Changes in injury patterns, injury severity and hospital mortality in motorized vehicle accidents: a retrospective, cross-sectional, multicenter study with 19,225 cases derived from the TraumaRegister DGU®

PURPOSE

In the last 20 years, the number of fatalities due to road traffic accidents (RTA) in Germany has steadily decreased from 7503 to 2724 per year. Due to legal regulations, educational measures and the continuous development of safety technology the number of severe traumatic injuries and injury patterns are most likely to change. The aim of the study was to analyse severely injured motorcyclists (MC) and car occupants (CO) that were involved in RTAs in the last 15 years and investigate the development and changes of injury patterns, injury severity and hospital mortality.

METHODS

We retrospectively evaluated data from the TraumaRegister DGU® (TR-DGU) considering all RTA-related injured MCs and COs (n = 19,225) that were registered in the TR-DGU from 2006 to 2020 with a primary admission to a trauma center with continuous participation (14 of 15 years) in the TR-DGU, an Injury Severity Score (ISS) ≥ 16 and aged between 16 and 79 years. The observation period was divided into three 5-year interval subgroups for further analysis.

RESULTS

The mean age increased by 6.9 years and the ratio of severely injured MCs to COs changed from 1:1.92 to 1:1.45. COs were in 65.8% male and more often severely injured in the age groups under 30, while the majority of severely injured MCs were in the age group around 50 years and in 90.1% male. The ISS (- 3.1 points) as well as the mortality of both groups (CO: 14.4% vs. 11.8%; MC: 13.2% vs. 10.2%) steadily decreased over time. Nevertheless, the standardized mortality ratio (SMR) hardly changed and stayed < 1. Regarding the injury patterns, the greatest decline of injuries with AIS 3 + were to the head (CO: - 11.3%; MC: - 7.1%), in addition, a decrease of injuries to extremities (CO: - 1.5%; MC: - 3.3%), to the abdomen (CO: - 2.6%; MC: - 3.6%), to the pelvis in COs (- 4.7%) and to the spine (CO: + 0.1%; MC: - 2.4%) were observed. Thoracic injuries increased in both groups (CO: + 1.6%; MC: + 3.2%) and, furthermore, pelvic injuries in MCs (+ 1.7%). Another finding was the increase of the utilization of whole body CTs from 76.6 to 95.15%.

CONCLUSION

The severity of injuries and their incidence, especially head injuries, have decreased over the years and seem to contribute to a decreasing hospital mortality of polytraumatized MCs and COs injured in traffic accidents. Young drivers and an increasing number of seniors are the age groups at risk and require special attention and treatment.

Analysis of the primary utilization of videolaryngoscopy in prehospital emergency care in Germany

BACKGROUND

In 2019, the German prehospital airway management guidelines were published. One of the recommendations was the primary utilization of videolaryngoscopy (VL) for every prehospital endotracheal intubation (phETI). Guideline compliance is extremely important in emergency medicine as non-compliance in the worst-case scenario leads to death. The study aims to quantify guideline compliance among emergency medical service (EMS) physicians and, subsequently to analyze subgroups influencing compliance.

MATERIAL AND METHODS

An online survey was developed and distributed as a hyperlink via email to all medical directors of EMS (n = 155) and the three main operators of helicopter emergency medical services (HEMS) in Germany. The survey was online from August 1^st 2021 until October 3^rd 2021. The primary outcome measure was the primary VL utilization. Data were evaluated descriptively. A multivariate regression analysis was used to determine associations between the primary VL utilization and age, sex, educational level, specialization, phETI per year, operating field, VL device type, and guideline knowledge.

RESULTS

The analysis included 698 EMS physicians. More than 55% of the EMS physicians do not primarily use a videolaryngoscope for phETI. Multivariate regression analysis showed a significantly higher compliance if the devices C‑MAC® or McGrath® were on board, guidelines were known or EMS physicians were female. Age, educational level, specialization or prehospital intubation experience had no significant impact.

CONCLUSION

The study shows non-compliance with prehospital airway management guidelines in Germany. The guideline recommendation is based on scientific evidence but is not yet generally accepted by all EMS physicians. Videolaryngoscope device type and sex seem to influence the primary VL utilization. Training for EMS physicians must be extended and individual prehospital airway management should be reconsidered by every EMS physician.

The predictive value of serum lactate to forecast injury severity in trauma-patients increases taking age into account

BACKGROUND

Two-tier trauma team activation (TTA)-protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15).

METHODS

We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15.

RESULTS

During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67-0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001).

CONCLUSIONS

The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Superiority of upper ankle arthrodesis over total ankle replacement in the treatment of end-stage posttraumatic ankle arthrosis

PURPOSE

Surgical treatment of end-stage posttraumatic upper ankle arthrosis is challenging. Highly variable revision rates have been reported with total ankle arthroplasty (TAA) of the upper ankle joint. The aim of this retrospective study was to compare revision rates with tibiotalar arthrodesis (TTA) and TAA with a prosthesis to determine the superior treatment approach.

METHODS

Data for 148 patients (96 males and 52 females) with end-stage posttraumatic upper ankle arthrosis-including 88 treated with TTA and 60 with TAA between 2008 and 2013, with a mean follow-up of 59 months-were analysed. Bone fusion was confirmed by x-ray radiography and computed tomography.

RESULTS

The overall revision rate was 28%; the rate was higher with TAA (42%) than with TTA (18%). The TAA group showed an increase in revisions from 12- to 24-month postsurgery. The most common cause of revision in the TAA group was cysts (20%), and the most frequent reason for revision was nonunion (8%). Mean American Orthopaedic Foot and Ankle Society (AOFAS) and Foot and Ankle Outcome (FAO) scores in all patients were 55.5 and 53.1, respectively, with no significant difference between the TTA and TAA groups (p > 0.05). In nine cases (15%) the prosthesis was explanted or converted to TTA. TAA patients who underwent conversion to TTA had worse outcomes (AOFAS score = 39; FAO score = 35.29).

CONCLUSION

TAA is associated with a high rate of revisions, especially from the 2nd year postsurgery. Therefore, TTA is the treatment of choice for end-stage posttraumatic upper ankle arthrosis. Level of evidence Level III, comparative series.

Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey

BACKGROUND

Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency.

METHODS

We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine.

RESULTS

Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants.

CONCLUSIONS

Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated.

LEVEL OF EVIDENCE

IV, cross-sectional study.

[Activity of antiseptic catheter lubricants against methicillin-resistant Staphylococcus aureus (MRSA)]

In recent years, general and urinary tract infections caused by methicillin-resistant Staphylococcus aureus (MRSA) have became an increasing problem worldwide. Catheterization of the urinary bladder is one of the most significant risk factors for MRSA contamination of the urine. In vitro tests have documented the antimicrobial activity of the catheter lubricants Instillagel and Endosgel against MRSA specimens within 5 min. These findings support recommending the use of these lubricants in high-risk patients in hospitals and old people's homes for prophylaxis of MRSA bacteriuria.

[Current therapy of prostate carcinoma]

Despite the high incidence and the intensive research, the appropriate diagnostic and therapeutic approach for prostatic carcinoma (PCA) is still controversial. PSA and its new subtests allow earlier diagnosis of PCA. No rigid guidelines can be given concerning therapy. The therapeutic regimen has always to be adapted to the patient's individual needs and situation. For organ-confined and progressive disease, new concepts have been introduced. They seem to improve quality of life rather than to achieve prolonged survival.

Video TUR: raising the gold standard. New aspects, techniques and tendencies to minimize invasiveness

Video TUR is a new and convenient technique of transurethral surgery in which resection is performed under visual control provided by a camera and a monitor. The method involves fewer risks for the patient and less discomfort for the surgeon. The postoperative stricture rate of the urethra could be reduced from 6 to 1% by using a new double-sheath continuous flow resectoscope (Olympus).

[Video-guided TUR]

Video-TUR has become a very important new technique in urology, causing far less discomfort than conventional techniques for the surgeon. A mini-chip camera (Olympus OTVS-2) is attached to the lens system of a continuous-flow resectoscope (Olympus). A television monitor (Sony PVM 1442) provides reliable guidance for the cutting loop when resection is necessary for the treatment of benign hypertrophy or carcinoma of the prostate or carcinoma of the bladder. To maintain a good intravesical flow system, which is very important for a clear field of view, a suprapubic cystostomy should be placed. The surgeon sits in a comfortable position with both eyes on the screen so that eye-strain, back pain and mental stress can be reduced. The excellent depth perception is due to a 50-times enlargement by the camera, so that tissue-orientated TUR is possible. Even when it is not possible to place the patient in an optimal position, because of scrotal hernia or coxarthrosis, TUR can still easily be performed. In 120 transurethral prostate resections and 30 transurethral bladder tumour resections, the video technique has proved comfortable for the surgeon and safe for the patient. Video-TUR has been helpful in the presentation of this technique in urologic teaching. TUR of the prostate has been freed from much of its mystique, since the procedure can be watched while it is in progress. The video technique has opened up a new epoch in endourology, whose importance cannot yet be realized.

[Problems and principles of hormone therapy of advanced prostate cancer]

The availability of hormones with few side effects has enlarged the indication for their use: In the presence of metastases, primary endocrine treatment which includes orchiectomy as standard therapy is employed with palliative intent. Adjuvant endocrine treatment is given after radical prostatectomy when positive margins or lymph nodes were present. A salvage endocrine treatment is administered if the primary tumor persists after radiotherapy or recurred after prostatectomy. The term diagnostic hormone treatment is misleading and should not be used. A secondary hormone application is supported by the observation that allaged hormone resistant tumor progressed after testosterone injection. The problem of early versus delayed endocrine therapy is unsolved, however, it is conceivable that the latter therapy is confronted with a larger tumor burden. The principle of endocrine treatment is properly described as means suppressing the androgenic stimuli. There are 5 different routes of androgen deprivation, among which the antiandrogens and LH RH analogs have the highest priority. Phase III-studies are under way to clarify their efficacy.

[Autologous blood replacement in urology]

In a total number of 67 urological operations (24 transurethral resections of the prostate, 30 transvesical resections of the prostate, 13 radical prostatectomies) intraoperative blood loss was saved, cleaned, and reinfused to the patients as washed, packed red blood cells with a "Cell Saver" (Haemonetics). Patients with preoperative urinary tract infection were excluded from reinfusion in transurethral resections of the prostate. Although radical prostatectomy is oncologic surgery we consider it an ideal possibility for intraoperative autotransfusion. Based on our experience, autotransfusion seems to be warranted also in urological surgery.

[Autologous blood transfusion in urology]

In a total of 67 urological patients (24 transurethral resections of the prostate, 30 transvesical resections of the prostate and 13 radical prostatectomies) the blood lost during the operation was collected by using the Haemonetics cell saver, washed and cleaned of cells, haemoglobin and plasma haemoglobin and retransfused to the patients in the form of erythrocyte concentrate. When patients lose a large volume of blood, the lost plasma volume and the lost clotting factors must be substituted: in addition to electrolyte and colloidal solutions we use autologous fresh frozen plasma (FFP). Preoperatively we usually obtain FFP from the patient by plasmapheresis. All patients have tolerated the preoperative plasmapheresis very well and also the subsequent retransfusion of the intraoperatively saved autologous blood. Only 1 patient (who unexpectedly suffered a postoperative haemorrhage) received homologous blood; in other cases no homologous transfusion became necessary despite blood losses of up to 4500 ml.

[Metastatic involvement of pelvic lymph nodes in relation to the morphological differentiation grade and clinical status of prostatic cancer]

The relationship of cytological and histological grade and local tumour extent to pelvic lymph node involvement was assessed surgically in 92 patients, who underwent pelvic lymphadenectomy alone (31 cases) or together with radical retropubic prostatectomy for adenocarcinoma of the prostate (61 cases). A direct correlation was observed between the histological and cytological grade and clinical stage and node involvement. A total of 26% complications were observed after the lymphadenectomy.

[Classification, histologic and cytologic grading and regression grading of prostate cancer]

The submitted recommendation of the pathologic- urologic team "prostatic carcinoma" is the result of several meetings, in order to provide a basis for a uniform nomenclature in diagnosis, therapy, and prognosis of prostatic carcinoma to urologists and pathologists in practice.

[Prostate cytology. 12 years' experience with transrectal fine needle biopsy]

From January 1970 until November 1982 7814 fine needle biopsies of the prostate were performed in 5856 patients in the urological clinic of the University of Munich. Our experience with this method demonstrates, that the technique is not as easy and must be taught carefully. The diagnostic accuracy depends mostly on the clinician who performs the procedure, less on the cytopathologist. It is possible to distinguish a normal cytological pattern as well as different degrees of infection and different types of tumour-malignancy of the prostatic cancer. Therapy-induced tumour-regression also can be diagnosed. Because of few complications and its high diagnostic reliability the method deserves increased use.

[Diagnostic and prognostic significance of cytological malignancy grading of prostatic carcinoma]

Clinical staging and morphological grading are very important for treatment of prostatic carcinoma. In 1980 a German pathological-urological study group of prostate cancer completed a new cytological grading system. This system has grades I-III of malignancy, based on six cellular criteria, whose relevance for prognosis was shown by cellkinetical investigations. The present study demonstrates less "undergrading" from transrectal fine needle biopsy and cytological diagnosis than from punch-biopsy and histological diagnosis. The cytological grade correlates well with the local extent of the tumor and metastases to pelvic lymph nodes. Despite of the wellknown problems with morphological grading on a biopsy it gives us very important information.

[Critical observations on the current diagnostic value of prostate cytology]

Based on an inquiry it was found that aspiration biopsy and cytology of the prostate in West-Germany is practiced less than in Scandinavia. This in spite of the fact that the fine needle biopsy can be done with the same accuracy as punch biopsy of the prostate, but with more advantages. Beside of that the cytological grading proofed to be very important for the biological activity of the carcinoma of the prostate. The technique of fine needle biopsy of the prostate is not easy and must be practiced very well.

[Use of dopamin (hydroxytyramine) in urosepsis of septic shock (author's transl)]

Gram negative sepsis is still a very serious disease with a very high mortality. The effect of Hydroxytyramine was tested in ten patients with urosepsis. Hydroxytyramine had a specific beneficial on the renal function during shock and eight of ten patients with severe urosepsis survived. The additional use of hydroxytyramine in the treatment of urosepsis seems to improve the prognosis of this life threatening condition.

Prognostic significance of cytological differentiation grading in estrogen-treated prostatic carcinoma diagnosed by fine-needle aspiration biopsy. (Five-year follow-up of 496 patients)

The value of fine-needle aspiration biopsy of carcinoma of the prostate and its cytological grading is demonstrated. The grade of morphological differentiation in cytological smears has proved to be a reliable criterion for the prognosis in 496 estrogen-treated prostatic carcinoma patients. The life expectancy of low-differentiated and anaplastic cancer patients undergoing treatment is so poor that the justification for antiandrogen treatment in this group of carcinomas appears extremely doubtful. For this reason, the degree of differentiation of the tumor should be considered when undertaking therapeutic measures in view of its relevance for the prognosis.

[Urethrotomia interna: clinical importance of internal urethrotomy in recurrent cystourethritis and irritable bladder in women (author's transl)]

The present results show that operative dilatation of the female urethra in recurrent bladder complaints and demonstrable obstruction is a very promising form of treatment which can be carried out by every practising urologist with anesthetic availability. Failures must be accepted, because at all events one question remains unanswered: why one patient can be helped by the treatment whereas in another the complaints persist.

[Transrectal aspiration biopsy of the prostate]

Transrectal aspiration biopsy and cytologic examination are reliable methods to diagnose a carcinoma of the prostate. However, it is not widely used in other than Scandinavian countries. The reason for this is the difficulty of using a correct biopsy technique and a good preparation of the smear. The technique is not as easy as one may think and must be taught carefully. The diagnostic accuracy depends mostly on the clinician who performs the needling, less on the cytopathologist. Cytological grading is a valuable indicator for the biological activity of a carcinoma of the prostate. Cytological follow-up of a treated carcinoma gives important information about the effectiveness of therapy.

[The prognostic significance of cytologic differentiation grades of estrogen-treated prostata carcinoma. Progress control of 496 prostate carcinoma patients treated with estrogen for five years (author's transl)]

The morphologic differentiation grade of cytologic smear preparations proved to be a reliable gradation measurement for the prognosis of 496 patients suffering from prostate cancer and treated with estrogen. Compared with that of other cancer patients, the life expectancy of low-differentiated and anaplastic cancer patients undergoing estrogen treatment is so poor that the rationale of using antiandrogenous treatment in this carcinoma group seems extremely questionable to us. This is why, in view of the predictable prognosis, the differentiation grade of the tumor should be considered when undertaking therapeutic measures.

[X-ray-video amplifier photography: use in urologie X-ray diagnosis and renovasography (author's transl)]

Our experiences indicate that the 'urograph', in combination with the 100-mm sheet-film camera, represents an x-ray apparatus that is just about optimally suited to the needs of urologic x-ray diagnoses. Only in extreme situations is the range of movement of the tabletop in the direction of the head and feet insufficient. A major advantage of the camera, and the one which, above all, plays a decisive role in the urologic x-ray diagnosis of children, is that the amount of radiation can be reduced by about 1/2 to 1/3 that necessary with conventional photo techniques. Through optimal use of the apparatus, considerable time and personnel can be saved. In view of the additional fact that kidney angiographs can be performed with this apparatus, in combination with the 100-mm camera, with minimal problems, minimal time, and minimal stress for the patient, x-ray-video amplifier photography represents an important addition to urologic x-ray examination possibilities that today we can no longer afford to do without.

[Coagulation disorders in prostatic carcinoma (author's transl)]

70 nonselcted patients with prostatic carcinoma underwent coagulation analysis. Sxi had typical evidence of diffuse intravascular coagulation and in 8 cases such a disorder was highly probable. In 3 patients coagulation alterations appeared only after estrogen treatment, 17 patients (24.3%) thus showed evidence of intravascular coagulation. The hemostatic distrubance was silent in all but 3 cases where bleeding occurred. Coagulation disorders were found mainly in advanced stages and poorly differentiated carcinomas. There was a much higher content of thromboplastic activity in prostatic carcinoma than in normal prostatic tissue. Heparin plays a predominant role in the treatment of the coagulation disorder. In addition to therapy of clinically maifest consuption coagulopathy heparin can be used in prophylaxis against bleeding and thrombosis in cases with clinically silent intravascular coagulation and also in estrogen treatment.