score“ (ISS), Blutdruck, Hb, AISThorax/Abdomen/Schadel, Alter] eingeschlossen. Innerhalb dieses Patientenkollektivs wurde dann fur 41 Patienten der Jahre 1998–2002 die Versorgungsqualitat (Dauer bis zur Operation, Dauer der Operation, Transfusionsbedarf) und Letalitat zwischen offen-chirurgischem und endovaskularem Verfahren verglichen. Von insgesamt 14.110 wiesen 100 (0,7%) Patienten mit einem Durchschnittalter von 38 (±19) Jahren eine Aortenlasion mit einer innerklinischen Gesamtletalitat von 39% auf. Der mittlere ISS betrug 41 (±14). Bei 36 Patienten wurde die Ruptur offen transthorakal und bei 5 Patienten endovaskular mittels Aortenstentimplantat versorgt. Die Letalitat in der Stentgruppe war mit 0% deutlich niedriger als in der offen operierten Gruppe (17%). Verletzungen der thorakalen Aorta stellen eine seltene aber schwerwiegende Begleitverletzung bei schwer- und schwerstverletzten Patienten dar. Die Krankenhausletalitat der traumatischen Aortenruptur scheint durch die Anwendung endovaskularer Stentverfahren deutlich gesenkt werden zu konnen. Da die Methode ein gering invasives und sicheres Verfahren darstellt, ist sie in Zentren mit entsprechender Erfahrung eine wichtige Alternative zum offenen transthorakalen Vorgehen.

Verletzungen des Tracheobronchialbaums nach stumpfem Thoraxtrauma sind mit unter 1% relativ seltene Ereignisse. Diagnostik und Behandlung stellen aufgrund ihrer Raritat an den erstbehandelnden Arzt hohe Anforderungen; wird die Verletzung nicht rechtzeitig erkannt, konnen lebensgefahrliche Komplikationen drohen. Im Folgenden wird der Fall eines 9-jahrigen Madchen beschrieben, das durch den Sturz auf den Lenker ihres Kickboards einen zervikalen Trachealeinriss im Bereich des Paries membranaceus erlitten hatte. Anhand dieses Falls sollen die diagnostischen Moglichkeiten der Tracheoskopie bzw. Computertomographie dargestellt werden. Ferner wird die Moglichkeit des von uns durchgefuhrten konservativen Behandlungsregimes diskutiert.

Limiting the morbidity of open fractures requires highly specific initial treatment. In addition to a stringent surgical strategy, correct antibiotic prophylaxis seems to be associated with an improved outcome. In the current literature, the duration and type of antibiotic prophylaxis are under discussion. The aim of the study was to survey the current initial treatment regimes for open fractures in German emergency departments.With an online-based anonymous 16-item questionnaire all 3006 members of the German Trauma Society were surveyed. A total of 585 questionnaires (19.5 %) were returned completed. This article presents a descriptive analysis of the current state of treatment.Mainly specialists (35 %), senior physicians (30 %) and chief physicians (17 %) answered as well as interns (8 %) and out-patient practitioners (10 %). Of the participants 65 % did not accept the classification of emergency services; however, 93 % carried out urgent or emergency surgery, 84 % started an antibiotic prophylaxis in the emergency department and 63 % used a standard operating procedure (SOP). A total of 60 % used 1 antibiotic drug, 25 % used 2 and 15 % used 3 or more substances. An antibiotic treatment for more than 3 days was performed by 60 % of participants.The early initiation of antibiotic prophylaxis seems to be the standard practice in German emergency departments as well as early surgery. Strategies to improve the communication between prehospital and in-hospital teams, as well as graded antibiotic prophylaxis depending on the severity of soft tissue damage are needed.

The management of gunshot wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. Penetrating injuries occur with an incidence of 5% in Germany. They are caused by gunshots or more commonly by knives or other objects, for example during accidents. Since even the number of patients who are treated at level 1 trauma centres is limited by the low incidence, the objective of this study was to assess the epidemiology and outcome of gunshot and stab wounds in Germany.Since 2009, the trauma registry of the German Trauma Society (TraumaRegister DGU®) has been used to assess not only whether a trauma was penetrating but also whether it was caused by a gunshot or a stabbing. On the basis of this registry, we identified relevant cases and defined the observation period. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2011. We did not specify exclusion criteria in order to obtain as comprehensive a picture as possible of the trauma entities investigated in this study. As a result of the high incidence of gunshot wounds to the head and the implications of this type of injury for the entire group, a subgroup of patients without head injuries was analysed.From 2009 to 2011, there were 305 patients with gunshot wounds and 871 patients with stab wounds. The high proportion of suicide-related gunshot wounds to the head resulted in a cumulative mortality rate of 39.7%. Stab wounds were associated with a lower mortality rate (6.2%). Every fourth patient with a gunshot or stab wound presented with haemorrhagic shock, which was considerably more frequently seen during the prehospital phase than during the inhospital phase of patient management. Of the patients with gunshot wounds, 26.9% required transfusions. This percentage was three times higher than that for patients with blunt trauma.In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicide. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required which can provide the basis for an evaluation of the long-term quality of the management of patients with stab or gunshot wounds.

Background Penetrating injuries are rare in European populations so their management represents a particular challenge. The aim was to assess early therapeutic aspects that are associated with favourable outcomes in patients with penetrating trauma. Methods Patients with penetrating injuries documented from 2009 to 2013 in the TraumaRegister DGU® were analysed. Patients with a primary admission and an Injury Severity Score (ISS) of at least 9 were included. The Revised Injury Severity Classification (RISC) II score was used for mortality prediction, and a standardized mortality ratio (SMR) calculated per hospital. Hospitals with favourable outcome (SMR below 1) were compared with those with poor outcome (SMR 1 or more). Results A total of 50 centres had favourable outcome (1242 patients; observed mortality rate 15·7 per cent) and 34 centres had poor outcome (918 patients; observed mortality rate 24·4 per cent). Predicted mortality rates according to RISC-II were 20·4 and 20·5 per cent respectively. Mean(s.d.) ISS values were 22(14) versus 21(14) (P = 0·121). Patients in the favourable outcome group had a significantly shorter time before admission to hospital and a lower intubation rate. They received smaller quantities of intravenous fluids on admission to the emergency room, but larger amounts of fresh frozen plasma, and were more likely to receive haemostatic agents. A higher proportion of patients in the favourable outcome group were treated in a level I trauma centre. Independent risk factors for hospital death following penetrating trauma identified by multivariable analysis included gunshot injury mechanism and treatment in non-level I centres. Conclusion Among penetrating traumas, gunshot injuries pose an independent risk of death. Treatment of penetrating trauma in a level I trauma centre was significantly and independently associated with lower hospital mortality.

In recent years, the treatment of trauma-associated coagulopathy and bleeding has advanced enormously. The aim of this study was to assess the current practice of coagulation and transfusion management in Germany.From October 2011 until January 2012 we conducted a survey via online-questionnaire that was sent per E-Mail to all members of the German Society for Trauma Surgery. It comprised 12 questions with respect to current treatment of coagulopathy and haemorrhage in trauma patients.The response rate was 145/3006 (5 %). The respondents had following specialties: 77.2 % trauma surgery 15.9 % anesthesiology, 6.9 % others. 64 % of respondents were employed by a Level 1 trauma centre, wheras 17 % worked in a local level 3 centre. The majority (94 %) claimed to treat hypothermia regularly. Only about half of the participants reported to follow a massive transfusion protocol in their institution. The potential components of these protocols were reported in varying rates, being it well-established components (e.g. FFP 78 %; Fibrinogen 75 %) or therapies with poor evidence in multiple trauma (Desmopressin 39 %, rFVIIa 47 %). Calcium was provided by only 48 % of respondents although generally recommended in all guidelines.The current study suggests that in Germany strategies and principles regarding management of trauma-associated coagulopathy are standardized only poorly. Level 1 centres appear to apply a more advanced approach, however to much variability exists with respect to the components of the transfusion protocols. The low response rate indicates that most German trauma surgeons consider coagulation and hemorrhage as "expert-topics" beyond their field of duty.

The TraumaRegister DGU® of the German Society for Trauma Surgery (TR-DGU) has collected data on the treatment of severely injured accident victims in Germany since 1993. Due to the current number of more than 600 participating clinics which regularly receive quality comparison reports, these register data are becoming an increasingly more valuable source for healthcare research.The aims of this article are to describe the potential of the TR-DGU for dealing with epidemiological questions and for describing the quality of the process and results for treatment of severely injured patients.The TR-DGU includes approximately 100 details per patient on the person, the circumstances of the accident, the injury pattern, the preclinical and hospital treatment, the condition of the patient and the outcome. Using comparative analyses the observed mortality is adjusted by considering prognostically relevant findings. Some key features of the register are reported for patients who were treated in German hospitals between 2002 and 2012 with an injury severity score (ISS) of ≥9 points.Since 1993 more than 122,000 patients have been included in the register. The majority are traffic accident victims (57 %), followed by patients with falls from low heights ( 3 m, 17 %) or greater heights ( 3 m, 16 %). Among the traffic accident victims approximately one half are car drivers or passengers (46 %), one quarter are motorbike drivers (25 %) and the rest are cyclists (14 %) and pedestrians (13 %). The mortality of patients with an ISS ³ 9 is 12.8 %. This value is approximately 1-2 % below the expected prognosis based on data from the 1990s.The TR-DGU is not only a successful instrument for external quality assurance of the treatment of severely injured patients but also an increasingly more valuable source for scientific evaluation within the framework of healthcare research. The introduction of regional trauma networks by the DGU has made a substantial contribution to the comprehensive compilation of severely injured patients and allows increasingly more detailed information on the epidemiology of severe injuries in Germany to be compiled.

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.

The aim of the study was to assess whether the use of recombinant factor VIIa (rFVIIa) in trauma patients was associated with improved outcome.Patients documented in the TraumaRegistry of the German Society for Trauma Surgery (primary admissions; Injury Severity Score, ISS ≥ 9) who received rFVIIa in the first 6 hours upon admission (rFVIIa +) were matched with patients that had not received rFVIIa (rFVIIa-).The matching comparison yielded two identical groups with 100 patients each (rFVIIa+: average age 40.6 ± 18.5 years, ISS 47.1 ± 16.7 versus rFVIIa-: 40.1 ± 19.1 years, ISS 45.1 ± 15.6). Patients were administered an average of 18.3 ± 13.1 (rFVIIa+) versus 19.5 ± 14.0 (rFVIIa-) red blood cell units (p = 0.55) and 15.2 ± 13.7 (rFVIIa+) versus 15.0 ± 13.1 (rFVIIa-) units of fresh frozen plasma (p = 0.92). Thromboembolisms occurred in 5% (rFVIIa+) versus 2% (rFVIIa-) (p = 0.44), multiple organ failure (MOF) in 82% versus 62% (p = 0.003) and hospital mortality was 48% versus 43% (p = 0.57), respectively.The early use of rFVIIa in severely injured patients was not associated with either lower transfusion requirements or with mortality reduction but with increased MOF.

The Trauma Registry of the German Society for Trauma Surgery (TR-DGU) has documented diagnostics, treatment and outcome of severely injured patients since 1993. In 2009 it became the obligatory tool for quality assessment in the regional trauma networks (TraumaNetzwerk DGU). During that time period many things changed, and data from the TR-DGU could be used to monitor these changes. For example, the time from accident until hospital admission, which is about 70 min, has not changed in recent years. Conversely, major trends were observed regarding a reduced amount of preclinical volume and, in conscious patients, a lower intubation rate. In the acute care hospital whole-body CT is used in nearly all hospitals and has contributed to the fact that the mortality rate today is 2-3% lower than a decade ago.

The Trauma Associated Severe Haemorrhage (TASH)-Score has been recognized as an easy-to-calculate scoring system to predict the probability for massive transfusion (MT) as a surrogate for life-threatening haemorrhage after injury. Changes with respect to management and outcome of these patients over time prompted a revalidation and an update of the TASH-Score.The performance of the TASH-Score developed from the 1993-2003 TR-DGU database (Trauma Registry Deutsche Gesellschaft für Unfallchirurgie/German Trauma Society) was revalidated on 5834 datasets from the 2004-2007 TR-DGU database with respect to discrimination, precision and calibration. The performance of the TASH-Score applied onto the 2004-2007 TR-DGU database was compared to its initial performance, and the logistic function to calculate the probability for MT was modified for score adjustment.When the original TASH-Score was applied onto the 2004-2007 TR-DGU database, a slight increase in discrimination was observed while precision was considerably lower. The predicted rate for MT within the development dataset was 13·9% while the observed incidence was 14·1%. In contrast, the predicted rate for MT within the revalidation dataset was 11·7%, while the observed rate was 8·4%. The logistic function to calculate MT probability was modified, and the TASH-Score was again evaluated against the most recent TR-DGU 2004-2007 database. The high performance of the score was not only restored but enhanced reflected by an increased ROC/AUC of 0·905. The score can be calculated quickly upon arrival of the patient in the emergency department and may be supportive to correct coagulopathy, to activate logistics and for research.

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

With over 1 million certified physicians in more than 50 countries worldwide, the Advanced Trauma Life Support (ATLS) concept is one of the most successful international education programs. The concept is simple, priority-orientated (ABCDE scheme) and assesses the situation of the trauma patient on the basis of vital signs to treat the life-threatening injuries immediately. With over 100 ATLS provider courses and 10 instruction courses accomplished in less than 6 years, no other land in the world has successfully established this concept in such a short time as Germany. Meanwhile nearly 1,600 colleagues have been trained and certified. Evaluation of the first 100 ATLS courses in Germany supports this concept. The total evaluation of all courses is 1.36 (1.06-1.8, n=100). The individual parts of the course were marked as followed: presentations 1.6 (1.0-2.81, n=100), practical skills stations 1.46 (1.0-2.4, n=100) and surgical skills stations 1.38 (1.0-2.38, n=100). In 2009 a total of 47 ATLS courses were accomplished which will clearly increase in 2010. Other ATLS formats, such as ATCN (Advanced Trauma Care for Nurses) and refresher courses are planned for the beginning of 2010.

Damage Control Orthopedics is a strategy for treatment of fractures in severely injured patients. The aim is to reduce secondary damage and thereby improve the patient's outcome. The relevant fractures are primarily stabilized with external fixators instead of a primary definitive osteosynthesis. The less traumatic and shorter surgical procedure is thought to reduce the additional trauma load and should thereby minimize the "second hit" situation. After stabilization of the patient on the intensive care unit secondary definitive ostesynthesis can then be performed after 4-14 days.The available animal studies, retrospective clinical studies and prospective cohort studies seem to support the concept of damage control. The only available randomized study shows an advantage of this strategy in a subgroup of borderline patients. A meta-analysis could not find convincing evidence that definitively proves the advantage of this concept. A new multi-center randomized study has been started to evaluate the concept of damage control in a defined group of critically injured patients with femoral shaft fractures.

Computer-assisted surgery (CAS) has become established in many hospitals throughout the world, especially in the form of computer navigation for total knee replacement (TKR). Analysis of the studies available revealed 18 comparative studies examining the precision of implantation of knee endoprostheses following CAS and after implantation by the conventional technique. In a meta-analysis of 13 studies in which the same safe zone of +/-3 from neutral alignment was defined for the leg axis, a total of 1,784 TKR were performed. In the group of patients in whom the conventional technique was used, 75.6% (654/865) of TKR were implanted within the safe zone. In the CAS group 93.9% (863/919) of the prostheses were implanted within the safe zone (p0.0001). The differences between the groups were statistically significant in 11 of the 13 studies, and the difference between groups for the entire patient population is highly significant. Only limited clinical results were ascertained in these comparative studies; there were no great differences between the treatment groups in clinical course.

The aim of the survey was to elucidate the significance of postoperative pain therapy for the patient and its influence on the choice of hospital.This prospective, anonymous survey of consecutive patients in a general surgical clinic was performed by an independent study nurse.A total of 161 patients were included; 90% of the surgical patients considered "good pain therapy" as a highly important factor, and three of four patients would admit themselves more likely to a clinic well known for "good pain therapy." If the patients could choose their hospital, factors such as "medical care by the physicians" are most important (rank 1; rank 1 most important, rank 10 most unimportant) followed by quality of "nursing care" (mean rank 2.6) and "good pain therapy" (mean rank 3.6). Older patients (or = 60 years) preferred a hospital with known "good pain therapy" more often for surgical therapy than younger patients (60 years).It can be concluded that postoperative pain relief is an important factor for the patients' selection of a clinic and is influenced by an age ofor = 60 years.

Herein we report our results of treatment of traumatic aortic ruptures in severely injured patients with either open surgery or endovascular stent graft repair. Data were analyzed retrospectively from the trauma registry of the DGU (Deutsche Gesellschaft fur Unfallchirurgie) over a time period from 1993 through 2002. All patients with traumatic rupture of the aorta were included and analyzed for injury severity (ISS), blood pressure (mmHg), hemoglobin (mg/%), and AIS (Abbreviated Injury Score) of the thoracic, abdominal, and upper extremity regions. Patients treated between 1998 and 2002 were further examined (operation within 24 h, duration of intervention, blood transfusion, and lethality with regard to either open surgical or endoluminal stent graft repair). Of 14,110 patients, 100 (0.7%) suffered from acute aortic rupture. Mean age was 38 years (+/-19) with an inhospital lethality of 39% (n=39). Mean ISS was 41 (+/-14); 36 patients were treated by open surgery and 5 patients by a stent-assisted endoluminal procedure. Lethality was 17% for open surgery and 0% for stent graft repair. Endovascular approach to traumatic rupture of the aorta is feasible and safe. It has been shown to reduce inhospital lethality and may offer an alternative to open surgery for severely injured patients.

Tracheobronchial lesions after blunt chest injury are rare. Diagnosis and therapy can prove to be challenging for the attending physician. Nonrecognition of this injury may entail severe complications. Herein we report the case of a 9-year-old girl with rupture of the trachea due to a fall against the handlebar of her kickboard. The clinical, radiological, and features of the therapy performed are discussed.

Im Mai 1998 wurde ein Qualitatsmanagement (QM)-System fur die Schwerstverletztenversorgung im Universitatsklinikum Essen eingefuhrt. Die Implementierung basierte auf: 1. Dokumentation 2. 20 Beurteilungskriterien 3. Statistischer Analyse. 4. Qualitatszirkel (QZ). Im Zeitraum von 5/1998 bis 9/1999 wurden 447 Pat. (ISS von 22 ± 17) behandelt. Die Beurteilung erfolgte anhand von 4 Quartalen (4 Monate). Es erfolgten insgesamt 8 QZ-Treffen, 16 Veranderungen wurden eingefuhrt. 60% (n =12) der 20 Beurteilungskriterien konnten deutlich optimiert werden. Die Letalitat ging von 17% im ersten auf 10% im letzten Quartal zuruck. Schlusfolgerung: Durch Implementierung des interdisziplinaren QM-Systems wurde die Schwerverletztenversorgung in Bezug auf die Effektivitat der Behandlung deutlich verbessert.

Im Traumaregister der AG „Polytrauma“ der Deutschen Gesellschaft fur Unfallchirurgie wurden 3814 Patienten von 1993–1998 (durchschnittlicher Injury Severity Score, ISS: 24,3 ± 13,2 Punkte) erfast, davon 186 Kinder bis einschlieslich 15 Jahre (ISS: 21,9 ± 15,5 Pkt.). Die Kinder verunfallten uberwiegend im Strasenverkehr, 25,3% als Zweiradfahrer, 19,9% als Fusganger, 17,7% als Fahrzeuginsassen. 48,4% der Kinder wiesen ein relevantes Schadel-Hirn-Trauma (SHT) auf (AIS > 2 Pkt. fur die Region Kopf). 16,2% der Kinder verstarben, davon 65,4% in den ersten 24 Stunden, meist am SHT. Die Kinder zeigten kurzere Therapiezeiten (Beatmung, ICU, stat. Behandlung), seltener ein Organversagen oder eine Sepsis gegenuber gleich schwer verletzten Erwachsenen und wurden zu 57,9% nach Hause entlassen.

Quality control requires the definition of a quality standard, followed by quality documentation and comparison. In the case of deviation from the standard, the first step in quality assurance is the search for the reasons. After identification of weak points, strategies for quality improvement must then be developed and implemented. With prehospital trauma care as an example, a practical model of quality assurance is presented. Data analysis was performed using the prospective database of 8792 trauma patients who received prehospital trauma care in Cologne from 1. 1. 87 to 31. 12. 90. The Trauma Score was used for classification of the severity of injury. The quality standard in prehospital treatment of severely injured patients is defined as institution of an intravenous line, early intubation and transportation to a trauma centre. The time at the scene of the accident should not exceed 31 min. Among the 8792 trauma patients, 834 had severe injuries, defined as a Trauma Score equal to or less than 12 or a Glasgow Coma Scale equal to or less than 7. An intravenous line was started in 91.6%, early intubation was performed in 82.7%, and transportation to a trauma centre was realized in 62.5% of the patients. The average time at the scene was 34 min. Obviously the standard was not always achieved. Reasons for deviation from the standard are discussed. The fascinating aspect of the model proposed is that it enables quality assurance of prehospital treatment without recourse to hospital data.