Die Damage-control-Strategie

Early total care or damage control orthopaedics for major fractures ? Results of propensity score matching for early definitive versus early temporary fixation based on data from the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

Damage control orthopaedics (DCO) und early total care (ETC) are well-established strategies for managing severely injured patients. There is no definitive evidence of the superiority of DCO over ETC in polytrauma patients. We conducted this study to assess the probability of a polytraumatised patient undergoing DCO. In addition, the effect of DCO on complications and mortality was investigated.

METHODS

We analysed data from 12,569 patients with severe trauma (Injury Severity Score ≥ 16) who were enrolled in the trauma registry of the German Trauma Society (TraumaRegister DGU®) from 2009 to 2016 and had undergone surgery for extremity or pelvic fractures. These patients were allocated to a DCO or an ETC group. We used the propensity score to identify factors supporting the use of DCO. For a comparison of mortality rates, the groups were stratified and matched on the propensity score.

RESULTS

We identified relevant differences between DCO and ETC. DCO was considerably more often associated with packed red blood cell (pRBC) transfusions (33.9% vs. 13.4%), catecholamine therapy (14.1% vs. 6.8%), lower extremity injuries (72.4% vs. 53.5%), unstable pelvic fractures (41.0% vs. 25.9%), penetrating injuries (2.8% vs. 1.5%), and shock (20.5% vs. 10.8%) and unconsciousness (23.7% vs. 16.3%) on admission. Based on the propensity score, patients with penetrating trauma, pRBC transfusions, unstable pelvic fractures, and lower extremity injuries were more likely to undergo DCO. A benefit of DCO such as reduced complications or reduced mortality was not detected.

CONCLUSION

We could identify some parameters of polytrauma patients used in the trauma registry (Traumaregister DGU®), which led more likely to a DCO therapy. The propensity score did not demonstrate the superiority of DCO over ETC in terms of outcome or complications. It did not appear to adequately adjust for the variables used here. Definitive evidence for or against the use of DCO remains unavailable.

[Current state of medical care of polytrauma and mass casualty incidents in Germany. Are we well-prepared?]

The white paper on the medical care of the severely injured published in 2006 is a collection of proposals and recommendations concerning structure, organization and equipment for the medical care of severely injured patients. Since its publication 50 networks ( http://www.dgu-traumanetzwerk.de/index ) have been established as part of the trauma network. This and the trauma register have helped to continuously improve the medical care of severely injured patients since 1993 [26]. Numerous studies have documented the progress made in measures required by the trauma network [4, 6]. For example, the mortality rate of severely injured patients has dropped from 25 % to approximately 10 % in the past 15 years. From the register and network data it is difficult to tell how each of these measures is implemented in the participating hospitals, who provides medical treatment to patients when, and how medical care is organized in detail. This is why a survey on medical care for polytrauma and in mass casualty situations was conducted among medical directors in German surgical hospitals who are members of the German Society for Trauma Surgery (DGU). Thanks to the 211 participants (most of whom specialize in orthopedic and trauma surgery) a detailed description of how medical treatment is currently organized and performed could be acquired. The survey showed that care of patients with polytrauma (i.e. medical treatment and management) is important irrespective of the level of training of physicians and of the level of patient treatment in hospitals. The central role of traumatologists was emphasized not only in terms of actual treatment but also as an administrator for organizational and management matters. Almost all hospitals have plans for a mass casualty situation; however, the levels of preparedness show considerable variation. A highly critical view is taken of the new surgical specialists with respect to interdisciplinary and comprehensive emergency medical treatment and casualty care. The survey also revealed the continual conflict between managing costs and maintaining quality and resources. It gives an overview of patient treatment in the transition from preclinical to clinical care and provides insights into the targets achieved, current problems and conflicts.

Rotational bed therapy after blunt chest trauma: a nationwide online-survey on current concepts of care in Germany

INTRODUCTION

Blunt chest injuries are amongst the most life threatening injuries in adult multiple trauma patients. Nevertheless, the treatment of these thoracic injuries has not been standardized yet. Previous publications have reported on the prevention and the treatment of respiratory complications by using continuous lateral rotational bed therapy (CLRT), but there is still a lack of information using this approach in the presence of pulmonary contusions. Therefore current literature indicates a variety of treatment protocols and its use is contended.

METHODS

We submitted a 32-item online-questionnaire to 155 hospitals participating in the nationwide TraumaNetwork to assess current treatment concepts in multiple trauma patients suffering from blunt chest trauma including lung contusions with particular focus on the use of CLRT. Overall, 21 level I, 53 level II and 81 level III trauma centres were contacted. The questionnaire was created using "interview 123 5.5.b.de ND6".

RESULTS

The overall response rate was 35.5% (55/155) and responses were received from 10 level I (47.6%), 17 level II (32.1%) and 24 level III (29.6%) trauma centres. Thirty-five of the responders (63.6%) declared to be able to perform lateral rotational bed therapy. For level I and II trauma centres more than 80% were able to apply kinetic positioning in contrast to only 50% of level III trauma centres. Although 42.9% of the participants reported on the existence of standardized treatment protocols, 57.1% failed to report a standardized operating procedure for CLRT. The annual mean number of patients per centre treated via CLRT was 15 (0-130). Treatment modalities such as PEEP and the duration of CLRT also showed great variability. Against this background three out of four centres declared an urgent need for further clinical research in the field.

CONCLUSIONS

Our data reflect the wide range of different CLRT treatment strategies performed for blunt pulmonary trauma involving lung contusions in German trauma centres. We conclude that a high-quality randomized-controlled trial is warranted to critically assess the role of CLRT in multiple trauma patients with blunt chest trauma to provide a sound basis for future clinical guidelines.