Aggressive operative treatment of isolated blunt traumatic brain injury in the elderly is associated with favourable outcome

Outcome after traumatic brain injury (TBI) in the elderly has not been fully elucidated. The present retrospective observational study investigates the age-dependent outcome of patients suffering from severe isolated TBI with regard to operative and non-operative treatment. Data were prospectively collected in the TraumaRegister DGU. Anonymous datasets of 8629 patients with isolated severe blunt TBI (AISHead≥3, AISBody≤1) documented from 2002 to 2011 were analysed. Patients were grouped according to age: 1-17, 18-59, 60-69, 70-79 and ≥80 years. Cranial fractures (44.8%) and subdural haematomas (42.6%) were the most common TBIs. Independent from the type of TBI the group of patients with operative treatment declined with rising age. Subgroup analysis of patients with critical TBI (AISHead=5) revealed standardised mortality ratios (SMRs) of 0.81 (95% CI 0.75-0.87) in case of operative treatment (n=1201) and 1.13 (95% CI 1.09-1.18) in case of non-operative treatment (n=1096). All age groups ≥60 years showed significantly reduced SMRs in case of operative treatment. Across all age groups the group of patients with low/moderate disability according to the GOS (4 or 5 points) was higher in case of operative treatment. Results of this retrospective observational study have to be interpreted cautiously. However, good outcome after TBI with severe space-occupying haemorrhage is more frequent in patients with operative treatment across all age groups. Age alone should not be the reason for limited care or denial of operative intervention.

[HIV prophylaxis kits. A concept for emergency treatment in the context of postexposure prophylaxis]

Occupational transmission of HIV among healthcare personnel is rare but has repeatedly been published in the literature. Early initiation of postexposure HIV prophylaxis (HIV-PEP) is crucial to prevent virus transmission. For this reason the need for HIV-PEP has to be evaluated immediately and if necessary, started as soon as possible. This article presents an early intervention program in a university hospital which enables healthcare personnel immediate 24/7/365 access to a HIV-PEP prophylaxis kit following occupational HIV exposure.

Impact of peer feedback on the performance of lecturers in emergency medicine: a prospective observational study

Background

Although it is often criticised, the lecture remains a fundamental part of medical training because it is an economical and efficient method for teaching both factual and experimental knowledge. However, if administered incorrectly, it can be boring and useless.

Feedback from peers is increasingly recognized as an effective method of encouraging self-reflection and continuing professional development. The aim of this observational study is to analyse the impact of written peer feedback on the performance of lecturers in an emergency medicine lecture series for undergraduate students.

Methods

In this prospective study, 13 lecturers in 15 lectures on emergency medicine for undergraduate medical students were videotaped and analysed by trained peer reviewers using a 21-item assessment instrument. The lecturers received their written feedback prior to the beginning of the next years’ lecture series and were assessed in the same way.

Results

In this study, we demonstrated a significant improvement in the lecturers’ scores in the categories ‘content and organisation’ and ‘visualisation’ in response to written feedback. The highest and most significant improvements after written peer feedback were detected in the items ‘provides a brief outline’, ‘provides a conclusion for the talk’ and ‘clearly states goal of the talk’.

Conclusion

This study demonstrates the significant impact of a single standardized written peer feedback on a lecturer’s performance.

[National data set "emergency department": development, structure and approval by the Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin]

BACKGROUND

The Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin (DIVI) is divided into sections one of which is the "Sektion Notaufnahmeprotokoll" (emergency department protocol section) founded in 2007. The main task was to create a national data set for the documentation of patients in emergency departments (ED).

MATERIAL AND METHODS

In order to create such a data set a careful look was taken at the current state of documentation in many different hospitals throughout Germany. In addition, existing registries and international requirements were also taken into consideration. The content of the dataset "ED documentation" was developed in interdisciplinary and interprofessional expert rounds.

RESULTS

The dataset "ED documentation" forms the first basis for documentation in German EDs. The modular data set contains 676 fields and covers all relevant information of the whole clinical process in the ED. Legal issues as well as several aspects for internal and external quality management are also included. For this reason the data of several German quality registries (e.g. TraumaRegister DGU® of the German Society of Trauma Surgery) are part of the data set. Furthermore, the data set forms the basis for several financial and billing aspects. A set of six forms was created in accordance with the developed modular data set. In 2010 the data set was approved by the executive committee of the DIVI. Several German medical associations (e.g. German Association for Emergency Medicine/Deutsche Gesellschaft Interdisziplinäre Notfall- und Akutmedizin, DGINA) recommend its use. Currently 80 hospitals are using the data set.

CONCLUSION

Beside the ability to exchange information the presented data set is the basis for internal and external quality assessment in the ED even if most of the available scoring and benchmarking tools are not validated for the German medical system. Implementing an ED register in Germany which is planned in the future, could close this gap.

Analysis of trainees' memory after classroom presentations of didactical ultrasound courses

Background

Emergency ultrasound is gaining importance in medical education. Widespread teaching methods are frontal presentations and hands-on training. The primary goal of our study was to evaluate the impact of frontal presentations (PS) by analysis of retained knowledge rate (RKR) and learning load (LL).

Methods

Our study was conducted during four introductory courses in emergency ultrasound covering Extended Focused Assessment with Sonography for Trauma (E-FAST) and Focused Echocardiography Evaluation in Life Support (FEEL). Standardized PS (length of 10 to 50 min) were presented by experienced trainers, who were asked to provide keywords, key messages, and images and assign a score to each. Group 1 consisted of 11 medical students with no prior ultrasound experience, and group 2 consisted of 80 physicians. Each group was audience to seven to eight standard PS and requested to answer a free text questionnaire after 0 h, 2.5 h, 24 h, and 14 days.

Results

In group 1, 168/176 questionnaires were analyzed, and 161/202 were analyzed in group 2. RKR in group 1 was 32.5%, 15%, 16%, and 12% at 0 h, 2.5 h, 24 h, and 2 weeks. The physicians' RKR were 23%, 20.5%, and 22.4% after 0, 2.5, and 24 h of a respective PS. The LL was 1.6/min for students and 1.2/min for physicians. There was no difference in RKR when comparing PS with higher and lower LL for both groups; shorter or case-based PS were associated with a higher RKR (p < 0.01).

Conclusions

Our study provides evidence that only a limited amount of information can be processed at a time. Only 12% of knowledge is retained after 2 weeks. Presentations of short duration can increase the retained knowledge rate. Therefore, frontal presentations and classroom-based ultrasound training and teaching should be adapted.

Best practice for needlestick injuries

PURPOSE

Needlestick injuries (NSIs) are a significant health hazard. Occupational transmission of bloodborne pathogens among healthcare workers (HCWs) is rare but has been repeatedly reported in the literature.

METHODS

In October 2010, new regulations were introduced for medical aftercare of HCWs following NSIs at the University Hospital Frankfurt. In June 2013, a university hospital-wide early intervention program was introduced that gives HCWs immediate 24/7/365 access to an HIV postexposure prophylaxis kit after confirmed or probable occupational HIV exposure.

RESULTS

Interdisciplinary collaboration between the attending surgeon and occupational health as well as infectious disease specialists facilitates optimal postexposure medical treatment of HCWs who suffer NSIs. Complete reporting of NSIs is a prerequisite for achieving optimal treatment of the affected HCWs.

CONCLUSION

An NSI is an emergency and needs to be evaluated immediately and, if necessary, treated as soon as possible. A standardized algorithm for initial diagnostic and treatment has proven to be helpful.

Balancing the need for big data and patient data privacy--an IT infrastructure for a decentralized emergency care research database

Emergency rooms of hospitals provide care to a lot of patients and have great impact on their outcome, so researching the quality of care seems important. Research using registries has yielded impressive results in other areas of medicine. However centralized data-storage has its pitfalls, especially regarding data privacy. We therefore drafted an IT infrastructure that uses decentralized storage to ensure data privacy, but still enables data transfer between participating hospitals. It implements an independent information broker to ensure anonymity of patients. Still it provides a way for researchers to request data and hospitals to contribute data on an opt-in basis. Although not an entirely new approach, the emphasis on data privacy throughout the design is a novel aspect providing a better balance between the need for big sample sizes and patient privacy.

Predictors of pulmonary failure following severe trauma: a trauma registry-based analysis

BACKGROUND

The incidence of pulmonary failure in trauma patients is considered to be influenced by several factors such as liver injury. We intended to assess the association of various potential predictors of pulmonary failure following thoracic trauma and liver injury.

METHODS

Records of 12,585 trauma patients documented in the TraumaRegister DGU® of the German Trauma Society were analyzed regarding the potential impact of concomitant liver injury on the incidence of pulmonary failure using uni- and multivariate analyses. Pulmonary failure was defined as pulmonary failure of ≥ 3 SOFA-score points for at least two days. Patients were subdivided according to their injury pattern into four groups: group 1: AIS thorax < 3; AIS liver < 3; group 2: AIS thorax ≥ 3; AIS liver < 3; group 3: AIS thorax < 3; AIS liver ≥ 3 and group 4: AIS thorax ≥ 3; AIS liver ≥ 3.

RESULTS

Overall, 2643 (21%) developed pulmonary failure, 12% (n= 642) in group 1, 26% (n= 697) in group 2, 16% (n= 30) in group 3, and 36% (n= 188) in group 4. Factors independently associated with pulmonary failure included relevant lung injury, pre-existing medical conditions (PMC), sex, transfusion of more than 10 units of packed red blood cells (PRBC), Glasgow Coma Scale (GCS) ≤ 8, and the ISS. However, liver injury was not associated with an increased risk of pulmonary failure following severe trauma in our setting.

CONCLUSIONS

Specific factors, but not liver injury, were associated with an increased risk of pulmonary failure following trauma. Trauma surgeons should be aware of these factors for optimized intensive care treatment.

[An online emergency physician survey - demography, education and experience of German emergency physicians]

BACKGROUND AND OBJECTIVE

German emergency patients are treated by (emergency) physicians (EP). The entry level to emergency medicine differs. Manual skills experience (e. g. tracheal intubation) and knowledge of guidelines are minimum requirements. It is currently unclear who works as an EP and what medical experience he or she has.

METHODS

The anonymous survey was online from 10/15/2010 to 11/16/2011 and distribution was supported by leading physicians informing society members. Online networks informed independent physicians.

RESULTS

2091 EP took part, 1991 datasets were evaluated, 100 datasets were excluded. All results are shown as mean ± standard deviation and range (minimum - maximum). Mean age of the EP was 42 ± 8 years (26-71 years), 80 % (n = 1604) were male, 20 % (n = 387) were female. Participants finished medical school in 1997 ± 8 years (1964-2010). Base specialty during rotation was anesthesiology 59 %, internal medicine 32 %, surgery 26 %, trauma surgery/orthopedics 21 %, others 16 %. Consultants were 75 %. Main income source was answered as "hospital physician" by 77 %, "resident doctor" by 15 %, "professional emergency physician" by 7 %. The participants use a widespread chance for CME (Continuing Medical Education).

CONCLUSION

The participants appear experienced in medicine and emergency medicine. They use a widespread chance for CME. Most of the participants work in anaesthesiology.

[Importance of the correct placement of the pelvic binder for stabilisation of haemodynamically compromised patients]

A 36-year-old motorcyclist sustained multiple severe injuries in a motorcycle accident. The leading injury was a type B open-book pelvic fracture, resulting in a relevant haemodynamic instability. Due to an initial misplacement of the pelvic binder (Samsling®) by the paramedics in the field, a sufficient compression of the fracture and stabilisation of the haemodynamic situation could not be obtained. After repositioning of the pelvic binder in the emergency room, the pelvis was adequately stabilised, leading to a transient stabilisation of the haemorrhagic shock. This example illustrates the benefit of a simple and effective tool for the initial stabilisation of pelvic fractures in haemodynamically compromised patients and in particular the importance of the correct placement of the pelvic binder.

The golden hour of shock - how time is running out: prehospital time intervals in Germany--a multivariate analysis of 15, 103 patients from the TraumaRegister DGU(R)

OBJECTIVES

Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals.

METHODS

We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST.

RESULTS

15 103 datasets were included in this study. Based on the mean OST of 32.7 (± 18.6) min and a constant absolute term of 16.2 (± 1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3 ± 0.8 min) and being a car occupant (8.0 ± 0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤ 8 (-4.5 ± 0.7 min) and cardiopulmonary resuscitation (-2.8 ± 1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0 ± 24.6 min) compared with Level I (70.0 ± 28.5 min) and II (66.8 ± 27.4 min) trauma centres.

CONCLUSIONS

This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.

Lung Organ Failure Score (LOFS): probability of severe pulmonary organ failure after multiple injuries including chest trauma

BACKGROUND

Pulmonary complications are common in multiple trauma patients with chest injury. Factors predisposing these critically ill patients to respiratory organ failure are not fully understood.

METHODS

Univariate and multivariate logistic regression analyses were used to assess the prognostic value of clinical and laboratory variables (2002-2008; n = 30,616) from the Trauma Registry of the German Trauma Society (DGU). Data from patients admitted to the ICU with lung contusion/lacerations, an Injury Severity Score ≥ 16 and age ≥ 18 were included in the study. Severe pulmonary organ failure was defined as PaO(2)/FiO(2)<200 for ≥ 3 days and based on the odds ratios (ORs) a simplified Lung Organ Failure Score (LOFS) was developed using integer values.

RESULTS

21.3% (1254) of the 5892 patients analysed developed severe pulmonary organ failure. We identified seven independent predictors with significant correlation: age, gender, head injury, fluid therapy, injury severity, degree of chest trauma and surgical interventions. The highest ORs were observed in cases of Abbreviated Injury Scale (AIS)(Thorax) = 5 (1.58), surgical intervention (1.71) and multiple surgeries (2.41). We found that patients with simplified score values ≥ 21 points were at a maximum risk (>30%) for developing severe pulmonary complications.

CONCLUSION

This scoring method could help trauma surgeons determine which multiple trauma patients are at risk for pulmonary complications after trauma. Efficacy analyses of prophylactic PEEP ventilation or rotational bed therapy in subgroups with comparable risks for respiratory complication could be based on the LOFS.

Accuracy of prehospital focused abdominal sonography for trauma after a 1-day hands-on training course

OBJECTIVES

To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and to evaluate the accuracy of the participants after the course and at the trauma scene.

METHODS

A training programme was developed to provide medical staff with the skills needed to perform P-FAST. In order to evaluate the accuracy of P-FAST performed by the students, nine participants (five emergency doctors and four paramedics) were followed during their course and in practice after the course. An assessment was made of 200 ultrasound procedures performed during the course in healthy volunteers and in patients with peritoneal dialysis or ascites. Regular P-FAST performed on-scene by the participants commenced immediately following the course. The results for the nine participants (C-group, course group) were compared with those members of medical staff with more than 3 years of experience in FAST (P-group, professional group). A group of physicians untrained in P-FAST served as a control (I-group, indifferent group). P-FAST findings were further verified by subsequent FAST and CT scans in the emergency department.

RESULTS

After the training programme the C-group performed 39 P-FAST procedures without any false negative or false positive findings (100% accuracy). In the P-group, 112 procedures were performed with one false positive case. In the I-group there were 2 false negative cases among the 46 procedures performed.

CONCLUSION

Following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.

[An educational skills programme for undergraduate training in orthopaedic and trauma surgery]

INTRODUCTION

Practical training on clinical cases and work with patients is one of the most important steps within the educational programme of undergraduates. Until now a general programme with specific learning targets for undergraduate training in orthopedic and trauma surgery is lacking.

MATERIAL AND METHOD

In this article we present an educational skills programme developed by a national committee composed of specialists in the field of orthopaedic and trauma surgery. This programme is based on existing guidelines of German medical universities.

RESULTS

The facultative and obligatory guidelines developed by the national committee are presented.

CONCLUSION

The presented learning programme contains chapters regarding the increasing requirements within the field of orthopaedic and trauma surgery and provides reproducible contents with the possibility for learning control.