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Level 3 guideline on the treatment of patients with severe/multiple injuries

AWMF Register-Nr. 012/019
  • Polytrauma Guideline Update Group
Guideline

Publisher:

German Trauma Society (DGU) (lead)

Office in Langenbeck-Virchow House

Luisenstr. 58/59

10117 Berlin

German Society of General and Visceral Surgery

German Society of Anesthesiology and Intensive Care Medicine

German Society of Endovascular and Vascular Surgery

German Society of Hand Surgery

German Society of Oto-Rhino-Laryngology, Head and Neck Surgery

German Interdisciplinary Association for Emergency and Acute Care Medicine

German Society of Oral and Maxillofacial Surgery

German Society of Neurosurgery

German Society of Thoracic surgery

German Society of Urology

German Radiology Society

German Society of Plastic, Reconstructive and Aesthetic Surgeons

German Society of Gynecology and Obstetrics

German Society of Pediatric Surgery

German Society for Transfusion Medicine and Immunohematology

German Society for Burn Medicine

German Interdisciplinary Association for Intensive and Emergency Medicine

German Professional Association of Emergency Medical Services

Society of Pediatric Radiology

Corresponding Address:

Prof. Dr. med. Bertil Bouillon

Department of Orthopedics, Traumatology and Sports Traumatology

Chairman of the University Witten/Herdecke at Merheim Hospital Cologne

Ostmerheimer Str. 200

51109 Cologne

bouillonb@kliniken-koeln.de

Methods Consultant:

Dr. Dawid Pieper

IFOM-Institute for Research in Operational Medicine

Chairman of Surgical Research, Faculty of Health

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Overall Coordination:

IFOM-Institute for Research in Operational Medicine

Department: Evidence-Based Health Services Research

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Guideline Commission:

Prof. Dr. med. Sascha Flohé

Department of Traumatology, Orthopedics and Hand Surgery

City Hospital Solingen gGMBH

Gotenstr. 1

42653 Solingen

Dr. med. Michaela Eikermann (until 12/2014)

Peggy Prengel (beginning 01/2015)

IFOM-Institute for Research in Operational Medicine

Department: Evidence-Based Health Services Research

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Prof. Dr. Steffen Ruchholtz

Clinic for Trauma, Hand and Reconstructive Surgery

University Hospital Gießen/Marburg

Baldingerstraße

35043 Marburg

Prof. Dr. med. Klaus M. Stürmer

Department of Trauma Surgery, Plastic and Reconstructive Surgery

University Hospital Göttingen

Georg-August-University

Robert-Koch-Straße 40

37099 Göttingen

Coordination of Sections:

Pre-Hospital

Prof. Dr. med. Christian Waydhas

Surgical University Clinic and Polyclinic

BG University Hospital Bergmannsheil

Bürkle-de-la-Camp-Platz 1

44789 Bochum

Dr.med. Heiko Trentzsch

Institute for Emergency Medicine and Medical Management – INM

Hospital of the University of Munich

Ludwig Maximilians University

Schillerstr. 53

80336 Munich

Emergency Department

Prof. Dr. med. Sven Lendemans

Department of Orthopedics and Emergency Surgery

Alfried Krupp Hospital

Steele

Hellweg 100

45276 Essen

Prof. Dr. med. Stefan Huber-Wagner

Rechts der Isar Hospital

Clinic and Polyclinic for Traumatology

Technical University Munich

Ismaningerstr. 22

81675 Munich

Primary Operative Management

Prof. Dr. med. Dieter Rixen

University Witten/Herdecke

Member Faculty of Health

Alfred-Herrhausen-Straße 50

58448 Witten

Prof. Dr. med. Frank Hildebrand

University Hospital RWTH Aachen

Clinic for Accident and Reconstructive Surgery

Pauwelsstraße 30

52074 Aachen

Organization, Methods Consulting and Support for the First Version 2011

Dr. med. Michaela Eikermann (beginning 07/2010)

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Christoph Mosch

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Ulrike Nienaber

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

PD Dr. med. Stefan Sauerland (bis 12/2009)

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Dr. med. Martin Schenkel

Cologne Hospitals

Hospital Merheim

Department of Orthopedics, Traumatology and Sports Traumatology

51058 Cologne

Maren Walgenbach

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Organization, Methods und Project Coordination of the 2016 Update

The following employees of the IFOM actively contributed to the Guideline Update:

Monika Becker

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Stefanie Bühn

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Dr. med. Michaela Eikermann (bis 12/2014)

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Simone Heß

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Thomas Jaschinski (until 06/2015)

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Dr. Tim Mathes

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Christoph Mosch (bis 03/2015)

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Dr. Dawid Pieper

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Peggy Prengel

Institute for Research in Operational Medicine (IFOM)

University Witten/Herdecke

Ostmerheimer Str. 200, Haus 38

51109 Cologne

Medical Societies and their delegates participating in the First Version 2011

PD Dr. med. Michael Bernhard

(German Society of Anesthesiology and Intensive Care Medicine)

Fulda Hospital gAG

Central Accident & Emergency

Pacelliallee 4

36043 Fulda

Prof. Dr. med. Bernd W. Böttiger

(German Society of Anesthesiology and Intensive Care Medicine)

University Hospital Cologne

Clinic for Anesthesiology and Operative Intensive Care

Kerpener Str. 62

50937 Cologne

Prof. Dr. med. Thomas Bürger

(German Society of Endovascular and Vascular Surgery)

Kurhessisches Diakonissenhaus

Department of Vascular Surgery

Goethestr. 85

34119 Kassel

Prof. Dr. med. Matthias Fischer

(German Society of Anesthesiology and Intensive Care Medicine)

Klinik am Eichert Göppingen

Clinic for Anesthesiology and Operative Intensive Care, Emergency Treatment & Pain Therapy

Eichertstr. 3

73035 Göppingen

Prof. Dr. med. Dr. med. dent. Ralf Gutwald

(German Society of Oral and Maxillofacial Surgery)

University Hospital Freiburg

Clinic for Oral and Maxillofacial Surgery

Hugstetterstr. 55

79106 Freiburg

Prof. Dr. med. Markus Hohenfellner

(German Society of Urology)

University Hospital Heidelberg

Urology Clinic

Im Neuenheimer Feld 110

69120 Heidelberg

Prof. Dr. med. Ernst Klar

(German Society of General and Visceral Surgery)

University Hospital Rostock

Department of General, Thoracic, Vascular & Transplantation Surgery

Schillingallee 35

18055 Rostock

Prof. Dr. med. Eckhard Rickels

(German Society of Neurosurgery)

Celle General Hospital

Clinic for Trauma Surgery, Orthopedics & Neurotraumatology

Siemensplatz 4

29223 Celle

Prof. Dr. med. Jürgen Schüttler

(German Society of Anesthesiology and Intensive Care Medicine)

University Hospital Erlangen

Clinic for Anesthesiology

Krankenhausstr. 12

91054 Erlangen

Prof. Dr. med. Andreas Seekamp

(German Trauma Society)

University Hospital Schleswig-Holstein (Kiel Campus)

Clinic for Trauma Surgery

Arnold-Heller-Str. 7

24105 Kiel

Prof. Dr. med. Klaus Michael Stürmer

(German Trauma Society)

University Hospital Göttingen – Georg-August University

Department of Trauma Surgery, Plastic and Reconstructive Surgery

Robert-Koch Str. 40

37075 Göttingen

Prof. Dr. med. Lothar Swoboda

German Society of Thoracic Surgery

Eißendorfer Pferdeweg 17a

21075 Hamburg

Prof. Dr. med. Thomas J. Vogl

(German Radiology Society)

University Hospital Frankfurt

Institute of Diagnostic & Interventional Radiology

Theodor-Stern-Kai 7

60590 Frankfurt/Main

Dr. med. Frank Waldfahrer

(German Society of Oto-Rhino-Laryngology, Head and Neck Surgery)

University Hospital Erlangen

Oto-Rhino-Laryngology Clinic

Waldstrasse 1

91054 Erlangen

Prof. Dr. med. Margot Wüstner-Hofmann

(German Society of Hand Surgery)

Klinik Rosengasse GmbH

Rosengasse 19

89073 Ulm/Donau

Medical Societies and their delegates participating in the 2016 Update

Prof. Dr. med. Werner Bader

(German Society of Gynecology and Obstetrics)

Klinikum Bielefeld Mitte

Center for Gynecology and Obstetrics

Teutoburger Strasse 50

33604 Bielefeld

PD Dr. med. Michael Bernhard

(German Society of Anesthesiology and Intensive Care Medicine)

Central Emergency Department

University Hospital Leipzig

Liebigstrasse 20

04103 Leipzig

Prof. Dr. med. Bernd W. Böttiger

(German Society of Anesthesiology and Intensive Care Medicine)

Department of Anesthesiology and Intensive Care Medicine

Cologne University Hospital (AöR)

Kerpenerstraße 62

50937 Cologne

Prof. Dr. med. habil. Thomas Bürger

(German Society of Endovascular and Vascular Surgery)

Agaplesion Deaconess Hospital Kassel

Vascular Surgery Department

Herkulesstraße 34

34119 Kassel

Dipl. med. Andreas Düran

(German Society of Gynecology and Obstetrics)

Hospital Nordwest

Gynecology and Obstetrics

Steinbacher Hohl 2-26

60488 Frankfurt am Main

Prof. Dr. med. Matthias Fischer

(German Society of Anesthesiology and Intensive Care Medicine)

Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy

ALB FILS KLINIKEN GmbH

Hospital am Eichert

Postfach 660

73006 Göppingen

Prof. Dr. med. Birgit Gathof

(German Society for Transfusion Medicine and Immunohematology)

Center for Transfusion Medicien

Cologne University Hospital (AöR)

Kerpenerstr. 62

50936 Cologne

Dr. med. Lucas Geyer

(German Radiology Society)

Institute for Clinical Radiology

Hospital of LMU Munich – Campus Innenstadt

Nussbaumst. 20

80336 Munich

Prof. Dr. Dr. med. Ralf Gutwald

(German Society of Oral and Maxillofacial Surgery)

Freiburg University Hospital

Department for Oral and Maxillofacial Surgery

Hugstetterstrasse 55

79106 Freiburg

David Häske, MSc MBA

(German Professional Association of Emergency Medical Services)

Eberhard Karls University Tübingen

Medical Faculty

Geissweg 5

72076 Tübingen

Prof. Dr. med. Matthias Helm, OTA

(German Society of Anesthesiology and Intensive Care Medicine)

Department of Anesthesia and Intensive Medicine

Section Emergency Medicine

Bundeswehrkrankenhaus Ulm

Oberer Eselsberg 40

89070 Ulm

Dr. med. Peter Hilbert-Carius

(German Society of Anesthesiology and Intensive Care Medicine)

Department of Anesthesiology, Intensive and Emergency Medicine

BG-Hospital Bergmannstrost Halle (Saale)

Merseburger Str. 165

06112 Halle an der Saale

Prof. Dr. med. Markus Hohenfellner

(German Society of Urology)

Department of Urology

Heidelberg University Hospital

Im Neuenheimer Feld 110

69120 Heidelberg

Prof. Dr. med. Karl-Georg Kanz

(German Interdisciplinary Association for Emergency and Acute Care Medicine)

Department of Traumatology

Rechts der Isar Hospital of the Technical UniversityMünchen

Ismaninger Strasse 22

81675 Munich

Prof. Dr. med. Ernst Klar

(German Society of General and Visceral Surgery)

University Medicine Rostock

Department of Surgery

Schillingallee 35

18057 Rostock

Prof. Dr. med. Ulrich Kneser

(German Society of Plastic, Reconstructive and Aesthetic Surgeons)

BG Trauma Hospital Ludwigshafen

Department of Hand, Plastic and Reconstructive Surgery – Severe Burn Injury Center

Ludwig-Guttmann-Straße 13

67071 Ludwigshafen

Prof. Dr. med. Marcus Lehnhardt

(German Society for Burn Medicine)

Department of Plastic and Hand Surgery Severe Burn Injury Center

BG-University Hospital Bergmannsheil Bochum

Bürkle-de-la-Camp Platz 1

44789 Bochum

Dr. med. Heiko Lier

(German Society of Anesthesiology and Intensive Care Medicine)

Department of Anesthesia and Surgical Intensive Medicine

Cologne University Hospital (AöR)

Kerpenerstraße 62

50937 Cologne

Dr. med. Carsten Lott

(German Society of Anesthesiology and Intensive Care Medicine)

University Medicine

Johannes Gutenberg University

Department of Anesthesiology

Langenbeckstr. 1

55131 Mainz

PD Dr. med. Corinna Ludwig

(German Society of Thoracic Surgery)

Department of Thoracic Surgery

Florence-Nightingale Hospital

Kreuzbergstr. 79

40489 Düsseldorf

Prof. Dr. med. Ingo Marzi

(German Interdisciplinary Association for Emergency and Acute Care Medicine)

Department of Trauma, Hand and Reconstructive Surgery

University Hospital Goethe University Frankfurt

Theodor-Stern-Kai 7

60590 Frankfurt am Main

Prof. Dr. med. Uwe Max Mauer

(German Society of Neurosurgery)

Bundeswehr Hospital Ulm

Dept. Neurosurgery

Oberer Eselsberg 40

89070 Ulm

Prof. Dr. med. Eckhard Rickels

(German Society of Neurosurgery)

General Hospital Celle

Department of Trauma Surgery, Orthopedics and Neuro-Traumatology-Section of Neurotraumatology

Siemensplatz 4

29223 Celle

Prof. Dr. med. Jürgen Schäfer

(Society of Pediatric Radiology)

Pediatric Radiology –Department of Diagnostic and Interventional Radiology

University Hospital Tübingen

Hoppe Seyler-Str. 3

72076 Tübingen

Prof. Dr. med. Robert Schwab

(German Society of General and Visceral Surgery)

Department of General, Visceral and Thoracic Surgery

Bundeswehr Central Hospital Koblenz

Rübenacher Straße 170

56072 Koblenz

PD Dr. med. Frank Siemers

(German Society of Hand Surgery)

BG Hospitals Bergmannstrost Halle

Department of Plastic and Hand Surgery, Burn Injury Center

Merseburger Straße 165

06112 Halle

Prof. Dr. med. Erwin Strasser

(German Society for Transfusion Medicine and Immunohematology)

Transfusion Medicine and Hemostaseology Department

University Hospital Erlangen

Krankenhausstrasse 12

91054 Erlangen

Dr. med. Frank Waldfahrer

(German Society of Oto-Rhino-Laryngology, Head and Neck Surgery)

University Hospital Erlangen

Ear, Nose and Throat Department, Head and Neck Surgery

Waldstraße 1

91054 Erlangen

Prof. Dr. med. Lucas Wessel

(German Society of Pediatric Surgery)

University Hospital Mannheim

Pediatric Surgery Hospital

Theodor-Kutzer-Ufer 1-3

68135 Mannheim

PD Dr. rer. biol. Dr. med. Stefan Wirth

(German Radiology Society)

Institute for Clinical Radiology

Hospital of LMU Munich – Campus Innenstadt

Nussbaumst. 20

80336 Munich

Prof. Dr. med. Thomas Wurmb

(German Society of Anesthesiology and Intensive Care Medicine)

Section Emergency Medicine

Department of Anesthesiology

University Hospital Würzburg

Oberdürrbacherstraße 6

97080 Würzburg

Authors und Coauthors of Individual Chapters

Authors/Coauthors

First Version 2011

Update 2016

Andruszkow, Dr. med. Hagen

-

3.8

Arnscheidt, Dr. med. Christian

-

2.4, 3.2

Aschenbrenner, Dr. med MSc. Ulf

1.9, 2.15

-

Bader, Prof. Dr. med. Werner

-

2.5

Bail, Prof. Dr. med. Hermann

1.4, 1.7, 2.5

-

Banerjee, Dr. med. Marc

3.10

-

Bardenheuer, Dr. med. Mark

1.4

-

Bartl, Dr. med. Christoph

3.2

-

Bayeff-Filloff, Dr. med. Michael

1.4, 1.6, 2.10, 3.8

-

Beck, Prof. Dr. med. Alexander

1.4, 1.6, 1.10

-

Bernhard, PD Dr. med. Michael

1.2, 2.15, 2.16

1.2, 2.15, 2.16

Bieler, Dr. med. Dan

-

1.9

Biewener, PD Dr. med. Achim

1.4, 1.9

-

Blum, Prof. Dr. med. Jochen

3.8

-

Böttiger, Prof. Dr. med. Bernd W.

1.2, 2.15, 2.16

1.2, 2.15

Bouillon, Prof. Dr. med. Bertil

1.4, 3.10

-

Braun, Dr. med. Jörg

1.9

-

Bühren, Prof. Dr. med. Volker

2.9, 3.7

-

Bürger, Prof. Dr. med. Thomas

-

2.10, 2.17

Burkhardt, PD Dr. med. Markus

2.7

-

Dahmen, Dr. med. Janosch

-

3.10

Dresing, Prof. Dr. med. Klaus

2.2

2.3

Ekkernkamp, Prof. Dr. med. Axel

3.3, 3.4

-

Engelhardt, Dr. med. Michael

-

1.7

Fiebig, Christian

2.17

-

Fischbacher, Dr. med. Marc

1.2, 1.4

-

Fischer, Prof. Dr. med. Markus

2.14

-

Fischer, Prof. Dr. med. Matthias

1.2, 2.15

1.2, 1.5

Flohé, Prof. Dr. med. Sascha

-

2.3, 2.5, 3.4

Frank, Dr. med. Mark D.

1.9

-

Franke, PD Dr. med. Axel

-

1.9

Friemert, Prof. Dr. med. Benedikt

-

1.10

Frink, Prof. Dr. med. Michael

-

3.8

Fritzemeier, Dr. med. Claus-Robin

-

3.10

Gathof, Prof. Dr. med. Birgit

-

1.3, 2.16

Gebhard, Prof. Dr. med. Florian

3.2

-

Geyer, Dr. med. Lucas

-

2.18

Gliwitzky, Bernhard

-

1.9, 2.15

Gonschorek, Dr. med. Oliver

-

2.9, 3.7

Gümbel, Dr. med. Denis

-

1.7, 3.10

Gutwald, Prof. Dr. med. Dr. med. dent. Ralf

2.13, 3.12

2.13, 3.12

Haas, Prof. Dr. med. Norbert P.

2.5

-

Hanschen, Dr. med. Marc

-

2.16

Häske, David, MSc MBA

-

1.6, 1.9, 1.10, 2.15

Helfen, Dr. med. Tobias

-

1.6

Helm, Prof. Dr. med. Matthias

-

1.2

Hentsch, Dr. med. Sebastian

1.4

-

Hilbert-Carius, Dr. med. Peter

-

1.2, 1.3

Hildebrand, Prof. Dr. med. Frank

-

3.1, 3.8

Hinck, Dr. med. Daniel

-

1.7

Hirche, PD Dr. med. Christoph

-

3.14

Högel, PD Dr. med. Florian

-

2.9, 3.7

Hohenfellner, Prof. Dr. med. Markus

1.8, 2.8, 3.6

1.8, 2.8, 3.6

Hohlweg-Majert, PD Dr. med. Dr. med. dent. Bettina

2.13, 3.12

-

Hörmann, Prof. Dr. med. Karl

2.14, 3.13

-

Huber-Wagner, Prof. Dr. med. Stefan

-

2.1, 2.4, 2.5, 2.15, 2.18, 3.2

Hüls, Dr. med. Ewald

1.4

-

Hußmann, Dr. med. Björn

2.10

1.3, 2.10, 3.10

Josten, Prof. Dr. med. Christoph

2.15

-

Kanz, Prof. Dr. med. Karl-Georg

1.2, 1.4

1.10, 2.15

Kinzl, Prof. Dr. med. Lothar

3.2

-

Klar, Prof. Dr. med. Ernst

-

2.5, 3.3, 3.4

Kleber, Dr. med. Christian

1.7

1.4, 2.4, 2.15, 3.2

Kneser, Prof. Dr. med. Ulrich

-

3.14

Knöferl, Prof. Dr. med. Markus W.

3.2

-

Kobbe, PD Dr. med. Philipp

-

1.6

Kollig, PD Dr. med. Erwin

-

1.3, 1.9

Kreinest, Dr. med. Dr. rer. nat. Michael

-

1.6

Kühne, Prof. Dr. med. Christian A.

2.2, 2.3

2.2, 2.3

Lackner, Prof. Dr. med. Christian K.

1.4

-

Lechler, PD Dr. med. Philipp

-

3.8

Lehnhardt, Prof. Dr. med. Marcus

-

3.14

Lendemans, PD Dr. med. Sven

2.1, 2.10

2.1, 2.10, 2.16

Liebehenschel, Dr. med. Dr. med. dent. Niels

2.13, 3.12

-

Liener, PD Dr. med. Ulrich C.

3.2

-

Lier, Dr. med. Heiko

2.16

1.2, 2.16

Lindner, Dr. med. Tobias

1.7, 2.5

-

Linsenmaier, PD Dr. med. Ulrich

 

2.17

Lott, Dr. med. Carsten

-

1.2, 1.7, 1.10, 2.2, 2.3, 2.4, 2.15, 3.2

Ludwig, PD Dr. med. Corinna

-

2.4, 3.2, 3.3

Lustenberger, Dr. med. Thomas

-

3.8

Lynch, Thomas H.

1.8, 2.8, 3.6

-

Mack, Prof. Dr. med. Martin G.

2.17

-

Maegele, Prof. Dr. med. Marc

-

2.16

Marintschev, Dipl.-Med. Ivan

1.4

-

Martínez-Piñeiro, Luis

1.8, 2.8, 3.6

-

Marzi, Prof. Dr. med. Ingo

-

2.16

Matthes, Prof. Dr. med. Gerrit

1.2, 1.4, 3.3, 3.4

1.2, 3.3, 3.4

Mauer, Prof. Dr. med. Uwe Max

-

1.5, 2.6, 3.5

Maxien, Dr. med. Daniel

-

2.17

Mayer, Dr. med. Hubert

1.4

-

Mor, Dr. med. Yoram

1.8, 2.8, 3.6

-

Mörsdorf, Dr. med. Philipp

-

2.7

Münzberg, Dr. med. Matthias

-

1.6, 1.9

Mutschler, Dr. med. Manuel

-

1.7, 2.10

Neubauer, Dr. med. Hubert

-

3.10

Obertacke, Prof. Dr. med. Udo

2.4

-

Ochmann, PD Dr. med. Sabine

-

2.12, 3.11

Oestern, Prof. Dr. med. Hans-Jörg

3.10

-

Perl, Prof. Dr. med. Mario

-

2.4, 3.2

Pfitzenmaier, Prof. Dr. med. Jesco

1.8, 2.8, 3.6

-

Plas, Eugen

1.8, 2.8, 3.6

-

Pohlemann, Prof. Dr. med. Tim

2.7

2.7, 2.17

Probst, PD Dr. med. Christian

-

1.7, 2.10, 3.10

Radtke, Dr. med. Jan Philipp

-

1.8, 2.8, 3.6

Rammelt, PD Dr. med. Stefan

2.12, 3.11

2.12, 3.11

Raum, Dr. med. Marcus

1.3, 1.4

1.3

Regel, Prof. Dr. med. Gerd

2.10

-

Rennekampff, Prof. Dr. med. Oliver

-

3.14

Reske, Dr. med. Alexander

2.15

-

Reske, Dr. med. Andreas

2.15

-

Rickels, Prof. Dr. med. Eckhard

1.5, 2.6, 3.5

1.5, 2.6, 3.5

Rixen, Prof. Dr. med. Dieter

3.1, 3.10

3.1, 3.10

Ruchholtz, Prof. Dr. med. Steffen

2.2

-

Ruppert, Dr. med. Matthias

-

1.9

Santucci, Richard A.

1.8, 2.8, 3.6

-

Sauerland, PD Dr. med. Stefan

1.4, 1.8, 2.8, 2.15, 3.6, 3.10

-

Schächinger, Dr. med. Ulrich

1.4

-

Schädel-Höpfner, Prof. Dr. med. Michael

2.11, 3.9

2.11, 3.9

Schäfer, Prof. Dr. med. Jürgen

-

2.18

Schiffmann, Dr. med. Bodo

2.14, 3.13

-

Schiffmann, Mechthild

2.14, 3.13

-

Schildhauer, Prof. Dr. med. Thomas

1.4

-

Schmelzeisen, Prof. Dr. med. Dr. med. dent. Rainer

2.13, 3.12

-

Schönberg, Dr. med. Gita

-

1.8, 2.8, 3.6

Schöneberg, Dr. med. Carsten

-

2.18

Schreiter, Dr. med. Dierk

1.9, 2.15

-

Schulz-Drost, PD Dr. med. Stefan

-

1.4, 2.4, 3.2

Schwab, Prof. Dr. med. Robert

-

1.4, 2.4, 2.5, 2.17, 3.2, 3.3, 3.4

Schweigkofler, Dr. med. Uwe

-

1.9, 2.7, 2.8

Schwerdtfeger, PD Dr. med. Karsten

1.5, 2.6, 3.5

1.5

Seekamp, Prof. Dr. med. Andreas

1.4, 2.7

-

Seifert, Prof. Dr. med. Julia

3.3, 3.4

-

Seitz, Dr. med. Daniel

3.2

-

Serafetinides, Efraim

1.8, 2.8, 3.6

-

Siebert, Prof. Dr. med. Hartmut

2.11, 3.9

-

Siemers, PD Dr. med. Frank

-

3.9, 3.14

Simanski, PD Dr. med. Christian

3.10

-

Spering, Dr. med. Christopher

-

2.2, 2.3

Stengel, Prof. Dr. med. Dirk

3.3, 3.4

3.3, 3.4

Stolpe, Dr. med. Erwin

1.4

-

Strasser, Prof. Dr. med. Erwin

-

2.16

Sturm, Prof. Dr. med. Johannes

1.4

-

Stürmer, Prof. Dr. med. Klaus Michael

2.2

-

Swoboda, Prof. Dr. med. Lothar

3.2

-

Täger, Prof. Dr. med. Georg

2.10

-

Tjardes, Dr. med. Thorsten

3.10

-

Trentzsch, Dr. med. Heiko

-

1.1, 1.2, 1.4, 2.15

Türkeri, Levent

1.8, 2.8, 3.6

-

Voggenreiter, Prof. Dr. med. Gregor

2.4

-

Vogl, Prof. Dr. med. Thomas

2.17

-

Wafaisade, PD Dr. med. Arasch

-

2.16

Wagner, Dr. med. Frithjof

-

1.5, 2.6, 3.5

Walcher, PD Dr. med. Felix

1.4

-

Waldfahrer, Dr. med. Frank

2.14, 3.13

2.14, 3.13

Waydhas, Prof. Dr. med. Christian

1.1, 1.2, 1.4

1.1, 1.2, 1.4

Weinlich, Dr. med. Michael

1.4

-

Wessel, Prof. Dr. med. Lucas

-

2.5, 2.17, 2.18, 3.4

Wirth, PD Dr. Dr. rer. biol. med. Stefan

-

2.17, 2.18

Wölfl, Dr. med. Christoph Georg

1.4

1.9

Woltmann, Prof. Dr. med. Alexander

2.9, 3.7

2.9, 3.7

Wurmb, Prof. Dr. med. Thomas

-

1.2, 1.10, 2.6, 2.18, 3.5

Yücel, Dr. med. Nedim

3.10

-

Zimmermann, Prof. Dr. med. Gerald

1.4

-

Zwipp, Prof. Dr. med. Hans

1.9, 2.12, 3.11

-

*The chapters marked in bold were chiefly coordinated for update by the corresponding author

Contents

List of Tables S15

List of Figures S16

List of Abbreviations S17

Foreward to the 2016 Update S21

A Background and Goals S22
  • Introduction S22

  • A.1 Guideline Objectives S22

  • A.2 Publisher/Experts/Society Members/Authors S23

  • A.3 Target User Groups S25

B Methods S25
  • B.1 Methods 2016 Update S25

  • B.2 Methods of the Original 2011 Version S31

  • B.3 Distribution and Implementation S33

  • B.4 Guideline Validity and Updates S34

1 Pre-Hospital Care S35
  • 1.1 Introduction S35

  • 1.2 Airway Management, Ventilation and Emergency Anesthesia S37

  • 1.3 Volume Replacement S57

  • 1.4 Thorax S62

  • 1.5 Traumatic Brain Injury S77

  • 1.6 Spine S80

  • 1.7 Extremities S83

  • 1.8 Genitourinary Tract S91

  • 1.9 Transport and Target Hospital S91

  • 1.10 Massive Casualty Incident (MCI) S97

2 Emergency Department S99
  • 2.1 Introduction S99

  • 2.2 Emergency Department – Staffing and Equipment S100

  • 2.3 Emergency Department Trauma Team Activation S105

  • 2.4 Thorax S108

  • 2.5 Abdomen S120

  • 2.6 Traumatic Brain Injury S127

  • 2.7 Pelvis S130

  • 2.8 Genitourinary Tract S139

  • 2.9 Spine S146

  • 2.10 Extremities S154

  • 2.11 Hand S158

  • 2.12 Foot S159

  • 2.13 Mandible and Midface S160

  • 2.14 Neck S162

  • 2.15 Resuscitation S163

  • 2.16 Coagulation System S171

  • 2.17 Interventional Hemorrhage Control S192

  • 2.18 Imaging S195

3 Primary Operative Management S206
  • 3.1 Introduction S206

  • 3.2 Thorax S208

  • 3.3 Diaphragm S212

  • 3.4 Abdomen S213

  • 3.5 Traumatic Brain Injury S221

  • 3.6 Genitourinary Tract S223

  • 3.7 Spine S230

  • 3.8 Upper Extremity S235

  • 3.9 Hand S237

  • 3.10 Lower Extremity S244

  • 3.11 Foot S257

  • 3.12 Mandible and Midface S262

  • 3.13 Neck S266

  • 3.14 Thermal Skin Injury and Burns S268

Acknowledgements S269

List of Tables
Table 1:

Levels of Guideline Development (AWMF) S22

Table 2:

Inclusion Criteria for Preliminary Screening S25

Table 3:

Inclusion and Exclusion Criteria for Guideline Searches S27

Table 4:

Classification of Consensus Strength S29

Table 5:

CEBM Evidence Classification S32

Table 6:

Pre-Hospital Volume Replacement – Mortality S58

Table 7:

Special Focus of the Physical Examination to Identify Relevant Thoracic Injuries S62

Table 8:

Statistical Probability for Clinically Relevant Hemo/Pneumothorax with Various Combinations of Findings After Blunt Chest Trauma (Basic Assumption: 10% Prevalence as Pre-Test Probability and Test Independence) S64

Table 9:

Average Chest Wall Thickness according to CT chest in millimeters (range in brackets) of the 2nd intercostal space in the mid-clavicular line (2nd ICS in the MCL) and of the 4th or 5th intercostal space in the anterior or mid-axillary lines (4th-5th ICS in the A/MAL) S69

Table 10:

Average Theoretical Failure Rate using CT Chest to reach the pleural space from the 2nd intercostal space of the mid-clavicular line (2nd ICS in the MCL) and from the 4th or 5th intercostal space along the anterior or mid-axillary lines (4th-5th ICS in the A/MAL) S70

Table 11:

Composition and presence of specialist level physicians in the expanded Emergency Department trauma team in relation to hospital care level S103

Table 12:

Grades of Renal Trauma according to Moore und Buckley S141

Table 13:

Standard Projections of the Foot S159

Table 14:

Glasgow Outcome Scale (GOS): S164

Table 15:

Escalating medical therapy options for coagulopathic bleeding (summary) S186

Table 16:

NOAC Assessment in the ED (rule of thumb) S186

Table 17:

Options to Oppose Common Antithrombotics S187

Table 18:

Regions to be examined with ultrasound on the eFAST (extended Focused Assessment with Sonography in Trauma) according to Brun et al. S196

Table 19:

NEXUS Criteria and Canadian C-Spine Rule (CCR) S201

Table 20:

Midline vs. Upper Abdominal Transverse Laparotomy in Abdominal Trauma S213

Table 21:

Damage Control vs. Definitive Treatment S214

Table 22:

Second Look after Packing S216

Table 23:

Grading Classification of Renal Trauma according to Moore und Buckley S223

The evidence tables to this guideline can be found in the guideline report available at: http://www.awmf.org/leitlinien/detail/ll/012-019.html

List of Figures
Figure 1:

Decision-Making Algorithm on Need for Update/Supplementation (according to Becker et al. 2014) S26

Figure 2:

Flowchart Guideline Research S27

Figure 3:

From Evidence to Recommendation S30

Figure 4:

Treatment Algorithm of Complex Pelvic Trauma S137

Figure 5:

ERC/GRC Sequence Algorithm for Traumatic Cardiac Arrest S169

Figure 6:

Pathophysiology of Trauma-Induced Coagulopathy (TIC) S173

Figure 7:

RoTEM-based Algorithm for Coagulation Management in the ED S176

Figure 8:

PECARN Decision Tree to identify children with very low risk for abdominal trauma requiring intervention S200

Figure 9:

Diagnostic Recommendations for TBI in Children Younger than 2 Years S202

Figure 10:

Diagnostic Recommendations for TBI in Children 2 Years and Older S203

Figure 11:

Algorithm for the Diagnostic and Therapeutic Procedure for Suspected Kidney Injuries S228

List of Abbreviations
A.

Artery

AAST

American Association for the Surgery of Trauma

ABC

Assessment of blood consumption

ABCD

Airway/Breathing/Circulation/Disability

ACS COT

American College of Surgeons Committee on Trauma

ACTH

Adrenocorticotropic Hormone

ÄZQ

German Agency for Quality in Medicine (Ärztliches Zentrum für Qualität in der Medizin)

AIS

Abbreviated Injury Scale

ACS

Abdominal Compartment Syndrome

ALI

Acute Lung Injury

ALS

Advanced Life Support

AP

Apheresis Platelets

a.p.

anterior-posterior

aPTT

activated Partial Thromboplastin Time

ArbStättV

Workplace Ordinance (Arbeitsstättenverordnung)

ARDS

Acute Respiratory Distress Syndrome

ASIA-IMSOP

American Spinal Injury Association – International Medical Society of Paraplegia

ASR

Workplace Guideline (Arbeitsstätten-Richtlinie)

ASA

Acetylsalicylic Acid (aspirin)

AT

Antithrombin

ATLS®

Advanced Trauma Life Support

AUC

Area under the curve

AWMF

Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften)

BÄK

German Medical Association (Bundesärztekammer)

BE

Base Excess

BGA

Blood Gas Analysis

BLS

Basic Life Support

BSA

Body Surface Area

BW

Body Weight

C1-7

Cervical Spine Vertebrae

Ca++

Calcium

CCT

Cranial Computed Tomography

CEBM

Oxford Centre for Evidenced Based Medicine

CI

Confidence Interval

CK-MB

Creatine Kinase-MB

CM

Contrast Medium

COPD

Chronic Obstructive Pulmonary Disease

CPAP

Continuous Positive Airway Pressure

CPP

Cerebral Perfusion Pressure

CPR

Cardiopulmonary Resuscitation

CRASH

Clinical Randomization of Antifibrinolytics in Significant Hemorrhage

C-Spine

Cervical Spine

CST

Cosyntropin-Stimulation Test

CT

Computed Tomography

CTA

CT Angiography

DC

Damage Control

DDAVP

Desmopressin

DGAI

German Society of Anesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin)

DGNC

German Society of Neurosurgery (Deutsche Gesellschaft für Neurochirurgie)

DGU

German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie)

DIC

Disseminated Intravascular Coagulation

DIVI

German Interdisciplinary Association for Emergency and Acute Care Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin)

DL

Definitive Laparotomy

DO2I

Oxygen Delivery Index

DPL

Diagnostic Peritoneal Lavage

DSA

Digital Subtractions Angiography

DSTC

Definitive Surgical Trauma Care

EAES

European Association for Endoscopic Surgery

EAST

Eastern Association for the Surgery of Trauma

ECG

Electrocardiogram

EL

Evidence Level

EMS

Emergency Medical System

EMT

Emergency Medical Technician

ENT

Ear Nose Throat (Otorhinolaryngology)

ERC

European Resuscitation Council

ERG

Electroretinogram

ETC

European Trauma Course

FÄ/FA

Attending Physician (Fachärztin/Facharzt)

FAST

Focused Assessment with Sonography for Trauma

FFP

Fresh frozen plasma

FR

French (equivalent to 1 Charrière [CH], thus 1/2 mm)

GCS

Glasgow Coma Scale /Score

GoR

Grade of Recommendation

GOS

Glasgow Outcome Scale

HAES

Hydroxyethyl Starch

Hb

Hemoglobin

HFS

Hannover Fracture Scale

ICP

Intracranial pressure

ICU

Intensive Care Unit

IU

International Unit

IFOM

Institute for Research in Operational Medicine (Institut für Forschung in der Operativen Medizin)

INR

International Normalized Ratio

INSECT

Interrupted or continuous slowly absorbable Sutures – Evaluation of abdominal Closure Techniques

ISS

Injury Severity Score

i.v.

intravenous

IVP

Intravenous Pyelography

L1-5

Lumbar Spine Vertebrae

LÄK

Regional Medical Association (Landesärztekammer)

LEAP

Lower Extremity Assessment Project

LISS

Less Invasive Stabilization System

LoE

Level of Evidence

LSI

Limb Salvage Index

L-Spine

Lumbar Spine

MAL

Median Axillary Line

MANDAT

Minimum Enrollment Database

MCI

Mass Casualty Incident

MCL

Mid-Clavicular Line

MESS

Mangled Extremity Severity Score

MILS

Manual In-Line Stabilization

MPH

Miles per hour

mRem

Millirem (entspricht 0,01 Millisievert)

MRI

Magnetic Resonance Imaging

MSCT

Multislice Spiral CT

MTRA

Medical-Technical Radiological Assistant

MVA

Motor Vehicle Accident

NaCl

Sodium Chloride

NASCIS

National Acute Spinal Cord Injury Study

NASS CDS

National Automotive Sampling System Crashworthiness Data System

NEF

Emergency Physician Service Vehicle (Notarzteinsatzfahrzeug)

NISSSA

Nerve injury, Ischemia, Soft-tissue injury, Skeletal injury, Shock and Age of patient

n. s.

not significant

OMF

Oral and Maxillofacial Surgery

PnS

Paranasal Sinuses

OP

Operation

OPSI

Overwhelming Postsplenectomy Syndrome

OR

Odds Ratio

OSG

Ankle Joint (Oberes Sprunggelenk)

PASG

Pneumatic Anti-Shock Garment

pAVD

peripheral Arterial Vascular Disease

PHTLS®

Pre-Hospital Trauma Life Support

PMMA

Polymethylmethacrylate

POVATI

Postsurgical Pain Outcome of Vertical and Transverse abdominal Incision

PPSB

Prothrombin Concentrate

PPV

Positive Predictive Value

pRBC

Packed Red Blood Cells

PSI

Predictive Salvage Index

PTFE

Polytetrafluorethylene

PTS

Polytrauma Score

PTT

Partial Thromboplastin Time

QM

Quality Management

RCT

Randomized Controlled Trial

RISC

Revised Injury Severity Classification

RR

Relative Risk

RSI

Rapid Sequence Induction

ROSC

Return of Spontaneous Circulation

ROTEM

Rotational Thromboelastometry

RöV

X-ray Order (Röntgenverordnung)

RTH

Rescue Helicopter (Rettungshubschrauber)

RTW

Ambulance/Rescue Vehicle (Rettungswagen)

SAGES

Society of American Gastrointestinal and Endoscopic Surgeons

SBP

Systolic Blood Pressure

SCIWORA

Spinal Cord Injury Without Radiographic Abnormality

TBI

Traumatic Brain Injury

SIRS

Systemic Inflammatory Response Syndrome

SR

ED Trauma Bay (Schockraum)

STaRT

Simple Triage and Rapid Treatment

STD

Hour (Stunde)

TARN

Trauma Audit and Research Network

TASH-Score

Trauma Associated Severe Hemorrhage Score

TEE

Trans-Esophageal Echocardiography

TEG

Thromboelastography

T 1-12

Thoracic Vertebrae

TIK

Trauma Induced Coagulopathy

PC

Platelet Concentrate

tPA

Tissue-specific Plasminogen Activator

Trali

Transfusion Associated Acute Lung Insufficiency

TRGS

Technical Rules for Hazardous Substances (Technische Regeln für Gefahrenstoffe)

TRIS

Tris(hydroxymethyl)aminomethane

TRISS

Trauma Injury Severity Score Method

T-spine

Thoracic Spine

TTAC

Trauma Team Activation Criteria

VEP

Visual Evoked Potential

WBCT

Whole Body Computed Tomography

WMD

Weighted mean difference

WS

Spine (Wirbelsäule)

XR

Xray

Foreward to the 2016 Update

The first S3 Guideline on the Treatment of Patients with Severe and Multiple Injuries (AWMF Registry Number: 012-019) was initially published in July 2011. With the active participation of eleven medical associations under leadership of the German Trauma Society (Deutschen Gesellschaft für Unfallchirurgie e.V., DGU), 264 recommendations for three main topics based on the phase of care (Pre-Hospital, Emergency Department, Primary Operative Management) were adopted.

Because of the regular expiration of the recommendations’ validity, preparations for update and potential thematic extension of the guideline were begun at the end of 2013. Auspiciously, the number of medical associations involved in the update process increased to twenty. During the process, 17 chapters have been updated according to current evidence. Two additional chapters have been added. In the chapters that were already present in the first version of the guideline, existing recommendations were adapted, new recommendations were formulated, and out-of-date recommendations were deleted. Authors checked the background text of each chapter for continued relevance, and revised if necessary.

A Background and Goals

Introduction

Medical guidelines are systematically-developed decision-aids for providers and patients regarding the appropriate procedures for special health problems [7]. Guidelines are important tools to make medical care decisions on a rational and transparent basis [6]. The transfer of knowledge they offer should lead to improvements in care [9].

The guideline creation process must be systematic, independent and transparent [6]. The development of level 3 guidelines takes place according to the criteria of the AWMF/ÄZQ (German Medical Center for Quality in Medicine), with all elements for systematic creation [2].

Table 1: Levels of Guideline Development (AWMF) [2]

Level 1

Expert Group:

A representative group of experts from the respective Medical Research Society creates a guideline by informal consensus, which is approved by the board of the society.

Level 2

Formal Evidence Research or Formal Consensus Development:

Guidelines are developed from conclusions in the scientific literature that have been formally evaluated, or debated and adopted in an established formal consensus process. Formal consensus processes are the nominal group process, the Delphi method, and the consensus conference.

Level 3

Guideline with all elements of systematic development:

Formal consensus attainment, systematic literature search and evaluation of references, as well as classification of studies and recommendations according to the criteria of evidence-based medicine, clinical algorithms, outcome analysis, decision analysis.

The current guideline is a Level 3 guideline

Background

Accidents are the most common cause of death in adolescents and young adults aged 15-24 years. Almost every third mortality in this group occurred because of an accident [11]. According to statistics of the Federal Institute for Occupational Safety and Health, in 2013 8.58 million people suffered accidental injuries and 21 930 people had fatal accidents [5]. Typically, care of the seriously injured is an interdisciplinary task. Due to the sudden occurrence of the situation, the unpredictability of the number of patients, and the heterogeneity of patient conditions, it is a great challenge for care providers [4].

Initially, for treatment of polytraumatized and seriously injured patients, there was the S1 Guideline of the German Society of Trauma Surgery in 2002. Thus, a comprehensive, interdisciplinary, current, and evidence-based guideline was lacking. This was the rationale behind the creation of the first version of the interdisciplinary guideline for the care of polytraumatized and/or seriously injured patients in 2011.

Requirements for the Guideline

The guideline must meet the following basic requirements:
  • Guidelines for the management of polytrauma and patients with severe injuries act as aids to decision-making for specific situations, and are based on the current state of scientific knowledge and on practically-proven procedures.

  • Due to the complexity of polytrauma and severe injuries, there is no single ideal concept for management.

  • Guidelines need to be constantly reviewed and adapted according to the current state of knowledge.

  • The recommendations in this guideline should enable good management for the vast majority of severely injured/polytrauma patients.

  • Routine monitoring of treatment and the effects/outcomes of treatment are necessary.

  • Regular dialogue of all involved parties (physicians, nursing staff, patients, relatives if possible) should make the goals and methods of polytrauma treatment transparent.

A.1 Guideline Objectives

This interdisciplinary S3 guideline is an evidence-based, consensus-based instrument with the goal of improving management of patients with multiple and severe injuries. Implementation of the recommendations should contribute to structural and procedural optimization in hospitals as well as in prehospital care, and help improve outcomes, measured by mortality rate or quality of life.

The guideline is intended to assist decision-making in specific situations, based on the current state of scientific knowledge and clinically-proven procedures. Thus, the guideline can be used not only in acute treatment situations, but also during follow up and/or for discussions regarding local protocols by quality circles of individual hospitals. Legal (insurance) and accounting aspects are not explicitly covered in this guideline. Regulations of the social security code (SGB VII) apply.

The guideline should be an aid to decision making from an interdisciplinary perspective. Thus, it is suitable to be used to create new treatment protocols for individual hospitals as well as to review existing protocols.

The guideline aims to provide support for the treatment of the vast majority of severe injuries. It is possible that the specific problems of individual patients with defined pre-existing comorbidities or particular injury patterns may not be adequately addressed.

The guideline is intended to stimulate further discussion regarding care optimization for severely injured patients. Thus, constructive criticism and suggestions are expressly welcomed. Ideally, suggested changes should be briefly summarized, referenced, and forwarded to the publisher.

This guideline is also intended to establish interdisciplinary recommendations for the continued process management of severely injured patients during the acute and post-acute phases of care.

A.2 Publisher/Experts/Society Members/Authors

The German Society of Trauma Surgery (Deutschen Gesellschaft für Unfallchirurgie e.V. DGU) is responsible for updates to the S3 Guideline to Treatment of Patients with Multiple and Severe Injuries.

The following professional associations were involved in the creation and update of the guideline:

Initial Version and Update

German Society of General and Visceral Surgery (Deutsche Gesellschaft für Allgemein- und Viszeral Chirurgie e.V.)

German Society of Anesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V.)

German Society of Endovascular and Vascular Surgery (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin e.V.)

German Society of Hand Surgery (Deutsche Gesellschaft für Handchirurgie e.V.)

German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (Deutsche Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie e.V.)

German Society of Oral and Maxillofacial Surgery (Deutsche Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie e.V.)

German Society of Neurosurgery (Deutsche Gesellschaft für Neurochirurgie e.V.)

German Radiological Society (Deutsche Röntgengesellschaft e.V.)

German Society of Thoracic Surgery (Deutsche Gesellschaft für Thoraxchirurgie e.V.)

German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie e.V.)

German Society of Urology (Deutsche Gesellschaft für Urologie e.V.)

Update

German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie & Geburtshilfe e.V.)

German Interdisciplinary Association for Intensive and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e.V.)

German Society of Pediatric Surgery (Deutsche Gesellschaft für Kinderchirurgie e.V.)

German Interdisciplinary Association for Emergency and Acute Care Medicine (Gesellschaft interdisziplinäre Notfall- und Akutmedizin)

Society of Pediatric Radiology (Gesellschaft für Pädiatrische Radiologie e.V.)

German Society of Plastic, Reconstructive and Aesthetic Surgeons (Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen e.V.)

German Professional Association for Emergency Medical Services (Deutscher Berufsverband Rettungsdienst e.V.)

German Society of Transfusion Medicine and Immunohematology (Deutsche Gesellschaft für Transfusionsmedizin und Immunhämatologie e.V.)

German Society for Burn Medicine (Deutsche Gesellschaft für Verbrennungsmedizin e.V.

Patient Participation

Patient representatives should be included in the update process to give a patient-centered perspective in the S3 Guideline on Treatment of Patients with Severe and Multiple Injuries. Through the Institute for Research in Operative Medicine (IFOM), diverse patient initiatives and self-help groups were queried. Unfortunately, no patient representative was able to participate actively in the guideline update process.

Methodology, Coordination, and Project Management of the 2016 Update

As the leading professional association, the German Trauma Society transferred central coordination of this guideline to the Institute for Research in Operative Medicine.

The tasks of the IFOM were:
  • Systematic collection of the areas requiring revision and thematic supplementation for the update based on preliminary research

  • Implementation of a prioritization process to define and prioritize the different subject areas

  • Coordination of the project group

  • Methods support and quality assurance

  • Systematic literature review

  • Literature search

  • Extraction and systematic evaluation of the quality of the included studies as well as the allocation of evidence levels (LoE)

  • Preparation of evidence reports

  • Data management

  • Structural and editorial standardization of the guideline text

  • Coordination of the necessary discussions, meetings and consensus conferences

Overriding Thematic Responsibilities for the 2016 Update

The initial version of the guideline was divided into three main sections according to the phase of care: Pre-Hospital Care, Emergency Department, and Primary Operative Management, and this structure was maintained for the update.

Coordinators were assigned responsibility for each of these treatment phases:

Pre-Hospital Care

Prof. Dr. med. Christian Waydhas

Department of Surgery

BG University Hospital Bergmannsheil

Bürkle-de-la-Camp-Platz 1

44789 Bochum

Dr.med. Heiko Trentzsch

Institute of Emergency Medicine and Medical Management - INM

Hospital of University of Munich

Ludwig-Maximilians-Universität

Schillerstr. 53

80336 Munich

Emergency Department

Prof. Dr. med. Sven Lendemans

Department of Trauma Surgery and Orthopedics

Alfried Krupp Hospital

Steele

Hellweg 100

45276 Essen

Prof. Dr. med. Stefan Huber-Wagner

Rechts der Isar Hospital

Department of Trauma Surgery

Technical University of Munich

Ismaningerstr. 22

D-81675 Munich

Primary Operative Management

Prof. Dr. med. Dieter Rixen

University of Witten/Herdecke

Member Faculty of Health

Alfred-Herrhausen-Straße 50

58448 Witten

Prof. Dr. med. Frank Hildebrand

RWTH Aachen University Hospital

Department of Trauma and Reconstructive Surgery

Pauwelsstraße 30

52074 Aachen

Tasks of the 2016 Update coordinators were:
  • Assignment of authors to topics needing update

  • Specialty expertise in the prioritization of the topics

  • Support to the authors for preparation of the approved recommendations (including grade of recommendation) and for the updates of the background text

  • If necessary, update of the introductory background text for the respective chapter sections

  • Final review and control of the chapters created within a thematic section

Moderation, Coordination and Project Management of the Initial 2011 Version

As the leading professional association, the German Trauma Society transferred central coordination of this guideline to the Institute for Research in Operative Medicine (Institut für Forschung in der Operativen Medizin, IFOM).

The tasks were:
  • Coordination of the project group

  • Methods support and quality assurance

  • Systematic literature review

  • Literature search

  • Data management

  • Structural and editorial standardization of the guideline text

  • Coordination of the necessary discussions, meetings and consensus conferences

  • Management of financial resources

Overall Thematic Responsibilities for the Initial 2011 Version

The guideline was divided into three main sections: Prehospital (now Pre-Hospital Care), Emergency Department, and Emergency Surgery (now Primary Operative Management). Coordinators were assigned responsibility for each of these treatment phases.

The tasks were:
  • Establishing guideline contents

  • Screening and evaluation of the literature for the different treatment strategies for polytrauma and severely injured patients, development and coordination of the guideline text

The AWMF, represented by Professor I. Kopp, provided methods guidance in developing the guideline.

A.3 Target User Groups

The primary target users of the guideline are the physicians and other medical professionals treating patients with multiple and severe injuries. The recommendations are for adult patients. Recommendations for the care of pediatric and adolescent patients are only occasionally specified in the guideline.

B Methods

B.1 Methods 2016 Update

1. Determination of the Requirements for Update and Supplementation

Prior to the actual update, the time from January until June 2014 was used to prioritize updated and newly introduced topics and recommendations.

As a first step, preliminary screening was carried out. As much as possible, these were based on the original searches of the initial guideline, but were less comprehensive than the final searches, and were limited in part to the relevant core journals and particular study types. The preliminary literature searches were performed within the MEDLINE database (via PubMed) for the time period of 2009 till January 14, 2014, using free text and subject headings (Medical Subject Headings/MeSH).

The results of the preliminary searches were screened by two independent reviewers according to predefined exclusion criteria (see Table 2). The abstracts of studies identified as potentially relevant were then assigned to the existing chapters of the guideline in a preliminary overview.

In the next step, the overview of potentially relevant studies was sent to the guideline group together with an online survey. One goal of the survey was to identify relevant literature in addition to results of the preliminary screening as well as any newly relevant topics. Another goal was to ask whether the new evidence warranted update (e.g. revisions or deletion of existing recommendations).

Based on the results of the preliminary screening and expert surveys, decisions regarding priority for updates/revision of thematic areas/chapters were made at a constituent consensus conference held in Cologne on June 4, 2014.

Figure 1 gives an overview of the entire decision-making process.

In addition, the steering committee later identified other individual topics with high update requirements.

Another short survey was sent to all delegates in June 2015 regarding the need for updates in individual chapters that had not yet been revised.

Some chapters identified as needing updates could not be revised due to lack of time and budget. These have been appropriately marked in the guideline and will be accounted for in the next regularly scheduled update.

Table 2: Inclusion Criteria for the Preliminary Screening

1. Study population: Adult patients (≥ 14 years) with polytrauma or trauma-related severe injury

2. Study type: systematic review (based on comparative studies), RCT, non RCT/CCT, prospective cohort studies, comparative registry database studies.

3. Language of publication: English or German

4. No multiple publications without additional information

5. Full text can be obtained

6. Not considered in the previous guideline

Figure 1: Decision-Making Algorithm on Need for Update/Supplementation (according to Becker et al. 2014 [3])

2. Search for existing guidelines updates

A systematic search for national and international guidelines was carried out within the databases of the AWMF, The Guideline International Network (GIN), and the National Guideline Clearinghouse (NGC) as well as the Internet sites of interdisciplinary and specialty-specific guideline providers. The guideline databases were searched using keywords and/or free text searches. The respective search strategies were based on the structure and capabilities of the websites.

Table 3: Inclusion and Exclusion Criteria for Guideline Searches

E1

It is a guideline

E2

The guideline contains recommendations on the subject of trauma

E3

The guideline contains recommendations for the treatment of polytrauma and/or severely injured patients

E4

The guideline contains recommendations for one or more of the following topics:

 Diagnostics

 Patient information/communication

 Therapy (psychotherapy, pharmacotherapy/other non-drug therapies)

 Coordination of measures and cooperation of providers

E5

Contains recommendations on Pre-Hospital, Emergency Department and/or Primary Surgical care in Germany or the guidelines are classified as transferable to the target situation.

E6

Publication period: 2012

E7

Language of publication: English or German

E8

The guideline is available at no cost in full text format

E9

The authors refer to the guideline as current or the revision date has not been exceeded and there is no updated version currently available.

E10

The guideline was classified as methodologically appropriate (methodological quality corresponds to S3) by two independent evaluators using the AGREE-II instrument

E11

Search strategy (of the relevant chapter) and evidence tables must be specified

Search Terms Used

Trauma, traumatic injur*, polytrauma, injur*

In some cases, additional keywords were also searched that were relevant to the individual chapter to be updated.

Research Period
Date of the initial search:

6 August 2013

Date of the last search:

23 August 2013

Post-Search:

23/24 July 2014

A detailed search protocol with statements of inclusion or exclusion criteria for individual guidelines can be seen at IFOM.

Assessment of methodological quality of the guidelines

The guidelines, which were considered according to theme for the adoption or adaptation of a recommendation, were assessed using the AGREE-II instrument by two independent evaluators. When there was disagreement, a third evaluator was called in. The assessments of the individual guidelines can be seen at IFOM.

Results

In total, 1040 guidelines were identified and 115 assessed in full text. Because of the specific topic of polytrauma/severe injury management in the initial treatment phases, many guidelines could not be included. In addition, many of the guidelines could not fulfill the E10 criterion and were excluded because of methodological aspects.

Figure 2: Flowchart Guideline Research

A guideline was included for the “Coagulation” chapter. The relevant newly adopted and/or adapted recommendations from the source guideline are identified in the corresponding chapter.

3. Systematic Literature Search Updates

For the update, one literature search per chapter was performed in the MEDLINE (via PubMed) and EMBASE databases. The search was performed using both medical keywords (Medical Subject Headings/MeSH) and free text searches. Search strategies to account for all relevant search terms for each chapter were agreed upon by the authors and chapter authorities in advance. Searches were carried out from the publication date of the initial version of each respective chapter. A detailed account of the search time period per chapter is given in the guideline. For newly submitted chapters determined during the upgrade process, searches were performed beginning in 1995. English and German were set as the languages of publication.

The systematic literature review was conducted by the Institute for Research in Operational Medicine (Institut für Forschung in der Operativen Medizin).

Selection of the Relevant Literature Update

For each chapter, inclusion criteria were defined a priori, as shown in the guideline report. Only literature with high evidence levels was included. Thus, the conclusions made according to this literature are based on study designs containing the least risk for distortion or bias. First, the titles and abstracts of the identified literature were screened against the inclusion criteria by two independent reviewers. In cases of potential relevance, reviews of the full text followed. Disagreements were discussed until consensus was reached. A detailed account of the screening process is presented in the guideline report.

Evaluation of Relevant Literature Update

Methodological quality of the primary studies was performed using checklists from the National Institute for Health and Clinical Excellence (NICE). The AMSTAR instrument was used to assess methodological quality of systematic reviews. Evaluations were performed independently by two experts. Any discrepancies were discussed until consensus was reached (see guideline report).

Classification of Study Type and Level of Evidence Assignment Update

The classification of the study type was performed according to the Hartling et al. algorithm. The level of evidence (LoE) was allocated according to the March 2009 provisions of the Oxford Centre for Evidence-Based Medicine. LoE is based on the study type. In addition, the risk of bias as well as the consistency and precision of the effect estimator was taken into account. When necessary, the LoE was downgraded and marked with an arrow (↓).

Extraction of Primary Studies Update

Extraction of studies was performed with pre-tested, standardized extraction tables. Data extraction was performed by one expert reviewer and controlled for quality by a second. Any discrepancies were discussed until consensus was reached.

For primary studies, the following data were extracted, depending on the type of study:
  • Title, date of publication, and aim of the study

  • Baseline Characteristics

  • Age, gender, ISS, TRISS, RTS, GCS or, if not given, the items used to assign scores; if necessary, further scores quantifying the severity of injury and/or relevant influencing variables1

  • Inclusion/Exclusion criteria

  • All demographic and clinical inclusion and exclusion criteria were extracted. Formal inclusion criteria were not considered (e.g. declaration of consent).

  • Other characteristics:

  • Region: country in which the study was performed, contextual information, i.e. data source, year

  • Patient Flow:

  • The number of included and evaluated patients well as patients who discontinued study participation (dropouts, lost to follow up). If this number was not given per group, and instead only as group-related information on patient flow regarding analysis, then the difference between randomized/included and evaluated patients was given.

  • Description of the intervention/control group:

  • The most detailed possible reports were made of the intervention and control or in diagnostic studies of the index and reference tests.

  • Results to the endpoints of studies:

  • The rate of each event at the endpoint (%), or for rare events the number per group, as well as the relative effect measures (odds ratio, relative risk, hazard ratio), if available, were extracted. Statistical significance was indicated with p-values and/or confidence intervals (CI). For continuous variables, the mean value or the mean value difference was indicated with CI or p-values. If no two-sided test was applied, it is indicated in brackets behind the p-value. When there were multiple endpoints, the final follow-up was used, provided that it represented a cumulative view of all events. If treatment and follow-up phases were observed separately, the events were indicated for each individual timeframe.

Extraction for Systematic Review Studies Update

For systematic review studies, data extraction included entries for study selection inclusion/exclusion criteria, research timeframe, as well as input on interventions and controls. In addition, for each comparison, the heterogeneity (I2) as well as the numbers of included studies (N) and included patients (n) were indicated. For the pooled results of meta-analyses, the relative or standardized effect measures were extracted. In cases where no meta-analysis was performed, the results were reported descriptively.

4. Formulation of Recommendations and Consensus Statements Update

The professional associations involved in the project each designated at least one delegate as a specialty representative to contribute to creation of the guideline. Each society had a voice in the consensus process. Votes were taken anonymously using a TED system (Turning Point Version 2008). Distribution of the TED devices was carried out with full transparency at the beginning of each consensus conference, and receipt of the voting device was confirmed by signature of each delegate.

The recommendations as well as the grade of recommendation were adopted during four consensus conferences (March 20-21, 2015, May 13, 2015, September 29, 2015, and November 17, 2015). The first, second and fourth consensus conferences were moderated by Prof. Dr. Edmund Neugebauer and the third guidelines conference by Prof. Dr. Bertil Bouillon. Prof Dr. Bouillon had no vote and maintained impartiality during discussions and balloting. The logs of each conference can be viewed at the Institute for Research in Operative Medicine (IFOM). PD Dr. med Ulrich Linsenmaier was present as external consultant at two consensus conferences.

Within the guideline update process, the following options to vote on recommendations were possible:
  1. 1.

    The recommendation of the initial version remains valid, requires no changes, and can therefore remain,

     
  2. 2.

    Individual elements of the recommendation require modification,

     
  3. 3.

    The recommendation is no longer valid and will be deleted,

     
  4. 4.

    New recommendations will be developed.

     
The voting process during the conferences consisted of six steps:
  1. 1.

    Presentation of the suggested recommendations made by a member of the author group,

     
  2. 2.

    Chance for questions, additions, and/or objections from the plenary,

     
  3. 3.

    Recording by the moderator of the opinions and alternatives proposed by the participants regarding the recommendations themselves as well as on the degree of recommendation,

     
  4. 4.

    Vote on the recommendations and grade of recommendations,

     
  5. 5.

    Potential discussion of points for which no “strong consensus” was achieved in the first round of voting,

     
  6. 6.

    Final vote with the TED system.

     

Most of the recommendations were adopted within the “strong consensus” range (approval by >95 of participants). Areas in which strong consensus was not achieved are identified in the guideline, and the various positions are presented. The strength of consensus was classified according to the rules and regulations of the AWMF as follows [1]:

Table 4: Classification of Consensus Strength

Strong Consensus

> 95 % of participants in agreement

Consensus

> 75–95 % of participants in agreement

Majority Approval

> 50–75 % of participants in agreement

No Consensus

< 50 % of participants in agreement

Three grades of recommendation (GoR) A, B, and 0 were assessed. Formulation of the key recommendations was thus, “must”, “should,” or “may/can.” In addition to the underlying evidence, benefit risk considerations, directness and homogeneity of the scientific evidence, as well as clinical expertise were used for determination of the GoR.[1].

Figure 3: From Evidence to Recommendation [1]

Good (Clinical) Practice Points (GPP)

If no (direct) evidence for a recommendation or goal was available, an expert opinion could be formulated using the wording of the evidence-based recommendations (must/should/may), but instead of a GoR, it would receive graduation/recommendation GPP points (good clinical practice points). This “clinical consensus point” was essentially based on the clinical experience of the guideline group, and thus represents the current clinical standards in treatment when evidence is not available.

5. Updated Topics

Within the recommendation headings it was noted when each topic was created or updated, and whether it was modified or newly introduced. The following categories are used for identification:
  • 2011 = The recommendation is part of the original guideline from 2011, and is still current and not voted on.

  • 2016 = the recommendation is from the year 2011 and is part of the 2016 update. It was approved without changes.

  • modified 2016 = The recommendation is from the 2016 update. The recommendation has been revised.

  • new 2016 = The recommendation is part of the 2016 update. The recommendation has been newly created.

Overview of Updated Chapters

No.

Chapter

Update Status

Pre-Hospital Care

1.1

Introduction

Updated 2016

1.2

Airway Management, Ventilation, and Emergency Anesthesia

Updated 2016

1.3

Volume Replacement

Updated 2016

1.4

Thorax

Updated 2016

1.5

Traumatic Brain Injury

Updated 2016

1.6

Spine

Updated 2016

1.7

Extremities

Updated 2016

1.8

Urogenital tract

Background text updated 2016

1.9

Transport and Target Hospital

Updated 2016

1.10

Mass Casualty Incident (MCI)

Background text updated 2016

Need for update has been registered

Emergency Department

2.1

Introduction

Updated 2016

2.2

Emergency Department - Staffing and Equipment

Background text updated 2016

Need for update has been registered

2.3

Emergency Department Trauma Team Activation

Background text updated 2016

2.4

Thorax

Updated 2016

2.5

Abdomen

Background text updated 2016

2.6

Traumatic Brain Injury

Background text updated 2016

2.7

Pelvis

Updated 2016

2.8

Urogenital tract

Background text updated 2016

2.9

Spine

Background text updated 2016

2.10

Extremities

Background text updated 2016

2.11

Hand

Original version remains valid.

2.12

Foot

Background text updated 2016

2.13

Mandible and Midface

Original version remains valid.

2.14

Neck

Original version remains valid.

2.15

Resuscitation

Updated 2016

2.16

Coagulation System

Updated 2016

2.17

Interventional Hemorrhage Control

Updated 2016

2.18

Imaging

newly created 2016

Primary Operative Management

3.1

Introduction

Updated 2016

3.2

Thorax

Updated 2016

3.3

Diaphragm

Background text updated 2016

3.4

Abdomen

Updated 2016

3.5

Traumatic Brain Injury

Updated 2016

3.6

Urogenital tract

Background text updated 2016

3.7

Spine

Background text updated 2016

3.8

Upper Extremity

Background text updated 2016

3.9

Hand

Background text updated 2016

Need for update has been registered

3.10

Lower Extremity

Background text updated 2016

3.11

Foot

Background text updated 2016

3.12

Mandible and Midface

Original version remains valid.

3.13

Neck

Original version remains valid.

3.14

Thermal Skin Injuries and Burns

newly created 2016

For the next revision, the following new chapters are planned:
  • Analgesia

  • Damage Control Vessels

  • Training (Hard and soft skills)

Funding of the Guideline and Disclosure of Potential Conflicts of Interest Update 2016

Financial resources for the methods support and covering costs for literature acquisition, organization of the consensus conferences, and of materials were provided by the German Trauma Society. Travel costs incurred by participants of the consensus conferences were covered by the medical societies/organizations sending representatives or by the participants themselves. The authors, delegates, and members of the steering committee creating the guideline volunteered their time and effort free of charge.

To make the update process as transparent as possible, all participants were requested to submit an explanation of any potential conflicts of interest prior to beginning work on the guideline. All participants of the consensus conference disclosed potential conflicts of interest in writing. Once submitted, these were always available to be updated and could be accessed by all members of the guideline group.

Prior to each consensus conference, a current summary of the delegates’ conflicts of interest declarations was sent along with a request for evaluation. Prior to the beginning of each conference, it was asked whether any of the delegates present saw grounds for any person listed in the summary of declarations to be excluded from the vote. Planned regulation of conflicts of interest through exclusion of any individual participant from discussions or votes was discussed by the delegates in each session. No delegates needed to be excluded from the voting. The risk of guideline content distortion due to conflict of interest was also countered by the balanced composition of the guideline group, the preparation of evidence by an independent institute (IFOM), and the use of a formal consensus process with independent moderation.

An overview of the declarations of potential conflicts of interest by all coordinators, methodologists, medical society delegates, authors, and organizers can be found in the Appendix of this guideline. In addition, the forms used to disclose potential conflicts of interest can be requested from the Institute for Research in Operative Medicine (IFOM).

B.2 Methods of the Original 2011 Version

The guideline project was initially announced in December 2004 and again in May 2009.

The “Guideline on Treatment of Patients with Severe and Multiple Injuries” was created according to a structured, planned, reliable process. It is the result of a systematic literature search and critical assessment of available data using scientific methods as well as discussion with experts in a formal consensus process.

Literature Search and Selection of Evidence Initial Version

The key questions for the systematic literature search and evaluation were formulated based on preliminary work from 2005. The literature searches were carried out in the MEDLINE database (via PubMed) using medical keywords (Medical Subject Headings/MeSH), partly supplemented by a free text search. The filter recommended in PubMed was used to identify systematic reviews. Supplementary searches were conducted in the Cochrane Library (CENTRAL) (in this case with keywords and text words in the title and abstract). The publication period selected was 1995-2010, and German and English as the publication languages.

The literature searches were carried out partly by the Institute for Research in Operative Medicine (IFOM) and partly by the authors themselves. The results of the literature searches, sorted according to topic, were forwarded to the individual authors responsible for each topic.

The underlying key questions, the literature searches carried out with date and number of hits and, if applicable, search limitations were documented.

Selection and Evaluation of the Relevant Literature Initial Version

The authors of each chapter selected and evaluated the literature included in the guideline (see Guideline report). This was carried out according to the criteria of evidence-based medicine. Sufficient randomization, allocation concealment, blinding and statistical analysis were taken into account.

The evidence statement for the recommendations was based on the evidence classification of the Oxford Center of Evidence-Based Medicine (CEBM), March 2009 version. In formulating the recommendations, priority was given to studies with the highest level of evidence available (LoE).

Table 5: CEBM Evidence Classification [10]

Grade

Studies of Therapy/Prevention/Etiology

1a

1b

1c

Systematic Overview of Randomized Controlled Studies (RCT)

RCT (with narrow confidence interval)

All-or-none principle

2a

2b

2c

Systematic Overview of Well-Planned Cohort Studies

A well-planned cohort study or a RCT of less quality

Outcome studies, ecological studies

3a

3b

Systematic Overview of Case-Control Studies

Case-control study

4

Case Series or Cohort/Case-Control Studies of Lesser Quality

5

Expert opinions without explicit evaluation of the evidence or based on physiological models/laboratory research.

Three grades of recommendation (GoR) A, B, and 0 were assessed. Formulation of the key recommendations was thus, “must”, “should,” or “may/can.” In addition to the underlying evidence, benefit risk considerations, directness and homogeneity of the scientific evidence, as well as clinical expertise were used for determination of the GoR [6].

Formulation of Recommendations and Consensus-Finding Initial Version

The professional associations involved in the project each designated at least one delegate as a specialty representative to contribute to creation of the guideline. Each society had a voice in the consensus process.

The recommendations as well as the grade of recommendation were adopted during four consensus conferences (March 18-19, 2009, May 30, 2009, September 8, 2009, and November 26-27, 2009).

The voting process during the conferences, performed with help of the TED system, consisted of six steps:
  • the opportunity to review the guideline manuscript before the conference and to compile notes on the proposed recommendations and grades;

  • presentation and explanation from each responsible author on the pre-formulated proposals for recommendations;

  • recording by the moderator of the opinions and alternatives proposed by the participants regarding the recommendations, with moderator contributions solely for clarification;

  • voting on all recommendations and grades of recommendations, as well as the suggested alternatives;

  • discussion of points for which no “strong consensus” was achieved in the first round of voting;

  • final vote.

Most of the recommendations were adopted within the “strong consensus” range (approval by >95 of participants). Areas in which strong consensus was not achieved are identified in the guideline, and the various positions are presented. In assessing consensus strength, the following consensus classification was created in advance:
  • Strong Consensus > 95 % of the participants in agreement

  • Consensus > 75-95 % of participants in agreement

  • Majority Approval > 50-75 % of participants in agreement

  • No Consensus < 50 % of participants in agreement

The logs of each conference can be viewed at the Institute for Research in Operative Medicine (IFOM). The Delphi method was then applied to recommendations for which no consensus could be reached in the consensus conferences. A detailed methods report is available for viewing on the AWMF website and has been filed at the Institute for Research in Operative Medicine (IFOM).

Funding of the Guideline and Disclosure of Potential Conflicts of Interest Initial Version

Financial resources for the methods support and covering costs for literature acquisition, organization of the consensus conferences, and of materials were provided by the German Trauma Society and the Institute for Research in Operative Medicine of the University of Witten/Herdecke. Travel costs incurred by participants of the consensus conferences were covered by the medical societies/organizations sending representatives or by the participants themselves.

All participants of the consensus conference disclosed potential conflicts of interest in writing. A summary of the declarations of potential conflicts of interest by all coordinators, methodologists, medical society delegates, authors, and organizers can be found in the Appendix of this guideline. In addition, the forms used to disclose potential conflicts of interest can be requested from the Institute for Research in Operative Medicine (IFOM).

Warmest thanks are extended to the coordinators of the individual subsections, the authors, and participants in the consensus process for their completely voluntary work.

B.3 Distribution and Implementation

  • Distribution of the guideline will be carried out as follows:

  • via the internet: AWMF website (http://www.awmf-online.de) as well as the websites of the medical societies and professional organizations involved in the guideline

  • via printed media:
    • Publication of the guideline as a manual/book by the DGU. Copies will be made available to all hospitals involved in the DGU Trauma Network. In addition, all hospitals involved will be notified in writing regarding where and how the guideline can be viewed on the AWMF homepage.

    • Publication of excerpts of the guideline and implementation strategies in the journals of the participating medical societies.

    • To simplify use of the guideline, a summary version of the guideline containing the key recommendations will be published in “Notfall- und Rettungsmedizin” [German medical journal].

  • via conferences, workshops, professional training courses offered by the participating medical societies.

Various complementary measures are to be implemented in this guideline. In addition to the presentation of the recommendations at conferences, a link to topic-specific professional training courses is planned.

In addition, implementation at all the German DGU trauma network hospitals will be evaluated approximately one year after guideline publication. In particular, information should be collected regarding guideline use and practical suggestions for other users.

Quality Indicators and Evaluation

Audit filters were developed for the DGU Trauma Registry as criteria for quality management. Based on available audit filters, the following criteria were established for this guideline:

Process quality for evaluation in the pre-hospital care phase:
  • duration of prehospital time from accident to hospital admission for severely injured patients with ISS ≥ 16 [min ± SD]

  • intubation rate in patients with severe chest injury (AIS 4-5) by the emergency physician [%, n/total]

  • intubation rate in patients with suspected traumatic brain injury (unconscious, Glasgow Coma Scale [GCS] ≤ 8) [%, n/total]

Process quality for evaluation of the emergency department phase:
  • time from hospital admission to performance of chest X-ray in severely injured patients (ISS ≥ 16) [min ± SD]

  • time from hospital admission to abdominal/chest ultrasound in cases of severe trauma (ISS ≥ 16) [min ± SD]

  • time to computed tomography (CT) scan of the cranium (CCT) in pre-hospital unconscious patients (GCS ≤ 8) [min ± SD]

  • time to full-body CT scan on all patients, if carried out [min ± SD]

  • time from emergency arrival to completion of diagnostic survey in severely injured persons, if this has been completed normally (ISS ≥ 16) [min ± SD]

  • time from emergency arrival to completion of diagnostic survey in severely injured persons, if interrupted due to emergency (ISS ≥ 16) [min ± SD]

Outcome Quality for Overall Evaluation:
  • standardized mortality rate: observed mortality divided by the expected prognosis based on RISC (Revised Injury Severity Classification) in severely injured patients (ISS ≥ 16)

  • standardized mortality rate: observed mortality divided by the expected prognosis based on TRISS (Trauma Injury Severity Score Method) in severely injured persons (ISS ≥ 16)

The routine collection and evaluation of these data offer a vital opportunity to monitor improvements in the quality of management of patients with multiple and severe injuries. From this it is not possible to ascertain which effects are due to the guideline. Quality indicators should continue to be developed based on the aforementioned criteria.

B.4 Guideline Validity and Updates

The present guideline is valid until June 2021. The German Trauma Society is responsible for initiating the update procedure. The next update is planned to address the topics of analgesia, damage control vessels, and a special chapter on training (hard and soft skills).

References
  1. 1.

    Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) Ständige Kommission Leitlinien. AWMF-Regelwerk „Leitlinien“. 1. Auflage 2012. http://www.awmf.org/leitlinien/awmf-regelwerk.html.

     
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    Arbeitsgemeinschaft Wissenschaftlicher Medizinischer Fachgesellschaften (AWMF). 3-Stufen-Prozess der Leitlinien-Entwicklung: eine Klassifizierung. 2009. http://www.awmf.org/leitlinien/awmf-regelwerk/ll-entwicklung.html.

     
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    Becker M, Neugebauer EA, Eikermann M. Partial updating of clinical practice guidelines often makes more sense than full updating: a systematic review on methods and the development of an updating procedure. J Clin Epidemiol. 2014;67(1):33–45.

     
  4. 4.

    Bouillon, B., Weißbuch Schwerverletzten-Versorgung. Empfehlungen zur Struktur, Organisation und Ausstattung stationärer Einrichtungen zur Schwerverletzten-Versorgung in der Bundesrepublik Deutschland. 2006, Berlin: Dt. Gesellschaft für Unfallchirugie e.V. (DGU).

     
  5. 5.

    Bundesanstalt für Arbeitsschutz und Arbeitsmedizin. Gesamtunfallgeschehen. 2013. http://www.baua.de/de/Informationen-fuer-die-Praxis/Statistiken/Unfaelle/Gesamtunfallgeschehen/Gesamtunfallgeschehen.html.

     
  6. 6.

    Council of Europe. Developing a Methodology for drawing up Guidelines on Best Medical Practices: Recommendation Rec (2001) 13 adopted by the Committee of Ministers of the Council of Europe on 10 October 2001 and explanatory memorandum. Council of Europe: Strasbourg Cedex; 2001.

     
  7. 7.

    Field MJ, Lohr KN (Eds). Clinical practice guidelines: directions for a new program. 1990.

     
  8. 8.

    Hartling L, et al. Testing a tool for the classification of study designs in systematic reviews of interventions and exposures showed moderate reliability and low accuracy. J Clin Epidemiol. 2011;64(8):861–71.

     
  9. 9.

    Kopp IB. Perspectives in guideline development and implementation in Germany. Z Rheumatol. 2010.

     
  10. 10.

    Oxford Center for Evidence based Medicine (CEBM). Levels of Evidence March 2009. 2009. https://www.cebm.net/index.aspx?o=1025.

     
  11. 11.

    Robert Koch-Institut. Gesundheit in Deutschland. Gesundheitsberichterstattung des Bundes. Gemeinsam getragen von RKI und Destatis, Berlin. 2015.

     
  12. 12.

    Schmiegel W, et al. S3-Leitlinie „Kolorektales Karzinom“. 2008.

     

1. Pre-Hospital Care

1.1 Introduction

Professional treatment of seriously injured patients begins at the accident scene with a structured rescue service. Already at this first phase of treatment, the introduction of life-saving measures, a time-critical approach, and transport to the appropriate target hospital set the overall trajectory of the course to come.

Often before the emergency physician arrives, an emergency rescue service without a physician is first at the scene of the accident [1]. Thus, the “Pre-Hospital Care” section of this guideline is directed not only towards physicians, but also to emergency medics, paramedics, and other pre-hospital assisting personnel.

Five years ago, the first comprehensive AWMF guideline for the treatment of severely injured patients was published, and is updated now for the first time. What has changed since then - and what has not?

For the pre-hospital care section - but not only here - a number of situations have been singled out and worked out in more detail, situations in which pre-hospital measures could be life-saving and in which full implementation of these measures could prevent potentially avoidable deaths, for example situations with problems securing the airway, decompression of a tension pneumothorax, or insufficient hemorrhage control [3].

In the chapter, “Airway Management, Ventilation, and Emergency Anesthesia,” new recommendations regarding the use of video laryngoscopy have been included. An increasing collection of evidence shows clearly that use of video laryngoscopy enables higher success rates of endotracheal intubation for very experienced as well as less-experienced users. However, since advantages in survival with the use of video laryngoscopy have not yet been proven, the recommendations have been formulated as “good clinical practice points” (GPP).

For the treatment of thoracic trauma, the importance of rapid decompression for tension pneumothorax has been more strongly emphasized. Several analyses have identified tension pneumothorax as one of the most important preventable causes of death.

The importance of hemostasis outside of the operating room has moved further into the foreground. A substantial new section has been added to the “Extremities” chapter dealing with profusely bleeding wounds and the use of newer methods for hemorrhage control such as tourniquets and hemostatic bandages. In particular, situations are defined in which tourniquets can be considered a primary management option. In this context, the reader should also pay attention to the “Pelvis” chapter in the “Emergency Department” section of the guideline, in which aspects of examination and emergency stabilization are considered that are also relevant to the pre-hospital care situation.

Since publication of the last S3 guideline, numerous studies have addressed the use and performance of cardiopulmonary resuscitation for cases of trauma-induced cardiac arrest [11, 14, 18, 20]. Registry data show that in traumatic cardiac arrest, even after blunt trauma, resuscitation measures can have positive results with good neurological outcomes [9]. For this reason, the extensive and reorganized “Resuscitation” chapter in the “Emergency Department” section must be pointed out, as it is also extremely relevant for pre-hospital management. Here, the special measures for resuscitation after trauma have been clearly prioritized and presented, and in particular, the differences versus resuscitation for classic cardiac or pulmonary induced arrest are highlighted. The algorithms and recommendations presented are closely aligned with the international guidelines of the ERC (European Resuscitation Council).

The chapter “Thermal Skin Injuries and Burns” is completely new and is dedicated mostly to the special management of severely injured patients with concomitant burn injuries. It is therefore considered a supplement to existing guidelines [7, 17]. That chapter is found in the “Primary Operative Management” section of this guideline, but also contains information relevant to pre-hospital care.

Another chapter that has undergone revision is the “Mass Casualty Incident” chapter. A mass number of trauma patients represents a rare, but very challenging situation. Current events and the global political situation clearly show that being prepared for a mass attack, e.g. a terrorist strike, is more necessary than ever. In a modern and mobile society, however, there are also other scenarios with large numbers of severely injured persons, e.g. the recent train accident at Bad Aibling, which are unavoidable despite high safety standards. Prior to arrival of the executive emergency physician on duty, the primary tasks focusing on triage and allocation of scarce resources and treatment capacity must be handled by the first emergency physician on the scene.

It cannot be stressed often enough that treatment of severely injured patients is a time-critical enterprise. Interestingly, the pre-hospital time, i.e. the time from the accident until arrival in the Emergency Department, is apparently not an independent risk factor, at least not for all patients as a whole. Nevertheless, even data collection by the best current risk prediction tool, the RISC II [13], identifies pre-hospital time as an independent risk factor predicting mortality. On the other hand, it is known that in cases of severe intra-abdominal bleeding, a time delay of one minute increases mortality by 3% [5]. Since the predictive power of recognizing these injuries in the pre-hospital setting is low and the concerned patients can easily go unrecognized [2, 10, 16], it is advisable to transport all patients with potentially severe injuries as quickly as possible to the hospital, where the full range of diagnostic and targeted interventions can be performed. In the end, however, whether some time-consuming procedures are performed at the accident scene or are postponed until the early hospital phase must be weighed. It certainly plays a role here as to how urgent the indication for an intervention is, whether there are particular difficulties in carrying it out, or whether individual skills are sufficient to do it safely and correctly. In the meantime, it has also been found that the time gained by skipping interventions in the pre-hospital phase is lost again during the Emergency Department phase. Thus, the balance between the “load and go” and “stay and play” approaches to pre-hospital management must be based first and foremost on the urgency of the required intervention [12]. Life-saving interventions should not be foregone in favor of a shorter pre-hospital time. Conversely, some measures, e.g. surgical hemostasis of internal bleeding, must be performed in the hospital. As a guideline, the Key Points Paper on Emergency Medical Management of Patients recommends a maximum pre-hospital time of 60 minutes [8]. This does not preclude the fact that faster transport for certain patient groups would be better.

Regarding the critical time period as well as rapid injury-appropriate management, selection of the appropriate hospital is of great importance. Germany now has a national system of certified trauma centers in three levels of care, resulting from a transparent catalog of available services. This catalog is revised and published every four years in the white paper Treatment of the Severely Injured [6]. Recently, the benefits of air rescue in particular have proliferated, because it seems to be associated with improved survival after severe accident-related trauma. One suspected reason for this advantage is the ability of helicopters to reach an appropriate target hospital more rapidly than ground-based rescue services, especially when the hospital is far away. Particularly when it comes to special requirements, e.g. a neurosurgical department in cases of severe TBI, center-related effects could be a reason for the benefits of air rescue. This topic is a focus of the chapter “Transport and Target Hospital,” which has been correspondingly expanded and made more detailed. Here again, the Key Paper [8] calls for accessibility-oriented treatment with a recourse to national treatment capacity involving air rescue regardless of the time of day.

During registration in the target hospital, it’s important that the treatment of the patient continues smoothly and without unnecessary loss of time. As a benchmark, the Key Paper calls for a time interval of 90 minutes from accident until the start of lifesaving, operative interventions [8]. The hub of continued hospital treatment is in the trauma bay of the Emergency Department. Criteria for the requirements there are listed in the “Trauma Team Activation” chapter of the “Emergency Department” section of this guideline. The guideline group placed low priority on the revision of this chapter. However, questions surrounding over- and under-triage based on the recommendations there continue to present in daily practice as a stress test for hospital resources. In 2012, the US Center for Disease Control (CDC) published an update of its recommendations regarding assignment of patients to a trauma center, which has also been translated into German [19]. The criteria given there are similar to the German trauma team activation criteria. The main problem, however, is that especially the criteria regarding accident mechanism, in the absence of other criteria, might invite speculation that trauma team management is not indicated. Leaders in the emergency medical services (EMS) and the medical director of the EMS should work together with the trauma network to develop locally-adapted processes to meet their respective needs. In view of the difficulties in making an accurate diagnosis in the pre-hospital setting, however, the pre-hospital team should accept higher rates of over-triage over under-triage, for the benefit of patients. In cases of doubt, the assessment by the emergency physician to activate the trauma team should be generally accepted.

Recommendations for pain therapy were already lacking in the last guideline. Unfortunately, due to the generous but still limited resources, it was not possible to amend this already detailed draft according to all methodological, structural, and substantive requirements. It is envisaged, however, that the draft text will first be published independent of the guideline. This will provide a systematic review, which can be both critically recognized and used as a guideline for individual management decisions, and then can be added to the consensus process of the update and thus be added to the next S3 guideline version.

Because of the challenging conditions of the prehospital emergency environment, the level of evidence is low, while experience and expertise are considerable. Numerous difficulties contribute here:
  • Compliance with the standards of good clinical practice

  • As a rule, patients are incapable of consent

  • Heterogeneity of the patient population

  • The difficulty of correctly and completely identifying, with limited diagnostic capabilities, the actual pattern of injury or pathophysiological processes (e.g. coagulopathy)

  • Ethical concerns in omitting certain interventions in a comparison group (e.g. decompression of a tension pneumothorax)

  • Doubts regarding transferability of results between differently organized rescue services

Nevertheless, it is necessary to translate evidence-based and expert recommendations into practical management recommendations and priority-driven processes. With the “Trauma Care Bundle” for pre-hospital management of severely injured patients, the German Trauma Society’s section on Emergency, Intensive care, and Injuries (section NIS) transferred key recommendations into a short and practical treatment guide, thus attempting to create a basis for improving quality of care [15]. There are also a variety of commercially available course formats, such as Prehospital Trauma Life Support® (PHTLS), International Trauma Life Support® (ITLS) or TraumaManagement®, which provide and distribute practical treatment protocols. The individual steps in these protocols conform to the key recommendations of the S3 guideline, but cannot be scientifically backed up in detail, as explained above. Thus, the present guideline did not aim to redevelop a similar concept. It should be emphasized here that all of these management interventions must be physically practiced and trained within the team. Within the “pre-hospital” section of the guideline, the current state of knowledge was accepted without much disagreement by the expert representatives, and high levels of agreement were attained. At the same time, the available knowledge remains incomplete in many areas, which is why consensus is often shaped by expert opinions. For this reason, the “new” recommendation grading system of GPP (Good Clinical Practice Points) was introduced for recommendations for which there is not evaluable evidence, but are considered important enough to make a recommendation. We hope that knowledge deficits and gaps, or recommendations that are not accepted universally, will inspire efforts to close these gaps, at least partially, with solid scientific research leading up to the next revision of the S3 guideline. We expressly encourage all interested parties to take on this important task [4].

References
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    Aschenbrenner U, et al. Air rescue missions at night: Data analysis of primary and secondary missions by the DRF air rescue service in 2014. Unfallchirurg. 2015;118(6):549–63.

     
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    Blaivas M, Sierzenski P, Theodoro D. Significant hemoperitoneum in blunt trauma victims with normal vital signs and clinical examination. Am J Emerg Med. 2002;20(3):218–21.

     
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    Clarke JR, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420–5.

     
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    Deutsche Gesellschaft für Unfallchirurgie, Weißbuch Schwerverletztenversorgung, 2. erweiterte Auflage – Empfehlungen zur Struktur, Organisation und Ausstattung der Schwerverletztenversorgung in der Bundesrepublik Deutschland. Orthopädie und Unfallchirurgie Mitteilung und Nachrichten, 2012(Supplement 1):4–34.

     
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    Ellerkamp V, et al. S2k-Leitlinie 006-128: Behandlung thermischer Verletzungen im Kindesalter (Verbrennungen, Verbrühungen). 2015. http://www.awmf.org/leitlinien/detail/ll/006-128.html. Accessed 4 Mar 2016

     
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    Fischer M, et al. Eckpunktepapier zur notfallmedizinischen Versorgung der Bevölkerung in der Prähospitalphase und in der Klinik. Notfall Rettungsmedizin. 2016;19(5):387–95.

     
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    Grasner JT, et al. Cardiopulmonary resuscitation traumatic cardiac arrest–there are survivors. An analysis of two national emergency registries. Crit Care. 2011;15(6):R276.

     
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    Hasler RM, et al. Accuracy of prehospital diagnosis and triage of a Swiss helicopter emergency medical service. J Trauma Acute Care Surg. 2012;73(3):709–15.

     
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    Kleber C, et al. Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation. 2014;85(3):405–10.

     
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    Kulla M, et al. Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the Trauma Registry of the German Society of Trauma Surgery. Emerg Med J. 2012;29(6):497–501.

     
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1.2 Airway Management, Ventilation, and Emergency Anesthesia

Preamble

Endotracheal intubation and ventilation, and thus definitive airway protection aimed at optimized oxygenation and ventilation, are central therapeutic measures in emergency medicine [146]. This is about securing the basic vital functions directly associated with survival. In established standards of trauma care, the “A” for airway and “B” for breathing are given the highest priority and thus, are particularly important for both pre-hospital and early hospital management [4, 131, 183].

One problem with evaluating the evidence available is that information cannot be directly referred to the German rescue and emergency physician system, due to the divergent organization of emergency rescue services internationally and the resulting differences in experience and routines used to secure the airway. This applies particularly for negative results from paramedic systems [102, 157]. Although paramedics are often employed in the Anglo-American region, the emergency physician system is widely used in continental Europe. But even here there is variation. In Germany, (specialist) physicians from all disciplines can participate in emergency services after acquiring the appropriate qualification, but in Scandinavian countries, this is mainly reserved for anesthesiologists [14]. As a consequence, the evaluation of international studies regarding pre-hospital securing of the airway reveals emergency medical personnel with very different levels of training. Depending on the personnel employed and how commonly they perform intubation, high rates of unsuccessful intubations are found in the literature, with 15 to 31%. Esophageal intubations occur in up to 12% of cases [38, 174]. Within paramedic systems, there is a higher rate of guideline non-compliant airway management [64]. For the emergency physician system in Germany, the stipulated minimum “Additional qualification in emergency medicine” and the use of emergency anesthesia produce a different scenario than that in the Anglo-American paramedic system, in which securing the airway is sometimes attempted without medications.

For the key recommendations to come, the following features of the pre-hospital care setting, which influence the development of indications to perform emergency anesthesia, intubation and ventilation, must be considered:
  • Level of experience and the routine training of the emergency physician

  • Circumstances of the medical emergency (e.g., patient is trapped, rescue time)

  • Type of transport (land-based versus air-supported)

  • Transport time

  • Concomitant injuries of the airway region and any (recognizable) impediments to intubation

Depending on the individual case, the decision to perform or not perform pre-hospital anesthesia, intubation/airway management, and ventilation ranges between the extremes of “advanced training level, long transport time, simple airway,” and “minimal experience, shorter transport time, predicted difficult airway.” In any event, sufficient oxygenation must be secured using appropriate measures.

The following recommendations cover the overall topics of emergency anesthesia, airway management, and ventilation in the pre-hospital phase and in the Emergency Department.

Key Recommendations:

1.1

Recommendation

2016

GoR A

For multiply injured patients with apnea or agonal breathing (respiration rate <6), emergency anesthesia, endotracheal intubation and ventilation must be performed in the pre-hospital setting.

1.2

Recommendation

Modified 2016

GoR B

For multiply injured patients, emergency anesthesia, endotracheal intubation and ventilation should be performed in the pre-hospital setting for the following indications:

 • Hypoxia (SpO2 < 90 %) despite oxygen administration and after tension pneumothorax is ex• cluded

 Severe TBI (GCS < 9)

 • Trauma-associated persistent hemodynamic instability (SBP < 90 mmHg, age adapted for children)

 • Severe chest trauma with respiratory insufficiency (respiration rate > 29, age-adapted for children)

1.3

Recommendation

2016

GoR A

Multiply injured patients must be pre-oxygenated before anesthesia induction.

1.4

Recommendation

Modified 2016

GoR A

During in-hospital emergency anesthesia, endotracheal intubation and ventilation must be performed by trained and experienced anesthesia staff.

When complicated in-hospital induction and/or endotracheal intubation is expected, an anesthesiologist must perform the procedure.

Explanation:

Indications for Intubation

Severe polytrauma has serious effects on the integrity of the human body. In addition to the acute consequences of trauma on individual body regions, there is a mediator-mediated whole-body reaction, i.e. Systemic Inflammatory Response Syndrome (SIRS) [48, 93]. Tissue oxygenation takes on special significance in this damage cascade. Tissue oxygenation can only be achieved if oxygen uptake, transport and release are maintained. Oxygen uptake is only possible with a free airway. Direct consequences of trauma (e.g. facial fractures, laryngeal injuries or obstruction due to blood, vomit and/or secretions), but also inability to keep the airway open independently because of loss of consciousness, can make securing the airway necessary. Endotracheal intubation is the gold standard for definitive airway protection according to current European and non-European guidelines [56, 130, 131]. Treatment recommendations of the German Society of Anesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin) and the S1 Guideline (AWMF) also support the indications for airway management listed above in the Key Recommendations [19].

Severe impairment of consciousness with a Glasgow Coma Score (GCS) < 9 due to a traumatic brain injury is regarded as an indication for intubation [12]. For the trauma patient with impaired consciousness GCS ≤ 8, endotracheal intubation in both pre-hospital and hospital settings is also recommended in the guideline of the Eastern Association for the Surgery of Trauma (EAST) [56] and other training programs (e.g., ATLS® [4], ETC [70]). Hypoxia and hypotension are the “lethal duo” inducing secondary damage particularly in polytrauma patients with traumatic brain injury [36, 37, 90, 155, 158]. Abnormal brain computed tomography (38%) and intracranial bleeding (28%) have been reported even in patients with GCS of 13 or 14 who were endotracheally intubated in the pre-hospital phase [61]. In a pre-hospital cohort study, endotracheal intubation had a positive effect on survival following severe traumatic brain injury [96]. A comparative registry database study, which due to a number of factors is not comparable to the German emergency physician system, found a higher mortality for patients with a GCS of 3 who were intubated in the pre-hospital setting (Odds Ratio [OR] 1.93; 95 % CI: 1.74–2.15, p < 0.0001) [88]. However, in the post-hoc subgroup analysis by the Resuscitation Outcome Consortium (ROC) Hypertonic Saline (HS) trials (RCT) [173], which looked at data from two randomized clinical studies using hypertonic infusions, there was no increased 28-day mortality in TBI patients intubated in the pre-hospital setting versus those intubated in the Emergency Department (OR 1.57; 95% CI: 0.93–2.64). This study is also not transferable to the German emergency physician system for numerous reasons. There was increased 28-day mortality for patients in shock (SBP < 70 mmHg or SBP 71-90 mmHg + HR > 108 bpm) who had been intubated in the pre-hospital setting (OR 5.14; 95% CI: 2.42–10.90). Limitations in the interpretations of the secondary analysis of the ROC HS trial [173] include the pre-hospital paramedic system, the lack of data regarding the type of airway/anesthetic management, and the fact that muscle relaxants were used in only 70% of cases. Another retrospective study showed reduced mortality for children with severe TBI who were intubated by emergency physicians in the pre-hospital phase versus those receiving Basic Life Support (BLS) and delayed intubation in regional trauma centers [159]. Limiting consideration to the pediatric population, pre-hospital intubation was carried out by emergency medical physicians in this study, meaning good transferability to the German emergency physician system. Using the Trauma and Injury Severity Score (TRISS), another study also confirmed that pre-hospital intubation yields improved survival and neurologic outcomes [63]. Another paper showed improvements in the measured systolic blood pressure, oxygen saturation, and end-tidal carbon dioxide (etCO2) compared to baseline values prior to pre-hospital intubation in patients with severe TBI [16]. A methodically weaker retrospective analysis in a paramedic system showed no survival advantage for patients with TBI [30]. Regarding the time point of intubation in patients with traumatic brain injury and decreased level of consciousness, important results can be found in a prospective randomized controlled trial (RCT) in which intubation was performed by paramedics with a standard rapid sequence induction (RSI) protocol (fentanyl 0.1 mg + midazolam 0.1 mg/kg + succinylcholine 1.5 mg/kg) in patients with GCS < 10 (intubation success rate of 97%) compared to cases intubated by physicians on arrival to the hospital [17]. Using the extended Glasgow Outcome Scale (eGOS), patients undergoing pre-hospital intubation had better neurological outcomes after six months [eGOS 5-8 (n = 157 vs. n = 142): 51% vs. 39% with RR 1.28; 95% CI: 1.00-1.64, p = 0.046] than those managed in-hospital [17]. However, duration of intensive care and hospital admissions as well as survival until discharge did not differ [17]. A comparative registry database study also supports the recommended indications for intubation in TBI listed above, particularly for severely affected patients [47]. A retrospective cohort study of comparable patient groups (ISS 10 vs. 11) reported that delayed endotracheal intubation (n = 34, intubation 24 min) was associated with higher mortality than earlier intubation (n = 56, intubation 10-24 min) after admission to the Emergency Department (11.8 % vs. 1.8 %, p = 0.045) [112]. The authors calculated a relative risk reduction of 85 % for mortality when the patient airway was secured early (i.e., within 10-24 min) on admission to the hospital.

Current review studies include heterogeneous patient populations, various types of emergency medical services, as well as differing levels of experience for the care providers and thus, do not always yield positive results for intubation [14, 22, 45, 53, 102, 104, 124, 131, 172, 175] The EAST guideline group also addressed this problem. In the “Guidelines for Emergency Intubation Immediately Following Traumatic Injury,” it was stated that there are no randomized controlled trials on this research question. On the other hand, however, the authors of the EAST Guideline also found no studies presenting a proven alternative treatment strategy. In summary, endotracheal intubation was assessed overall as such an established procedure in hypoxia/apnea that, despite a lack of scientific evidence, a Grade A recommendation was formulated [56].

Other conditions requiring a definitive airway are gas exchange disturbances, even when the native airway is open. A current investigation on airway protection in moderately injured patients supports apnea as an indication for intubation [85]. Other indications for endotracheal intubation (e.g. chest trauma) are disputed in the literature [141]. Hypoxia and respiratory failure have been established as consequences of severe chest trauma (multiple rib fractures, lung contusion, flail chest). If hypoxia is refractory to oxygen administration, exclusion of tension pneumothorax, and basic measures of airway support, endotracheal intubation is recommended [56]. Pre-hospital endotracheal intubation in patients with severe thoracic trauma can prevent hypoxia and hypoventilation, which are associated with secondary neurologic damage and severe repercussions on the rest of the body. However, with difficult, prolonged attempts at intubation and the associated hypoventilation and risk of hypoxia, endotracheal intubation itself can cause procedure-associated secondary damage or even death. A database analysis of the Trauma Registry of the German Trauma Society showed no advantage in prehospital endotracheal intubation in patients suffering chest trauma without respiratory insufficiency [141]. Severe chest injury with respiratory insufficiency does present an indication for prehospital endotracheal intubation; however, the decision to intubate should be made based on respiratory insufficiency and not the (suspected) diagnosis of severe chest injury, which is associated with a degree of uncertainty [10].

Endotracheal intubation is included as an “Advanced Life Support” procedure in the pre-hospital action algorithms of various training programs (e.g., PHTLS®, ETC) [70, 126]. In this context, studies have been conducted to examine compliance with these recommendations. Using a scoring system to evaluate management problems along with the relevant autopsy reports, a series of fatal traffic accidents were retrospectively analyzed to characterize the effectiveness of pre-hospital care and potentially avoidable mortality [136]. Here factors leading to avoidable death included prolonged “pre-hospital and early in-hospital care period” as well as “lack of airway protection with intubation” [136].

Considering the cases presented in the Preamble, the following aspects have particular relevance. A retrospective cohort study of 570 intubated patients versus 8137 non-intubated patients reported that patients intubated pre-hospital had pre-hospital times lasting 5.2-10.7 minutes longer than that of non-intubated patients [43]. A prospective non-randomized study assessed the influence of early intubation within two hours of trauma on subsequent organ failure [169]. Despite a significantly higher degree of injury in the group of patients who were intubated “early” (within 2 hours of trauma), the incidence of organ failure and mortality were decreased compared to those intubated “later.” A retrospective trauma registry database study compared 3571 patients intubated pre-hospital to 746 patients intubated in the Emergency Department and 11 586 patients who were not intubated at all [7]. Intubation performed in the Emergency Department was associated with significantly higher mortality risk compared to non-intubated patients (OR 3.1; 95% CI: 2.1-4.5, p < 0.0001) and patients intubated in the pre-hospital setting (OR 3.0; 95 % CI: 1.9–4.9, p < 0.0001) [7]. It should also be noted that patients intubated in the pre-hospital setting did not have a higher mortality risk than patients who were not intubated in the Emergency Department (OR 1.1; 95 % CI: 0.7–1.9; p = 0.6). The authors concluded that patients who weren’t intubated before arriving in the Emergency Department should have been intubated in the pre-hospital setting [7]. Thus, when choosing the optimal time point for anesthetic induction and endotracheal intubation, one must consider the pattern of injury, the personal experience of the emergency physician/anesthesiologist, the ambient environment, the time needed for transfer, the equipment available, and the procedure-related complications. With these points in mind, for definitive care, the polytrauma patient must undergo emergency anesthesia with endotracheal intubation and ventilation. Endotracheal intubation must be carried out for appropriate indications and corresponding level of training in the pre-hospital setting, or at the latest in the Emergency Department. According to an analysis of the German Trauma Society’s trauma registry database, of 24 771 patients, 31% unconscious at the accident scene (GCS < 9), 19% showed severe hemodynamic instability (SBP < 90 mmHg), and 55% were intubated by the emergency physician in the pre-hospital setting [140]. According to this analysis, 9% of polytrauma patients’ time in the Emergency Department was cut short for a necessary emergency intervention, 77% of the polytrauma patients eventually underwent an operative intervention, and 87% were in intensive care [140]. A large number of polytrauma patients require intensive care ventilation and invasive ventilation therapy because of traumatic brain injury and/or chest trauma, and all require adequate pain therapy. In the study mentioned above, the mean duration of ventilation for polytrauma patients was nine days [140].

To prevent damaging effects like hypoxia and hypoventilation, emergency anesthesia, intubation, and ventilation must be performed in the pre-hospital setting or at the latest in the Emergency Department when the corresponding indications are present and the provider has an appropriate level of training. A large retrospective study using the trauma registry of a Level I trauma center evaluated 6088 patients in whom endotracheal intubation had been performed within the first hour of hospital admission [156]. According to this trauma registry, an additional 26 000 trauma patients were intubated on the day of hospital admission after the first hour of hospital care. As shown in this hospital study, in the hands of experienced anesthesiologists, rapid sequence induction is an effective and safe procedure. No patients died during intubation. Of 6088 patients, 6008 were successfully intubated orotracheally (98.7%), and a further 59 nasotracheally (0.97%). Only 17 patients (0.28%) needed cricothyroidotomy and 4 patients (0.07%) underwent emergency tracheotomy. Three other patients later required emergency tracheotomy after endotracheal intubation [156]. Another retrospective study of a monocenter trauma registry studied 1000 trauma patients (9.9% of 10 137 patients) who had been endotracheally intubated within 2 hours of admission to the trauma center [153]. At < 1%, the incidence of surgical airway placement was also uncommon. Aspiration occurred in 1.1% of intubations. Early intubation was also considered safe and effective by the authors [153]. These data also confirm that endotracheal intubation of trauma patients is a safe procedure in the hands of anesthesiologists. Another retrospective study from a paramedic-supported system showed a success rate of 96.6% and a markedly higher cricothyroidotomy rate of 2.3% in 175 endotracheally intubated patients [62]. In 1.1% of cases, patients were ventilated by bag-valve-mask during transfer to hospital. There were five cases of right endobronchial intubation (2.9%) and two cases of tube displacement (1.1%). There were no documented cases of failed intubation. In pre-hospital emergency medicine, intubation success varies among various provider types and physicians of various specialties [72]. An observational study of 7259 trauma patients examining failed intubation found significant differences between anesthesiologists and non-anesthesiologists performing the procedure (11/2587, 0.4 % vs. 41/4394, 0.9 %, p = 0.02) [105]. In the pre-hospital as well as in-hospital settings, the most experienced provider must secure the airway. In-hospital, this is generally an anesthesiologist [38].

In a pre-hospital cohort study with comparable injury severity (ISS 23 versus 24) and similar duration of care (27 versus 29 min, p = 0.41), 60 patients were treated by emergency services personnel (emergency medical technician [EMT], intubation rate 3%) and 64 patients in Advanced Life Support mode by emergency physicians (intubation rate 100%). For the patients treated by emergency physicians, oxygen saturation was significantly improved upon hospital arrival (SaO2: 86% versus 96%; p = 0.04) and systolic blood pressure was significantly higher (105 versus 132 mmHg, p = 0.03). Overall mortality did not vary between the groups (42 % vs. 40 %, p = 0.76). However, sub-group analysis showed a significant survival advantage for those patients with GCS between 6 and 8 treated by an emergency physician (Mortality: 78 versus 24%, p < 0.01; OR 3.85, 95% CI: 1.84–6.38, p < 0.001). The authors concluded that mortality is reduced by a pre-hospital emergency physician system offering rapid sequence induction, sufficient oxygenation, and hemodynamic drug therapy, particularly for patients with decreased levels of consciousness [96].

One point of criticism regarding pre-hospital endotracheal intubation and the associated emergency anesthesia is a theorized loss of time. In fact, an analysis of patients with ISS ≥ 16 in the German Trauma Society database found that endotracheal intubation at the accident scene is associated with an average pre-hospital time increase of 9 ± 1 min [184]. However, this does not necessarily reflect a disadvantage regarding the entire treatment time for patients from trauma to end of Emergency Department care. Another comparative study of the German Trauma Society’s trauma registry over the years 2002-2007 performed by Kulla et al. [99] stratified the patients into three groups: Group AA (n = 963, pre-hospital intubation and chest tube placement), group AB (n = 1547; pre-hospital intubation and in-hospital chest tube placement), and group BB (n = 640; in-hospital intubation and chest tube placement). While the pre-hospital care times of all groups differed (time of trauma until hospital arrival: 80 ± 37 vs. 77 ± 44 vs. 64 ± 46 min), there was no difference in overall treatment time (time of trauma until end of Emergency Department care: 152 ± 59 vs. 151 ± 62 vs. 148 ± 68 min). This study makes clear that in cases where pre-hospital (indicated) interventions are postponed, although the time to Emergency Department arrival is decreased (while life-threatening risks persist), the saved time is lost again during the Emergency Department care phase. Thus, no overall time benefit (pre-hospital phase + Emergency Department phase) is produced. For this reason, indicated pre-hospital and potentially life-saving interventions (e.g., endotracheal intubation, chest tube placement) should also be performed in the pre-hospital phase [99].

In the German-speaking emergency physician system, pediatric and adult emergency patients are endotracheally intubated with very high success rates when the procedure is carried out by experienced and trained personnel. In a prospective study over a period of 8 years, 4% of all pediatric emergency patients (82 of 2040 children) were endotracheally intubated [60]. Pediatric calls accounted for 5.6% of all emergency calls (2040 out of 36 677 physician ambulance calls). Anesthesiologists performed 58 of the pediatric endotracheal intubations, with a success rate of 98.3%. Based on the incidence, the known number of emergency physicians employed per year, and their absolute number of ambulance calls, each emergency physician in the emergency physician service has an average gap of 3 years between pediatric intubations and 13 years between infant intubations. These results show that endotracheal intubation in childhood is rare outside of the hospital setting, and thus, special attention must be paid to maintaining expertise and appropriate training outside the emergency services and emergency physician service.

A prospective study of 16 559 patients treated in the pre-hospital setting included 2850 trauma patients of whom 259 (9.1%) were endotracheally intubated. More than two attempts were required in 3.9% of cases before endotracheal intubation was successful, and intubation failed in 3.9% of cases. A difficult airway was reported in 18.2% of cases. In comparison, a difficult airway was reported in only 16.7% of patients with cardiac arrest. In this study as well, anesthesiologists working as emergency physicians showed a success rate of 98.0% [165]. Another prospective study of 598 patients (of these, 10% trauma patients) in an emergency physician system showed a success rate of 98.5% [162]. Another prospective study reported a success rate of 100% in a collective of 342 patients [n = 235 (68.7%) trauma patients] when anesthesiologists working in the emergency services performed the intubations. In this case, the first attempt was successful in 87.4% of cases, the second attempt in 11.1% and the third attempt in 1.5% [78]. Another study of the German emergency physician system showed a prehospital endotracheal intubation success rate of 97.9% in trauma patients [2].

In a retrospective cohort study of 194 patients with traumatic brain injury, the mortality of patients treated with basic life support (BLS) by the land-based emergency services differed significantly from that of patients treated with advanced life support (ALS) by anesthesiologists in the air-supported emergency services (25 versus 21 %, p < 0.05). In this study, the survival rate of patients with TBI treated with significantly more invasive measures by the air rescue group (intubation 92 versus 36%, chest tubes 5 versus 0%) was better than that of patients treated by the land-based emergency services (54 versus 44%, p < 0.05) [15].

Procedure-Related Complications

Regarding procedure-related complications, a retrospective trauma registry database study found no higher risk of pneumonia in 271 or 357 patients intubated in the respective pre-hospital or in-hospital settings [167]. Regarding epidemiological data, patients intubated pre-hospital showed lower GCS (4 versus 8, p < 0.001) and higher injury severity scores (ISS 25 versus 22, p < 0.007), but otherwise no differences. Nevertheless, although expected, length of hospital stay for both patient collectives (15.7 versus 15.8 d), length of intensive care stay (7.6 versus 7.3 d), number of days on a ventilator (7.8 versus 7.2 d), mortality rates (31.7 versus 28.2%), and resistant bacteria rates (46% in each case) did not vary. On average, it took 3 days until the onset of pneumonia in both groups, and the pneumonia rate was also comparable in both groups [167]. Another study did report a significantly increased rate of pneumonia following pre-hospital versus in-hospital intubation [154]. However, this had no influence on the 30-day mortality rate and the number of days in intensive care. Moreover, the group of patients intubated pre-hospital had increased injury severity. In another study, frequency of pulmonary complications was related to injury severity but not to intubation mishaps [152]. A post hoc sub-group analysis of data from the Resuscitation Outcomes Consortium (ROC) Hypertonic Saline trial with 1676 patients (inclusion criteria: age > 14 years, SBP < 70 mmHg or 71-91 mmHg with HR > 107bpm or GCS < 9; survival > 24 hours) evaluated the association between intubation timeframe and rate of pneumonia [6]. The overall rate of pneumonia was 22% [6]. Compared to patients without an invasive airway, patients intubated pre-hospital had a 6.8-fold increased adjusted risk (95% CI: 2.0-23.0, p = 0.003) for developing pneumonia after the 2nd-4th hospital day (defined as the index time point for an external airway-associated pneumonia); Patients receiving an invasive airway in-hospital had a 4.8-fold increased adjusted risk (95% CI: 1.4-1.6, p = 0.01) [6]. Pre-hospital versus in-hospital airway management showed no significant difference. The authors concluded that invasive airway management itself increases the risk for pneumonia. However, a correlation between pre-hospital endotracheal intubation and the occurrence of pulmonary complications could not be reliably confirmed. Given the limited methodology of the study and the low case number, the results must be interpreted with caution.

In a retrospective study of 244 patients intubated in the prehospital phase by an emergency physician, desaturation with an SpO2 < 90% was documented in 18% of cases, and hypotension with systolic blood pressure < 90 mmHg in 13% of cases. The two complications did not occur in parallel for any of the cases [129].

Matched-pair analysis was used to evaluate the effects of endotracheal intubation performed in the pre-hospital setting, using the German Trauma Society’s trauma registry database over the years 2005 to 2008 [85]. In this analysis, moderately injured patients were selected (> 16 years, AIS < 4, GCS 13-15, no pRBC transfusion). Owing to the inclusion criteria, it appears, at least after the fact, that the authors endorsed relatively minor needs for invasive airway management. These patients were matched with comparable cases who were treated without pre-hospital endotracheal intubation. Comparison of the two homogeneous groups showed that intubated patients differ significantly from non-intubated regarding longer pre-hospital time, increased volume replacement, and worse coagulation parameters on admission to the Emergency Department. In addition, intubated patients had higher rates of sepsis (not intubated 1.5% vs. intubated 3.7%; p ≤ 0.02) and organ failure (not intubated 9.1% vs. intubated 23.4%; p ≤ 0.001). Regarding the harder treatment outcome “hospital mortality,” however, the groups did not differ (intubated 0.5 vs. non-intubated 1.0%, p = 0.32). One weakness of this study is the retrospective design based on registry data, since it remains unclear what the pre-hospital indications for intubation were. Accurate determination of true severity of injury is often difficult in the pre-hospital setting [75, 122], and it is possible that the indications for intubation in the investigated cases later proved to be unnecessary, distorting the end results of the study. In cases of doubt, it is advisable to favor pre-hospital intubation if it is indicated by the airway evaluation or the suspected pattern of injury, since there is no difference in hospital mortality. The basic prerequisite for this is that the provider is proficient with the procedure. In any case, however, like in any therapy, the potential complications and consequences must be weighed against the potential benefits. The available data speak in favor of intubation for the indications given in the key recommendations, and of critical consideration for others.

The key recommendations of the current S3 guideline on indications for pre-hospital airway protection correspond to those in the Treatment Recommendations for Pre-Hospital Emergency Anesthesia in Adults by the German Society of Anesthesiology and Intensive Care Medicine as well as of the S1 Guideline (AWMF) by the same name [19].

Pre-Oxygenation

To avoid drops in oxygen saturation during anesthetic induction and endotracheal intubation, the spontaneously breathing polytrauma patient should, if feasible, be pre-oxygenated for up to 4 minutes with 100% oxygen via a face mask with reservoir [131]. In a non-randomized controlled study of 34 intensive-care patients, the mean paO2 at the onset of pre-oxygenation was (T0) 62 ± 15 mmHg, after 4 minutes (T4) 84 ± 52 mmHg, after 6 minutes (T6) 88 ± 49 mmHg, and after 8 minutes (T8) 93 ± 55 mmHg. The differences in paO2 were significantly different between T0 and T4–8, but not individually between T4, T6 and T8. In 24% of patients, there was even a PaO2 reduction between T4 and T8. A longer period of pre-oxygenation for 4 to 8 minutes did not lead to any marked improvement in arterial oxygen partial pressure and it delays securing the airway in critical patients [119, 120]. Thus, appropriately performed pre-oxygenation for 4 minutes has particular importance in securing the airway of polytrauma patients. The recommendations listed here correspond to those in the Treatment Recommendations for Pre-Hospital Emergency Anesthesia in Adults by the German Society of Anesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin) as well as of the S1 Guideline (AWMF) by the same name [19]. Pre-oxygenation by emergency personnel begins immediately after the decision to anesthetize/intubate, while anesthetic and emergency medications as well as equipment for airway support and ventilation are being prepared. Pre-oxygenation must be performed exclusively with 100% oxygen using a face mask or a tight-fitting bag-valve-mask, each with an oxygen reservoir (at least 12-15 L O2/min) or, even more effective, through use of a demand valve or by non-invasive ventilation (NIV) when contraindications are excluded [19]. Even with maximum oxygen flow, a facemask without a reservoir is not sufficient. One approach that can facilitate pre-oxygenation (particularly in non-cooperative patients) is the use of dissociative anesthesia by administration of ketamine (similar to “delayed sequence intubation) [182].

Education and Training

Key recommendation:

1.5

Recommendation

2016

GoR A

Emergency personnel must be regularly trained in emergency anesthesia, endotracheal intubation, and alternative methods of airway protection (mask ventilation, laryngeal tube, cricothyrotomy).

Explanation:

In a recent survey of emergency physicians working in the emergency physician service, questions were posed regarding knowledge of and experience in endotracheal intubation and alternative methods for securing an airway [163]. This survey received responses from 340 anesthesiologists (56.1%) and 266 non-anesthesiologists. It found that all anesthesia-trained emergency physicians had performed more than 100 in-hospital endotracheal intubations compared to only 35% of non-anesthesiologists. A similar picture emerged for alternative methods of securing an airway. 97.8% of anesthesiologists-as-emergency physicians had used alternative methods of securing an airway on more than 20 occasions, while only 11.1% of non-anesthesiologist emergency physicians had equivalent experience (p < 0.05). In addition, it came out that only 27% of emergency equipment included CO2 monitoring (capnography). From this study, it can be concluded that there is an urgent need for training of non-anesthesiologist emergency physicians in endotracheal intubation, capnography, and alternative airway methods [131].

Studies on first-year anesthesiology residents have reported that more than 60 intubations are necessary to achieve a success rate of 90% within the first two attempts under standardized, optimum conditions in the operating room [98]. Another proficiency study of 20 non-anesthesiologist physicians performing endotracheal intubation on 438 patients for elective anesthesia found an increasing success rate and better vocal cord visualization up to the 35th intubation. An 80% success rate was observed after the 35th intubation, and 90% after the 47th [123]. The largest prospective monocenter study to date on the development of intubation proficiency of first year anesthesia residents (n = 21) showed progressive intubation success rates from the 25th to the 200th intubation for first pass intubation success (FPS: 67 vs. 83%, p = 0.0001) and overall intubation success (OPS: 82 vs. 92%, p = 0.0001) [20]. With an increasing number of performed intubations, the attempts required for success decreased (1.6 ± 0.8 vs. 1.3 ± 0.5, p = 0.0001). The investigation found that a trainee needs a range of approximately 100-150 intubation procedures performed to reach an overall success rate (OPS) of 95% [20]. There are no published studies to date reporting on the development of proficiency for endotracheal intubation under pre-hospital, Emergency Department, polytrauma, or severely injured in emergency situations. In clinical practice, only the most experienced providers perform airway support during these situations, and thus, the availability of such studies with inexperienced trainees can hardly be expected in the future. The evidence regarding proficiency during endotracheal intubation in well-observed and safe elective situations led to the key recommendation by the German Society of Anesthesia and Intensive Care Medicine that endotracheal intubation should only be carried out by providers who have performed at least 100 endotracheal intubations overall and perform 10 intubations per year [164]. Regarding proficiency of securing the airway with alternative methods, a prospective monocenter study of first year residents (n = 10) and 394 patients compared placement success rates for the ProSeal laryngeal mask for the first five insertions and the 40th insertion. The first pass success increased from 72 to 86% (p = 0.09) and overall success from 74 to 96% (p = 0.001) [113]. The evidence regarding proficiency during alternative airway management in well-observed and safe elective situations led to the key recommendation by the German Society of Anesthesia and Intensive Care Medicine that alternative airway placement should only be carried out as a primary procedure when the indications for endotracheal intubation listed above are not met or as a supraglottic alternative for a difficult airway, and by providers who have performed at least ten alternative airway placements overall and perform three alternative airway placements per year [164]. However, since the success of alternative methods for securing an airway (e.g., supraglottic airways: laryngeal mask, laryngeal tube) are only as good as the corresponding level of training for the procedure, and current evidence indicates that the appropriate level of training is not available everywhere [163], endotracheal intubation continues to be the gold standard. These findings also illustrate that emergency medical personnel must be regularly trained in endotracheal intubation as well as alternative airway management [131]. This is particularly important because the experience level of the person securing the airway is negatively correlated with patient mortality. A systematic review study and meta-analysis showed higher mortality rates for patients with TBI intubated by less experienced providers in the pre-hospital setting (OR 2.33; 95 %-CI: 1.61-3.38, p < 0.001). In cases where experienced providers performed pre-hospital intubation, there was no increased mortality (OR 0.75, 95% CI: 0.52-1.08, p = 0.126). Meta-regression identified experience in airway management as a significant predictor for mortality of these patients (p = 0.009) [25]. Regarding emergency crichothyrotomy, a retrospective cohort study for the years of 2007 to 2013 found that of 493 airway protection procedures performed by “ambulance nurses,” a helicopter emergency physician detected and corrected failed intubation and hypoxia in 42% (8.5%) of cases [134]. For a further 1406 endotracheal intubations, there was a success rate of 98.4%. Seven patients were ventilated with bag-valve-mask ventilation (n = 2) and alternative airway support (n = 2); in 30 cases, surgical airway procedures (emergency crichothyrotomy n = 28 and tracheotomy n = 2) were performed; in three cases airway management was abandoned for non-survivable injuries. This data shows that a surgical airway is rarely necessary, but to perform it, the appropriate training is necessary and this measure can be life-saving [134].

In the literature, there are numerous references to standard operation procedures (SOPs) and checklists for anesthetic induction and airway management [114, 149]. The Treatment Recommendations of the German Society of Anesthesiology and Intensive Care Medicine offer a national proposal for a structured approach to emergency anesthesia [19].

Alternative Methods of Airway Management

Key Recommendations:

1.6

Recommendation

2016

GoR A

A difficult airway must be anticipated when performing endotracheal intubation of the trauma patient.

1.7

Recommendation

2016

GoR A

During anesthesia induction and endotracheal intubation of the polytrauma patient, alternative methods to secure the airway must be available.

1.8

Recommendation

Modified 2016

GoR A

Fiberoptic equipment must be available for anesthesia induction and endotracheal intubation performed in-hospital.

1.9

Recommendation

Modified 2016

GoR A

Alternative methods of ventilation and/or securing the airway must be considered after more than 2 attempts at intubation.

Explanation:

Because of the environmental factors, endotracheal intubation of emergency patients in the pre-hospital setting is significantly more difficult than in-hospital. Thus, a difficult airway must always be anticipated when endotracheally intubating a trauma patient [131]. In a large study of 6088 trauma patients, risk factors and impediments to endotracheal intubation were foreign bodies in the pharynx or larynx, direct injuries to the head or neck with loss of normal upper airway anatomy, airway edema, pharyngeal tumors, laryngospasm, and difficult pre-existing anatomy [156]. In another study, a difficult airway was present more frequently in trauma patients (18.2%) than e.g., patients with cardiac arrest (16.7%) and particularly patients with other diseases (9.8%). Reasons given for difficult airway management were patient position (48.8% of cases), difficult laryngoscopy (42.7% of cases), secretions or aspiration in the oropharynx (15.9% of cases), and traumatic injuries (including bleeding/burns) in 13.4% of cases [165]. Technical problems occurred in 4.3% and other causes in 7.3% of cases. Further studies show similar statistics for difficult intubation (blood 19.9%, vomit 15.8%, hypersalivation 13.8%, anatomy 11.7%, trauma-induced anatomical changes 4.4%, patient position 9.4%, lighting conditions 9.1%, technical problems 2.9%) [78]. In a prospective study of 598 patients, adverse events and complications occurred significantly more often in patients with severe injuries than non-traumatized patients (p = 0.001) [162]. At least one event was documented in 31.1% of traumatized patients. The number of attempts required for intubation was also significantly increased in trauma patients (p = 0.007) [162]. Patients with severe maxillofacial trauma in particular show increased risk for difficult intubation (OR 1.9, 95% CI: 1.0–3.9, p = 0.05) [41]. In fact, maxillofacial trauma represents an independent risk factor for difficult airway management (OR 2.1, 95% CI: 1.1–4.4, p = 0.038). A retrospective analysis of a trauma registry over seven years identified 90 patients with severe maxillofacial injuries. Of these, 93% initially received definitive airway protection, by means of endotracheal tube in 80% of cases and through a surgical airway in 15% [39]. Based on this data, the presence of blood, vomit or other fluids in the oropharynx is to be expected, and with it, a difficult intubation. The patient should also be assumed to be non-fasting. A high-performance suction unit must therefore be available as a matter of course. Because of structural and procedural considerations of the pre-hospital setting, back-up with an experienced anesthesiologist often isn’t possible. In-hospital, however, the standard is for an anesthesiologist to participate in the anesthesia and intubation of patients expected to be difficult. A prospective cohort study found that the presence of an attending anesthesiologist at in-hospital emergency intubations resulted in significantly fewer complications (6.1 versus 21.7%, p < 0.0001) [147]. However, there was no difference in the number of ventilator-free days or the 30-day mortality rate.

If endotracheal airway protection fails, oxygenation must be ensured using an appropriate algorithm to revert to bag-valve-mask ventilation and/or alternative methods of airway management [5, 27, 79, 130, 131]. Treatment Recommendations for Pre-hospital Airway Management by the German Society of Anesthesiology and Intensive Care Medicine and the Treatment Recommendations for Pre-Hospital Emergency Anesthesia in Adults suggest readiness and implementation of alternative methods for airway protection [19] [164]. In a prospective study, intubation success was evaluated in 598 patients in an emergency physician system staffed solely by anesthesiologists. Endotracheal intubation was successful at the first attempt in 85.4% of all patients, and the second attempt in 10.4%. Only 2.7% required more than two attempts; in 1.5% (n = 9), alternative methods such as the supralaryngeal combitube (n = 7), laryngeal mask (n = 1) or an emergency cricothyroidotomy (n = 1) were used after the third unsuccessful intubation attempt [162]. The study illustrates that alternative airway protection methods must be provided even in highly professional systems [94].

The success of endotracheal intubation on the first pass (FPS) has relevant effects on patient morbidity [18]. When multiple intubation attempts are necessary, the complication risk increases markedly (multiple attempts at intubation, MAI > 1: 4-fold complication rate, MAI > 2: 4.5 - 7.5-fold complication rate). The success of the first intubation attempt and the occurrence of multiple attempts depends on the experience of the provider [18]. In a retrospective study of 2833 patients intubated in-hospital at a Level I trauma center, the risk of airway-associated complications was markedly increased with more than 2 intubation attempts: hypoxemia 11.8 vs. 70%, regurgitation 1.9 vs. 22%, aspiration 0.8 vs. 13%, bradycardia 1.6 vs. 21%, cardiac arrest 0.7 vs. 11% [117]. Another prospective, multicenter study examined the number of intubation attempts (through the oropharynx) necessary for successful endotracheal intubation in emergency patients over an 18-month period [176]. Endotracheal intubation was carried out by paramedics in 94% of cases and by nurses or emergency physicians in the remaining 6%. Overall, 1941 intubations were carried out, of which 1272 (65.5%) occurred in patients with cardiac arrest, 463 (23.9%) were performed without drug administration in patients without cardiac arrest, 126 (6.5%) occurred under sedation in patients without cardiac arrest, and 80 (4.1%) took place by rapid sequence induction using a hypnotic agent and a muscle relaxant. Over 30% of patients required more than one attempt to achieve successful endotracheal intubation. More than 6 intubation attempts were not reported in any case. The cumulative success rates during the first, second and third intubation attempts were 70%, 85% and 90% in patients in cardiac arrest. This was markedly higher than in the other 3 patient subgroups with intact circulatory function (intubation without drugs: 58%, 69% and 73%; intubation under sedation: 44%, 63% and 75%; intubation with rapid sequence induction: 56%, 81% and 91%). The specific success rates were not further differentiated according to provider type (paramedics, nurses and emergency physicians). The results of this study [176] show that the cumulative success rate of endotracheal intubation in a paramedic system is markedly below that of emergency physician systems staffed solely by anesthesiologists, with rates of 97-100% [78, 162, 165]. In addition, the use of medications, e.g. those used in rapid sequence induction (including muscle relaxants), helps facilitate intubation in patients without cardiac arrest and thus leads to a markedly higher success rates. Both are often crucial to survival during an emergency situation. According to the above-cited study and other study results [18, 55, 73, 74, 95, 109, 117, 138], alternative methods must be considered to secure an airway after two unsuccessful intubation attempts [5, 117]. In particular, it must be considered that the intubation success rate after the second attempt by inexperienced providers is < 1% in elective anesthesia [20]. Thus, the current key recommendation of this S3 Guideline corresponds to the S1 Guideline Airway Management by the German Society of Anesthesiology and Intensive Care Medicine, which states that intubation attempts with direct laryngoscopy should be limited to a maximum of two [135]. Although fiberoptic procedures are infrequently available in the prehospital setting, fiberoptic intubation must be available as part of hospital anesthesia equipment according to the specifications of the S1 “Airway Management” Guideline of the German Society of Anesthesiology and Intensive Care Medicine [135]. With appropriate experience and conditions, fiberoptic (conscious) intubation, preserving spontaneous respiration, is considered an alternative for emergency airway management by all common guidelines and recommendations [57, 76, 79, 101].

In contrast, emergency cricothyroidotomy is simply the last resort in a “cannot ventilate - cannot intubate” situation to secure emergency ventilation and oxygenation. In national and international recommendations and guidelines, emergency cricothyroidotomy has a firm place in the prehospital and hospital settings and is indicated if alternative methods for securing an airway and bag-valve-mask ventilation are not successful [14, 76, 79, 125].

Monitoring Emergency Anesthesia

Key recommendation:

1.10

Recommendation

2016

GoR A

ECG, blood pressure, pulse oximetry, and capnography must be monitored during anesthesia induction, endotracheal intubation, and emergency anesthesia.

Explanation:

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) specifies certain requirements for a “standard workplace” in its update to the guideline on equipping anesthesia work areas [49, 135]. Special attention must be paid to the often difficult environment (e.g., confined space, unfavorable lighting, limited resources) in the pre-hospital emergency setting and particularly in trauma care. The complication rate in emergency anesthesia induction, airway insertion, and ventilation is not to be underestimated and according to results of prospective observational studies and prospective multicenter registry studies is something between 11-13% [32, 127, 139]. Obesity, poor vocal cord visualization (Cormack/Lehane III/IV), and difficult intubation situations are particularly associated with complications in pre-hospital airway management [32].

According to the S1 guideline and Treatment Recommendations for Pre-hospital Emergency Anesthesia in Adults of the German Society of Anesthesiology and Intensive Care Medicine, the following equipment should be available for the procedure and monitoring of emergency anesthesia in the pre-hospital setting [19, 131]: electrocardiogram (ECG), non-invasive blood pressure monitoring, pulse oximetry, capnography/capnometry, defibrillator, emergency respirator and suction unit. Appropriate equipment must be provided based on the guideline “Airway Management” of the German Society of Anesthesiology and Intensive Care Medicine [27] as well as the German DIN standards for emergency physician vehicles (NEF) [52], rescue helicopter (RTH) [50] and ambulance (RTW) [51].

In-hospital, the directives of the DGAI must be followed in the emergency room and in the other hospital wards [49, 135].

Emergency Ventilation and Capnography

Key Recommendations:

1.11

Recommendation

Modified 2016

GoR A

Capnometry/capnography must be used pre-hospital and in-hospital during endotracheal intubation to control tube placement and afterwards, to monitor displacement and/or ventilation.

1.12

Recommendation

2016

GoR A

Normoventilation must be carried out for endotracheally intubated and anesthetized trauma patients.

1.13

Recommendation

2016

GoR A

Beginning in the Emergency Department, ventilation must be monitored and controlled with frequent arterial blood gas analyses.

Explanation:

In the pre-hospital and in-hospital phases, capnometry/capnography must always be used during endotracheal intubation for monitoring tube placement and afterwards to reduce displacement and monitor ventilation. Capnography is an essential component here in monitoring the intubated and ventilated patient [131]. Normoventilation must be carried out for endotracheally intubated and anesthetized trauma patients. Beginning in the Emergency Department, ventilation must be monitored and controlled with frequent arterial blood gas analyses.

Capnography as Monitor of Tube Position/Displacement

The most serious complication of endotracheal intubation is an unrecognized esophageal intubation, which can lead to patient death. For this reason, every alternative must be used, in both pre-hospital and hospital settings, to recognize esophageal intubation and remedy it immediately.

The range of esophageal intubation rates reported in the literature begins at less than 1% [175, 181] goes through 2% [65] and 6% [133], and reaches almost 17% [92]. In addition, high mortality was shown as a result of tube misplacement in the hypopharynx (33%) or in the esophagus (56%) [92]. Thus, esophageal intubation is not such a rare event. Especially recently, various studies have examined this catastrophic complication of endotracheal intubation also in Germany. In a prospective observational study, helicopter anesthesiologists-as-emergency physicians identified esophageal tube placement in 6 (7.1%) and endobronchial tube placement in 11 (13.1%) of 84 trauma patients intubated by land-based emergency physicians before helicopter arrival [166]. In this study, the mortality rate for esophageally intubated patients was 80%. Another prospective study of 598 patients within the German emergency physician system found a rate of esophageal intubations by non-medical personnel or non-emergency physicians before arrival of the emergency physician system of 3.2% [162]. One more prospective observational study reported esophageal intubation in 5.1% of 58 patients intubated by the land-based emergency service or emergency physician before arrival of the helicopter emergency physician (anesthesiologist) [68]. In another study, the admitting trauma team in the Emergency Department identified esophageal intubation in 4 out of 375 (1.1%) patients intubated and ventilated in the pre-hospital setting [66].

A prospective observational study of 153 patients found no misplaced intubation in patients monitored with capnography, but in 14 of 60 unmonitored (with capnography) patients (23.3%) [151]. Capnography thus belongs in the standard anesthesia equipment and has dramatically increased anesthesia safety.

In a prospective observational study of 81 patients (n = 58 with severe TBI, n = 6 with maxillofacial trauma, n = 17 with multiple injuries), markedly greater sensitivity and specificity were demonstrated by monitoring tube placement with capnography versus auscultation alone (sensitivity: 100 vs. 94%; specificity: 100 vs. 66%, p < 0.01) [69]. These data confirm that capnography must always be used to monitor tube placement.

A survey reported that in Baden-Wurttemberg, only 66% of 116 emergency physician sites had capnography available in 2005 [67]. There is an urgent need for optimization. In addition, it is unknown how often capnography is actually used when available during pre-hospital endotracheal intubation, for verification of tube position, and monitoring of ventilation. The goal must be to reach a capnography rate of 100% in the prehospital and in-hospital phases of care. Based on the “Airway Management” guideline of the German Society of Anesthesiology and Intensive Care Medicine and the German DIN standards for emergency physician vehicles (NEF) [52], rescue helicopters (RTH) [50] and ambulances (RTW) [51], capnography equipment is mandatory, and the lack of appropriate equipment already constitutes organizational negligence [67].

Capnography for Normoventilation

Emergency anesthesia is used not only to maintain adequate oxygenation but also effective ventilation and thus, the elimination of carbon dioxide (CO2), which accumulates in human metabolism. Both CO2 accumulation (hypercapnia and hypoventilation) and hyperventilation with consecutive hypocapnia can cause damage, particularly in patients with traumatic brain injury, and must be avoided in the first 24 hours [26, 31]. This results in a vicious circle of elevated intracranial pressure, hypercapnia, hypoxemia, additional cellular swelling/edema and subsequent further increases in intracranial pressure.

In a retrospective analysis of pre-hospital care data from 100 patients intubated and ventilated in the pre-hospital setting, an etCO2 > 30 mmHg was measured in 65 patients and etCO2 ≤ 29 mmHg in 35 patients. There was a trend towards a lower mortality in normoventilated patients (mortality rate: 29 versus 46%; OR 0.49, 95% CI: 0.1–1.1, p = 0.10) [33]. A prospective observational study of 74 trauma patients reported that abnormal etCO2 values compared to normal etCO2 vales on hospital admission resulted in markedly increased mortality (RR 6.2; 95% CI: 1.5-26.5, p = 0.004) [82]. For patients with TBI, this study found an even higher mortality risk when normoventilation was lacking on hospital admission (RR 7.4; 95% CI: 1.0-54.5, p = 0.02) [82]. The S1 Guideline and Treatment Recommendations for Pre-hospital Emergency Anesthesia in Adults by the German Society of Anesthesiology and Intensive Care Medicine also suggests normoventilation as well as the use of capnography to monitor tube position and, indirectly, hemodynamics [19].

In a prospective observational study, only 155 of 492 patients intubated and ventilated in the pre-hospital setting showed normoventilation according to paCO2 levels of 30 to 35 mmHg on the initial arterial blood gas analysis (BGA) in the emergency department [177]. Eighty patients (16.3%) were hypocapnic (paCO2 < 30 mmHg), 188 patients (38.2%) were mildly hypercapnic (paCO2 36–45 mmHg), and 69 patients (14.0 %) were severely hypercapnic (paCO2 > 45 mmHg). The injury severity of the severely hypercapnic patients (paCO2 > 45 mmHg) was markedly increased, and these patients also had hypoxia, acidosis, or hypotension significantly more often than the other 3 groups. The mortality of trauma patients intubated/ventilated in the pre-hospital setting, both with and without TBI, was specifically lowered by normoventilation (OR: 0.57, 95% CI: 0.33–0.99). Patients with isolated TBI benefitted the most from normoventilation (OR: 0.31, 95% CI: 0.31–0.96). According to the available results, hyperventilation with consequent hypocapnia (paCO2 < 30 mmHg) appears to be particularly harmful in severely injured patients. These results make clear that beginning in the Emergency Department, ventilation must be monitored and controlled with frequent arterial blood gas analyses.

In a prospective study of 97 patients, patients monitored with capnography had significantly higher rates of normoventilation (63.2 versus 20%, p < 0.0001) and significantly less hypoventilation (5.3 versus 37.5%, p < 0.0001) compared to patients ventilated without capnography, using the 10:10 rule [77]. Thus, capnography is an orientation procedure for emergency ventilation. Nevertheless, when capnography is used as ventilation monitoring, it must be remembered that the correlation between etCO2 and paCO2 is weak (r = 0.277) [179]. A prospective observational study of 180 patients found that 80% of patients with etCO2 of 35–40 mmHg were actually hypoventilated (paCO2 > 40 mmHg). A prospective study of 66 intubated and ventilated trauma patients reported that patients with high ISS, hypotension, severe chest injury, and metabolic acidosis in particular showed larger differences in etCO2 and paCO2 [103]. The arterial CO2 (paCO2) therefore cannot always be directly inferred from the end-tidal CO2 (etCO2) obtained by capnography [131].

Capnography serves primarily to evaluate tube placement and to monitor on-going ventilation, with monitoring of ventilation parameters a secondary use. This was also briefly demonstrated in a retrospective cohort study of 547 trauma patients. All trauma patients, and particularly patients with severe TBI, gained from paCO2-controlled ventilation (OR: 0.33, 95% CI: 0.16–0.75). There was a significant survival advantage if paCO2 was already between 30 and 39 mmHg on admission to the emergency department (OR 0.32, 95% CI: 0.14–0.75). In patients whose paCO2 was brought into the target range first in the emergency department, there was a non-significant trend towards lower mortality (OR 0.48, 95% CI: 0.21–1.09). A markedly worse survival rate was evident in trauma patients with initial paCO2 of 30–39 mmHg but were then hypoventilated (paCO2> 39 mmHg), hyperventilated (paCO2 < 30 mmHg), or never attained the target paCO2 of 30–39 mmHg in the emergency department. This study also shows that paCO2 may not be freely inferred from etCO2 [178].

Using capnography to check tube placement and to detect tube displacement is advisable and indispensable. Beginning in the Emergency Department, ventilation should be regulated as soon as possible according to blood gas analyses.

Lung Protective Ventilation

A prospective randomized study reported that ventilation with small tidal volumes (6 ml/kg BW) in patients with acute respiratory distress syndrome (ARDS) led to significantly reduced mortality and lower incidence of barotrauma, and it improved oxygenation compared to ventilation with high tidal volumes [3]. The multi-center randomized, controlled trial conducted by the ARDS network confirmed these results ventilating with low tidal volumes and limiting plateau pressure to ≤ 30 cm H2O in patients with ARDS [128]. Chest injuries are observed in approximately 60% of polytrauma patients, with corresponding repercussions (e.g., pulmonary contusions, ARDS), and the development of mild ARDS is an independent associated factor for mortality (trauma patient mortality with mild ARDS [n = 93]: 23.7 versus without mild ARDS [n = 190]: 8.4%, p < 0.01) [148]. Thus, lung protective ventilation with tidal volume of 6 ml/kg BW and with lowest possible peak pressures must be implemented as soon as possible after endotracheal intubation [71].

Emergency Anesthesia

Key Recommendations:

1.14

Recommendation

2016

GoR A

Emergency anesthesia for endotracheal intubation must be performed with rapid sequence induction due to the general non-fasting state and aspiration risk of polytrauma patients.

1.15

Recommendation

Modified 2016

GoR B

Etomidate should be avoided as an induction agent because of the associated adrenal effects. Ketamine is generally a good alternative.

Explanation:

Emergency anesthesia is a frequently unavoidable component of proper polytrauma patient care. Anesthesia induction must be carried out in a structured way; if carried out improperly, it is associated with increased risks of morbidity and mortality [131]. In a retrospective study, compared to non-emergency intubation (n = 2136), emergency intubation (n = 241) was linked to markedly higher risks of: severe hypoxemia (SpO2 < 70%: 25 vs. 4.4%, p < 0.001), regurgitation (25 vs. 2.4%, p < 0.001), aspiration (12.8 vs. 0.8%), bradycardia (21.3 vs. 1.5%, p < 0.001), arrhythmia (23.4 vs. 4.1%, p < 0.001) and cardiac arrest (10.2 vs. 0.7%, p < 0.001) [118].

In trauma patients, rapid sequence induction (RSI) (ileus or crash induction) is performed to secure the airway in the shortest possible time with the least aspiration risk. One prospective study evaluated the number of intubation attempts (laryngoscope through the oral cavity) necessary for successful endotracheal intubation in 1941 emergency patients over an 18-month period. The cumulative intubation success over the first three attempts in patients with intact circulatory function differed greatly among patients receiving no medications (58%, 69% and 73%), patients receiving sedation alone (44%, 63% and 75%), and patients undergoing rapid sequence induction (56%, 81% and 91%) [176]. Analysis of the Resuscitation Outcome Consortium Epistry - Trauma Registry found that endotracheal intubation without muscle relaxation was associated with a higher mortality in patients with GCS < 9 (OR 2.78; 95% CI: 2.03–3.80, p < 0.01) [46]. Other studies have also reported higher rates of failed intubation when conditions are not optimized with muscle relaxation during anesthetic induction [58, 106]. Medication-induced anesthesia like rapid sequence induction is thus crucial to the success of endotracheal intubation.

Depending on the hemodynamic state of the patient, the injury pattern, and the personal experience of the physician, various hypnotic agents can be used for induction (e.g., etomidate, ketamine, midazolam, propofol, thiopental). Each of these drugs has its own pharmacologic profile and associated side effects (e.g., etomidate: superficial anesthesia, adrenal function effects; ketamine: arterial hypertension; midazolam: slower onset of effect, superficial anesthesia; propofol: arterial hypotension; thiopental: histamine release and asthma trigger, necrosis due to extravasation). Ketamine in particular can be used, also in combination with midazolam or low-dose propofol, for rapid sequence induction in patients with marked hemodynamic instability, including patients with TBI [40, 89, 116, 131]. As analgesia, fentanyl or sufentanil are suitable for hemodynamically stable, and ketamine for unstable patients [89, 116, 131]. The recommendations listed in the current S3 guideline correspond to those in the S1 guideline and Treatment Recommendations for Pre-Hospital Emergency Anesthesia in Adults by the German Society of Anesthesiology and Intensive Care Medicine [19].

Etomidate

Etomidate will be considered here in detail, because important side effects have been recently discussed [168, 170]. A retrospective analysis of a trauma registry database found potentially negative effects from using etomidate in severe trauma [180]. Etomidate was given to 35 of 94 trauma patients (37%) during rapid sequence induction. Patients treated with and without etomidate did not differ according to demographic data (age: 36 vs. 41 years), cause of trauma, and injury severity (ISS: 26 vs. 22). After adjustment of the data (according to physiology, injury severity, and transfusion), etomidate was linked to increased risks of ARDS and multiple organ failure (adjusted OR: 3.9, 95% CI: 1.24–12.0). Trauma patients anesthetized with a single dose of etomidate also had longer hospital stays (19 versus 22 d, p < 0.02), more ventilation days (11 versus 14 d, p < 0.04) and longer intensive care stays (13 versus 16 d, p < 0.02).

Another retrospective study of a US trauma registry examined the results of the cosyntropin stimulation test (CST) on 137 trauma patients in intensive care units [42]. 61% of the trauma patients were non-responders. Responders and non-responders did not differ according to age (51 ± 19 vs. 50 ± 19 years), sex (male: 38 vs. 57%), or mechanism and severity of injury (ISS: 27 ± 10 vs. 31 ± 12, Revised Trauma Score: 6.5 ± 1.5 vs. 5.2 ± 1.8). In addition, there was no difference in the rates of sepsis/septic shock (20 vs. 34%, p = 0.12), need for mechanical ventilation (98 vs. 94%, p = 0.38) and mortality (10 vs. 19%, p = 0.67). However, responders differed significantly from non-responders regarding the incidence of hemorrhagic shock (30 vs. 54%, p < 0,005), need for vasopressors (52 vs. 78%, p < 0.002), incidence of coagulopathies (13 vs. 41%, p < 0.001), days in intensive care (13 ± 12 vs. 19 ± 14, p < 0.007), days of mechanical ventilation (12 ± 13 vs. 17 ± 17, p < 0.006), and the use of etomidate as an induction hypnotic (52 vs. 71%, p < 0.03). The authors concluded that etomidate administration is one of the few modifiable risk factors for the development of adrenocortical insufficiency in critically ill trauma patients.

In another prospective, randomized study, trauma patients received either etomidate and succinylcholine or fentanyl, midazolam and succinylcholine for rapid sequence induction after arriving in a Level I trauma center [80]. The baseline serum cortisol concentration was recorded before anesthetic induction and an ACTH (adrenocorticotropic hormone) test carried out. Altogether, 30 patients were examined. Patients receiving etomidate (n = 18) were comparable to those receiving fentanyl/midazolam (n = 12) regarding the following patient characteristics: age (42 ± 25 vs. 44 ± 20 years, p = 0.802); ISS (27 ± 10 vs. 20 ± 11 years, p = 0.105); baseline serum cortisol concentration (31 ± 12 vs. 27 ± 10 µg/dl, p = 0.321). The etomidate patients showed a smaller rise in serum cortisol concentration after the ACTH test than the fentanyl/midazolam patients (4.2 ± 4.9 µg/dl versus 11.2 ± 6.1 µg/dl, p < 0.001). The etomidate patients spent more days in intensive care (8 versus 3 d, p = 0.011), more days on mechanical ventilation (6.3 versus 1.5 d, p = 0.007) and more days in hospital (14 versus 6 d, p = 0.007). Two trauma patients died, and both had been treated with etomidate. The authors concluded that other induction hypnotics should be used rather than etomidate for trauma patients.

One prospective cohort study evaluated patients treated by physicians of an air-rescue system with either (Group 1) etomidate (0.3 mg/kg bodyweight) + succinyl choline (1.5 mg/kg bodyweight) or (Group 2) with fentanyl (3 µg/kg bodyweight) + ketamine (2 mg/kg bodyweight) + rocuronium (1 mg/kg bodyweight). A third group (Group 3) received a reduced dose ratio (1:1:1). Overall, compared to group 1, group 2 achieved better vocal cord visualization (Cormack/Lehane) and better post-procedure vital parameters. The authors reported a comparable mortality rate, each 19%, for etomidate/succinyl choline vs. fentanyl/ketamine/rocuronium [107]. This study also documents the expendability of etomidate under good intubation conditions and stable hemodynamic parameters.

Overall, analysis of the currently available data in a large survey, considering a large number of studies [1, 8, 9, 13, 34, 35, 44, 54, 59, 81, 87, 91, 97, 110, 115, 132, 137, 161], etomidate should only be used for emergency anesthesia and rapid sequence induction if no alternative medication is available or the provider has insufficient experience with these alternatives [168]. At the current time, the body of evidence is not ready for final assessment. In conclusion, the above-mentioned survey formulates its conclusion that etomidate should be limited to use in well-planned, randomized, controlled studies [168].

Endotracheal Intubation with Suspected Cervical Spine Injury

Key recommendation:

1.16

Recommendation

2016

GoR B

For endotracheal intubation, manual in-line stabilization should be performed with temporary removal of the cervical spine immobilizer.

Explanation:

Normally, trauma patients, particularly polytrauma patients, are immobilized with a neck collar until cervical spine fracture can be excluded with imaging. However, a correctly positioned c-spine immobilization device restricts the mouth opening and thus, the ability to insert a laryngoscope during an intubation maneuver. The c-spine immobilizer prevents reclination of the head. Thus, a prospective multi-center study reported cervical spine immobilization as a cause of a difficult endotracheal intubation [100]. For this reason, c-spine immobilizers are replaced by manual in-line stabilization (MILS) during endotracheal intubation. In such a case, the c-spine is immobilized by an assistant using both hands to manually immobilize the c-spine. The consequent direct laryngoscopy under MILS was the standard of care in emergency situations for many years. However, MILS is not without controversy, and some negative effects have been reported [108, 145]. As an alternative to direct laryngoscopy, fiberoptic intubation by an experienced provider is the gold standard of care for conscious and spontaneously breathing, hemodynamically stable patients in-hospital [24, 131]. Current data show that video laryngoscopy allows good laryngeal visualization when the c-spine immobilizer is in place, so that it can be used here as an alternative procedure [29, 83, 84, 160].

Video Laryngoscopy

Key Recommendations:

1.17

Recommendation

New 2016

GoR B

Video laryngoscopy should be liberally considered pre-hospital and in-hospital given the better adjustability of vocal cord level and optimal chance of primary intubation success.

1.18

Recommendation

New 2016

GPP

Video laryngoscopy must be on hand pre-hospital and in-hospital and used as primary and reserve procedure.

Explanation:

There is increasing evidence for the use of video laryngoscopy during in-hospital airway management. Several recently-published studies have shown that first pass intubation success (FPS) can be significantly improved with the primary and increasing use of video laryngoscopy (VL) [28]. During endotracheal intubation of 619 patients in an emergency department, the FPS with VL was twice as high as with conventional direct laryngoscopy (DL) (85.0 vs. 81.5 %; 95% CI: 1.1-3.6) [171]. Multivariate regression analysis showed an advantage for FPS using VL vs. DL (OR 1.96; 95% CI: 1.10–3.49, p = 0.23). With very experienced providers, VL-assisted intubation increased FPS more than 2.5-fold compared to DL (OR 2.7; 95% CI: 1.03–7.09, p = 0.043). Another study of 3rd year emergency medicine residents in the U.S. found that EPS improved to 90% using VL vs. 73% for DL [144]. Similar results were found in a cohort study with 313 patients each in VL and DL groups, with comparable intubation conditions in the operating room area (94 vs. 81 %) [86]. A randomized, controlled trial (RCT) of in-hospital anesthesia induction reported increased FPS with VL vs. DL (93 vs. 84%, p = 0.026), with concomitant better cord visualization (Cormack/Lehane, C/L I/II: 93 vs. 81%, p < 0.01) [11]. Intubation success depends on cord visualization. With VL, positive effects are seen because there is better visualization. Although intubation time is somewhat longer in VL vs. DL (46 vs. 33 seconds, p < 0.001), the complication rate of the two procedures was comparable (20 vs. 13%, p = 0.146) [11]. In another prospective monocenter observational study on intubation in trauma patients in the Emergency Department found marked improvement of FPS (76 vs. 71%, p = 0.17, OR 0.55; 95% CI: 0.35-0.87, p = 0.01) and overall success rate (88 vs. 83 %, p = 0.05) in VL vs. DL. In this study, the injury severity was higher in the VL group (ISS: 2.4 vs. 20.5, p = 0.01) [111]. A randomized controlled trial of 623 patients in the Emergency Department with indications to intubate according to the EAST trauma guideline (airway obstruction, hypoventilation, severe hypoxemia, GCS < 9, and hemorrhagic shock, supplemented with altered level of consciousness, uncooperativeness, severe pain), which induced anesthesia of stable patients with thiopental (4 mg/kg bodyweight) and succinyl choline (1.5 mg/kg bodyweight) and of hemodynamically unstable patients with reduced doses of thiopental or etomidate (0.2-0.4 mg/kg bodyweight), found a minimal, non-relevant longer intubation time for VL vs. DL (71 vs. 56.5 seconds, p = 0.002). In this study, FPS (80 vs. 81%, p = 0.46) and mortality (9.2 vs. 7.5%, p = 0.43) were comparable for VL and DL [185]. In a prospective observational study in an Emergency Department with 2677 patients (of these, 1173 trauma patients), VL significantly reduced the frequency of short-term esophageal intubation vs. DL (1.0 vs. 5.1%, p < 0.001) [142]. There were significantly more complications after short-term, recognized esophageal intubation compared to patients intubated correctly from the beginning (aspiration: 8.6 vs. 1.4%, arrhythmia: 3.2 vs. 0.5%, hypotension: 2.2 vs. 0.7%, hypoxemia: 35.5 vs. 16.8%). Another study by Sakles et al. [143] found that for 255 patients intubated with VL versus 495 with DL, there were marked advantages for VL regarding FPS (OR 2.2; 95% CI: 1.2–3.8) and the overall success rate (OR 12.7; 95% CI: 4.1–38.8). A prospective observational study in an intensive care unit with 290 patients found for VL versus DL higher FPS (78.6 vs. 60.7%, p = 0.009), higher overall success rate of endotracheal intubation (98.3 vs. 91.2 %, p = 0.04), and higher success rate in patients with a difficult airway (76.3 vs. 57.7 %, p = 0.04) [121]. In this study, VL also showed better cord visualization (CL1: 85.8 vs. 61.8%, p < 0.001). A randomized controlled study (RCT) in an intensive care unit found higher FPS for VL (75 vs. 40%, p < 0.01) and a decreased rate of > 2 intubation attempts (9 vs. 27%, p = 0.02) as well as decreased time for the intubation procedure (120 vs. 218 seconds, p < 0.01) compared to DL. VL resulted in better visualization of the vocal cords compared to DL (CL1: 93 vs. 57%, p < 0.001) [150]. Additional pre-hospital studies of trauma patients appear to support these observations [84].

Currently, the high price of a video laryngoscope is often cited as an argument against use in the pre-hospital setting. However, the first studies in the pre-hospital setting have given overwhelming evidence in favor of video laryngoscopy. In a prospective monocenter observational study in an air rescue system with a high trauma fraction of 71.5%, VL was successful in 227 of 228 patients (99.6%), and supraglottic airway was necessary in only one case (0.4%) [83]. In 57 of these patients, who were treated by experienced anesthesiologists, vocal cord visualization was improved from CL grade III/IV with DL to grade I/II with VL (p < 0.001). Similar positive results were achieved during intubations by U.S. paramedics using VL in a retrospective data analysis of an air rescue system over a nine-year period with 790 emergency patients with a trauma fraction of 60%. Here, VL showed a higher FPS than DL (94.9 vs. 75.4%, p < 0.0001) [23]. VL increased the success rate of endotracheal intubation within two attempts (97.4 vs. 89.2%, p = 0.0002). The overall intubation success rate using VL was also significantly higher than with DL (99.0 vs. 94.9%, p < 0.011). In addition, VL reduced the average number of intubation attempts until success (1.08 vs. 1.33, p < 0.0001) and the need to use supraglottic airways by group (0.5 vs. 3.2%, p = 0.036) [23].

The advantage of VL is particularly evident with c-spine immobilization. In the above-mentioned prospective, monocenter observational study by Michailidou et al. [111], the subgroup of patients with c-spine immobilization had significantly higher FPS with VL than DL (87 vs 80%, p = 0.03) [111]. In this study as well, there were fewer complications for VL-assisted intubations.

Limitations of the procedure are present in 14% of cases because of the following: strong light causing reduced contrast or contamination of the objective lense with blood or secretions [21, 83, 84]. In this context, a VL blade should be used, which allows DL in addition to indirect VL (e.g., Macintosh blade). If the airway is particularly difficult, a specially curved laryngoscopy blade can be carried, which allows only indirect laryngoscopy (e.g., D-blade).

The evidence table for this chapter is found on page 48 of the guideline report.

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1.3 Volume Replacement

Key Recommendations:

1.19

Recommendation

2016

GoR B

Volume replacement should be begun in severely injured patients. In cases of uncontrollable bleeding this should be done at a reduced level to maintain minimal hemodynamic stability while not increasing blood loss.

1.20

Recommendation

2016

GoR B

In hypotensive patients with traumatic brain injury, volume replacement should be performed with the goal of maintaining normal blood pressure.

1.21

Recommendation

Modified 2016

GoR A

Intravenous access must be placed in trauma patients.

1.22

Recommendation

Modified 2016

GoR 0

Volume replacement can be foregone when there is no evidence of volume depletion.

Explanation:

The hypoperfusion produced by traumatic hemorrhage and consequent hemorrhagic shock results in an imbalance between oxygen supply and tissue demand [45, 72]. This disturbance in the microcirculation is blamed for secondary damage that occurs after hemorrhagic shock. Thus, the goal of volume replacement should be improvement of the microcirculation and with it, organ perfusion. In the past, expert opinion was that aggressive volume replacement has favorable effects on the outcomes for acutely bleeding patients [2, 46]. However, four current randomized controlled trials have not confirmed this rationale for volume replacement during the pre-hospital phase [12, 31, 51, 72]. A study from Turner et al. [72] randomized patients to receive or not receive volume replacement. 1309 patients were included. The results of both groups did not differ regarding mortality, morbidity, and long-term outcome [72].

In 2002, Dutton et al. [31] assigned 110 patients in hemorrhagic shock to two different volume replacement regimens. For one group, the target systolic blood pressure (SBP) was over 100 mmHg, and for the other, 70 mmHg. No differences were evident. Four patients of each group died. Morisson et al. [51] used a very similar protocol. Here too, patients with hemorrhagic shock were assigned to treatment groups with different target blood pressures. In this case, the mean arterial blood pressure (MAP) was used. The target MAP for group 1 (n = 44) was 50 mmHg, and for group 2 (n = 46) was 65 mmHg. Group 1 patients had significantly decreased mortality in the first 24 hours (1 vs. 8 patients).

Another study from Bickell et al. [12] found a negative survival effect from volume replacement after bleeding. However, only patients with penetrating chest injuries were included. There were 1069 patients in the study. In this select population, volume replacement given in the pre-hospital phase increased mortality from 30 to 38% and increased post-operative complications from 23 to 30%. The authors concluded that pre-hospital volume replacement should not be administered and that surgical treatment should be initiated as rapidly as possible.

A meta-analysis by Wang et al., referring essentially to these four studies, concluded that forced volume replacement leads to increased mortality [77]. On the other hand, the heterogeneity of the patient population was pointed out.

Another large meta-analysis from Curry et al. assessed the literature for the extent today’s volume replacement therapies have been found to improve mortality, coagulation, and need for transfusion and concluded that there are no significant improvements [27].

In addition to the four controlled studies mentioned, there are a number of publications that join in the conclusions [11, 42, 58, 67, 71]. However, the authors continually emphasize the situation of uncontrolled intrathoracic or intraabdominal bleeding. In such cases, surgical treatment should begin as soon as possible and not be delayed by pre-hospital measures. Moderate volume replacement with “controlled hypotension” and systolic blood pressure of 90 mmHg should be the goal [31, 45, 60]. In patients with cardiac injury or TBI, this is also seen as critical [30, 45, 69]. On the other hand, other authors promote forced volume replacement, and often for different patient cohorts e.g. with extremity injuries without uncontrolled bleeding [46, 52, 62]. Other studies have not confirmed the results of Bickell [39, 81].

A retrospective study by Balogh et al. [10] compared 156 patients in shock treated with supra-normal volume replacement (resuscitation) with others receiving less aggressive treatment that stopped at the oxygen delivery index (DO2I). An oxygen delivery index (DO2I) >/= 500 ml/min per square meter body surface area (BSA) was set for group 1, and DO2I >/= 600 ml/min/m2BSA for group 2. Increased intrabdominal pressure, associated with increased organ failure, was observed in group 2.

Once the hospital is reached and surgery begun, or in controlled bleeding situations, most studies recommend initiating intensive volume replacement. Expert opinion recommends a target hematocrit value of 25-30% as a reference for the quantity of volume replacement [13, 34]. There are no controlled studies on this topic.

Catecholamine administration is disputed and is considered only as a last resort [1, 35].

In one study, the pre-hospital treatment time was extended by 12-13 minutes because of volume replacement interventions [72]. Some authors interpret this time loss as less relevant [72], and others as a major detrimental factor on mortality [63, 64]. However, it is unclear whether this statement from North America is transferrable to the German emergency physician system.

Since venous access is a fundamental prerequisite for the administration of any medication or volume replacement, each patient must have venous access placed.

Table 6: Pre-Hospital Volume Replacement–Mortality

Study

LoE

Patient Collective

Mortality with Volume Replacement

Mortality without Volume Replacement

Turner et al. 2000 [72]

1b

Multiply injured patients (n = 1309)

10.4%

9.8%

Bickell et al. 1994 [12]

2a

Patients with penetrating chest trauma (n = 1069)

38%

30%

Crystalloid versus Colloid

Key Recommendations:

1.23

Recommendation

2016

GoR B

Crystalloids should be used for volume replacement in trauma patients.

1.24

Recommendation

Modified 2016

GoR A

Isotonic saline solution must not be administered.

1.25

Recommendation

Modified 2016

GoR B

Balanced crystalloid, isotonic electrolyte solutions should be used.

1.26

Recommendation

Modified 2016

GoR 0

Balanced solutions, i.e. Ringer’s acetate or malate instead of lactate can be considered.

1.27

Recommendation

2016

GoR A

Human albumin must not be used during pre-hospital volume replacement.

Explanation:

The choice of infusion solution has been debated for years. Since most of the data came from animal studies or operations, the evidential value was always limited. The use of colloids in particular was the subject of intense debate. In 2013, however, the German Federal Institute for Drugs and Medical Devices (Bundesinstituts für Arzneimittel und Medizinprodukte) circulated urgent safety information markedly restricting the use of solutions with hydroxyethyl starch (HES) [50]. Thus, HES is no longer important for volume replacement.

Even prior to the warning by the Federal Institute, there were indications that the use of crystalloids is advantageous for trauma patients. In 1989, Velanovich et al. found a 12.3% decrease in mortality when crystalloid solutions were used for volume replacement [74]. In 1999 Choi et al. confirmed this result and hypothesized that mortality is decreased for trauma patients treated with crystalloid [20]. A Cochrane analysis performed in 2008 yielded no difference between colloid and crystalloid treatment after trauma [16-18]. From this, the authors concluded already that colloid could be foregone as volume replacement, since no advantage was evident and crystalloids are less costly.

Regarding the choice of crystalloid, Ringer’s Lactate is preferable to isotonic saline [25, 36, 38, 68]. Experimental studies have reported dilution acidosis occurring after infusion of large quantities of isotonic saline [53, 54]. Lactate metabolism results in bicarbonate and water. Thus, the addition of lactate to a Ringer’s balanced electrolyte solution prevents dilution acidosis and buffers the bicarbonate pool. More recent studies have reported experimental disadvantages of Ringer’s Lactate. According to these reports, Ringer’s Lactate triggers neutrophil granulocyte activation, thus increasing lung damage [5-7, 57]. It also appears to result in increased rates of granulocyte apoptosis [28]. This has not been confirmed in clinical studies.

Lactate levels in the plasma are used as a diagnostic shock parameter. Because Ringer’s Lactate results in iatrogenic increase in plasma lactate levels, it can interfere with diagnosis [55, 56]. Ringer’s Malate or Ringer’s Acetate can be used as replacement solutions. Animal studies have found decreased mortality when Ringer’s Malate is used. The challenge of the slight hypoosmolarity of Ringer’s Lactate and the associated potential for increased cerebral edema after traumatic brain injury is not present with Ringer’s Acetate/Malate solutions, since these are completely isoosmolar [55, 82]. In summary, the use of Ringer’s Lactate is no longer worthy of recommendation.

Because of the clear limitations for HES in volume replacement, other colloids like gelatin or albumin have experienced a renaissance. However, the use of albumin appears to be associated with increased mortality after severe trauma, and because of additional logistical reasons like the need for cooling and glass bottles, it is not recommended [32, 36]. Regarding the use of gelatin, there is the risk of an immune reaction. In 1977, Ring et al. published a study in Lancet that this risk is significantly higher than for other colloids (probability of an immune reaction: HAES 0.006%, dextran 0.0008%, gelatin 0.038%) [59]. Because of fibrin polymerization disorders, a coagulation disorder can occur, although in comparison to HES or dextran, this role for gelatin is less important [65]. “Infusions containing HES should be used to treat patients with hypovolemia from acute blood loss only when the administration of crystalloid alone is considered insufficient” [50]. The authors of the chapter point out, however, that patients with suspected trauma-induced coagulopathy should stay away from artificial colloids as volume replacement.

Hypertonic Solutions

Key Recommendations:

1.28

Recommendation

2016

GoR 0

Hypertonic solutions can be used for hypotensive patients with multiple injuries after blunt trauma.

1.29

Recommendation

Modified 2016

GoR 0

In cases of penetrating trauma, hypertonic solutions can be used provided pre-hospital volume therapy is being performed.

1.30

Recommendation

2016

GoR 0

Hypertonic solutions can be used in hypotensive patients with severe traumatic brain injury.

Explanation:

In recent years, the use of hypertonic 7.5% saline solutions has gained increasing importance, especially in the realm of pre-hospital volume replacement. As described above, disordered microcirculation appears to be the damaging factor in cases of traumatic hemorrhagic shock.

Hypertonic solutions work by mobilizing intracellular and interstitial fluid into the intravascular space, and thus, improving microcirculation and the overall blood rheology.

Although most studies have infused pure 7.5% saline solution at 4 ml/kg bodyweight, in Germany, only the combination solutions with HES (Hyperhaes®) or 6% dextran 70 (RescueFlow®) have been used. Because of the problems discussed above regarding the use of HES, soon neither of these solutions will be available in Germany. Thus, the Southwest German Emergency Physicians’ Working Group (Arbeitsgemeinschaft Südwestdeutsche Notärzte e.V.) has recommended either importing RescueFlow® (250 ml 7.5% NaCl solutions with 6% dextran 70) or using 10% NaCl solution. Neither recommendation is unproblematic. In Germany, the import and use of non-distributed pharmaceuticals requires individual prescription with corresponding documentation, and the allergic potential of dextran remains [59]. In addition, the dosage of hypertonic solutions has been extensively studied by Rocha e Silva et al., and is explicitly given as 7.5% saline. All other dosages have increased mortality in dogs [61]. The damaging factor is the potential hypernatremia. The use of a 10% saline solution increases the quantity of NaCl from 18g to 20g. Thus, use must be considered critically and should be first evaluated in studies.

Although there is much promising evidence for hypertonic infusions in the literature, the poor availability of appropriate hypertonic solutions allows no higher grade of recommendation.

Disordered microcirculation is the essential factor leading to complications from hemorrhage. Hypertonic saline solutions work by rapidly mobilizing intracellular and interstitial fluid into the intravascular space and thus, improving blood rheology and with it, the microcirculation [43]. Controlled studies have shown significant advantages for hypertonic infusions. In 2004, Bunn et al. used a Cochrane review to evaluate hypertonic versus isotonic solutions [17]. The authors concluded that the available data was not sufficient to make a final judgment regarding use of hypertonic solutions. In 1991, in two controlled randomized studies, Mattox et al. and Vassar et al. found survival advantages for the use of hypertonic solutions, particularly after traumatic brain injury [49, 73]. The work of Alpar et al. from 2004 took the same direction in a study of 180 patients. There were improved outcomes, particularly in patients with TBI [3]. In 2009, Baker et al. also reported a positive effect for hypertonic solutions given after TBI [9]. Another controlled study of 229 patients from 2004, however, found no significant difference in long-term outcomes after TBI [24]. Positive effects for the clinical treatment of TBI have been reported in other studies. Wade et al. and Vassar et al. reported improved mortality after TBI after initial therapy with hypertonic solutions [73, 76]. Mortality decreased from 60 to 49% in the Vassar et al. study, and from 37.0 to 26.9% in the Wade et al. study with use of hypertonic solution. In the follow-up treatment for increased intracranial pressure, the combination of hypertonic solution/HES in particular showed lowering effects [37, 41, 66, 78-80]. However, this effect was not confirmed in a controlled clinical trial [67]. In another current study by Bulger et al., no benefit from hypertonic solutions was evident, so that the study was discontinued after 1313 patients [67]. Wade et al. performed a comparative investigation through a short meta-analysis of 14 studies of hypertonic saline solutions with and without dextran, and found no relevant benefit for hypertonic solutions [76]. In 2003, the same author reported a positive effect of hypertonic solutions for penetrating trauma. In a double-blind study, 230 patients received initial infusion of either hypertonic NaCl solution or an isotonic solution. Mortality of patients receiving hypertonic NaCl solution was 75.5%, significantly less than patients receiving isotonic solution, with 82.5%. The rates of surgery and bleeding were the same. The authors concluded that hypertonic solutions improve survival after penetrating trauma without increasing bleeding [75].

A current study of 209 polytrauma patients with blunt trauma by Bulger et al. [15] compared Ringer’s Lactate to hypertonic NaCl solution with dextran. The endpoint of the study was ARDS-free survival. The study was discontinued after intention-to-treat analysis, because there was no apparent difference. In one subgroup analysis, an advantage for hypertonic solution with dextran was evident only after massive transfusion. Even the most recent publication by this group reported no advantage for hypertonic solutions after hemorrhagic shock [15]. In fact, patients not requiring transfusion had even higher mortality rates after administration of hypertonic solution (28-day mortality hypertonic solution with dextran: 10%, isotonic solution: 4.8%, p<0.01) [15].

Immunological effects from hypertonic solutions have also discussed. Experimental reports have described a reduction in neutrophil activation and the pro-inflammatory cascade [5-8, 22, 23, 26, 29, 57, 70]. Junger et al. also attempted to demonstrate an inhibitory effect of pure hypertonic solutions on post-traumatic inflammation in trauma patients [40].

Hypertonic solutions lead to a rapid increase in blood pressure and reduced volume needs [4, 14, 19, 21, 33, 44, 47, 48, 80]. The extent to which this affects treatment outcomes cannot yet be conclusively answered by the literature.

The evidence table for this chapter is found on page 80 of the guideline report.

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    Raum M, et al. Influence of lactate infusion solutions on the plasma lactate concentration. Anasthesiol Intensivmed Notfallmed Schmerzther. 2002;37(6):356–8 [LoE 5].

     
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    Rhee P, et al. Lactated Ringer’s solution resuscitation causes neutrophil activation after hemorrhagic shock. J Trauma. 1998;44(2):313–9 [LoE 5].

     
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    Riddez L, Johnson L, Hahn RG. Central and regional hemodynamics during crystalloid fluid therapy after uncontrolled intra-abdominal bleeding. J Trauma. 1998;44(3):433–9 [LoE 5].

     
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    Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet. 1977;1(8009):466–9.

     
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    Roberts K, et al. Hypotensive resuscitation in patients with ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2006;31(4):339–44 [LoE 1a].

     
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    Sampalis JS, et al. Ineffectiveness of on-site intravenous lines: is prehospital time the culprit? J Trauma. 1997b;43(4):608–15 (discussion 615-7).

     
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1.4 Thorax

Diagnosis

The decision of whether to perform drainage/decompression of the pleural space is based on the examination, the assessment of the findings (diagnosis), and the risk-benefit analysis of the intervention (the certainty of diagnosis with limited diagnostic capabilities, time factor, concomitant problems as well as the risks of the intervention itself).

Examination

Key Recommendations:

1.31

Recommendation

2011

GoR A

Clinical examination of the chest and respiratory function must be performed.

1.32

Recommendation

2011

GoR B

The examination should include at least respiratory rate measurement and lung auscultation. Repeated examinations should follow.

1.33

Recommendation

Modified 2016

GoR 0

Inspection, palpation, and percussion of the chest as well as pulse oximetry and monitoring of ventilatory pressure and capnography in ventilated patients are also useful.

Explanation:

Initial Examination

The physical examination of the patient is necessary to establish a diagnosis, which is necessary to initiate treatment interventions. Acutely life-threatening problems can only be recognized by examination. Thus, even without scientific confirmation, it is absolutely required [88].

Scientific research studies focus generally only on auscultation, determination of respiratory rate as well as assessment for spontaneous and elicited pain/tenderness. Therefore, only experience can define the scope of physical examination necessary in a pre-hospital emergency setting.

In an emergency situation at the scene of trauma, once the vital parameters have been examined and stabilized, the initial examination should include measurement of the respiratory rate and auscultation (presence and quality of breath sounds bilaterally) [15, 35, 39, 40]. All of these signs are correlated with significant pathologies or directly influence medical decisions. Other signs of thoracic injuries can be identified using other examination techniques of inspection, palpation, percussion, and technical monitoring [53] (Table 7). Capnometry can indicate a problem with ventilation, although this is non-specific for particular injuries or disorders.

Table 7: Special Focus of the Physical Examination to Identify Relevant Thoracic Injuries

Examination

Special focus on:

Inspection

Respiratory rate

Symmetrical excursion on respiration

Unilateral bulging

Paradoxical respiration

Dyspnea

Palpation

Elicited and spontaneous tenderness/pain

Pain points

Crepitus

Subcutaneous emphysema

Instability of the bony thorax

Percussion

Hyperresonance

Auscultation

Presence and quality of breath sounds bilaterally

Technical monitoring

Pulse oximetry

Ventilation pressure

Capnography

(Ultrasound)

(Lung scan)

All of the examination techniques mentioned above are used to detect life-threatening or potentially life-threatening disorders and injuries that can make immediate and specific interventions or logistic decisions necessary right away. All of the diagnostic measures performed pre-hospital are without specific risks. The disadvantage is loss of time, which is generally minimal.

Some findings are strongly dependent on the examiner, the patient, and the environment. Surrounding noise levels can make auscultation difficult or impossible. Such circumstances need to be considered when selecting and interpreting the primary diagnostic studies [35, 39, 72, 134].

Monitoring

Respiratory rate and auscultation as well as pulse oximetry and ventilation pressure monitoring/capnography when necessary should be continued, since airway problems, tube displacement, tension pneumothorax, or acute respiratory insufficiency can develop dynamically. Serial examinations can serve as control of the interventions that have already been performed.

Diagnosing Pneumothorax

Key Recommendations:

1.34

Recommendation

2011

GoR A

A provisional diagnosis of pneumothorax and/or hemothorax must be made in cases of unilateral absence or decrease in breath sounds (after controlling for correct tube placement). The lack of such findings on auscultation, particularly with normal respiratory rate and absence of thoracic discomfort, generally rules out a large pneumothorax.

1.35

Recommendation

2011

GoR B

Potential progression of a small, initially (in the pre-hospital stage) undetectable pneumothorax should be kept in mind.

Explanation:

At the present time, there are no evaluated methods available in the pre-hospital setting to definitively detect or exclude pneumothorax.

Ultrasound Examination

In hospital conditions, an ultrasound examination shows evidence of pneumothorax and hemothorax (lung sliding, seashore sign, B-lines/comet tail artifacts, etc.) with extreme accuracy [5, 57], and is superior to both clinical diagnosis and standard radiography. However, the estimated magnitude of a confirmed pneumothorax is uncertain and so far, poorly documented. Similarly, there has been little study of the risk-benefit analysis including the therapeutic consequences from the results of the investigation. In addition to dependence on the examiner, the loss of time and misdiagnosis by less experienced examiners must be considered. In particular, there has been no reliable experience with pre-hospital use, so a general recommendation can’t be given. Nevertheless, pre-hospital ultrasound performed by an experienced examiner can contribute to confirmation of a provisional diagnosis of pneumothorax. Increasing experience with ultrasound diagnosis of pneumothorax in the pre-hospital setting could lead to more prominence in the coming years. For these reasons, the lack of expert consensus means that no recommendation for or against the use of pre-hospital ultrasound for the diagnosis of pneumothorax can be made. A new radar-based technology with a hand-held device has shown initial promising results for the detection of pneumothorax [4, 90]. Further studies must be performed to confirm the value and practicality of widespread use before recommendations can be given.

Auscultation, Dyspnea, Pain

A systematic review [137] analyzed studies regarding the accuracy of clinical examination for the diagnosis of pneumothorax.

Sensitivity was 90%. The specificity of a unilateral decrease or lack of breath sounds, i.e. the probability that patients without pneumothorax would not have these findings, is very high, with 98%. The positive predictive value, i.e. the probability that pneumothorax is actually present when breath sounds are decreased, is also very high with 86 - 97%. Pneumothorax not recognized on auscultation had an average volume of 378 ml (max 800 ml), and hemothorax of 277 ml (max 600 ml). In this study, thus, no large, acutely life-threatening lesions were missed.

A requirement for this is that the appropriate position of the endotracheal tube (when present) must be ensured, as much as possible (capnography). The studies mentioned here were performed in the emergency department of the hospital, and not at the scene of the trauma. They appear to be transferable, however, since there are also many comparable disruptions (e.g. increased noise, surrounding activity) in the emergency department. False positive findings occur occasionally (4.5% of cases in [87]) with tube misplacement, diaphragmatic rupture [1, 6], or ventilatory disruption (large atelectasis, movement on deep respiration).

In cases of severe bilateral chest trauma, bilateral pneumothorax needs to be considered. In such cases, atypical findings might be present.

Data regarding differentiation between pneumothorax and hemothorax or a mixed clinical picture are not available. Here percussion can be helpful, although this has only limited relevance in the pre-hospital setting, since differentiation between pneumothorax and hemothorax has no verifiable effect on the need for therapy (see below). Ultrasound examination can make the distinction (discussed above).

Although the symptoms of dyspnea and tachypnea are difficult to quantify when patients have decreased levels of consciousness, normopnea (respiratory rate between 10 - 20 breaths per minute) can be used in clinical practice as an indication. Multiple studies have found that normopnea after blunt trauma is a very good sign that large hemo/pneumothorax can be excluded (specificity 98%). On the other hand, the presence of dyspnea does not indicate that pneumothorax is present (sensitivity 43%).

Patients with normal levels of consciousness can be asked directly about pain. In addition, there is the physical examination for tenderness on palpation in the chest area. Only one study has reported on the importance of a lack of pain/tenderness, which shows good specificity particularly for acute trauma [23]. Thoracic pain can only be used for accurate diagnosis in combination with other findings and the overall clinical picture.

Table 8 gives a summary of the accuracy of the three criteria, individually and in various finding constellations. Highest accuracy is when all three criteria are present, followed by pathological auscultation in combination with one of the other two criteria. Conversely, unremarkable auscultation, palpation, and normopnea virtually exclude the presence of hemo/pneumothorax [23].

Table 8: Statistical Probability for Clinically Relevant Hemo/Pneumothorax with Various Combinations of Findings After Blunt Chest Trauma (Basic Assumption: 10% Prevalence as Pre-Test Probability and Test Independence). Modified according to [137]:

Thoracic Pain

(Sensitivity 57 %, Specificity 79 %)

Dyspnea

(Sensitivity 43 %, Specificity 98 %)

Auscultation

(Sensitivity 90 %, Specificity 98 %)

Probability of Hemo/Pneumothorax

+

+

+

> 99 %

+

+

-

40 %

+

-

+

89 %

+

-

-

2 %

-

+

+

98 %

-

+

-

12 %

-

-

+

61 %

-

-

-

< 1 %

Other Investigations and Pneumothorax

Detection of subcutaneous emphysema is considered a sign of pneumothorax. However, there are no good diagnostic studies on this topic available. The specificity and the positive predictive value are not known. Sensitivity is low, between 12 and 25 % [45, 125]. However, a higher positive predictive value is suspected due to non-systematic experience.

A 30-year-old study reported a 100% sensitivity of subcutaneous emphysema for tension pneumothorax in intensive care patients. This data is possibly not transferable to acute trauma patients in the pre-hospital phase [130].

Considering the relatively high rate of false findings, the presence of flail chest and crepitus should be assessed as indications of chest trauma, but not of pneumothorax.

Pneumothorax and Progression

The potential progression of an initially asymptomatic pneumothorax is important, particularly in air rescue. The progression of pneumothorax can vary considerably among individual patients. The full spectrum from in-hospital discovery to rapid progression is possible. Certain clues can be drawn from observations of small pneumothoraxes. A small retrospective series was performed of 13 patients with occult pneumothorax treated with observation. Of these, six were mechanically ventilated. In two cases, chest tube drainage was necessary for progressive pneumothorax on the 2nd and 3rd days after admission [38]. In a prospective randomized study of 21 patients with occult pneumothorax treated expectantly, 8 cases progressed and three of these were tension pneumothorax. All of these patients were mechanically ventilated [59]. The three tension pneumothoraxes occurred in the operating room, post-operatively in the intensive care unit, and during a prolonged stabilization phase, but more specific data regarding the hours after trauma are not available. A period of at least 30 - 60 minutes after hospital admission are assumed. In another prospective randomized study on therapy for occult pneumothorax, pneumothorax progression requiring intervention showed a higher tendency in patients treated conservatively (9.5%) versus patients treated with chest tubes (5.6%) [24, 139]. Information regarding the timeframe of pneumothorax progression was not available. A prospective multicenter study reported a 6 % progression rate of occult pneumothorax requiring chest tube drainage, and 14 % in ventilated patients. In a randomized study in ventilated patients (for an operation) with occult pneumothorax, all reported parameters were comparable except whether a chest tube had been placed or not [83]. 20% of patients treated with initial observation required chest tube placement over the course of care, although less than half of these because of pneumothorax progression, i.e. in 8% of the total patient population. A review by Yadav et al. [139] observed only three of the older, smaller studies, and contributed no additional evidence.

As far as the standard radiographic data of occult pneumothorax is transferable to non-clinically diagnosable pneumothorax, the risk of progression is rather low (between 6 and 9.5 %, i.e. in fewer than every tenth patient). For ventilated patients, this rate is higher (approximately 14 %), so that the classic situation of progressive pneumothorax (up to tension pneumothorax) after intubation actually occurs in one of seven patients receiving positive pressure ventilation [106].

In summary, the data suggests that small, clinically non-diagnosable pneumothorax, especially in non-ventilated patients, progresses relatively seldom (and most only slowly) as a rule, and thus, generally does not require emergency decompression in the pre-hospital setting. Nevertheless, progression of even an initially clinically undetectable pneumothorax must be reckoned with. Increased attention to monitoring, progress checks, and readiness for decompression are necessary to recognize cases of progression in a timely manner.

Diagnosis Tension Pneumothorax

Key Recommendations:

1.36

Recommendation

Modified 2016

GoR B

A provisional diagnosis of tension pneumothorax should be made in cases of unilaterally absent breath sounds on lung auscultation (after controlling for correct tube placement) along with the presence of typical symptoms, particularly severe respiratory or hemodynamic instability.

Explanation:

A number of systematic reviews have been published regarding the diagnostic accuracy of examination findings in the case of tension pneumothorax, based on cohort studies, small case series, and case reports. However, there is no uniform understanding of exactly what falls under the definition of tension pneumothorax. Definitions range from pneumothorax with life-threatening consequences to vital functions, to a hiss of escaping air on needle decompression, to mediastinal shift on chest x-ray, to increased ipsilateral intrapleural pressure, and on to hemodynamic compromise [89].

Experimental investigations have found that the respiratory changes and paralysis of the respiratory center as a result of the hypoxia precede circulatory arrest. The hypotension, which culminates in circulatory arrest, is a late sign of tension pneumothorax [14, 122].

A review article from 2005 characterized “shortness of breath,” and “tachycardia” as the typical and most common symptom/sign of tension pneumothorax in conscious patients [89]. The same authors also found, however, that the hemodynamic symptoms occur earlier in ventilated patients, and that respiratory symptoms and the drop in blood pressure often manifest at the same time. In mechanically ventilated patients, extremely elevated or increasing airway pressures are another important sign found in some 20% of patients with hemo/pneumothorax [15, 39]. A current systematic review reported significant differences in the manifestation of tension pneumothorax between spontaneously breathing patients and those being mechanically ventilated [120].

Chest pain, tachypnea, and decreased breath sounds occurred in more than 45 % of spontaneously breathing patients. Dyspnea/respiratory distress, hypoxia with oxygen demand, tachycardia, and hyperresonance were present in 30 to 45 % of cases. Tracheal deviation (15-30 %) or hypotension (when present, with a slow progression), distended neck veins, subcutaneous emphysema, cardiac arrest (each under 15%) were much more seldom.

In contrast, in ventilated patients, the most common signs (> 45%) were decreased breath sounds as well as hypotension (often with an acute beginning) and hypoxia. Also common (30-45 %) were tachycardia, subcutaneous emphysema, and cardiac arrest.

The diagnostic accuracy of the individual clinical signs and findings has not yet been evaluated.

According to expert opinion, the combination of (unilateral) absence of breath sounds (with verified tube position) and changes of vital respiratory or hemodynamic parameters makes tension pneumothorax so probable that the diagnosis should be given and the necessary therapeutic interventions should be performed. Further diagnostic studies represent avoidable delay and should be foregone. The consequences of a false positive tension pneumothorax diagnosis are much less severe than those from the omission of required decompression.

Indications for Pleural Decompression

Key Recommendations:

1.37

Recommendation

New 2016

GoR A

Tension pneumothorax is the most frequent reversible cause of traumatic cardiac arrest and must be decompressed in the pre-hospital setting.

1.38

Recommendation

2011

GoR A

Clinically suspected tension pneumothorax must be decompressed immediately.

1.39

Recommendation

2011

GoR B

Pneumothorax diagnosed on auscultation should be decompressed in patients receiving positive pressure ventilation.

1.40

Recommendation

2011

GoR B

Pneumothorax diagnosed on auscultation should be treated expectantly with close observation in non-mechanically ventilated patients.

Explanation:

There are no investigations comparing intervention and expectant therapy. The treatment recommendations are based on expert opinions and consideration of probabilities.

Tension pneumothorax

Tension pneumothorax is an acute life-threatening situation. Left untreated, it generally leads to death. Death can occur within minutes of the onset of signs of insufficient respiratory and hemodynamic function. There is no alternative to decompression. Expert opinion is that particularly in cases of circulatory or respiratory impairment, emergency decompression must be performed immediately and that the time lost in transport even to a hospital in the immediate vicinity represents an unjustifiable delay. A study of 3500 autopsies identified 39 cases of tension pneumothorax (incidence 1.1%), of which half were not diagnosed while the patient was still living. Among soldiers of the Vietnam war, tension pneumothorax occurred in 3.9 % of all patients with chest injuries and in 33 % of soldiers with deadly chest injuries [99]. An analysis of 20 patients categorized as unexpected survivors according to TRISS prognosis reported that seven of them underwent pre-hospital decompression for tension pneumothorax [27]. In cases of pre-hospital resuscitation post-trauma, spontaneous circulation was restored in 4 of 18 patients with decompression (once with needle, four with mini-thoracotomy) [105]. An analysis of patients with trauma-associated circulatory arrest identified decompression of tension pneumothorax as the most important factor contributing to improved prognosis [76]. In a current analysis, untreated tension pneumothorax was identified as one of the most frequent preventable causes of death [84]. Through a special training program for paramedics on the detection and treatment of tension pneumothorax, the rate of tension pneumothorax untreated by rescue services decreased from 1.35% (10 of 740 patients) to 0.4% (4 of 1034) [30].

Diagnosed Pneumothorax

A large pneumothorax, which can be assumed with typical auscultation findings, is a basic indication for evacuation of the pleural cavity. Whether this needs to be done in the pre-hospital setting or in the hospital is difficult to decide for individual cases. The risk of progression from simple to tension pneumothorax as well as the time this takes is variable and difficult to estimate. The literature offers neither general data on the topic nor risk factors. There is evidence that tension pneumothorax is found on admission to the Emergency Department more frequently in cases of chest trauma that have been intubated versus non-intubated patients.

Overall, it seems plausible to the experts that pneumothorax diagnosed by auscultation in ventilated patients has markedly higher risk to develop tension pneumothorax, and thus an indication for pre-hospital decompression.

If a patient with pneumothorax diagnosed on auscultation is not ventilated, the risk for developing tension pneumothorax appears to be much less. In a series of 54 cases of trauma-induced pneumothorax, 29 were treated conservatively, i.e. without chest tube placement. These patients were not mechanically ventilated, and most had no accompanying injuries. Chest tube drainage was placed in only two cases, as a result of radiologically progressing pneumothorax six hours after hospital admission [81]. In this case, pre-hospital decompression appears unnecessary (over expectant therapy with close monitoring and clinical controls). Due to the potential risks of pre-hospital decompression, in such cases it should only be carried out with strict consideration of risks versus benefits.

If appropriate monitoring and clinical controls are not easily possible, e.g. during helicopter transport, there is a certain, unquantifiable risk that tension pneumothorax could develop and that this would not be noticed in time or adequate therapy would not be possible due to space limitations. In such situations, when appropriate clinical signs are present and according to individual circumstances, pneumothorax decompression may be required for non-intubated patients prior to transport.

Chest Trauma Without Direct Diagnosis of Pneumothorax

If there are equal breath sounds bilaterally, the presence of clinically relevant pneumothorax is very improbable. In this case, there is no indication for pre-hospital decompression or pleural space evacuation, even when there is other evidence of chest trauma (not specific for pneumothorax).

A systematic review [137] found that the incidence of pneumothorax is relatively low (10 to 50 %) even when chest trauma is present. Thus, if an invasive intervention is carried out for a diagnosis of chest trauma alone without concrete evidence of pneumothorax, at least every second patient and up to nine of ten patients would be treated unnecessarily. Since cases of occult pneumothorax, only detectable on CT, were also included in this study, the rate of pneumothoraxes requiring evacuation was low. Even when pneumothorax was suspected due to specific clinical signs, the rate of unnecessary needle decompression and chest tube evacuation was between 9 and 65 % [8, 15, 124].

Thus, for individual cases with grounds, in ventilated patients with unmistakable signs of thoracic trauma but unsuspicious auscultation findings, decompression can be performed prior to longer transports or helicopter transport with limited clinical monitoring or treatment options. The high rate of false positive diagnoses for chest trauma by the emergency physician must be considered.

Under these conditions, decompression is not indicated in non-ventilated patients.

Hemothorax

The only general indications for pleural drainage/decompression in the acute pre-hospital setting are tension pneumothorax and massive hemothorax. The management of pneumothorax has been characterized above. Although hemothorax is a basic indication for pleural evacuation, there is generally no direct danger of compression from this blood and thus, no indication for pre-hospital drainage. Only in cases of massive bleeding, possibly with the development of a problem such as a tension pneumothorax, would emergency drainage be indicated. However, such situations would generally be associated with abnormal auscultation and thus, would proceed as in the case of pneumothorax. In the pre-hospital setting it is typically difficult to differentiate hemothorax from hemopneumothorax. Clinical signs of hemothorax versus pneumothorax would be dullness versus hyperresonance to percussion, provided the ambient conditions enable differentiation. Ultrasound examination can differentiate the two.

Therapy

Methods

The goal of treatment is decompression of the positive pressure in tension pneumothorax or tension hemothorax. The second goal of treatment is to avoid development of a tension pneumothorax from simple pneumothorax. Permanent and thorough evacuation of air and blood is not important in the pre-hospital setting.

Key Recommendations:

1.41

Recommendation

Modified 2016

GoR B

Tension pneumothorax should be decompressed with single needle decompression. Surgical opening of the pleural cavity should follow, with or without chest tube placement.

1.42

Recommendation

2011

GoR B

When indicated, pneumothorax should be treated with chest tube placement.

Explanation:

Because there are no suitable comparisons of data from the three methods (needle decompression, surgical opening of the pleural space alone, opening of the pleural space with immediate chest tube drainage), there can be no evidence-based recommendations for one method over another. For all three methods, there are (predominantly retrospective) data, case series, and case reports available that demonstrate that successful decompression of tension pneumothorax is possible.

Pathophysiologically, for sustained decompression it is necessary that the amount of air expelled into the pleural space with each inhalation also exits through the decompression device (regardless of which method has been chosen, thus needle or chest tube). The diameter with x4 then joins flow resistance. Thus, needle decompression (and even single chest tube placement) could remain ineffective, e.g. in tracheobronchial injury.

With the low level of evidence regarding the various methods, and to directly compare the different methods according to risk-benefits profile, the individual abilities of the treating emergency provider should also be taken as a practical consideration. One investigation reported a significantly reduced complication rate after chest tube placement by surgeons versus emergency physicians [61]. A more current study in North America also reported lower complication rates in resident physicians training in surgical versus non-surgical specialties [11]. The extent to which these results are transferable to the German emergency physician system cannot be evaluated due to the lack of reliable data.

Chest Tube Drainage: Effectiveness and Complications

Chest tube insertion is an appropriate, highly effective (> 85 %), but complication-ridden intervention to decompress tension pneumothorax, which must be applied particularly when alternative measures fail or prove inadequate. Typically, it offers definitive treatment and has the highest success rate. In 79 to 95 % of cases, chest tube drainage placed in the pre-hospital setting was the definitive and successful intervention [10, 51, 115].

Conversely, chest tube drainage has a failure rate of 5.4 - 21 % (mean 11.2 %) due to misplacement or insufficient effectiveness. Need for additional chest tube placement occurred with the same frequency [10, 33, 44, 51, 61, 70, 115, 124]. Affected cases were roughly equally divided between pneumo and hemothorax. Persisting tension pneumothorax was also observed in individual cases of chest tubes placed in the pre-hospital setting [10, 29, 98]. In addition to tube misplacement, this condition can occur in rare cases of a highly productive bronchopulmonary air fistula, which exceeds the discharge capacity of the established chest tube (e.g. in cases of large parenchymal tears or injuries to larger bronchi).

The pooled complication rates for chest tube drainage placement for pre-hospital versus hospital placement show increased complications in the former for subcutaneous placement (2.53 vs. 0.39 %), intraparenchymal misplacement (1.37 vs. 0.63 %), and intra-abdominal misplacement (0.87 vs. 0.73 %). Conversely, the infection rates are reversed (0.55 vs. 1.74 %) [52, 137]. Two studies directly comparing the complication rates pre- and in-hospital at the same institution [129, 141] found comparable infection rates (9.4 vs. 11.7 %) and misplacement (0 vs. 1.2 %). Duration of drainage placement was comparable in both groups. A current study of chest tubes placed in the emergency department found that 70 % of patients suffered acute and 40 % delayed complications [127]. In addition to retroperitoneal misplacement (1.1 %), intercostal artery injury (1.1 %), persisting pneumothorax (12.2 %) and over-advancement of the drain (33.3 %), 38.9 % of patients suffered pneumothorax recurrence with the chest tube in place, and more seldom (each 2.2 %) pleural empyema or local infection at the entry site. Another study observed a complication rate of 22.1 % [102].

In addition, for anterior to mid-axillary line chest tube drainage insertion, case studies have reported injury to the intercostal arteries [31], lung perforation [63], perforation of the right atrium [32, 100, 128], the right ventricle [117], and the left ventricle [47], subclavian artery stenosis from internal pressure of the drainage tip [107], ipsilateral Horner syndrome from drain pressure on the apex of the stellate ganglion [21, 29], intra-abdominal misplacement [62], perforation of the liver [45], the stomach [6], and the colon [1] in case of diaphragmatic hernia, a lesion of the subclavian vein, perforation of the inferior vena cava [60], and provocation of atrial fibrillation [13].

With insertion at the mid-clavicular line, there have been reports of subclavian vessel fistula [42], cardiac wall perforation [54], and perforation of the right atrium [100].

Other known complications include perforations of the esophagus, the mediastinum with creation of contralateral pneumothorax, phrenic nerve injury, etc.

Simple Surgical Opening: Effectiveness and Complications

Simple surgical opening of the pleural space is an appropriate, effective, and relatively simple measure to decompress a tension pneumothorax. However, it is only appropriate for patients receiving positive pressure ventilation, because only they have constant positive intrapleural pressure. In spontaneously breathing patients, negative intrapleural pressure is created, which can then suck air through the thoracotomy into the thorax.

Clinical experience shows that air is released when the pleural space is opened with a mini-thoracotomy for chest tube placement to decompress pneumothorax or hemothorax. Symptoms can improve dramatically in cases of a tension pneumothorax with hemodynamic effects. This technique was evaluated in the pre-hospital setting in a case series of 45 patients and was found to be effective without major complications [48]. In a prospective observational study of an air rescue system over two years, 55 patients with 59 suspected cases of pneumothorax were treated with simple surgical opening. The average arterial oxygen saturation increased from 86.4 % to 98.5 % as a result of the procedure. On surgical opening, either pneumothorax or hemothorax was found in 91.5 % of patients. Recurrent pneumothorax was not observed by these authors, nor any other serious complications (significant bleeding, lung laceration, pleural empyema) [96].

However, another series found relevant complications in 9 % of patients, in whom almost half of the cases had to do with non-decompressed or recurrent (e.g. through overlapping layers of soft tissue) tension pneumothorax [9].

Thus, insertion of chest tube drainage through the existing mini-thoracotomy is indicated in hospital.

Needle Decompression: Effectiveness and Complications

Needle decompression is an appropriate, frequently effective (approximately 32 - 53 %), simple, but not complication-free drainage procedure. If the effects are absent or insufficient, surgical decompression and/or chest tube insertion must be performed immediately.

The problem with clinical studies in the pre-hospital setting is the lack of scientific certainty that tension pneumothorax was actually present prior to needle decompression, which makes it difficult to judge effectiveness. With a pig model, the failure rate was 58 %, either because within five minutes a secondary malfunction occurred (bending, blockage, displacement) or because the pressure release was not sufficient [94].

In pre-hospital studies, needle decompression yielded air in 32 - 47 % of cases [15, 46]. Clinical improvements were seen in 12 to 60 % of patients in whom needle decompression was performed [15, 46, 58].

In contrast, one prospective series of 14 patients (five further patients died in the Emergency Department and were unsuitable for analysis) after needle decompression found eight patients without evidence of pneumothorax, two patients with occult pneumothorax, two patients with persistent pneumothorax, one case of successfully decompressed tension pneumothorax, and one case of persistent tension pneumothorax [43], so that of 14 patients only one clearly benefited.

In the Barton [15] study, needle decompression needed to be supplemented with chest tube placement in 40 % of cases (32 of 123) because of insufficient effectiveness. In other pre-hospital studies [37, 46], chest tubes were needed after needle decompression in 53 - 67 % of cases.

In one study, needle decompression did not work at all in 4.1 % of verified cases of pneumothorax, because the needle could not be placed deep enough. In 2.4 % of cases there was secondary needle displacement and in 4.1 % it was too difficult to place. No organ injuries were reported [15]. Another study found that needle decompression was unsuccessful in 2 % of patients because the needle was not deep enough. In another 2 % there was no indication and iatrogenic pneumothorax was the result. There were no infections or vascular injuries [58]. However, other investigators reported individual cases of lung injury [46] or cardiac tamponade [28]. Another group reported three patients with severe bleeding requiring thoracotomy [118]. In addition, several case reports and series have discussed needle decompression failure [26, 80]. The most probable cause is insufficient needle length. In individual cases, unilateral or bilateral tension pneumothorax was not identified in patients with chronic obstructive pulmonary disease (COPD) or asthma, in whom the entire lung was not collapsed [74, 104].

Needle Decompression versus Pleural Drain (Tension Pneumothorax Only!)

In two studies, needle decompression required significantly reduced overall treatment time, about five minutes, at the accident scene compared to chest tube placement (20.3 vs. 25.7 min) [15, 46]. More important than the overall treatment time is the duration between the recognition of the need for decompression and the successful implementation. Even for an experienced team with a trained provider, needle puncture is the fastest possible intervention. This applies even more so when optimal conditions do not exist for the treating team and there is no normal routine for chest tube placement. Therefore, needle decompression is recommended as the primary and most rapid intervention for life-threatening tension pneumothorax. Also, needle decompression is well suited as a primary procedure in cases where tactical use for trapped patients or adverse ambient conditions, e.g. subway tunnels, is called for.

When needle decompression is not successful on the first try, a second attempt should not be made. Possible causes of failure can include insufficient needle length, wrong puncture site, or misdiagnosis. The chances of success for a second attempt thus appear low. Instead, immediate surgical opening of the pleural space, if necessary with chest tube placement, must be performed, since the indication for decompression of the tension pneumothorax persists and may be more urgent. Essential to the effective treatment of tension pneumothorax is the surgical opening of the pleural space, through which the positive pressure can be released. Chest tube placement is a definitive air release and offers the best prophylaxis against recurrence.

For obese patients, primary surgical opening should be considered.

The guideline members believe that definitive treatment with surgical opening of the pleural space (mini-thoracotomy) and chest tube placement should be performed even after successful needle decompression. The reasons for this are possible displacement, bending, or obstruction of the needle during further therapy, transfer, or transport as well as insufficient decompression in cases with large fistula volumes under positive pressure ventilation. This assessment was confirmed in a study with 47 pre-hospital needle decompressions [55]. In 85 % of cases, secondary chest tube drainage was necessary for persistent symptoms, pneumothorax on standard x-rays, or relevant pneumothorax on CT. When possible, this should be performed in the pre-hospital setting. When there is an indication for urgent transport (e.g. profuse bleeding) or the emergency physician is less experienced, transport with readiness for chest tube placement can be considered.

Implementation

Needle Decompression: Puncture Site and Needle Length

There is no available evidence regarding the type or diameter of cannula to be used. Generally, the largest possible cannula diameter (14 or 12G) is recommended to allow the maximum amount of air to be released.

Some authors recommend needle decompression in the 2nd to 3rd intercostal space in the mid-clavicular line [15, 39, 43, 58], while others recommend using the 5th intercostal space in the anterior to mid-axillary line [22, 40, 118].

A number of studies have assessed determination of chest wall thickness, mostly based on CT scans of the thorax (Table 9). Although some studies have found that the chest wall was thinner in the 2nd intercostal space along the mid-clavicular line than in the 4th or 5th intercostal space along the anterior or mid-axillary lines, other studies have reported the opposite. Thus, from these studies there is no clear recommendation for one or the other puncture site.

According to the measured chest wall thickness, the theoretical success rate of a needle decompression should be a function of the length of needle used (Table 10).

In one of the few studies that actually investigated the effectiveness of different needles of varying lengths, CT or ultrasound investigations showed residual pneumothorax in 65 % of patients in whom a 32 mm needle was used versus 4 % when a 45 mm needle was used [12].

In general, the average chest wall is 5 to 15 mm thicker in women than in men. Chest wall thickness typically correlates to body mass index [34, 78, 116]. The failure rate of 50 mm needles was 43 % in patients with normal body weight (BMI 18.5-24.9) and 89 % in highly obese patients (BMI> 30) [116].

Table 9: Average Chest Wall Thickness according to CT chest in millimeters (range in brackets) of the 2nd intercostal space in the mid-clavicular line (2nd ICS in the MCL) and of the 4th or 5th intercostal space in the anterior or mid-axillary lines (4th-5th ICS in the A/MAL). The larger thickness value of the body side/gender was used for each case

Study

Chest Wall Thickness

2nd ICS in the MCL

Chest Wall Thickness

4th-5th ICS in the A/MAL

Akoglu [3]

Males: 38.8 ± 13.9

Females: 52.0 ± 18.4

Males: 32.7 ± 13.9

Females: 39.3 ± 15.6

Bristol * [25]

30 ± 15.9

32 ± 14.7

Chang [34]

46.7 (17.8-98.7)

39.9 (13.6-116.6)

Givens [65]

41.6 (22-82) #

-

Harcke [68]

54.0 ± 11.9

-

Inaba [78]

46.0 (22.5-93.4)

32.9 (11.9-103.3)

Powers [116]

63.0 ± 19

-

Sanchez [123]

46.3 (CI 44.3-48.3)

63.7 (CI 61.1-66.3)

Schroeder [126]

40.8 ± 14

45.5 ± 17

Zengerik [142]

39.0 ± 14.2

-

* Cadaver study

# in males; in females 49.0 mm

Table 10: Average Theoretical Failure Rate using CT Chest to reach the pleural space from the 2nd intercostal space of the mid-clavicular line (2nd ICS in the MCL) and from the 4th or 5th intercostal space along the anterior or mid-axillary lines (4th-5th ICS in the A/MAL)

Study

Needle Length (mm)

Failure Rate 2nd ICS in the MCL

Failure Rate 4th-5th ICS in the A/MAL

Akoglu [3]

50

up to 54 %

up to 33 %

Chang [34]

80

34 %

4 %

Givens [65]

50

25 %

-

Inaba [78]

50

43 %

17 %

Powers [116]

50

25-93% *

-

Sanchez [123]

50

30 %

53 %

Schroeder [126]

45

30 %

45 %

Zengerik [142]

45

19% (males)

35 % (females)

-

* in relation to BMI (< 18.5 vs. > 30.0)

There is very little evidence regarding the complication rate according to puncture site and needle length. In a study of CT chests of trauma patients, the theoretical success rate as well as the shortest distance to vital structures was estimated with an 8 cm puncture needle [34]. In this study, various needle lengths and puncture sites were assessed on chest CT regarding possible complications from iatrogenic lesions. The average distance from puncture site to the nearest vital structure (regardless of insertion angle) in the 2nd ICS MCL was 114 mm and in the 4th-5th ICS in the anterior axillary line was 109 mm. Using an 80 mm needle, 32 % of cases could have resulted in injuries to vital structures (usually the left ventricle). If the needle was inserted perpendicular to the skin surface, however, the rate of potential injuries would decrease to 9 %. In other sites, the potential injury rate was ≤ 9% with an 80 mm needle and ≤ 1% for a 50 mm needle. The pleura was reached for each puncture site in 96-100 % of cases with the 8.0 cm needle, and only 66-81 % of cases with the 5.0 cm needle. Thus, the lower complication rate is also associated with a higher risk of failure.

A current meta-analysis including 18 studies determined that the pleura would be reached in 95 % of cases with a needle length of 6.44 cm, and thus, use of a 6.5 cm needle was proposed [36]. However, there is no clinical evidence of an actually improved success rate or possible increase in puncture complication rates.

Experts say that the risk of lung injury from adhesions after a lateral approach is greater, and air in the pleural space is more likely found towards the apex. Whether these assumptions are a good argument to use the mid-clavicular line cannot be said, because there are no investigative results available. An investigation on models found that with an anterior puncture site, there is a strong tendency for the puncture site to occur medial to the mid-clavicular line, with associated risks of injuring the heart, the internal thoracic or the large vessels [109].

There are no investigations directly analyzing the actual risks and benefits for the use of longer versus normal needles. The risk of injuring a vital structure with a 45 or 50 mm needle appears very low; however, the failure rate is over a third of cases. With a longer needle (80 mm), successful decompression appears much more likely, but it is also associated with greater risks of injuring vital structures, particularly in left sided punctures from a lateral approach. Some experts thus advise the use of standard needles (4.5 cm) followed by surgical opening of the pleural space (mini-thoracotomy) in cases without success. In the military sphere, however, 14 G needles measuring 8.9 cm (3.5 inches) or 8.2 cm (3.25 inches) are used routinely [73] [49, 108]. These needles are specially designed for pleural decompression, as opposed to intravenous cannulas used for this indication. With the data currently available, a general recommendation regarding needle length cannot be given. Depending on education and training level, among other things, of the rescue provider performing the needle decompression, a balance must be found between increased success rates and decreased injury rates. In cases of resuscitation (and similarly threatening situations), it may be preferable to choose the longer needle, as the risk-benefit ratio is clearly shifted.

Chest Tube Drainage: Tube Placement and Size

Recommendations for placement for pleural evacuation drains are either in the 4th to 6th intercostal space in the anterior to mid-axillary line [39, 131, 135] or in the 2nd to 3rd intercostal space in the mid-clavicular line. The nipple is an orientation point. Puncture should not occur beneath this point, because below the nipple the risks for abdominal misplacement and abdominal organ injury increases. In women with larger breasts, the submammary fold (where the wire of the bra usually lies) can be used as the orientation point. Another method is one hand width below the axilla, using the hand width of the patient. It is important to note that the puncture site should always be between the ribs. The skin incision can also be a bit inferior to the intercostal space (see Implementation section).

Complications have been published for both puncture sites in clinical case reports. One prospective study found no influence of the level of puncture (2nd to 8th ICS) or the lateral positioning (MCL or MAL) on the success rates regarding decompression of pneumothorax or hemothorax after penetrating trauma [56]. A cohort study analyzed the complications for chest tubes placed in the 2nd to 3rd intercostal space in the mid-clavicular line (n = 21) and in the 4th to 6th intercostal space in the anterior axillary line (n = 80) [75]. Although the rate of interlobar misplacement is significantly higher with a lateral approach, rates of functional misplacement from both sites were comparable (6.3% vs. 4.5%). In contrast, a Japanese study [97] reported significantly lower rates of residual pneumothorax (22 vs. 64 %) and functional misplacement (6 vs. 43 %) with an anterior approach. A recommendation for a preferable puncture site cannot be given, even if an anterior approach is at least as favorable as the lateral.

Even a thin drain should suffice for pneumothorax decompression. In cases of non-traumatic pneumothorax, 75-87 % of patients were successfully treated with size 8-14 French (Fr) chest tubes [41, 95]. A study of patients with pneumothorax after isolated thoracic trauma found a success rate of 75 % with thinner catheters (8 Fr). The remaining 25 % required insertion of a large lumen chest tube [50]. One case study reported the progression of simple to tension pneumothorax despite an indwelling 8 Fr tube. This was a mechanically ventilated patient with a ruptured emphysematous bulla [17].

Because at least 30 % of trauma cases are combination hemopneumothorax, it is feared that a thin chest tube can be too easily blocked. For this reason, use of 24-32 Fr tubes is suggested in adults [16, 77, 131, 135]. This recommendation was confirmed with a current prospective observational study [79]. In 353 cases overall, there was no disadvantage regarding size of a retained hemothorax or need for extra tube placement when thinner tubes (28-32 Fr) were inserted. A randomized study [140] treated patients with isolated hemothorax (without pneumothorax, unilateral, without coma or sedation, coagulopathy, etc.) either with conventional chest tube drainage or with central venous 16G catheter. Success and complication rates were comparable. Another randomized study of patients with traumatic uncomplicated pneumothorax by Kulvatunyou et al. [85] had similar results. This study, however, included only patients who were conscious and cooperative, without urgent need of decompression. Complication and success rates were comparable, but the 14 Fr pigtail catheter was less painful than the 28 Fr chest tube. The same group reported similar good experiences with drainage of hemothorax [86].

Because of general experience with blood clots blocking small-lumen catheters, these studies should be considered critically. Additional studies are needed before recommendations regarding the use of small lumen tubes to decompress hemothorax can be included or given, especially since the patients in these studies were stable, non-ventilated patients. It’s possible that such patients can be adequately treated with less invasive catheters.

Implementation (Needle Decompression)

Controlled studies have not investigated the best technique, so this section is according to expert opinion. It is important to choose the correct puncture site, because there is a tendency to puncture medial to the mid-clavicular line [109]. An in-dwelling venous cannula with an attached syringe set to aspirate should be inserted in a straight path until air is aspirated [39]. Once the pleural space has been reached, the steel stylet should be left in place to prevent kinking of the unprotected plastic cannula [43, 112]. Some authors argue that the stylet should be withdrawn several millimeters or removed completely, leaving only the plastic cannula in place [58, 109]. However, kinks in the cannula have been documented [109].

Implementation (Surgical Decompression and Chest Tube Drainage)

Key Recommendations:

1.43

Recommendation

2011

GoR B

The pleural space should be opened by mini-thoracotomy. Chest tubes should be placed without a trocar.

Explanation:

Controlled studies have never assessed the best technique. Most experts recommend a standardized procedure as follows. Chest tubes must be placed using sterile technique. After skin disinfection, local anesthesia will be applied to the level of the parietal pleura to patients who are not deeply unconscious. A horizontal skin incision approximately 4-5 cm in length is made with a scalpel along the upper border of the rib below the intercostal space to be punctured, or one rib deeper (for cosmetic reasons, this should be done at the appropriate level in the sub-mammary fold for women). The subcutaneous tissues and the intercostal muscles on the upper rib border are opened with blunt scissors or a clamp. The pleura can be separated by blunt dissection or using a small cut with the scissors. Next, a finger (sterile glove) is inserted into the pleural space to verify the correct approach and to ensure a lack of adhesions or release any adhesions present [16, 48, 103, 121, 131, 132, 135]. If a simple thoracic opening is desired, the wound is then covered with a sterile dressing, left untaped on one side (for venting).

If a chest tube drain is to be inserted, the procedure continues as follows. A subcutaneous tunnel is not considered necessary by all experts [132]. Blind preparation of the passage with a trocar should never be performed. Serious complications have been reported with this, such as perforation of the left ventricle, the right atrium in a patient with kyphoscoliosis [100], or the lungs [63]. The complication rates in studies of the trocar technique are much higher than those evaluating surgical technique (11.0 % vs. 1.6 %). A prospective cohort study (in intensive care patients) reported that the use of a trocar was associated with significantly higher rates of misplacement [119]. Some experts recommend that ventilation should be paused briefly at the moment of pleural separation and tube insertion to reduce the risk of parenchymal injury in the inflated lung [63, 113, 114].

The chest tube is then inserted through the prepared channel. A finger can be inserted as well to guide the tube. The tip of the tube can also be held and inserted with a clamp. Alternatively, a trocar can be used to guide the tube (not for preparation or for perforation of the thoracic wall!). When doing this, it is important that the tip of the trocar does not protrude beyond the tip of the drain, and that no force is applied while the tube is advanced [135].

It is unclear how the tube tip should be positioned. Generally, recommendations are that the tube tip should be directed posterior/caudal for hemothorax and anterior/cranial for pneumothorax. This doctrine was challenged in a recent study, in which the drain position had no influence on success rate (drainage of air and blood) [19].

To avoid displacement, the tube must be secured with steri-strips or a suture. A self-locking plastic loop can also be used for fixation [101].

Alternative Insertion Techniques

Alternative insertion techniques have not been used much in the pre-hospital setting. There is a lack of studies for the pre-hospital setting, particularly studies comparing to standard technique. Two techniques (Seldinger technique, Veres needle) must be briefly discussed.

Use of a laparoscopic trocar cannula has been well studied compared to other alternative techniques, but has not been directly compared to the standard surgical technique [18, 64, 82, 92, 136]. A prospective cohort study including 112 patients, 39 of them trauma patients, compared techniques and complications [136]. The only complication was lung injury (0.89 %). In a pig model, the technique with a Veres nail had a 100 % success rate within an average 70 seconds, versus a classic 14G needle with 21 % success within 157 seconds. Puncture-related injuries to the internal organs were not seen with either method [69, 91].

In 1988, Thal and Quick described a technique of inserting a guidewire after direct puncture, then expanding the canal with progressive dilators and eventual inserting the chest tube (to 32 Fr) over the guidewire [111, 133]. The patient had initial success in 24 pediatric patients (14 pneumothorax, three hemothorax, seven other). Kinking of the catheters (10-20 Fr) occurred in five cases (approximately 20 %) [2]. A systematic review found no advantage for the Seldinger technique over other techniques [7].

Drainage Systems

Suitable collection systems are also commercially available for pre-hospital use. An ideal system, in which positive pressure cannot develop, should have an appropriate valve, an indicator for the presence of an air fistula, and a sufficiently large reservoir to collect blood or secretions. Systems that operate only in upright or hanging positions seem impractical, since this cannot be guaranteed at all times, particularly during transport. For use in the pre-hospital setting, systems not requiring the additional filling with water are preferable. Systems using bags have the advantage over bottles or containers, since they require less space.

Reliable data regarding the question of whether and when chest drainage can be left open or not, and which collection system should be used are not available. Thus, a strong, evidence-based, uniform expert recommendation cannot be given. However, it seems that the commercially available thorax drainage bags with pressure-relief valves are the most appropriate in fulfilling all of these requirements, even if there have not been published sustainable clinical results.

No Closure

Theoretically, for patients receiving pressure ventilation, the chest drainage could be left open. In such cases, there would be a higher risk of contamination of the pleural space with subsequent pleural empyema. A potentially increased risk for the transmission of infectious diseases to the emergency personnel and contamination would occur with unprotected leakage of blood from the tube.

In spontaneously breathing patients, however, there would be the danger that on inspiration, air could be sucked into the pleural space and lead to lobar collapse. In this situation, the tube cannot remain open to the outside, and addition of a valve mechanism is necessary.

For these reasons, leaving the chest tubes open is not recommended.

Heimlich Valve

One commercially available valve device is the Heimlich valve. It was originally used to decompress spontaneous pneumothorax in spontaneously breathing patients [20]. In one of 18 cases, the valve stuck and no longer worked. In a retrospective comparison, the 19 Heimlich valve patients had shorter drainage and hospitalization times than 57 patients treated with a standard drainage system (one third of the patients had traumatic pneumothorax). However, patients with hemothorax were excluded and four patients in the Heimlich valve group transferred to the control group [110]. Thus, it’s unclear whether this experience is transferable to the pre-hospital setting. Other case reports have found that the valve stuck, causing an outflow diversion and leading to recurrent tension pneumothorax [71, 93]. Heimlich valves were used routinely during the Falklands War, and it was reported that valves stuck frequently from clots and needed repeated replacement, without further quantification of the problems [138]. Experimental studies found that two of eight valves malfunctioned, and after exceeding the expiration date, seven of eight valves were defective [71]. In addition to material fatigue, coagulated blood can also lead to malfunction. Uncertainty regarding valve function leads to an incalculable risk potential, and close monitoring during its use is necessary. The same concerns apply to all other valves except for multi-bottle systems. Because of the risk of a stuck valve from blood clots, contraindication of Heimlich valves for hemothorax has been discussed [66]. Thus, Heimlich valves can no longer be recommended.

Closed Bag or Chamber Systems

Although the attachment of a closed collection bag can reduce the risk of contamination and infection, in cases where there is a large enough air fistula, filling of the bag with air or blood can lead to recreation of positive pressure and tension developing in the pleural space. Here, continuous observation and repeated bag emptying is necessary. One must fear that failure of the chest tube drainage through the reversed pressure ratios in a bulging collection bag, particularly in the pre-hospital setting, could be easily overlooked because the inserted chest tube suggests that the tension pneumothorax has already been successfully treated. Perforation of a primarily closed simple bag system to avoid positive pressure is strongly discouraged for hygienic reasons.

In hospital conditions, generally a derivative of a two or three chamber system is used, with mainly closed commercial collection systems in use. The advantages are the good functionality and the protection against environmental contamination with blood. They are also the definitive collection systems for further treatment in the hospital. In prehospital use, problems arise because they are awkward to handle when repositioning and during transport, and there is a resulting risk of overturning. Overturning can lead to uncontrolled displacement of the filling fluids between the chambers, risking functionality [67]. One major advantage of these systems, however, is the ability to place suction and to quantify the collected fluids.

The evidence table for this chapter is found on page 113 of the guideline report.

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1.5 Traumatic Brain Injury

Interventions at the Accident Scene

Vital Functions

Key Recommendations:

1.44

Recommendation

Modified 2016

GoR B

In adults, the goal should be normal arterial pressure with systolic blood pressure not falling below 90 mmHg (age-adapted in children).

1.45

Recommendation

Modified 2016

GoR B

Arterial oxygen saturation below 90% should be avoided.

Explanation:

Due to ethical considerations, prospective randomized controlled trials examining the effects of hypotension and/or hypoxia on treatment outcomes are not justifiable. However, there are many retrospective studies [9, 20] that provide evidence of markedly worse outcomes when hypotension or hypoxia are present. The absolute priority of diagnostic and therapeutic measures at the accident scene are thus, the recognition and, if possible, immediate elimination of all conditions associated with decreased blood pressure or blood oxygen saturation. However, aggressive therapy to increase blood pressure and oxygen saturation has not always been supported, due to adverse effects. The goals should be normal oxygen, carbon dioxide, and blood pressure levels.

Indications for intubation include insufficient spontaneous respiration and decreased level of consciousness with or without adequate spontaneous breathing. The major argument for intubation is the efficient prevention of secondary brain injury through hypoxia. This is a threat in unconscious patients even when there is adequate spontaneous breathing, since impaired reflexes can result in aspiration. The major argument against intubation is the hypoxic injury that can occur during an unsuccessful intubation. However, Bernard et al. reported a significantly higher percentage of good neurological outcomes (defined as 5 to 8 points on the extended Glasgow Outcome Scale, GOSe) six months after traumatic brain injury in patients with GCS ≤ 9 who were intubated at the accident scene [4].

Interventions to support hemodynamic stability in multiply injured patients are described elsewhere in this guideline (see Chapter 1.3). Specific recommendations cannot be made regarding the infusion solution to be used for volume replacement in multiply injured patients with traumatic brain injury [9].

Neurologic Examination

Key Recommendations:

1.46

Recommendation

Modified 2016

GoR A

Repeated examinations and documentation of level of consciousness, pupillary function, and Glasgow Coma Scale must be performed.

Explanation:

In the literature, the only clinical findings with prognostic value are the presence of wide, fixed pupils [9, 19, 21] and deteriorations in the GCS score [9,13,19,21], both of which correlate with a poor treatment outcomes. There are no prospective randomized controlled trials on guiding treatment according to clinical findings. Since such studies are not ethically justifiable, during the development of this guideline, the importance of the clinical examination was raised to grade of recommendation A under the assumption (currently unconfirmable) that outcomes can be improved with the earliest possible detection of life-threatening conditions that have associated therapeutic consequences.

Despite various difficulties [3], the Glasgow coma scale (GCS) has established itself internationally as the assessment tool to estimate of the momentary severity of a brain injury/impairment. It enables a standardized assessment of eye opening, verbal response, and motor response. The neurologic findings, documented according to the time, are essential to the further course of treatment. Frequent checks of neurologic findings must be performed to detect any deterioration [9, 10].

However, the use of GCS alone risks a diagnostic gap, particularly if only total values are considered. This applies particularly to an early acute midbrain syndrome, which can manifest as spontaneous decerebrate rigidity, which is not recorded on GCS, or to associated injuries of the spinal cord. Thus, motor function of the extremities must be examined and recorded, with lateral differentiation of the arms and legs - whether complete, incomplete, or no paralysis is present. The presence of decorticate or decerebrate rigidity should be noted. If voluntary movements are not possible, all extremities should be examined for reactions to painful stimuli.

If the patient is conscious, then orientation, cranial nerve function, coordination, and speech must also be noted.

Neuroprotective Therapy

Key Recommendations:

1.47

Recommendation

2011

GoR A

Glucocorticoid administration must be avoided.

Explanation:

According to current scientific understanding, the goals of interventions performed at the accident scene are to achieve homeostasis (normoxia, normotension, prevention of hyperthermia) and to prevent threatening complications. Secondary brain injury must be limited and optimal conditions must be provided for functional regeneration of injured but intact brain cells. This applies equally when multiple injuries are present.

To date, there has been no published evidence confirming the benefits derived from more extensive treatment regimens focused solely on neuroprotection. At present, no recommendation can be given for pre-hospital administration of 21-aminosteroids, calcium antagonists, glutamate receptor antagonists, or tris-(tris[hydroxy methyl]aminomethane) buffers [9,12,16,23].

Antiepileptic treatment prevents the incidence of epileptic seizures in the first week after trauma. However, the incidence of a seizure in the early phase does not lead to worse clinical outcomes [18, 20].

The administration of glucocorticoids is no longer indicated due to a significantly increased 14-day mortality [1, 17] with no improvements in clinical outcome [8].

Therapy for Suspected Severely Elevated Intracranial Pressure

Key Recommendations:

1.48

Recommendation

Modified 2016

GoR 0

In suspected cases of severely increased intracranial pressure, particularly with symptoms of transtentorial herniation (pupillary dilation, extensor synergy, extensor reflex to pain stimulation, progressive disorientation), the following measures can be applied:

•Hyperventilation

•Hypertonic saline

•Mannitol

Explanation:

In cases where transtentorial herniation is suspected and there are signs of acute midbrain syndrome (pupillary dilation, decerebrate rigidity, extensor reaction to painful stimuli, progressive loss of consciousness), hyperventilation can be initiated in the early phase after trauma [9, 20]. The reference value is 20 breaths per minute in adults and must be adapted for children according to age. Hyperventilation was often used in the past because of its often impressive effects in reducing intracranial pressure. However, because of associated vasoconstriction, it also reduces cerebral perfusion. Thus, aggressive hyperventilation involves a risk of cerebral ischemia and with it a worsening in clinical outcomes [20].

Administration of mannitol can reduce intracranial pressure (ICP) for a short time (up to one hour) [20]. When transtentorial herniation is suspected, it can be given without ICP measurement.

To date, there is little evidence that hypertonic saline solutions are neuroprotective. Mortality appears somewhat less than mannitol. However, this conclusion is based on a small number of cases and is not statistically significant [22].

In the time since the first version of this guideline was published, there has been no new evidence that mannitol or hypertonic saline solutions lead to better clinical outcomes in severe TBI [6, 14]. Unfortunately, there are no meaningful studies to date regarding this specific question (measures to combat suspected transtentorial herniation). One newer study [7] shows effects on ICP by both infusion solutions. Methodological weaknesses (small population, unclear statistics without confidence intervals, variation in GCS between the groups) limit the relevance of the study. Nevertheless, based on pathophysiological considerations, an optional recommendation for these interventions appears to be justified when there is clinical suspicion of severely increased ICP also at the accident scene or during transport. Since there are no clear differences in the effectiveness of mannitol and hypertonic saline solutions, the change in the order of recommendation is based principally on the relative ease of storage for hypertonic saline (see the “Hypertonic Solutions” section).

Although barbiturates have been recommended in previous guidelines for otherwise-uncontrollable increases in ICP [11], there is insufficient evidence for their use [15]. When barbiturates are administered, attention must be given to the negative inotropic effects, possible hypotension, and impaired neurological assessment.

Transport

Key Recommendations:

1.49

Recommendation

2011

GoR B

In cases of penetrating injuries, the perforating object should be left in place, or removed if necessary.

Explanation:

It is essential that polytrauma patients with symptoms of accompanying traumatic brain injury be admitted to a hospital with adequate treatment facilities. In cases of TBI with persistent unconsciousness (GCS ≤ 8), increasing confusion (deterioration of individual GCS values), pupillary changes, paralysis, or seizures, the treating hospital should definitely provide neurosurgical treatment for intracranial injuries [9].

No clear recommendations can be given regarding analgesia or relaxation for transport, as there is a lack of studies showing positive effects for TBI. Cardiopulmonary issues are much easier to manage with such measures; thus, the decision must be left to the judgment of the treating emergency physician. The disadvantage of this is the more or less severe limitations to neurologic assessment [20].

In cases of penetrating injuries, the perforating object should be left in place, or removed if necessary. Injured intracranial vessels are often compressed by the foreign body, so that removing it encourages the development of intracranial bleeding. Thus, removal must be carried out under surgical conditions with the ability for hemostasis in the injured brain tissue. Although there are no prospective randomized controlled studies on the optimal procedure for penetrating injuries, this approach makes sense from a pathophysiological perspective.

During transport, the possibility of accompanying unstable spine fractures should be considered and appropriate positioning applied (see Chapter 1.6).

Teeth and Tooth Fragments:

Key Recommendations:

1.50

Recommendation

New 2016

GPP

Avulsed teeth and tooth fragments should be collected, stored in a moist environment, and brought to the trauma center for re-implantation.

Explanation:

This can be carried out in a container with a specific cell-friendly solution, Ringer’s, or UHT milk [2, 5].

The evidence table for this chapter is found on page 122 of the guideline report.

References
  1. 1.

    Alderson P, Roberts I. Corticosteroids for acute traumatic brain injury. Cochrane Database Syst Rev. 2005;(1):CD000196.

     
  2. 2.

    Andersson L, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2012;28(2):88–96.

     
  3. 3.

    Balestreri M, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. 2004;75(1):161–2.

     
  4. 4.

    Bernard SA, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010;252(6):959–65.

     
  5. 5.

    Blomlof L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J Suppl. 1981;8:1–26.

     
  6. 6.

    Bulger EM, et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: A randomized controlled trial. JAMA J Am Med Assoc. 2010;304(13):1455–64.

     
  7. 7.

    Cottenceau V, et al. Comparison of effects of equiosmolar doses of mannitol and hypertonic saline on cerebral blood flow and metabolism in traumatic brain injury. J Neurotrauma. 2011;28(10):2003–12.

     
  8. 8.

    Edwards P, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365(9475):1957–9 [LoE 1b].

     
  9. 9.

    Gabriel EJ, et al. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma. 2002;19(1):111–74 [Evidenzbasierte Leitlinie].

     
  10. 10.

    Karimi A, Buchardi H. Deutsche Interdisziplinäre Vereinigung für Intensiv-und Notfallmedizin (DIVI)—Stellungnahmen, Empfehlungen zu Problemen der Intensiv-und Notfallmedizin, ed. Aufl. Köln: asmuth druck+crossmedia; 2004.

     
  11. 11.

    Kraus JF, et al. The incidence of acute brain injury and serious impairment in a defined population. Am J Epidemiol. 1984;119(2):186–201.

     
  12. 12.

    Langham J, et al. Calcium channel blockers for acute traumatic brain injury (Cochrane Review). The Cochrane Library. vol. I. Chichester, John Wiley & Sons, Ltd.; 2004.

     
  13. 13.

    Marmarou A, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. 2007;24(2):270–80 [LoE 3a].

     
  14. 14.

    Morrison LJ, et al. The Toronto prehospital hypertonic resuscitation–head injury and multiorgan dysfunction trial: feasibility study of a randomized controlled trial. J Crit Care. 2011;26(4):363–72.

     
  15. 15.

    Roberts I. Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev. 2000;(2):CD000033.

     
  16. 16.

    Roberts I, et al. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004;(4): CD000567.

     
  17. 17.

    Roberts I, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004;364(9442):1321–8.

     
  18. 18.

    Schierhout G, Roberts I. Anti-epileptic drugs for preventing seizures following acute traumatic brain injury. Cochrane Lib. 2004;1.

     
  19. 19.

    The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Guidelines for the Management of Severe Traumatic Brain Injury, 3rd ed; 2007.

     
  20. 20.

    The Brain Trauma Foundation. Guidelines of prehospital management of traumatic brain injury, 2nd ed. Prehospital Emergency Care, vol. 12(Suppl); 2007. p. S1–52.

     
  21. 21.

    Tien HC, et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma. 2006;60(2):274–8 [LoE 3b].

     
  22. 22.

    Wakai A, Roberts I, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev. 2007;(1): CD001049 [LoE 3b].

     
  23. 23.

    Willis C. Excitatory amino acid inhibitors for traumatic brain injury (Cochrane Review). Cochrane library, vol. I. Chichester: John Wiley & Sons, Ltd.; 2004.

     

1.6 Spine

When should a spinal injury be presumed?

Which diagnostic interventions are necessary?

Key Recommendations:

1.51

Recommendation

2016

GoR A

A targeted physical examination including the spine and related functions must be performed.

Explanation:

Evaluation of the accident mechanism can give indications as to the probability of a spine injury [7]. Thus, the probability for these injuries increases with falls from a height and high-speed accidents [18].

Once the vital functions have been checked and secured in a conscious patient, examination of the spine at the accident scene includes an orienting neurological examination with sensory and motor components. A neurological deficit can indicate a spinal cord injury. Absence of back pain is not an exclusion criterion for relevant injury to the spine [17].

Inspection (signs of injury/deformity) and palpation (tenderness to pressure/palpation or palpable step deformity/ gaps between the spinous processes) complete the examination.

Although there are no scientific studies regarding the importance and required scope for physical examination of the spine in pre-hospital emergency medicine, these examinations remain indispensable for diagnosing potential spinal injuries. All of the investigations listed above serve to detect relevant, threatening or potentially threatening disorders and injuries that taken together can necessitate immediate and specific therapy or logistical decisions [6, 39].

Which associated injuries make a spinal injury more probable?

Key Recommendations:

1.52

Recommendation

2016

GoR A

In unconscious patients, spine injury must be assumed until there is evidence to exclude it.

Explanation:

There are particular injury patterns that are more commonly associated with spinal injuries. For example, there is a high incidence of spinal injuries in patients with relevant supraclavicular injuries or with severe injuries of other body regions [41].

How is the diagnosis of spinal injury made and how definite is it?

Explanation:

A number of groups have developed clinical decision-making rules to simplify the diagnosis of spinal injury and the indications for pre-hospital spine immobilization as well as to give structure to the primary radiological approach to potential spinal injuries after blunt trauma. Some of these decision-making rules have to do with the pre-hospital setting [13-15], and others with the emergency department [3, 18-20, 38].

The NEXUS Study [14, 29] formulated five criteria which, when lacking, make injury to the cervical spine unlikely.
  • Impaired level of consciousness

  • Neurological deficit

  • Spinal pain or muscle tension

  • Intoxication

  • Extremity trauma

Application of these five criteria yielded a sensitivity of 95 % with a negative predictive value of 99.5 %. Another study concentrating on polytrauma patients with potential c-spine injuries [33] found similar predictors. Thus, generalization of the NEXUS criteria seems appropriate and, in our opinion, also applicable to the thoracic and lumbar spine.

Prospective studies by Bandiera et al. and Stiell et al. demonstrated that clinically significant injuries can be unmasked in unconscious patients with a sensitivity of 100 % by applying the Canadian C-spine rule [1, 38].

Neurological deficits are crucial for the diagnosis of spinal cord damage (sensory and motor). Whether it is a complete or incomplete lesion and the segment height of the injury can often be determined only to a limited extent in the pre-hospital setting.

How should a spine injury be treated in the pre-hospital setting?

What is the technical rescue procedure of a person with spinal injury?

Key Recommendations:

1.53

Recommendation

Modified 2016

GPP

The cervical spine must be immobilized prior to the actual technical rescue during rapid and careful rescues. An exception is the need for immediate rescue (e.g. fire or risk of explosion).

Explanation:

The indications for spine immobilization during the technical rescue are based on patient condition. For example, in cases of acute life-threatening danger (fire, need for resuscitation), immediate rescue (e.g., with a Rautek/firefighter’s grip) can be performed without spinal immobilization. In cases of a rapid rescue, manipulation of the spine must be minimized; nevertheless, due to the patient’s condition, short rescue time is the focus. For the cervical spine, immobilization should be carried out with a cervical collar, even though the research literature has not yet substantiated this procedure to avoid secondary damage.

Depending on patient condition, slower, careful rescue (e.g., with removal of a car roof) can be considered, during which strict spinal immobilization should be carried out.

Treatment aids, such as scoop stretchers or backboards facilitate rescue of patients with spinal injuries from adverse locations.

How should a patient with spinal injuries be positioned/immobilized?

Explanation:

The first pre-hospital measure for someone injured in an accident should be c-spine immobilization manually or with a cervical collar, even though there is no high level of evidence for this. This places the c-spine in a neutral position. If this causes pain or increased neurological deficits, reposition to the neutral position should not be carried out. Neutral position of the c-spine can also be achieved with adults in the supine position by placing padding underneath the head [37].

Using a cervical collar alone allows some residual mobility of the c-spine. Better immobilization of the c-spine can be achieved with additional positioning on a vacuum mattress. This achieves the most effective immobilization of the entire spine. Incorporating the head with cushions or straps can further restrict possible residual movement of the c-spine. To date, no randomized studies have shown positive effects of spine immobilization [25]. Other aids such as a scoop stretcher provide only limited immobilization.

When traumatic brain injury is present and c-spine injury is suspected, the use of a rigid collar should be weighed with the risk of a potential increase in intracranial pressure [8, 11, 21, 23, 24, 31]. An alternative immobilization method is fixation of the patient in a vacuum mattress with upper body positioning and additional fixation of the head without the rigid collar.

How is a person with spinal injury transported?

Key Recommendations:

1.54

Recommendation

Modified 2016

GPP

Transport should be as gentle and pain-free as possible.

Explanation:

A patient with spinal injury should be transported as gently as possible, i.e. without unnecessary external force, to avoid pain and potential secondary injury. After appropriate immobilization, analgesia can be administered for transport. A helicopter offers the smoothest form of transport. It also often offers a time advantage for patients with spine and neurological injuries who must be transported to a specialized center that is farther away.

Are there specific interventions to be performed in the pre-hospital phase for spinal injuries?

Explanation:

Currently, there is no evidence for meaningful treatment of spinal injuries in the pre-hospital setting. Pre-hospital administration of cortisone to patients with spine injuries and neurological deficits cannot be recommended according to the current body of evidence [2, 30]. In general, the goals should be adequate perfusion and oxygenation for patients with spinal injuries and neurological deficits. The diagnosis of neurogenic shock requires that hemorrhagic shock with hypovolemia has been excluded. The level of evidence of specific therapy for neurogenic shock is not high; however, volume replacement should be cautious considering the normovolemia of the patient, and vasopressors should then be favored.

Is it advantageous for a spinal injury patient to be transported primarily to a spine trauma center?

Key Recommendations:

1.55

Recommendation

Modified 2016

GoR B

Patients with neurologic deficits and suspected spine injury should be primarily transported to an appropriate trauma center.

Explanation:

Various studies have found that operative treatment of spine injuries within 72 hours significantly reduces morbidity (ventilation time, incidence of pneumonia and pulmonary failure) as well as duration of intensive care and hospital admission [4, 5, 9, 22, 35, 36]. The most severely injured patients (ISS > 33) with thoracic spine injuries seem to benefit particularly [34]. Current evidence is inconclusive as to the extent that early decompression of spinal injuries with neurological deficits positively influences neurological outcomes [10, 12, 16, 28, 30, 32, 42]. However, several of these studies do show a positive trend for early decompression (although the definition of “early” varies according to study from 8 to 72 hours after trauma), particularly in cases where there are symptoms of incomplete cord lesions, without increasing the intraoperative complication rate [27, 43]. Neurological outcome was, however, correlated with the expertise of the trauma center in the treatment of spinal injuries [26].

Thus, particularly in isolated spinal trauma and when the patient’s condition is not acutely life-threatening, the patient should be transported directly to an appropriate spine trauma center [40, 42].

Notes:

The references underlying these recommendations generally refer to in-hospital situations that, when relevant, were transferred to the pre-hospital setting. It should also be considered that the organization of pre-hospital care in certain countries varies considerably compared to the German emergency physician service (e.g. paramedics), which is why the results from the global literature are often not completely relevant to the situation in Germany.

References
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    Bandiera G, et al. The Canadian C-spine rule performs better than unstructured physician judgment. Ann Emerg Med. 2003;42(3):395–402.

     
  2. 2.

    Bernhard M, et al. Spinal cord injury (SCI)—prehospital management. Resuscitation. 2005;66(2):127–39.

     
  3. 3.

    Blackmore CC, et al. Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use. Radiology. 1999;211(3):759–65.

     
  4. 4.

    Bliemel C, et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76(2):366–73.

     
  5. 5.

    Cengiz SL, et al. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959–66.

     
  6. 6.

    Chen XY, et al. Corticospinal tract transection prevents operantly conditioned H-reflex increase in rats. Exp Brain Res. 2002;144(1):88–94.

     
  7. 7.

    Cooper C, Dunham CM, Rodriguez A. Falls and major injuries are risk factors for thoracolumbar fractures: cognitive impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma. 1995;38(5):692–6.

     
  8. 8.

    Craig GR, Nielsen MS. Rigid cervical collars and intracranial pressure. Intensive Care Med. 1991;17(8):504–5.

     
  9. 9.

    Croce MA, et al. Does optimal timing for spine fracture fixation exist? Ann Surg. 2001;233(6):851–8.

     
  10. 10.

    Curt A, Ellaway PH. Clinical neurophysiology in the prognosis and monitoring of traumatic spinal cord injury. Handb Clin Neurol. 2012;109:63–75.

     
  11. 11.

    Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996;27(9):647–9.

     
  12. 12.

    Dobran M, et al. Surgical treatment of cervical spine trauma: Our experience and results. Asian J Neurosurg. 2015;10(3):207–11.

     
  13. 13.

    Domeier RM, et al. Prospective validation of out-of-hospital spinal clearance criteria: a preliminary report. Acad Emerg Med. 1997;4(6):643–6 [LoE 1a].

     
  14. 14.

    Domeier RM, et al. Multicenter prospective validation of prehospital clinical spinal clearance criteria. J Trauma. 2002;53(4):744–50.

     
  15. 15.

    Ducker TB. Treatment of spinal-cord injury. N Engl J Med. 1990;322(20):1459–61.

     
  16. 16.

    Fehlings MG, Cadotte DW, Fehlings LN. A series of systematic reviews on the treatment of acute spinal cord injury: a foundation for best medical practice. J Neurotrauma. 2011;28(8):1329–33.

     
  17. 17.

    Frankel HL, et al. Indications for obtaining surveillance thoracic and lumbar spine radiographs. J Trauma. 1994;37(4):673–6.

     
  18. 18.

    Hanson JA, et al. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. AJR Am J Roentgenol. 2000;174(3):713–7.

     
  19. 19.

    Hoffman JR, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94–9.

     
  20. 20.

    Holmes JF, et al. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003;24(1):1–7.

     
  21. 21.

    Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56(6):511–3.

     
  22. 22.

    Kerwin AJ, et al. The effect of early spine fixation on non-neurologic outcome. J Trauma. 2005;58(1):15–21.

     
  23. 23.

    Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J Emerg Med. 1999;17(2):135–7.

     
  24. 24.

    Kuhnigk H, Bomke S, Sefrin P. Effect of external cervical spine immobilization on intracranial pressure. Aktuelle Traumatol. 1993;23(8):350–3.

     
  25. 25.

    Kwan I, Bunn F, Roberts I. Spinal immobilisation for trauma patients. Cochrane Database Syst Rev. 2001;2:CD002803.

     
  26. 26.

    Macias CA, et al. The effects of trauma center care, admission volume, and surgical volume on paralysis after traumatic spinal cord injury. Ann Surg. 2009;249(1):10–7.

     
  27. 27.

    McKinley W, et al. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil. 2004;85(11):1818–25.

     
  28. 28.

    Mirza SK, et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. 1999;359:104–14 [LoE 4].

     
  29. 29.

    Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 1999;3(1):1–6 [LoE 1a].

     
  30. 30.

    Pointillart V, et al. Pharmacological therapy of spinal cord injury during the acute phase. Spinal Cord. 2000;38(2):71–6.

     
  31. 31.

    Raphael JH, Chotai R. Effects of the cervical collar on cerebrospinal fluid pressure. Anaesthesia. 1994;49(5):437–9.

     
  32. 32.

    Rosenfeld JF, et al. The benefits of early decompression in cervical spinal cord injury. Am J Orthop. 1998;27(1):23–8.

     
  33. 33.

    Ross SE, et al. Clinical predictors of unstable cervical spinal injury in multiply injured patients. Injury. 1992;23(5):317–9 [LoE 2b].

     
  34. 34.

    Schinkel C, Anastasiadis AP. The timing of spinal stabilization in polytrauma and in patients with spinal cord injury. Curr Opin Crit Care. 2008;14(6):685–9.

     
  35. 35.

    Schinkel C, et al. Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. J Trauma. 2006a;61(1):156–60 (discussion 160).

     
  36. 36.

    Schinkel C, et al. Does timing of thoracic spine stabilization influence perioperative lung function after trauma? Orthopade. 2006b;35(3):331–6.

     
  37. 37.

    Schriger DL, et al. Spinal immobilization on a flat backboard: does it result in neutral position of the cervical spine? Ann Emerg Med. 1991;20(8):878–81.

     
  38. 38.

    Stiell IG, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841–8.

     
  39. 39.

    Surgeons ACo. Advanced Trauma Life Support for Doctors. 1997.

     
  40. 40.

    Tator CH, et al. Neurological recovery, mortality and length of stay after acute spinal cord injury associated with changes in management. Paraplegia. 1995;33(5):254–62.

     
  41. 41.

    Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. AJR Am J Roentgenol. 1990;155(3):465–72.

     
  42. 42.

    Walters BC, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60(Suppl 1):82–91.

     
  43. 43.

    Waters RL, et al. Emergency, acute, and surgical management of spine trauma. Arch Phys Med Rehabil. 1999;80(11):1383–90.

     

1.7 Extremities

Priority

Key Recommendations:

1.56

Recommendation

2011

GoR A

Profusely bleeding extremity injuries that can impair vital functions must be given priority.

1.57

Recommendation

2011

GoR A

The treatment of extremity injuries must avoid further damage and not delay overall rescue time in cases when other threatening injuries are present.

Explanation:

Securing vital signs and examination of the head and torso should precede examination of the extremities. Particular features nay be found in extremity injuries with severe blood loss [41, 52].

Severe and immediately life-threatening bleeding must be controlled immediately with appropriate positioning, compression, or tourniquet placement. For example, according to the ETC (European Trauma Course), this type of bleeding can be recognized and treated during the 5 second check.

The recognition of major external but not immediately life-threatening bleeding is important and is generally performed with the “C” (circulation), while minor bleeding is recorded during the secondary survey [41].

The highest priorities are to avoid further damage, to restore and stabilize vital functions, as well as to transport to the closest suitable hospital [20, 47]!

Management of extremity injuries (irrigation/wound care/splinting) should not delay rescue time when additional life-threatening injuries are present [44].

Diagnostic Studies

Medical History

An exact account of the circumstances of the accident (by the patient or a witness) should be collected with as much detail as possible to obtain sufficient information regarding the forces at work and when applicable, the grade of contamination for open wounds [5, 52].

In addition to the accident history and time of trauma, if possible, information should be gathered regarding allergies, medications, and previous medical history as well as time of the last meal. Tetanus immunization status should also be collected with the history [41, 60].

Examination

Key Recommendations:

1.58

Recommendation

2011

GoR B

All extremities of an accident victim should be examined in the pre-hospital setting.

Explanation:

Conscious patients should be asked first regarding complaints and localization. If they are pain, adequate analgesia should be given early [41]. A pre-hospital examination should be performed [20]. At the accident scene, injuries should be evaluated enough to assess injury severity without unnecessary delay in overall rescue time [5]. It should be an exploratory survey from head to feet and not take longer than five minutes [60].

The examination should be performed in this order: inspection (deformity, wounds, swelling, perfusion), test for stability (crepitus, abnormal mobility, direct or indirect signs of fracture), assessments of circulation, motor function, and sensation. The soft tissues should also be evaluated (closed vs. open fractures, evidence of compartment syndrome) [20, 41, 52]. Capillary reperfusion can be compared bilaterally [41].

Leather clothing, e.g. motorcycle apparel, should be left in place as much as possible, since it serves as a splint with compression effects, especially for the pelvis and lower extremities [25, 41].

Treatment

General

Key Recommendations:

1.59

Recommendation

2011

GoR B

Even in cases of suspected injury, the extremity should be immobilized prior to moving/transporting a patient.

Explanation:

Immobilization of an injured extremity is an important pre-hospital intervention. An injured extremity should be immobilized against rough motion and prior to patient transport. The reasons for this are to alleviate pain, to avoid further soft-tissue injury or bleeding, as well as to minimize the risk of fat emboli and neurological damage [41, 60].

Even suspected injuries should be immobilized [19, 60].

The joints proximal and distal to the injury should be included in the immobilization [19, 20, 46, 60]. The injured extremities should be supported in a flat position [10]. Particularly in cases of shortened femur fracture, traction/immobilization should be carried out under traction to minimize bleeding [5, 41]. Vacuum splints enable immobilization in abnormal positions. Vacuum splints are rigid and adapt to the shape of the extremity [41]. Air chamber splints are suitable to splint upper extremity injuries except for injuries around the shoulder joint. They are appropriate to immobilize lower extremity injuries of the knee, lower leg, and foot. Once applied, the air in the air chamber splints and the peripheral circulation must be checked regularly to recognize early any perfusion problems or development of compartment syndrome [10]. The time of splint application should be documented, for example noted on the splint itself. One advantage of the air splint is its low weight. The disadvantage is compression of the soft tissues, which can cause secondary damage. Thus, vacuum splints are preferred. Air and vacuum splints are both unsuitable for immobilization of fractures near the shoulder joint or femur fractures [11]. Cooling can reduce swelling and alleviate pain [19]. Femoral injuries can be adequately immobilized with a vacuum mattress or a rigid splint without complications. Traction splints can be applied by rescue workers.

A retrospective study with 4513 rescue calls by paramedics in the American Emergency Medical Service (EMS) identified 16 patients (0.35 %) with injuries of the mid-femur. While only minor injuries were diagnosed in eleven of these patients, five (0.11 %) were treated for femoral fractures. Traction splints were applied in three of these five patients. In one case, the traction splint needed to be removed because of excessive pain, and rigid immobilization was applied. One patient could not be treated with traction because of a concomitant hip trauma injury. One other patient was free of pain and transported in a comfortable position. The authors concluded that femoral injuries and/or suspected fractures are uncommon and easily treated on a backboard or with rigid immobilization. Thus, traction splints do not necessarily need to be applied by the rescue service [1]. Traction splints should not be applied to patients with multiple injuries in particular, since there are often contraindications to their use (pelvic/knee/leg/ankle injuries) [59]. Because of the existing contraindications for use of traction splints, particularly in critically injured patients, they are used only rarely. Traction splints are also contraindicated for use in displaced proximal femoral fractures [13].

Traction splints are useful and depending on the model, easy to apply for femoral fractures; thus, further studies are necessary. Traction splints reduce muscle spasms and thus, alleviate pain. Femoral shape is restored through traction and with the reduced volume there is a corresponding decrease in bleeding [14, 54, 55].

Photographs of wounds/open fractures can be taken for documentation (polaroid/digital). Photographic documentation of wounds, open fractures, or identified deformities appears useful, since this can avoid the need for re-exposure of wounds dressed or extremities immobilized in the pre-hospital setting until it is time for definitive treatment. Photographic documentation can help the subsequent treating physician in injury assessments. Photographic documentation may not extend the management/rescue time and must comply with privacy protection requirements [5, 41].

Severity and extent of injuries must be documented in the emergency physician protocol and the findings should be submitted to the subsequent treating surgeon, personally if possible [9].

Fractures

Key Recommendations:

1.60

Recommendation

2011

GoR B

Grossly displaced fractures and dislocations should be approximately reduced in the pre-hospital setting if possible, particularly in cases of accompanying limb ischemia or longer rescue times.

Explanation:

The primary goal is to secure the local and peripheral circulation and to avoid secondary damage. Anatomic reduction is not the primary goal. More important is appropriate axial alignment and stable positioning with restoration of an adequate local and peripheral circulation [9, 11]. If there is no neurovascular compromise of the extremity distal to the injury, reduction can be foregone, in principle [5]. Grossly displaced fractures and dislocations should be approximately reduced to a more neutral position with axial traction and manual correction in the pre-hospital setting if possible, particularly in cases of accompanying limb ischemia or longer rescue times. It is important to perform assessments of peripheral perfusion as well as motor and sensory function (as possible) before and after reduction [9-11, 20, 41, 47]. Too much axial traction should be avoided, as this increases compartment pressures and decreases soft-tissue perfusion [9, 11].

Immediate attempts at reduction are called for when there are neurological or vascular deficits distal to the fracture. The same applies when the soft tissues or skin are compromised [41]. After successful immobilization, the peripheral perfusion, sensory and motor function should be re-checked [5, 41]. If neurovascular status worsens after a reduction attempt, the limb should be restored to the original position and stabilized as well as possible [41]. It is necessary to check whether reduced traction is necessary.

Reduction of ankle fracture/dislocations should only be performed by experienced providers. Otherwise, immobilization in the presenting position should be attempted [41]. In the case of common displaced ankle fractures with obvious deformity of the joint, the reduction should be performed at the accident scene. With adequate analgesia, controlled and continuous longitudinal traction with both hands on the calcaneus and dorsum of the foot can achieve an approximate reduction, which can then be immobilized. Neurovascular status of the limb should be documented again after the reduction.

Obvious fractures of a long bone shaft should also be treated in this manner. It is more difficult to estimate the full extent of fractures closer to the joints. Once the fracture is immobilized in a pain-free position, the patient should be transferred as quickly as possible to the hospital for further diagnostic studies [5, 60].

Excessive longitudinal traction should be avoided in distal femur fractures as this can compromise the popliteal vessels. The knee joint can be positioned in slight flexion (30-50 degrees) [10].

Open Fractures

Key Recommendations:

1.61

Recommendation

2011

GoR B

Each open fracture should be cleaned of coarse contamination and given a sterile dressing.

Explanation:

Each open fracture should be identified and coarse contamination should be removed immediately [41]. Active bleeding should be controlled according to the following levels of intervention. Open fractures can be irrigated with normal saline solution [5, 41, 44, 51]. All open wounds should be covered with sterile dressings [9, 10, 20, 41, 51, 60]. Sterile dressings should be applied to open wounds without further measures for cleaning or disinfection. Coarse contamination should be removed [9-11]. Afterwards, they should be immobilized like closed injuries [51, 60]. Similar to closed fractures, it is important to give sufficient analgesia. The status of peripheral perfusion, sensory and motor functions should be documented immediately before and after application of an immobilization aid and should be checked regularly over the course of transport. When there is sufficient information and documentation from the rescue services, the dressings applied in the pre-hospital setting can be left in place until primary surgical treatment, with the goal of preventing further microbial contamination [41, 51].

Anti-microbial therapy should be initiated as soon as possible. Without antibiotic prophylaxis, the risk of infection rises markedly after five hours [51]. If available, intravenous antibiotics can be administered in the pre-hospital setting, normally with a 2nd generation cephalosporin with good bone penetration [10]. If the rescue time is prolonged, pre-hospital antibiotics should be given [44].

Key Recommendations:

1.62

Recommendation

Modified 2016

GoR A

Active bleeding must be treated according to the following stepwise interventions:

1. Manual compression

2. Compression dressing

3. Tourniquet

1.63

Recommendation

New 2016

GoR 0

If the foregoing measures are unsuccessful, hemostyptics can also be applied.

Explanation:

Measures to control bleeding must follow a stepwise approach. A primary attempt must be made to control active bleeding with manual compression and elevation of the extremity. Afterwards a pressure dressing must be placed. If this fails, a second pressure dressing must be placed over the initial dressing. A pack of bandages can be used as an aid to focused compression. If bleeding persists, an attempt must be made to apply pressure to an artery proximal to the injury. If possible, a tourniquet must be applied. For exceptional cases, the vessel can be clamped (cases of amputation, longer transport, neck vessels, anatomic positioning making tourniquet placement impossible) [9, 10, 20 41, 56].

Key Recommendations:

1.64

Recommendation

Modified 2016

GoR B

•A tourniquet should be used immediately in cases of:

•Life-threatening bleeding/multiple sources of extremity bleeding

•No access to the actual injury

•Multiple bleeding patients

•Profuse bleeding of the extremities with concomitant critical A, B, or C problems

•Lack of hemostasis using other measures

•Profuse bleeding of the extremity with time pressure from a dangerous environment

Tourniquet

Use of a tourniquet requires appropriate analgesia [41]. Blood pressure cuffs can be applied with 250 mmHg to the upper arm and 400 mmHg to the thigh [9, 11]. The time of tourniquet application should be recorded [41, 42, 53]. The tourniquet must completely interrupt arterial blood flow. An incorrectly applied tourniquet can increase bleeding (when only the low-pressure system is compressed) [42]. Effectiveness should be assessed according to bleeding stoppage, and not by the disappearance of the distal pulse. In cases of fracture, bleeding can continue from the bone marrow [42].

If a tourniquet is ineffective, it should be re-applied with more pressure, and only after that, a second tourniquet should be considered, applied directly proximal to the first [42]. Cooling the extremity with an applied tourniquet can increase ischemia tolerance for longer rescue times [27].

There is insufficient evidence regarding the safe duration of tourniquet application. The general recommendation is 2 hours; however, this is based on evidence collected from normovolemic patients with pneumatic tourniquets [42]. If the transport time until operative treatment is less than one hour, the tourniquet can be left in place. For longer rescue times (> 1 hour), attempts should be made to release the tourniquet in a patient whose condition has stabilized. If bleeding is renewed, the newly applied tourniquet should remain in place until it is managed in the operating room [42]. After 30 minutes, the tourniquet should be checked to see whether it is still necessary. This is not indicated if the patient is in shock or if the attendant circumstances are adverse [21].

A retrospective case study of war casualties from the British military database found that of 1375 patients treated in English field hospitals over a particular time period, tourniquets were applied in 70 (5.1%). There were 107 tourniquets applied overall; 17 patients (24 %) had two or more tourniquets in place. Of these, five had double tourniquets applied for the same injury, and twelve had bilateral tourniquets (maximum number per patient: four, two on each lower extremity). 106 of the tourniquets were applied before reaching the field hospital. 61 of these 70 patients (87.1 %) survived. The mean ISS for survivors was 16, and for the mortalities (only six could undergo autopsy) was 50.

In the period of time before tourniquet use became standard (February 2003 to April 2006), only 9% of patients (6 %) were treated with tourniquets. In the following period (April 2006 to February 2007), 64 patients (91 %) received tourniquets. Without mentioning the total number of casualties in this period, the authors reported a 20-fold increase in tourniquet use. There were three complications directly caused by the tourniquets. There were two compartment syndromes (one each of the upper and lower leg, one after incorrect tourniquet application) as well as an ulnar nerve injury (without further details of follow up). Tourniquet application was assessed as life-saving in four cases of patients with isolated extremity injuries, hypovolemic shock and massive transfusion (including Factor VIIa administration) [15].

A retrospective study by Beekley et al., including 165 patients with traumatic amputation or severe vascular injury to an extremity, reported that pre-hospital application of tourniquets resulted in better bleeding control; this was particularly true in patients with multiple injuries (ISS > 15). Forty percent of soldiers (n = 67) received a tourniquet. There was no reduced mortality. The average tourniquet time was 70 minutes (minimum 5 minutes, maximum 210 minutes); there were no complications associated with use [12].

In a prospective cohort study of 232 patients with 428 applied tourniquets, Kragh et al. found no correlation between tourniquet time (average 1.3 hours) and morbidity (thromboses, number of fasciotomies, paresis, amputations). With tourniquet times over two hours there was a trend towards increased morbidity regarding amputations and fasciotomies.

A tourniquet should be applied as soon as possible. If the distal pulse is still present after tourniquet application, another tourniquet should be placed just proximal to the first to increase effectiveness. No materials should be used beneath the tourniquet, as these can lead to loosening. Tourniquets should be placed directly proximal to the wound. Tourniquets should be reevaluated for effectiveness over the course of treatment [36]. The use of tourniquets has been associated with higher survival probability. The use of tourniquets before the onset of shock has been associated with a higher survival probability, also when application occurs in the pre-hospital phase. Amputation was not required as a result of tourniquet use. The time of tourniquet application must be documented in the emergency medical record and must be reported during patient handover. In addition to the emergency medical record, the time of application can be written on the patient’s skin with a waterproof marker just proximal to the tourniquet.

A study of 2838 U.S. military casualties in Baghdad with severe extremity injuries found that 232 patients (8.2 %) were treated with 428 tourniquets (on 309 injured extremities). Of these, 13 % died. Matched pair analysis including the parameters Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), gender (all male), and age, of 13 casualties receiving tourniquets (survival rate 77 %, 10 of 13) and five patients (more were not identified during the time period in question) not receiving tourniquets (in whom there was indication for tourniquet application, and who all died in the pre-hospital phase, most after only 10-15 minutes!) found that early application of tourniquets significantly increased the survival probability in severe extremity injuries (p < 0.0007). In ten patients, the tourniquet was only applied after shock had manifested, and of these, nine died (90 %). The tourniquet was applied before the onset of shock in 222 patients, and only 22 of these died (10 %, p < 0.0001). 22 of the 194 patients receiving tourniquets during the pre-hospital phase (11 %), and 9 of 38 (24 %) receiving tourniquets first in the “emergency department,” died (p = 0.05). Transient nerve paralysis occurred in ten cases without correlation to tourniquet time [37].

The use of tourniquets is an effective and simple (for medical and non-medical personnel) method to prevent exsanguination in the military pre-hospital setting [40]. The use of tourniquets is a safe, fast, and effective method to control bleeding from open extremity injuries and should be used routinely, and not only as a last resort (civilian study) [29]. Application of a tourniquet is considered a temporary measure to achieve rapid and effective hemostasis.

The goal should always be conversion of a tourniquet. This means that it should be replaced as soon as possible with other bleeding control measures. Given the short pre-hospital rescue times in civilian emergency services, conversion should only occur during the pre-hospital setting in exceptional cases (e.g. during long transport times during mountain rescues). More often the conversion should be delayed until early definitive surgical management occurs in the emergency department or in the operating room. Tourniquets can contribute to decreased mortality of war casualties and have low complication rates (nerve paralysis, compartment syndrome). The loss of an extremity because of tourniquet application is a rarity [23]. As with other emergency techniques, tourniquet application should not be performed for the first time during an actual rescue; rather, it should be learned under supervision and practiced with regular training.

Hemostyptics

In areas where tourniquets cannot be applied (proximal extremities), hemostyptic dressings can be used [23].

An analysis of autopsies for potential survivors of 982 soldiers from OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom) found that of the group of potential survivors (n = 232, 24 %), 85 % of the soldiers died of treatable hemorrhage.

In 13-33 % of cases, extremity bleeding was actually well or completely controlled; however, 20 % of cases had difficult-to-access axillary, cervical, or inguinal bleeding (junctional bleeding) [26, 30].

These numbers indicate the need to develop additional local hemostyptics/hemostatic devices.

According to Pusateri et al. [49], the following properties are desirable:
  1. 1.

    The product reliably stops strong arterial and venous bleeding within two minutes

     
  2. 2.

    No necessary and time-consuming preparations prior to product use

     
  3. 3.

    Simplicity of application, minimal training requirements

     
  4. 4.

    Lightweight and robust product performance

     
  5. 5.

    Durable, with a long shelf-life under extreme climatic conditions

     
  6. 6.

    No patient side effects

     
  7. 7.

    Biodegradable and resorbable

     
  8. 8.

    Inexpensive

     

As a result of this, a flood of new products has been developed in the past 15 years to prove themselves in various animal bleeding models, but to date, they have found only partial success.

In the course of the truly excessive testing of these products, the following experiences have crystallized.
  1. 1.

    Pressure to the site of bleeding is indispensable, regardless of the hemostyptic [43],

     
  2. 2.

    Not every product is suitable for every type of bleeding [24], and

     
  3. 3.

    To date, none has fulfilled all of the criteria.

     
The most common products can be divided into two groups based on hemostatic action.
  1. 1.

    Physically tissue-adherent and occluding the vessel injury (muco-adhesive)

     
  2. 2.
    The acceleration and amplification of intrinsic blood coagulation through two different mechanisms.
    • •Fluid absorbing and thus, concentration of the pro-coagulant factors.

    • •Activation of intrinsic coagulation and platelets.

     

The various most common local hemostyptics will be presented in the following and evaluated.

Chitin and Chitosan

The chitosan-based compress HemCon® (HemCon Medical Technologies Inc.®, Portland, OR, USA) can be called the “mother” of local hemostyptics for the treatment of bleeding in the pre-hospital setting.

Chitin and chitosan are polysaccharides in a group of biopolymers, and chitosan is derived from chitin.

In all likelihood, the hemostatic effect is based on induced vasoconstriction and rapid activation of erythrocytes, platelets, and coagulation factors. Chitosan also enhances platelet adhesion and aggregation along the damaged tissues [17].

The HemCon® compress was approved by the Food and Drug Administration/USA (FDA) for external hemostasis in 2002 with financial support of the U.S. Army. In 2003, the U.S. Army equipped its soldiers with this product, in contrast to the U.S. Marine Corps. In addition to the simple application and moderate cost of only 75 USD, storage under extreme conditions is also unproblematic.

The application option for narrow wound canals was improved with another FDA-approved chitosan dressing (ChitoFlex®, North American Rescue Inc.®, Greer, SC, USA) which, unlike the HemCon® dressing, can be shaped and inserted into a wound cavity.

The problem with these products is that effectiveness regarding survival is very inconsistent. Pusateri et al. reported that survival increased significantly in pigs with a grade V liver injury after HemCon® application [49]. However, the product showed varied levels of effectiveness following this, even within a single batch. This problem has also occurred with other chitin-based products (Rapid Deployment Hemostat®, Marine Polymer Technologies®, Danvers, MA, USA) [28, 50]. Even after a change to the manufacturing process, only one study showed satisfactory primary hemostasis for the product [31]. In further studies with arterial or arterial/venous bleeding, the product failed entirely [2, 22, 57] and has been removed from the armed services inventory over the past few years.

Celox® (MedTrade Products Ltd®, Cheshire, UK) is a chitosan-based powder. The mechanism of action is the formation of a gel-like plaque on the damaged tissue that remains there permanently. Hemostasis occurs as described above for chitosan. Like the products mentioned above, Celox® is not allergenic or exothermic. It is also in the same price realm as the other chitin products. In two studies, Celox® was more effective than Quikclot® and HemCon®. Both Kheirabadi et al. and Kozen et al. found decreased mortality and better primary hemostasis [32, 35].

The disadvantage is the powder form, which makes application to the wound base more difficult, particularly in cases of heavy bleeding. This was taken into account with a new form of delivery. Celox-D® (medical products, Portland, OR, USA) packages the powder into water soluble bags. However, this decreases the hemostatic effectiveness. A new injection system (Celox-A®, SAM medical products, Portland, OR, USA) appears promising. In a modified animal model that did not simulate a large wound, rather a typical gunshot canal (3 cm diameter) with complete transection of the femoral artery and vein, this product form achieved 100 % primary hemostasis as well as an 88 % survival rate [43]. Now there is also a dressing based on Celox® (Celox rapid Gauze®, MedTrade Celox-A Ltd®, Cheshire, UK) on the market. However, this dressing shows the positive results regarding rebleeding but not survival rate like Combat Gauze® [38].

Zeolite Group

In 2002, almost simultaneously with the HemCon® product, the Quikclot® product (Z-Medica®, Wallingford, CT, USA) entered the American market. It was approved by the FDA without clinical testing for moderate to severe external bleeding and introduced to the American armed forces, the U.S. Marine Corps, in 2003.

Quikclot® is based on a zeolite powder. It is a microporous, crystalline aluminosilicate of volcanic rock. It is distributed only as powder-filled pouches (Quikclot ACS ).

Effectiveness is based on the extremely rapid withdrawal of fluid and concentration of the cellular blood components like platelets and clotting factors at the bleeding site in an exothermic reaction. In addition, the negative surface charge of the powder accelerates the coagulation cascade [3, 45].

The advantage of this product is the low price (approximately 20 USD) and the fact that it is not an allogenic or xenogenic preparation.

Because of the disadvantages regarding the temperature of the exothermic reaction (42–140.4 °C), Quikclot® was modified (Quikclot ACS +®). Nevertheless, increased temperatures still occur [7, 8, 48].

The study results for effectiveness are varied. On the one hand, in animal models with Grade V liver injuries and femoral artery and venous injuries, Quikclot® was associated with reduced blood loss as well as better survival compared to simple dressings [4, 48].

However, with pure femoral artery damage, studies were prematurely canceled due to decreased or no hemostasis [2, 32, 57].

There were also skin burns as well as nerve and tendon injuries [18]. Until its replacement with Combat Gauze®, however, it was used by official bodies according to the “life before wound” principle.

Kaolinite

Combat gauze® (Z-Medica®, Wallingford, CT, USA) is a dressing based on Kaolinite aluminum silicate. Kaolinite acts as an activator and accelerator of the intrinsic coagulation cascade. It has historic value in the control of clinical heparin therapy and for the treatment of diarrhea.

The prototype X-sponge, used as compress, showed a survival rate of 84% in a pig model [6]. Other animal studies achieved similar positive results with Combat Gauze® for arterial and arteriovenous bleeding [32, 34]. Even in an experimental set-up with animals with coagulopathy and acidosis, the kaolin-coated gauze was convincing [16]. There are no side effects except for mild endothelial swelling, and particularly none like those of WoundStat® (TraumaCure®, Bethesda, MD, USA, no longer on the market), known for embolization of hemostyptic components [33, 34].

It is stable for storage, inexpensive (approximately 25 USD) and easy to apply to the wound, even for narrow canals. However, the gauze is not biodegradable.

Since 2010, Combat Gauze® has been issued to various armed forces and in 2009 was introduced to the recommendations of the Committee on Tactical Combat Casualty Care.

Assessment

An assessment of the use of local hemostyptics is extremely difficult. Local hemostyptics fulfilling the criteria published by Pusateri et al. (see above) are not yet in existence. The hemostatic effectiveness of the products is difficult to compare with the different bleeding models/studies (arterial, venous, arterial/venous).

The study results are particularly sobering when simple, cheap, bandaging gauze achieves the same positive results as the hemostyptic to which it is compared [38, 43, 58]. These observations show all the more that the main focus of the treatment of penetrating, bleeding wounds must be on the trained packing of the gauze dressings or the hemostyptic and the application of pressure.

Amputations

Key Recommendations:

1.65

Recommendation

2011

GoR B

Amputated parts should be coarsely cleaned and wrapped in sterile, damp compresses. They should be cooled indirectly during transport.

Explanation:

In addition to bleeding control, the amputation stump should be splinted and a sterile dressing applied. Only coarse contamination should be removed [9, 10]. The amputated part must be preserved. Bony parts or amputated digits should be taken from the accident scene or if necessary, brought afterwards.

The amputated part should be wrapped in damp compresses and cooled for transport, when possible using the “double bag” method. For this, the amputated part is placed in an inner plastic bag with sterile, damp compresses. This bag is then placed in another bag with ice water (1/3 ice cubes, 2/3 water), which is then sealed. This avoids secondary cold damage from direct tissue contact with ice or cool packs [5, 9, 10, 39]. The carrier used for transport should be marked with the patient’s name as well as the time of cooling.

Amputations influence the choice of target hospital and advance warning should be given [5, 9].

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    Perkins TJ. Fracture management. Effective prehospital splinting techniques. Emerg Med Serv. 2007;36(4):35–37, 39.

     
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    Probst C, et al. Prehospital treatment of severely injured patients in the field: an update. Chirurg. 2007;78(10):875–84 [LoE 5].

     
  48. 48.

    Pusateri AE, et al. Application of a granular mineral-based hemostatic agent (QuikClot) to reduce blood loss after grade V liver injury in swine. J Trauma. 2004;57(3):555–62 (discussion 562).

     
  49. 49.

    Pusateri AE, et al. Effect of a chitosan-based hemostatic dressing on blood loss and survival in a model of severe venous hemorrhage and hepatic injury in swine. J Trauma. 2003;54(1):177–82.

     
  50. 50.

    Pusateri AE, et al. Advanced hemostatic dressing development program: animal model selection criteria and results of a study of nine hemostatic dressings in a model of severe large venous hemorrhage and hepatic injury in Swine. J Trauma. 2003;55(3):518–26.

     
  51. 51.

    Quinn RH, Macias DJ. The management of open fractures. Wilderness Environ Med. 2006;17(1):41–8.

     
  52. 52.

    Regel G, Bayeff-Filloff M. Diagnosis and immediate therapeutic management of limb injuries. A systematic review of the literature. Unfallchirurg. 2004;107(10):919–26 [LoE 3a].

     
  53. 53.

    Richey SL. Tourniquets for the control of traumatic hemorrhage: a review of the literature. World J Emerg Surg. 2007;2:28.

     
  54. 54.

    Scheinberg S. Traction splint: questioning commended. JEMS. 2004;29(8):78.

     
  55. 55.

    Slishman S. Traction splint: sins of commission vs. sins of omission. JEMS. 2004;29(8):77–8.

     
  56. 56.

    Strohm PC, et al. Prehospital care of surgical emergencies. MMW Fortschr Med. 2006;148(27–28):34, 36–38.

     
  57. 57.

    Ward KR, et al. Comparison of a new hemostatic agent to current combat hemostatic agents in a Swine model of lethal extremity arterial hemorrhage. J Trauma. 2007;63(2):276–83 (discussion 283-4).

     
  58. 58.

    Watters JM, et al. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios. J Trauma. 2011;70(6):1413–9.

     
  59. 59.

    Wood SP, Vrahas M, Wedel SK. Femur fracture immobilization with traction splints in multisystem trauma patients. Prehosp Emerg Care. 2003;7(2):241–3.

     
  60. 60.

    Worsing RA Jr. Principles of prehospital care of musculoskeletal injuries. Emerg Med Clin N Am. 1984;2(2):205–17.

     

1.8 Genitourinary Tract

Key recommendations:

1.66

Recommendation

2011

GoR B

When urethral injury is suspected, pre-hospital catheterization should be omitted.

Explanation:

In contrast to other injuries, injuries to the ureters, bladder, and urethra are not directly life-threatening [1, 2]. Kidney rupture is potentially life-threatening, but cannot be addressed directly in the pre-hospital setting except through volume replacement as an anti-shock measure. Thus, there are few specific pre-hospital measures for diagnosis and therapy of urologic injuries. Only transurethral catheterization of the bladder has been assumed to be valuable in this phase of care, since the presence and severity of hematuria can be important for the choice of target hospital as well as management on hospital arrival [3, 5]. Because loss of time especially during pre-hospital management is a relevant risk quoad vitam for multiply injured patients, pre-hospital catheterization may be advantageous in the pre-hospital setting when longer transport times are expected, providing it does not cause delay [4]. Insertion of a transurethral bladder catheter is a commonly accepted procedure internationally in pre-hospital treatment for polytrauma patients. There is a slight risk that the bladder catheterization itself can cause additional injury by transforming an incomplete urethral rupture into a complete rupture [3, 4]. In addition, the catheter can create a false passage in cases of complete urethral rupture [6-8]. Transurethral catheterization should thus be avoided in patients with clinical signs of urethral injury, until further diagnostic studies can be performed. Hematuria and blood at the urethral meatus are the leading clinical criteria suggesting urethral injury. In addition, dysuria, suspected pelvic fracture, local hematoma, and general mechanism of injury provide diagnostic clues [3].

References
  1. 1.

    Corriere JN Jr, Harris JD. The management of urologic injuries in blunt pelvic trauma. Radiol Clin North Am. 1981;19(1):187–93.

     
  2. 2.

    Corriere JN Jr, Sandler CM. Management of the ruptured bladder: seven years of experience with 111 cases. J Trauma. 1986;26(9):830–3 [LoE 4].

     
  3. 3.

    Dguc, S3 Polytrauma/Schwerverletzten Behandlung. 2011(012).

     
  4. 4.

    Glass RE, et al. Urethral injury and fractured pelvis. Br J Urol. 1978;50(7):578–82 [LoE 4].

     
  5. 5.

    Monstrey SJ, et al. Emergency management of lower urinary tract injuries. Neth J Surg. 1987;39(6):179–84.

     
  6. 6.

    Morehouse DD. Emergency management of urethral trauma. Urol Clin North Am. 1982;9(2):251–4.

     
  7. 7.

    Morehouse DD, Mackinnon KJ. Posterior urethral injury: etiology, diagnosis, initial management. Urol Clin North Am. 1977;4(1):69–73 [LoE 5].

     
  8. 8.

    Nagel R, Leistenschneider W. Urologic injuries in patients with multiple injuries. Chirurg. 1978;49(12):731–6 [LoE 5].

     

1.9 Transport and Target Hospital

Key recommendations:

1.67

Recommendation

Modified 2016

GoR B

Air rescue operations should be used primarily for pre-hospital care of severely injured patients. Tactical considerations and the time factor should be taken into account.

Explanation:

For years, air rescue has been an important component of emergency services care not only in Germany but also internationally. In most European countries over the past few decades, a comprehensive network of air rescue bases has been constructed covering primary and secondary management sectors. To date, numerous studies have attempted to prove the effectiveness of air rescue. Potential causes for improved outcomes in multiply injured patients include shorter pre-hospital times (time of accident until hospital admission) as well as more aggressive pre-hospital management. Whether the use of air rescue services actually leads to decreased mortality, however, has remained controversial. Newer studies, some based on data from the DGU trauma registry database (TraumaRegister DGU®), seem to have found recognizable positive effects from air rescue, at least in Germany [2, 23]. More recent studies focus less on the value of air rescue itself, and more on, e.g., whether operations should be expanded to 24 hours.

Regarding pre-hospital management, up to 40% of polytrauma patients are treated by ground and air rescue teams together [48]. The importance of pre-hospital treatment time may need to be reevaluated. On the other hand, pre-hospital treatment time was also found to be approximately 16 minutes longer with air rescues than with ground rescue alone [2]. The reasons for this are primarily logistical aspects like the post-alarm of the air rescue service instead of immediate parallel alarm, such as can be seen e.g., in the BoLuS study (ground and air rescue interface, multi-centric cross-system interface analysis) from Hessen. The need for the sometimes enormous logistical costs for trauma centers was also examined. In addition to more complex technology, personnel resources in particular are necessary for optimal logistical support of multiply injured patients. To date, healthcare research has not yielded a clear evidence-based need for organization of trauma management within the DGU Trauma Network (TraumaNetzwerk DGU®, TNW) and the trauma centers of that structure, but this is most likely because no structured data is available for comparison prior to the introduction of the TNW. One current study from Schweigkofler et al. reported improved survival for severely injured patients when treated with air rescue and hospital treatment [35, 36, 38, 39] in a national trauma center [50]. However, it was not clear how much of that was due to air rescue, and how much to management within the corresponding national trauma center.

The results regarding pre-hospital management of multiply injured patients by air rescue versus ground rescue services has been compared in many studies (evidence level 2B [2, 7 to 10, 12, 18, 28, 34, 45, 47, 48, 50, 59]). The primary endpoint for all cases was mortality. In most studies, the primary target hospital was exclusively a Level 1 Trauma Center [3]. In an analysis of air rescue missions for trauma in Germany (2005-2011), Schweigkofler et al. found that 85 % of patients were flown to a national trauma center, 14% to a regional trauma center, and only 1% to a local trauma center [50].

Eleven studies reported significantly reduced mortality (between -8.2 and -52 %) with air rescue.

For treatment of polytrauma patients, Schweigkofler et al. found a mortality of 13.6 % in the ground rescue emergency physician service group and 14.3 % in the air rescue group.

This represents an expected mortality (mean of RISC prognoses) of 15.6 % for ground rescue versus 18.0 % for air rescues. Thus, the standardized mortality rates for both groups are less than 1: ground rescue 0.874 and air rescue 0.793; this difference is significant (p < 0.001).

In the subgroup of polytrauma patients with severe TBI, there was improved survival for the 7 % of patients who were flown to a national trauma center. In a multivariate regression analysis for air rescue, Andruszkow et al. reported decreased mortality for cases flown to national trauma centers (OR 0.88; 95 CI 0.85–0.90) as well as to regional trauma centers (OR 0.86; 95 CI 0.83-0.91) [2].

A retrospective study (2007-2009) of patients with ISS > 15 treated in American Level I and II trauma centers found significantly improved survival for patients transported by air and significantly better quality of life after discharge from the corresponding acute care hospital.

On the other hand, six studies found no benefits for patients transported with air rescue, although they did show the following features.

Phillips et al. 1999 [39]: Mortality was the same in both groups, but the injury severity of the rescue helicopter (RTH) group was significantly higher (p < 0.0001); adjusted mortality comparison was not performed. Schiller et al. 1988 [45]: Patients in the RTH group had significantly higher mortality and injury severity, adjusted mortality comparison was not performed. Nicholl et al. 1995 [38]: Patients in both treatment groups were treated in Level II and III hospitals as well as in trauma centers. Cunningham et al. 1997 [18]: Patients in the RTH group with moderate injury severity (ISS = 21-30) had significantly reduced mortality; however, this result was not confirmed in the logistical regression. Bartolomeo et al. 2001 [19]: Only patients with severe head injuries were investigated (AIS ≥ 4). The ground-based emergency physician team performed invasive pre-hospital interventions relatively often so that the treatment level “gap” with the RTH group was minimal.

Comparability and Transferability of Study Results

As a result of the very different country-specific emergency rescue service structures, comparability of the studies must be debated. Particularly in the Anglo-American region, for example, there is a paramedic-based system, which cannot be compared structurally with the German emergency physician system. The patterns of injury also vary markedly among the studies. In Europe, trauma is predominantly blunt, while in the American region there is more penetrating trauma. The studies also vary significantly in terms of the transport route to be taken and the extent of pre-hospital management. The majority of studies have reported statistically significant decreases in the mortality of multiply injured patients, particularly those with moderate injury severity, with the use of air rescue. Other studies without evidence of direct treatment benefits, however, still show a trend for better results with RTH, since increased injury severity yields identical mortality rates.

In addition, all studies show a marked prolongation of pre-hospital treatment time. This is due in part to the longer transport distance, but also to a more comprehensive pre-hospital management strategy. Thus, Schweigkofler et al. found that an average 2.4 versus 1.8 of the 6 interventions documented by the DGU trauma registry database were carried out during air versus ground rescues. Invasive measures such as intubation and/or chest tube placement were more frequently implemented during air rescues. In summary, the present evidence finds a trend for decreased mortality of polytrauma patients with air rescue compared to ground-based rescue. This is especially true for patients with moderate injury severity, whose survival is very much dependent on the treatment received. This is likely due to better clinical diagnostic and management skills because of the increased training and experience of the RTH team. This conclusion is limited in its general validity and transferability because of the systematic failures of the cited studies, the heterogeneity of the regional emergency services and hospital structures, as well as types of injury.

Comparison Trauma Center versus Level II and III Hospitals

The importance of the duration of pre-hospital management for polytrauma patients has been intensively discussed and the term “golden hour” created. The goal must be to transport patients to hospitals with 24-hour acute diagnostic and treatment units, with rapid availability of all medical and surgical disciplines and of all corresponding acute care capacity. In addition, hospitals with increased numbers of critically injured patients had clearly better outcomes than those with fewer patients per year [66]. According to the DGU trauma registry database, the cut-off appears to be at a case number of 40 polytrauma patients per year.

Key recommendations:

1.68

Recommendation

Modified 2016

GoR B

Severely injured patients should be primarily transported to an appropriate trauma center.

Explanation:

When analyzing the studies, hospital levels I-III but also sometimes I-IV are used. In this context, a Level 1 hospital equates to a maximum care facility, generally a trauma center, although the expression “Trauma Center” is not internationally consistent.

A Level 2 hospital equates to a specialty hospital, and Level 3 to a basic, general hospital.

With the development of the DGU trauma network, three new categories or trauma care have been defined [42, 55]: “national trauma center,” “regional trauma center,” and “local trauma center.”

Each treatment level is clearly defined according to a certification process and there are obligations to maintain the qualification. In addition to previous structures, these facilities are linked via a “network.” This enables resource sharing and integration of patient care, and it structures and simplifies transfers between hospitals. Because of the linking of the various care centers, the treatment of polytrauma patients is legitimized, according to the recommendations of the “White Paper” [54] by the German Trauma Society (DGU), even in local trauma centers.

The DGU’s “White Paper” was produced in connection with the creation of the trauma network [54]. Among other things, it summarizes data from relevant international and national clinical studies, prospective data from the DGU trauma registry database, and data and critical analysis of the interdisciplinary S3 Guidelines for treatment of severely injured patients by the DGU, to give recommendations regarding structure, organization, and equipment for care of severely injured patients.

The authors of the White Paper recommend that severely injured patients be transported to the closest regional or national trauma center when there is a need for specialized trauma diagnosis/management in the emergency department based on mechanism of injury, pattern of injury, and vital parameters, and if it’s within 30 minutes transport time. In cases where such a center cannot be reached within that time frame, the patient must be transported to an appropriate and if necessary local trauma center. From there, once the vital parameters have been stabilized and if there is reason to do so, the patient can be transported secondarily to a regional or national trauma center. This assignment must consider local and regional features of care as well as national treatment capacity, including the need for air rescue services, ideally regardless of the time of day.

Comparison of Level I Trauma Center vs. Level II/III Hospitals

The research yielded seven studies from the USA (n = 3), Canada (n = 2), Australia (n = 1), and Germany (n = 1) directly comparing outcomes from trauma centers (maximal care facilities) with Level II/III hospitals (specialty/general hospitals) [9, 16, 17, 31, 41, 43, 44].

All of these studies conclude that mortality decreases when primary treatment of blunt and penetrating trauma is performed in a trauma center. This has also been confirmed in current studies. Clement et al. (2013) compared outcomes of treatment in hospitals with higher versus lower case numbers for patients with TBI; there were significantly worse outcomes when fewer than six cases per year were treated [15]. Interestingly, hospitals treating more than 60 cases per year also showed somewhat worse outcomes than hospitals with moderate case numbers. Whether the explanation for this is increased injury severity in the large centers is unclear because of the study design.

Traumatic brain injury in conjunction with polytrauma has a worse prognosis when sent to an inappropriate center. Thus, once primary management is completed at the accident scene, these patients should be transported as soon as possible to a hospital with diagnostic and treatment capabilities for neurotrauma. Because of the considerable, not completely controllable sources of bias [20, 31] and the heterogeneity of the care systems investigated, this conclusion cannot be considered as definitive scientific evidence. Some authors have reported that stabilization in a regional hospital followed by transfer to a trauma center did not negatively impact mortality compared to patients brought there primarily [11, 27, 37, 40, 53, 55, 61]. Patients who died prior to possible transfer were not included in the studies. Thus, the “transfer” cohort has been positively selected. This needs to be considered in the final analysis. Concluding whether this treatment path is truly an equivalent alternative to direct admission to a trauma center or a clinic with comparable levels of care is thus impossible.

Even after implementation of the national trauma network, the potential positive effects of the network on outcomes cannot be clearly identified, especially because a before and after comparison is lacking. Only with the introduction of trauma network hospitals did the input of data from patients treated at certified centers become mandatory and available as a key source of data. An appropriate trauma center is defined by the resources offered, and also by the proven level of care within the framework of this external quality control. Logistical and especially regional conditions, however, must always be taken into account.

Key recommendations:

1.69

Recommendation

New 2016

GPP

In cases of penetrating thoracic or abdominal trauma, the patient should be transported as quickly as possible to the nearest trauma center.

Explanation:

Penetrating trauma to the chest and/or abdomen requires a structured management approach. Depending on the severity of injury and/or on the thoracic/abdominal structures involved, exsanguination is a life-threatening consequence of trauma that can be treated only provisionally in the pre-hospital setting.

Although chest tube placement is an intervention that can be performed in the pre-hospital setting and that can adequately treat some 80-90 % of penetrating thorax trauma, there is currently no pre-hospital intervention that is considered to be definitive treatment [24, 30, 33, 65]. Thus, 10-20 % of all penetrating trauma to the chest and almost all penetrating trauma to the abdomen require diagnostic studies and treatment in hospital.

For pre-hospital management of the severely injured, a standardized and priority-oriented approach (e.g., according to the PHTLS algorithm) has prevailed that is time-sparing, effective, and safe for trauma patients [1, 25, 63].

In addition, several working groups have reported that after this pre-hospital care, critically injured patients benefit from rapid transport to an appropriate hospital and long-term outcomes improve [32, 44, 51, 56, 58, 67]. Particularly in cases of penetrating trauma to the chest and/or abdomen, the minimization of pre-hospital time is considered essential to allow life-saving hemostasis via surgery or other interventions that can only be carried out in a hospital [32, 51, 58].

In Germany, in view of the shorter reaction times between alert and arrival of the rescue service at the accident site, there is no significant potential for time-related optimization. According to the work of several research groups, the shortest possible on-scene time seems to improve survival probability in cases of penetrating trauma and when there is no chance for pre-hospital measures to prevent exsanguination [13, 14, 26, 52, 58].

Spaite et al. documented an average on-scene time of 8.1 minutes in a U.S. American urban setting (Tucson). McCoy et al. reported 13 minutes in cases of blunt trauma and 11 minutes for penetrating trauma in Orange County, CA, and Ball et al. found an average on-scene time of 12 minutes in Atlanta, GA [5, 32, 57].

The short on-scene times are not directly due to the “scoop and run” approach (Basic Life Support, BLS). Eckstein at al. found that the implementation of ALS measures, such as intubation, does not necessarily prolong on-scene time (average 12.8 minutes) [21].

Similar results with times under ten minutes “on-scene” in cases of penetrating trauma and an Advanced Life Support (ALS) approach were evident in a 2011 study by Funder et al. of 467 patients in a European, urban setting (here: Copenhagen). Thus, in this patient group with penetrating trauma, increased mortality was found with on-scene times over 20 minutes. Similarly, more frequent implementation of invasive measures in the pre-hospital setting was associated with a significantly higher mortality [22].

A single-center study by Ball et al. found that reductions in pre-hospital on-scene times and transport times in an urban setting increased overall in-hospital mortality. However, the authors did not conclude that this outcome resulted from minimal pre-hospital treatment. The reduction in pre-hospital time enabled 34% more patients to reach the hospital alive compared to the control group. These patients were also frequently hemodynamically unstable. The authors concluded that despite increased overall mortality, the only chance to positively affect outcomes in patients with bleeding penetrating abdominal and chest trauma is surgical hemostasis. They also found that certain injuries are severe enough to appear un-survivable despite this measure; however, this severity cannot be clearly evaluated in the pre-hospital setting [5].

Band et al. reached a similar conclusion [6]. They compared pre-hospital transport of patients with penetrating trauma by the police versus the Emergency Medical Service (EMS) in a U.S. American urban setting (here: Philadelphia). In their group of 2127 patients, they found that the overall mortality in patients transported by the police was higher, but that mortality adjusted according to injury severity (TRISS) did not differ.

In a cohort of 91 132 patients, Johnson et al. even found a survival advantage (TRISS adjusted) for patients with penetrating trauma transported privately (9.6 %) [26]. They also attribute this to reduced pre-hospital time and fewer pre-hospital interventions, but also do not exclude other confounders, e.g. urban versus rural environment, pre-trauma health status, or unrecorded pre-hospital mortalities.

Based on these results, prompt surgical (and/or interventional) hemostasis in hemodynamically unstable patients with penetrating trauma to the chest and/or abdomen is the only therapy that has guaranteed benefits. Correspondingly, for patients with penetrating chest and/or abdominal trauma, the most rapid transport possible to the closest trauma center or hospital equipped to perform immediate surgical hemostasis is recommended to guarantee the fastest possible diagnostic and therapeutic measures.

Key recommendations:

1.70

Recommendation

New 2016

GPP

To avoid transition problems during registration and/or transfer of severely injured patients, appropriate and standardized communication methods must be used.

Explanation:

In order to guarantee a smooth treatment course for severely injured patients, and thus, also meet time-associated demands, for example according to the 2008 Key Points Paper on Emergency Medical Management of Patients in Hospital and Pre-Hospital, it is necessary to establish appropriate documentation procedures using resources available (e.g. IVENA [49]) and communication methods (e.g. establishment of a trauma mobile phone, Rescuetrack™, MANDAT) [29, 62, 64].

During hand-over in the emergency department, appropriate interdisciplinary and inter-professional training methods for the emergency physicians, the paramedical staff, and the corresponding hospital personnel ensure standardized transfers according to the ABCDE scheme. The use of checklists for registration and transfers can also reduce mistakes at the intersection of pre-hospital and hospital care [4, 46].

Benefits for teamwork, technical competence, system checks, and a culture of safety among other things are evident in the areas of polytrauma and emergency department care. However, scientific proof of the positive effects of such interventions regarding increased survival of affected patients is not available [60].

Conclusion

The studies comparing air with ground rescue reveal a trend towards decreased mortality with the use of air rescue. If available, primary air rescue should be used for pre-hospital management of severely injured patients, because survival improves as a result, especially for moderate to high injury severity. Logistical aspects and the time-factor should be considered. Severely injured patients should be primarily transported to an appropriate trauma center, since this approach decreases mortality. If a regional or national trauma center is not reachable within a reasonable timeframe (recommendation according to the White Paper: 30 minutes), a closer hospital capable of implementing primary stabilization as well as life-saving emergency surgery should be selected for transport. If transfer to a regional or national trauma center is necessary, the patient can be transferred secondarily when hemodynamically stable and when other specific criteria are met.

In cases of penetrating thoracic or abdominal trauma, the patient should be transported as quickly as possible to the nearest trauma center. Prompt surgical (and/or interventional) hemostasis in this type of hemodynamically unstable patients is the only therapy that has guaranteed benefits.

To reduce errors as well as information gaps, a structured and thus, standardized handover process should be performed. Corresponding education and training should thus be carried out in an interdisciplinary and inter-professional setting.

The evidence table for this chapter is found on page 135 of the guideline report.

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    Nathens AB, et al. The effect of interfacility transfer on outcome in an urban trauma system. J Trauma. 2003;55(3):444–9.

     
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    Nicholl JP, Brazier JE, Snooks HA. Effects of London helicopter emergency medical service on survival after trauma. BMJ. 1995;311(6999):217–22 [LoE 2b].

     
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    Phillips RT, et al. One year’s trauma mortality experience at Brooke Army Medical Center: is aeromedical transportation of trauma patients necessary? Mil Med. 1999;164(5):361–5 [LoE 2b].

     
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    Rogers FB, et al. Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting. J Trauma. 1999;46(2):328–33.

     
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    Rogers FB, et al. Population-based study of hospital trauma care in a rural state without a formal trauma system. J Trauma. 2001;50(3):409–13 (discussion 414).

     
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    Ruchholtz S, Kuhne CA, Siebert H. Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU. Unfallchirurg. 2007;110(4):373–9.

     
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    Sampalis JS, et al. Trauma care regionalization: a process-outcome evaluation. J Trauma. 1999;46(4):565–79 (discussion 579–81).

     
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    Sampalis JS, et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34(2):252–61.

     
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    Schiller WR, et al. Effect of helicopter transport of trauma victims on survival in an urban trauma center. J Trauma. 1988;28(8):1127–34 [LoE 2b].

     
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    Scholtz BG, Gliwitzky B, Boullion B, Lackner CK, Hauer T, Wölfl CG. Mit einer Sprache sprechen. Die Bedeutung des Pre-Hospital Trauma Life Support® (PHTLS®)-Konzeptes in der präklinischen und des Advanced Trauma Life Support® (ATLS®)-Konzeptes in der klinischen Notfallversorgung schwerverletzter Patienten. Notfall + Rettungsmedizin. 2010;13(1):58–64.

     
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    Schwartz RJ, Jacobs LM, Yaezel D. Impact of pre-trauma center care on length of stay and hospital charges. J Trauma. 1989;29(12):1611–5 [LoE 2b].

     
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    Schweigkofler U, et al. Significance of helicopter emergency medical service in prehospital trauma care. Z Orthop Unfall. 2015;153(4):387–91.

     
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    Schweigkofler U, et al. Web-based evidence of treatment capacity. An instrument for optimizing the interface between prehospital and hospital management. Unfallchirurg. 2011;114(10):928–37.

     
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    Schweigkofler U, et al. Importance of air ambulances for the care of the severely injured. Unfallchirurg. 2015;118(3):240–4.

     
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    Seamon MJ, et al. Prehospital interventions for penetrating trauma victims: a prospective comparison between Advanced Life Support and Basic Life Support. Injury. 2013.

     
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    Seamon MJ, et al. Prehospital procedures before emergency department thoracotomy: “scoop and run” saves lives. J Trauma. 2007;63(1):113–20.

     
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    Sharar SR, et al. Air transport following surgical stabilization: an extension of regionalized trauma care. J Trauma. 1988;28(6):794–8.

     
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    Siebert H. White book of severely injured-care of the DGU. Recommendations on structure, organization and provision of hospital equipment for care of severely injured in the Federal Republic of Germany. Unfallchirurg. 2006;109(9):815–20.

     
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    Siebert HR, Ruchholtz S. Projekt TraumaNetzwerk DGU. Trauma Berufskrankheit. 2007;9:265–70.

     
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    Smith RM, Conn AK. Prehospital care—scoop and run or stay and play? Injury. 2009;40(Suppl 4):S23–6.

     
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1.10 Mass Casualty Incident (MCI))

A mass casualty incident must be differentiated from a disaster. Strategies for coping with a mass casualty incident can be transferred to a disaster scenario only to a limited extent.

One particular type of mass casualty incident is a terrorist attack, which distinguishes itself from other events strategically/tactically and according to required medical treatment based on the patterns of injury, the time-related development (multiple attacks at various times), and the chance of a continuing threat also to rescue personnel.

Strategies for dealing with a mass casualty incident should therefore include penetrating injuries from automatic firearms and specific injuries from improvised explosive devices that can be present during terrorist attacks, in addition to “classic” patterns of injury. These multidimensional injuries represent a particular qualitative medical challenge, since there is limited expertise in Germany.

A mass incident of severely injured presents an extreme challenge for emergency rescue personnel at the site as well as in the receiving hospitals. The human and material resources standing by must be allocated based on triage for the most efficient individual treatment possible. However, it must be clear to all parties that it may be necessary to abandon individual-based medicine for a certain time to ensure survival of the greatest number of patients. This conversion is a special challenge and also a burden for the entire staff, and requires particular attention.

As a rule, triage performed by physicians or non-physician staff is complicated by the fact that the severely injured patients must be rapidly and reliably identified among a large number of patients with minor injuries. In general, there is less of a problem with “under-triage,” i.e., not recognizing the critically injured, than with “over-triage,” in which non-critical injuries are overestimated. The rate of over-triage correlates directly with mortality of critically injured patients [4], since in this case, limited pre-hospital and hospital resources that are urgently needed for the critically injured will be expended inappropriately.

In 2008, Jenkins et al. analyzed various established Anglo-American triage systems and found that no algorithm was superior to the others, considering the evidence available at the time. Therefore, the authors concluded that there was a need to develop a universally workable algorithm [8].

In 2011, representatives of U.S. medical societies/organizations approved the SALT triage concept (Sort, Assess, Lifesaving Interventions, Treatment/Transport) that had been presented by Lerner et al. in 2008 [11–13].

In 2015, Streckbein et al. evaluated twelve international and national triage systems using an evidence-based literature review [18]. The authors concluded that none of the systems was superior to the others according to scientific data, and that none of the various concepts is well-established in Germany.

Because of higher priority assignments of other key recommendations, an improved version of the previous triage algorithm, which was based on a previous consensus because of insufficient evidence, could not be approved in this current version of the S3 Guidelines.

The basis for the current triage system was the STaRT algorithm (Simple Triage and Rapid Treatment) used in North America, which enables targeted sorting of injured patients immediately by the first-responding emergency personnel. The STaRT concept was originally developed for California Fire Departments [2]. In addition to priorities of the ATLS® and PHTLS guidelines [1, 15], the algorithm for pre-hospital triage considers specific requirements of the German emergency physician service [16] in terms of both the duties and the functions of the Chief Emergency Physician or the Health Care Administration, as well as the corresponding triage categories.

Patients in an acutely life-threatening condition of triage category I/red are identified according to ABCD priority (Airway, Breathing, Circulation, Disability) and treated as quickly as possible. When an acute surgical indication is present, such as thoracotomy/laparotomy to control bleeding or decompression for traumatic brain injury, the patient is released after a second screening by the Chief Physician for immediate transport to the nearest appropriate hospital. After the start of triage, all injured patients who are able to walk are initially assigned to triage category III/green and are referred to the meeting area for slightly injured. This approach particularly considers the problem that among the large number of patients, only a small proportion have acutely life-threatening injuries and require immediate treatment. In addition to life-saving interventions that can be carried out at the scene, this also includes rapid, resource-dependent transport for acute surgical care.

National developments of the STaRT algorithm and the previous triage algorithm are published in the mSTaRT algorithm from 2006, which defines additional types and extent of emergency treatment, the time point and consequences of the second triage regarding the urgency of emergency transport, as well as critical findings for the detection of patients in triage category II/yellow [9].

The mSTaRT Trauma and Intox, introduced in 2013, includes detection of potential toxic agents and the corresponding procedures necessary such as decontamination for each patient category [6]. In addition, critical findings have been incorporated regarding subsequent triage in terms of traumatic brain injury, inhalation injury with stridor, and possible intoxication.

For military or police situations, Ladehof et al. introduced the tacSTaRT in 2012. The tacSTaRT modifies the early reaction to critical bleeding prior to triage and supplements with further explanations [10]. This approach is particularly relevant because, as seen in the “Resuscitation” chapter, life-saving emergency measures such as hemostasis with tourniquets and decompression of tension pneumothorax, etc., must be performed as soon as possible in acute life-threatening situations.

Future national triage algorithms based on STaRT and/or ATLS/PHTLS should accordingly prioritize these aspects of life-saving interventions, e.g. hemostasis with tourniquets, decompression for tension pneumothorax, freeing the airway (including 2x ventilation in children), as well as antidote administration, to occur prior to triage. First responders should therefore have the required equipment as well as training in these interventions.

In 2014, the German Society of Disaster Medicine (Deutschen Gesellschaft für Katastrophenmedizin, DGKM) and the Federal Office for Civil Protection and Disaster Relief (Bundesamt für Bevölkerungsschutz und Katastrophenhilfe, BBK) proposed a universal triage system for surgical and medical-conservative clinical pictures [3]. PRIOR (Primary Ranking for Initial Orientation in Rescue service), based partially on the established ABCDE algorithm, references conditions instead of physiological parameters, and is not completely compatible with mSTaRT and tacSTaRT.

The use of triage systems should be included in local considerations, which along with medical treatment basics must coordinate emergency medical services with cooperating services (e.g., fire department, police, THW, disaster protection, military) [17]. Triage algorithms are adapted to local considerations if necessary and should also be adjusted to existing disaster contingency plans or similar.

One thing remains unaffected: appropriate preparation [5] is the best prerequisite to confront this type of situation, regardless of contingencies [7, 14]. This means consistent processing and improvement of structure and process quality of all participating bodies at the scene. In addition to the analysis of previous disasters, simulation is an appropriate method for evaluation and further development.

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    Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE—a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11(2):117–24.

     
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    Bubser F, Callies A, Schreiber J. PRIOR: Vorsichtungssystem für Rettungsassistenten und Notfallsanitäter. Rettungsdienst. 2014;37(8):730–4.

     
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    Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53(2):201–12.

     
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    Kanz KG, et al. mSTaRT-Algorithmus für Sichtung, Behandlung und Transport bei einem Massenanfall von Verletzten. Notfall+ Rettungsmedizin. 2006;9(3):264–70.

     
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    Ladehof K. Triage und MASCAL/MANV. In: Neitzel C, Ladehof K, editors. Taktische Medizin: Notfallmedizin und Einsatzmedizin. Berlin: Springer; 2015. p. 221–48.

     
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    Lerner EB. Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011;5(2):125–8.

     
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    Lerner EB, et al. Mass casualty triage: an evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep. 2011;5(02):129–37.

     
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    Sefrin P, Wilhelm Weidringer J, Weiss W. Katastrophenmedizin-Sichtungskategorien und deren Dokumentation. Deutsches Arzteblatt-Arztliche Mitteilungen-Ausgabe A. 2003;100(31–32):2057–8.

     
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    Streckbein S et al. Sichtungskonzepte bei Massenanfallen von Verletzten und Erkrankten: Ein Uberblick 30 Jahre nach START. Unfallchirurg. 2015; p. 1–11.

     

2 Emergency Department

2.1 Introduction

Because of the complexity of the individual processes, the management of severe and/or multiply injured patients in the Emergency Department presents a great challenge to the treatment team. Treatment in the emergency department should thus be definitively characterized by predefined procedures and a common language. Here, the pre-hospital, emergency department, and primary operative management phases meet. Course concepts such as Pre-Hospital Trauma Life Support® (PHTLS®) for pre-hospital treatment and Advanced Trauma Life Support® (ATLS®) or European Trauma Course® (ETC®) for in-hospital treatment can be used to automate and improve this process using a clear hierarchy of treatment levels and a common language [9, 12]. Trauma care in the emergency department is very relevant regarding survival probability of severely injured patients. Mathematical models show that about two thirds of the explainable variance of a model including the patient-dependent factors of the pre-hospital and emergency department phase are accounted for in the emergency department phase [8].

The establishment of defined standard operating procedures (SOPs) and the accompanying validation through the DGU trauma registry (TraumaRegister DGU®) have led to verified improvements in survival probability and quality of care after severe trauma [4, 5, 9, 10, 12]. In addition, there are numerous indications that the establishment of treatment recommendations as outlined in the first version of the S3 Guidelines on Treatment of Patients with Severe and Multiple Injuries in the clinical SOPs can lead to improvement in patient outcomes [11]. This also applies to increased frequency of multilayer spiral computer tomography (MSCT) in the early phase of emergency department trauma care, which enables a rapid, highly precise diagnostic study also for unstable patients [6, 7]. It is important that each hospital has a trauma algorithm developed by interdisciplinary consensus, and that all potential participants are familiar with it.

As with all complex medical process, errors can occur. In this case, not every error must adversely affect treatment quality [10]. However, an accumulation of errors can have fatal consequences for the patient. Thus, unemotional review and processing of complications is the basis for sensible quality management and should be permanently established within the quality circle of hospitals treating severely injured patients [5].

In many hospitals, task forces and quality circles have been successfully initiated, which regularly evaluate and improve their own trauma protocols using actual cases. The management of such quality circles, like responsibility within the trauma bay, remains a point of debate among specialty societies. Since the diagnosis and treatment of severe trauma is a core component of trauma surgery, physicians of this specialty could be candidates to run both quality circles and trauma care within the emergency department [5]. However, it can’t be forgotten that there are other functional treatment concepts for emergency department trauma care [1,3,13]. In the guideline, this sensitive territory is addressed in various places, since treatment concepts focused on pure multidisciplinary teamwork without a team leader can also be viable. In such cases, however, there should be a clear delineation of responsibility for various situations in advance, particularly in preparation for forensic issues [2].

This “Emergency Department” section has been completely revised and updated with the latest available evidence during the re-issue of the S3 Guideline on Treatment of Patients with Severe and Multiple Injuries. At the repeated requests of specialist societies, a section dealing with radiological diagnostic studies and imaging, and the best use of these, was completely redone. Thus, the Emergency Department section now includes its own chapter on “Imaging in the context of severely injured care in adults and children.”

References
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    Bouillon B. Brauchen wir wirklich keinen „trauma leader“ im Schockraum? Unfallchirurg. 2009;112(4):400–1.

     
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    Cummings GE, Mayes DC. A comparative study of designated trauma team leaders on trauma patient survival and emergency department length-of-stay. CJEM. 2007;9(2):105–10.

     
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    Ertel W, Trentz O. Neue diagnostische Strategien beim Polytrauma. Chirurg. 1997;68(11):1071–5.

     
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    Huber-Wagner S, et al. Whole-body CT in haemodynamically unstable severely injured patients—a retrospective, multicentre study. PLoS One. 2013;8(7):e68880.

     
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    Huber-Wagner S, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373(9673):1455–61.

     
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    Huber-Wagner S, et al. The sequential trauma score—a new instrument for the sequential mortality prediction in major trauma. Eur J Med Res. 2010;15(5):185–95.

     
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    Schoeneberg C, et al. Traumanetzwerk, TraumaRegister der DGU(R), Weissbuch, S3-Leitlinie Polytrauma—ein Versuch der Validierung durch eine retrospektive Analyse von 2304 Patienten (2002–2011) an einem uberregionalen (Level 1) Traumazentrum. Zentralbl Chir. 2014.

     
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    Sturm JA, et al. “Advanced Trauma Life Support” (ATLS) und “Systematic Prehospital Life Support” (SPLS). Unfallchirurg. 2002;105(11):1027–32.

     
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    Wurmb T, et al. Polytrauma management in a period of change: time analysis of new strategies for emergency room treatment. Unfallchirurg. 2009;112(4):390–9.

     

2.2 Emergency Department—Staffing and Equipment

For the care of polytrauma patients, there are over 600 trauma centers available in Germany. With the organization of these trauma centers into more than 50 trauma networks, almost comprehensive certification of the entire nation has been achieved.

The auditing processes required to pass through national, regional, and local trauma centers have enabled implementation of a higher degree of standardization throughout regarding personnel, structural conditions, and/or professional competence for the treatment of multiply injured patients.

To date, no investigations have yielded evidence that the implementation of trauma networks significantly reduces mortality for severely injured patients. However, Ruchholtz et al. found that triage required to distinguish mild and severe injuries works very well already. Among other things, the authors found that patients with severe injuries and relevant vital function disturbances (GCS, hypotension) were treated more often in national trauma centers than in regional and local trauma centers. Similarly, the authors found that the secondary (additional) transfer rate to national trauma centers, with 13.4 %, was significantly higher than rates to regional or local trauma centers (4.6 % and 2.3 %).

The Trauma Team

Key recommendations:

2.1

Recommendation

2011

GoR A

For the care of polytrauma patients, a specific team (the “Trauma Team”) must work according to an organized plan and/or have completed special training.

Explanation:

To achieve coordinated, balanced cooperation among various staff when managing polytrauma patients, it is commonplace over the world to assemble fixed teams for trauma care within the emergency department, which work according to pre-structured protocols and/or have completed special training (particularly ATLS®, ETC, Definitive Surgical Trauma Care [DSTC™]) [4, 33, 50, 52, 54, 59]. Various studies have found clinical benefits for this trauma team concept [13, 31, 41, 57]. For example, Ruchholtz et al. found that an interdisciplinary team, integrated into a quality management (QM) system and acting on the basis of internal hospital guidelines and discussions, works very efficiently under joint surgical and anesthesia management [8, 58].

Key recommendations:

2.2

Recommendation

2011

GoR A

The basic trauma team must consist of at least 3 physicians (2 surgeons, 1 anesthesiologist), of whom at least one anesthesiologist and one surgeon must have attending status.

Explanation:

There are no validated studies on the composition of the emergency department trauma team; thus, statements regarding team composition can be based only on how these are predominantly assembled worldwide. The question as to which specialties should be primarily represented in the emergency department trauma team often depends on local conditions [6, 9, 11, 12, 14, 21-26, 28, 32, 34, 35, 40, 43, 48, 53]. Some studies from abroad have reported that the majority of polytrauma patients can be effectively managed with only two physicians [3, 7, 12]. Depending on the pattern/severity of injury, however, the initial team of at least 2-3 people can then be supplemented with additional colleagues [30, 42, 49]. Review of the international literature indicates that almost all teams consist of either specialized trauma surgeons with varying levels of experience or general surgeons with (long-term) experience in trauma management, also with different levels of training.

The above constellation of at least three physicians can serve only as a minimum number, and should be enlarged as needed with 1-2 other physicians (e.g. radiologist, neurosurgeon) according to the size and treatment level of the hospital as well as patient numbers. In any case, management of severely injured patients must be carried out by a qualified surgeon. Minimal qualifications must be the level of specialist in either Orthopedics and Trauma Surgery or General Surgery according to the regional medical association (Landesärztekammer, LÄK), Rules for Specialist Training for Physicians, as at 07/2009. The treating anesthesiologist must also have a minimum qualification of specialist.

In addition to the required medical competence of the emergency department trauma team, medical/anesthesia/technical support personnel are of course indispensable. Regarding support personnel, the DGU White Paper (2nd Edition, 2012) calls for two surgical, one anesthesia, and one medical/technical/radiology (MRTA) nurse/technician(s) per individual care level.

The function and necessity for a “trauma leader” in the Emergency Department is debated in the literature. Even in the consensus conferences while developing the S3 guideline, the need for a “team leader,” his/her duties, and assignment to a particular specialty were debated intensely. A structured literature review of these topics was performed during the guideline development process. In terms of patient survival, there was no credible evidence for the superiority of one particular management structure in the emergency room (“trauma leader” versus “interdisciplinary management group”), or for the assignment of a “trauma leader” to one particular specialist area (trauma surgery, surgery versus anesthesia).

Hoff et al. [21] found that bringing in a team leader (“command physician”) improved the care and treatment sequences [22]. Alberts et al. also found evidence of improved treatment sequences and outcomes after introduction of the “trauma leader” strategy [1]. Because of the many tasks, including patient handover, patient examination, implementation and monitoring of therapeutic and diagnostic measures, consultation with other specialist disciplines, coordination of all medical and technical team members, preparation for examinations to follow emergency room care, communication with relatives after completion, etc., that the “trauma leader,” in principle, must oversee, this job and these duties must be performed either on an interdisciplinary basis or by a “team leader” experienced in the management of multiply injured patients. In interdisciplinary processes, it is even more important to ensure that treatment sequences are agreed to and consensual, to avoid any time delays [19, 22, 39, 53].

According to recommendations of the American College of Surgeons Committee on Trauma (ACS COT), a qualified surgeon must assume team leadership [8, 58]. A large comparative study of over 1000 patients found almost equal mortality and admission stays regardless of whether one of four trauma surgery specialists or one of twelve general surgeons were responsible for trauma care in the emergency department, although the general surgeons had trauma surgery experience [43]. Khetarpal reported shorter management times and time to surgery when “Trauma Surgeons” versus “Emergency Physicians” acted as leader, but this had no apparent effect on treatment outcomes [8, 58]. Sugrue et al. confirmed that there is no critical difference regarding who leads the trauma team, as long as the leader has sufficient experience, expertise, and training [8, 58]. Anesthesia leadership of the trauma team has also been practiced effectively, cooperatively, and successfully in many sites for years.

Interdisciplinary leadership models consider increased specialization of the individual disciplines in particular. Each specialty has predefined tasks and is responsible for those tasks at defined time points during the emergency department phase of care. The leadership group, comprised of anesthesiology, surgery, radiology, and trauma surgery (in alphabetical order), thus confers at strictly defined time points and also, when the situation calls for it [60].

Nevertheless, experts are in favor of clear delineation of responsibilities based on local conditions, agreements, and skills. Team leadership should be encouraged, regardless of specialty or whether coming from an individual or a group. The duties of team leadership are to collect and inquire about the findings from the individual specialty team members and to make consequent decisions. Team leadership leads communication and, with team agreement, establishes the next diagnostic and therapeutic steps. The functions and qualifications of the “Team Leader” or the “Interdisciplinary Leadership Group” should be established within the facility quality circle for the Emergency Department. Ideally, after agreement, the “best” candidate or candidates should be given the tasks of “Trauma Leader” or “Interdisciplinary Leadership Group.” Rules must be made in particular for the following points, which must stand up to a “best practice jurisdiction”:
  • Responsibility,

  • Leadership structure for coordination, communication, and decision-making within the context of trauma care in the Emergency Department,

  • Monitoring and quality assurance (implementation of quality circles; identification of quality and patient safety indicators; continuous review of structure, processes, and outcomes).

In addition to technical skills, non-technical skills (NTS) play an important role in trauma team work. The most important NTSs are
  • Decision-making,

  • Situational awareness,

  • Teamwork,

  • Task distribution,

  • Communication.

Training for NTSs should be carried out regularly in an interdisciplinary and inter-professional manner.

For organizational reasons, a multiply injured patient is generally assigned to the Emergency Department to which the Trauma Leader belongs. To enable optimal management of the post-acute phase, it is recommended that all involved specialties complete reevaluation of the injury pattern within 24 hours. At this time, the discipline to take primary responsibility for each polytrauma patient must be defined, with consensus of all participants. This ensures that the patient is appropriately assigned for further treatment according to the main injury.

Key recommendation:

2.3

Recommendation

2011

GoR A

Trauma centers must keep expanded trauma teams.

Explanation:

The size and composition of the expanded emergency department team is determined by the care level of the respective hospital and the corresponding expected level of injury severity, as well as by the maximum number of surgical interventions that can be performed on site if necessary (White Paper). National trauma centers, having the highest care levels, should thus involve principally all specialties performing emergency care. An overview of this is given in Table 11. A qualified specialist (attending) from a consulted department should be present within 20-30 minutes (see below).

Key recommendation:

2.4

Recommendation

2011

GoR A

Attending physicians needed for subsequent care must arrive within 20-30 minutes of being alerted.

Explanation:

A comparative hospital study found that it was not absolutely necessary for the trauma surgeon to be available in-house at all hours, provided the distance to the hospital was not greater than 15 minutes and a resident was already in the hospital [11]. Allen et al. and Helling et al. report a limit of 20 minutes [3, 20]. In contrast, Luchette et al. and Cornwell et al. found “in-house” readiness to be an advantage [9, 35], although Luchette showed that only diagnosis and start of surgery were more rapid when an attending physician was initially present; both the duration of intensive care and mortality for patients with severe thoraco-abdominal or head injuries were unaffected [13, 31, 41, 57].

In a comparison over several years, calculations from the English Trauma Audit and Research Network (TARN) indicated significantly reduced mortality (60 % vs. 32 %) with increased presence of a qualified specialist/attending physician [29]. Wyatt et al. also reported that severely injured patients in Scotland (n = 1427; ISS > 15) were treated more rapidly and were more likely to survive when they were treated by an experienced specialist/department chief than by a resident physician [61]. In the ACS COT recommendations, the presence of an attending surgeon for management of severely injured patients is not mandatory, provided a senior surgical resident is directly involved [8, 58]. In a retrospective analysis over a period of 10 years, Helling et al. found no relevant improvement in treatment outcomes when the attending physician was present from the outset [37, 41, 55]. For patients with penetrating injuries, in shock, with a GCS < 9 or ISS ≥ 26, there was no difference in care quality with regard to mortality, start of surgery, complications, or intensive care unit stay duration when the on-duty physician participated in subsequent care within 20 minutes (“on call”). Only the initial care period and the total hospital stay were decreased for blunt trauma patients when the attending physician was in the emergency room (“in-house”) from the outset. These outcomes have been largely confirmed by Porter et al., Demarest et al., as well as Fulda et al. [11, 17, 45].

Overall, it can be concluded from these results that an attending physician does not need to be present at the outset of emergency room trauma care when a surgeon qualified in the care of the severely injured (specialist grade and if applicable, ATLS® and ETC certified) carries out the initial management steps. However, rapid accessibility of the attending physician should be ensured.

A thoracic surgeon, ophthalmologist, oral and maxillofacial surgeon (OMFS), and otorhinolaryngologist (ENT) should be reachable within 20 minutes [19, 28, 36, 44]. According to Albrink et al. [2], the thoracic surgeon should be consulted as soon as possible, particularly in cases of aortic lesions.

According to the literature, the presence of a pediatric surgeon is not mandatory for the basic trauma team. The studies of Knudson et al., Fortune et al., Nakayama et al., Rhodes et al., Bensard et al., D’Amelio et al., Stauffer and Hall et al. found no evidence for improved treatment outcomes with the involvement of specialized pediatric surgeons [5, 10, 16, 18, 27, 38, 46, 51]. However, in cases of pediatric trauma at a hospital with a pediatric surgery facility, pediatric surgical/trauma experts should be involved in care. Details should be clarified in the local quality circles.

An anesthesiologist, required for continuing care of the multiply injured patient, must also present within 20–30 minutes of being alerted.

Key recommendation:

2.5

Recommendation

2011

GoR B

The treatment area within the emergency department should allow 25-50 m2 per patient.

Explanation:

The information provided is based on a) recommendations for primary management of the patient with traumatic brain injury in polytrauma by the individual working groups and circles of the German Society of Anesthesiology and Intensive Care Medicine (DGAI), the German Society for Neurosurgery (DGNC), and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI). Minimum size of 25 m2 is recommended per treatment area [56].

Room size can also be calculated b) using the specifications of the Technical Rules for Workplaces (Arbeitsstätten-Richtlinie, ASR), the Workplaces Ordinance (Arbeitsstättenverordnung, ArbStättV, 2nd section; room dimensions, air space), the German X-ray Ordinance (Röntgenverordnung, RöV), and the Technical Rules for Hazardous Substances (Technische Regeln für Gefahrenstoffe, TRGS). It specifies that 18 m3 of breathable air per person carrying out heavy physical activity, and 15 m3 for average physical activity, must be ensured in rooms with natural ventilation or air conditioning; 10 m3 is estimated for each additional person who is there temporarily. Thus, a room volume of about 75-135 m3 would be required for 5-9 persons (3-5 physicians, 1 medical radiology technician, 1-2 trauma surgery and/or anesthesia nurses), and an assumption of average physical work (lead aprons worn during care). With a ceiling height of 3.2 m, this corresponds to a room size of approximately 23-42 m2. Not included in the calculation is the loss of space through anesthesia and ultrasound equipment, work surfaces, patient stretcher, cupboards, etc., so that a total of 25-50 m2 per unit should be the starting point. If it is possible to treat a maximum of 2 severely injured patients simultaneously, the area is enlarged accordingly. Section 38 (2) of the German Workplaces Ordinance of 1986 specifies a clear door width of at least 1.2 m with a door height of 2 m for paramedic and first aid rooms. 

Key recommendation:

2.6

Recommendation

2011

GoR B

The treatment area, the ambulance entrance, the Radiology department, and the operating rooms should be located in the same building. The heliport should be located on the hospital grounds.

Explanation:

All screening tests necessary for emergency surgery (laparotomy, thoracotomy, external fixator/pelvic C-clamp) must be kept in readiness.

Table 11: Composition and presence of specialist level physicians in the expanded emergency department trauma team in relation to hospital care level

Specialty/Department

National TC

Regional TC

Local TC

Trauma Surgery

X

X

X

General or Visceral Surgery

X

X

X

Anesthesia

X

X

X

Radiology

X

X

X

Vascular Surgery

X

C

Neurosurgery

X

C

Cardiac or Thoracic Surgery

*

*

Plastic Surgery

*

*

Ophthalmology

*

*

ENT

*

*

OMFS

*

*

Pediatrics or Pediatric Surgery

*

*

Gynecology

*

*

Urology

*

*

X: Required

C: Cooperation agreement**

*: Optional

–: Not required

**C: Cooperation agreement

Treatment of vascular and/or neurosurgical injuries require “cooperation agreements” in regional trauma centers. This rule - if no vascular surgeon and/or neurosurgeon is available in-house, cooperation with a nearby department/hospital for vascular and/or neurosurgery (e.g., provision of a consultant, transfer of the patient, surgical readiness, etc.) can be agreed upon. 24 hours of acute care must be ensured 365 days per year.

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2.3 Emergency Department Trauma Team Activation

Efficient trauma score systems or parameters should select and/or identify patients precisely enough that the necessary treatment is allotted to each patient according to injury severity. The difficulty lies in adequate injury assessment. Ideally, trauma team activation criteria should minimize the rates of both undertriage and overtriage of severely injured patients. While undertriage carries a risk to patient safety, overtriage is associated with considerable costs as well as disruptions to clinical routine. Thus, the effectiveness of individual triage parameters leading to activation of the emergency department trauma team should be evaluated using measures such as sensitivity, specificity, positive predictive value, and the calculation of overtriage and undertriage rates. The American College of Surgeons Committee on Trauma (ACS COT) [1] considers an undertriage rate of 5 % with simultaneous overtriage rate of 25-30 % necessary for efficient trauma care in the emergency department. Kane et al. concluded that the rate of overtriage could not be brought under 70 % while achieving a sensitivity greater than 80 %.

Activation Criteria

Key recommendation:

2.7

Recommendation

Modified 2016

GoR A

The Emergency Department Trauma Team must be mobilized for the following injuries:

 •Systolic blood pressure below 90 mmHg (age adapted for children) after trauma

 •Penetrating injuries of the torso/neck area

 •Gunshot wounds to the torso/neck region

 •GCS below 9 after trauma

 •Respiratory impairment/need for intubation after trauma

 •Fractures of more than two proximal long bones

 •Flail Chest

 •Pelvic Fractures

 •Amputation injury proximal to the hands/feet

 •Spinal cord injury

 •Open head injury

 •Burns > 20% and grade ≥ 2b

Explanation:

Blood pressure/Respiratory rate

Individual studies have reported that hypotension with a systolic blood pressure below 90 mmHg after trauma is a good predictor/good criterion to activate the emergency department trauma team. Franklin et al. [6] found that 50 % of trauma patients with hypotension in the pre-hospital phase or on hospital arrival were sent for immediate surgery or transferred to the intensive care unit. Overall, 75 % of hypotensive patients underwent surgery during hospital admission.

Tinkoff et al. [22] reported 24-fold increased mortality, as well as 7-fold increased intensive care admission and 1.6-fold increased emergency surgery rates in patients with post-trauma hypotension as a sign of shock. In the recommendations by the American College of Surgeons Committee on Trauma [1], hypotension is considered an important criterion for admission to a trauma center. According to Smith et al. [21], hypotension is used consistently as a criterion for trauma team activation in all hospitals within the state of New South Wales in Australia. In a review of the New York State Trauma Registry, Henry et al. [8] reported mortality rates of 32.9 % in trauma patients with SBP (systolic blood pressure) < 90 mmHg and 28.8% for those with a respiratory rate < 10 or > 29/min.

Gunshot Wounds

Sava et al. [20] found that a gunshot wound to the torso, as sole activation criterion, has comparative predictive value to the previously used TTAC (trauma team activation criteria). In a subgroup with gunshot wounds to the abdominal/pelvic region, the frequency of severe injuries was the same in groups with and without TTAC (74.1 % and 70.8 %, p = 0.61). Tinkoff et al. [22] found a significant correlation between gunshot wounds to the torso or neck and admissions to the intensive care unit (see below). This criterion was also predictive for severe or fatal injuries and/or for emergency surgery. In a retrospective analysis, Velmahos et al. [6] reported an overall survival rate over 5.1 % in patients without vital signs in the emergency department after penetrating gunshot and stab wounds. In a review (25 years, 24 studies), Rhee et al. [18] identified a survival rate of 8.8 % after emergency thoracotomy in penetrating trauma.

In its last edition (2014), the ACS COT [1] listed various, weighted triage criteria. The Step One and Step Two criteria require transfer to a level 1 or 2 trauma center. Step One criteria include a) GCS below 14, b) SBP below 90 mmHg, or c) respiratory rate (RR) below 10/min or over 29/min. Step two criteria are a) penetrating injuries to the head, neck, torso, or proximal long bones, b) flail chest, c) fracture of two or more proximal long bones, d) amputation(s) proximal to the hands/feet, e) unstable pelvic fractures, f) open skull fractures, and g) spinal cord injuries. At present, there is relatively little evidence for these criteria. In a study of 1473 trauma patients, Knopp [9] found a positive predictive value (PPV) of 100% for ISS > 15 in spinal cord and amputation injuries; however, fractures of the long bones had a PPV of only 19.5%.

Tinkoff et al. [22] assessed several of these criteria for accuracy in the identification of severely injured and/or high-risk patients. Trauma patients fulfilling the ACS COT criteria had more severe injuries, increased mortality, and longer intensive care stays than control patients. Systolic blood pressure under 90 mmHg, endotracheal intubation, and gunshot wound to the torso/neck were predictive for emergency surgery or intensive care admission. Mortality was markedly increased in patients with SBP under 90 mmHg, endotracheal intubation, or GCS less than 9. Kohn et al. [10] analyzed various trauma team activation criteria (see Table 1), which are similar to those of the ACS COT. Respiratory rate under 10 or over 29 breaths per minute was the most predictive for presence of a severe injury. Other highly predictive parameters were: a) burns with over 20 % body surface area (BSA), b) spinal cord syndrome, c) systolic blood pressure under 90 mmHg, d) tachycardia, and e) gunshot wounds to the head, neck, or torso.

Open Head Injuries

With a lack of studies on the relevance of open head injuries, this criterion is regarded by the ACS COT rather as a significant indicator of severe injuries that require a high level of specialist medical competence and is thus assigned to the Step One criteria.

GCS

Kohn et al. [10] regard a GCS under 10 as an important predictor of severe trauma. Of patients activating the emergency department trauma team for low GCS, 44.2% had confirmed severe injuries. The value of GCS as predictor of severe injury or as activation criterion for the trauma team has been confirmed in studies by Tinkoff et al., Norwood et al., and Kühne et al. [11, 16, 22]. Norwood and Kühne both saw pathological intracerebral findings and need for inpatient admission already at GCS values under 14. At the same time, trauma team activation does not appear absolutely necessary with these patients (GCS ≤ 14 and ≥ 11). For GCS under 10, Engum [5] found a 70 % sensitivity for the endpoints surgery, intensive care unit (ICU), or death. The odds ratio (OR) was 3.5 (95% CI: 1.6-7.5). The authors found a PPV of 78 % for severe injuries in children with a GCS < 12.

Key recommendation:

2.8

Recommendation

2011

GoR B

The emergency department trauma team should be mobilized for the following additional criteria:

 •Falls from over 3 meters

 •Motor vehicle accident (MVA) with

 •Frontal collision with intrusion greater than 50-75 cm

 •Vehicle speed change of delta > 30 km/h

 •Pedestrian/bicycle collision

 •Occupant mortality (driver or passenger)

 •Occupant ejection (driver or passenger)

Explanation:

Accident-related/dependent criteria

In the literature, accident-related/dependent criteria are evaluated very differently regarding predictive value for severe trauma.

Norcross et al., Bond et al., and Santaniello et al. [2, 15, 19] report rates of overtriage up to 92%, sensitivity of 50-70 %, and PPV of 16.1% when accident-related mechanisms are used as the sole criterion for predicting injury severity. When physiological criteria are added, sensitivity of 80 % and specificity of 90 % are reached [2].

Knopp et al. found poor positive predictive values for the parameters of motor vehicle accident (MVA) with ejection or death of an occupant (driver or passenger) and MVAs involving a pedestrian [9]. Engum et al. also found the lowest predictive values for MVAs involving a pedestrian at 20 mph (miles per hour) and MVAs with occupant death and trauma from vehicle rollover [5]. The current ACS COT recommendations removed vehicle rollover trauma from the criteria. Frontal impact with intrusion greater than 20-30 inches, death of a car occupant, MVA with pedestrian/bicycle collision with ≥ 20 mph, and ejection of an occupant were cited as Step Three Criteria, i.e., there is no absolute necessity to transport these patients to a maximum care level hospital, provided these are isolated criteria. Kohn et al. [10] also consider vehicle rollover trauma as inadequate. According to Kohn et al., the same also applies to the criteria of MVA with occupant ejection or death and MVA with pedestrian involvement [10].

Champion et al. [3] consider vehicle rollover an important indicator of severe injury. The average probability of suffering a lethal injury is much higher in an overturned vehicle than in those not rolling over.

Nevertheless, the ACS COT removed the rollover mechanism from its triage criteria because relevant injuries after this type of accident should already be included in Step One or Step Two.

Vehicular Body Damage

In a multivariate analysis of 621 patients, Palanca et al. [17] found no significant association between vehicle deformation (intrusion of > 30 cm or > 11.8 inches) and the presence of relevant severe injury (OR: 1.5; 95% CI: 1.0–2.3; p = 0.05). Henry reported comparable results in another multivariate analysis [8]. Using data from the National Automotive Sampling System Crashworthiness Data System (NASS CDS), Wang found a PPV of 20% for ISS > 15 [24].

Occupant mortality (driver or passenger)

Knopp et al. found increased risks for surgery or death when a car occupant was fatally injured (OR: 39.0; 95% CI: 2.7–569; PPV 21.4%) [9]. Palanca et al. [17] did not confirm a significant association between occupant mortality and severe injury, although the concurrence of the two was 7 %.

Falls from a great height

In a prospective study by Kohn et al. [10], 9.4% of patients falling from more than 6 meters had severe injuries - defined as requiring intensive care admission or immediate surgery. Yagmur et al. [25] reported 9 meters as the average fall height from which patients died.

Burns

It is essential to determine whether burns are present without concomitant injuries. In the case of combination injuries where the non-thermal component is predominant, the patient should be brought to a trauma center [1].

Age

A 2015 review study identified age cutoffs between 45 and 70 years. Patients older than the respective cutoff should be treated in a trauma center by the trauma team. In addition to extended monitoring, surgical management should be adapted according to age-related pathophysiology. Treatment in trauma centers with geriatric expertise can reduce trauma-associated mortality of older patients.

Kohn et al. [10] evaluated various trauma team activation criteria similar to those of the ACS COT. Of the evaluated criteria, “age over 65” had the least informative value. Thus, the authors recommended that this criterion be removed from the “first-tier activations.” Demetriades et al. [4] found markedly higher mortality (16 %), increased ICU admission and need for surgery (19%) in patients over 70 years of age compared to younger patients. However, in this study, all patients not requiring hospital admission were excluded, so the cited percentages are probably overestimations. In a retrospective study of over 5000 patients from the DGU trauma registry, Kühne et al. [12] found increased mortality - irrespective of ISS - with increasing age. The cutoff value for increased mortality was 56 years. MacKenzie et al. [13] also found a marked increase in (fatal) injuries with age > 55 years. In a 13-year review, Grossmann et al. [7] found that mortality increased 6.8 % per year of life after 65. In a study by Morris et al. [14], patients who died from the consequences of an accident had lower ISS than younger patients in the control group.

Overall, the influence of age on trauma outcomes is a controversial topic. The ACS COT has classified age as a relatively low indication to transfer to Level 1 or 2 trauma center (Step Four criterion). Hildebrand considers age as a relevant influencing variable; however, accompanying medication, physiological reserves, and weak immune systems should be taken into account when evaluating geriatric patients (see above).

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    American College of Surgeons Committee on Trauma. Resources for optimal care of the injured patient. Chicago: American College of Surgeons; 2014.

     
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    Bond RJ, Kortbeek JB, Preshaw RM. Field trauma triage: combining mechanism of injury with the prehospital index for an improved trauma triage tool. J Trauma. 1997;43(2):283–7.

     
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    Champion HR, Lombardo LV, Shair EK. The importance of vehicle rollover as a field triage criterion. J Trauma. 2009;67(2):350–7.

     
  4. 4.

    Demetriades D, et al. Old age as a criterion for trauma team activation. J Trauma. 2001;51(4):754–6 (discussion 756–7).

     
  5. 5.

    Engum SA, et al. Prehospital triage in the injured pediatric patient. J Pediatr Surg. 2000;35(1):82–7.

     
  6. 6.

    Franklin GA, et al. Prehospital hypotension as a valid indicator of trauma team activation. J Trauma. 2000;48(6):1034–7 (discussion 1037–9).

     
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    Grossman MD, et al. When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma. 2002;52(2):242–6.

     
  8. 8.

    Henry MC. Trauma triage: New York experience. Prehosp Emerg Care. 2006;10(3):295–302.

     
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    Knopp R, et al. Mechanism of injury and anatomic injury as criteria for prehospital trauma triage. Ann Emerg Med. 1988;17(9):895–902.

     
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    Kohn MA, et al. Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med. 2004;11(1):1–9.

     
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    Kuhne CA, et al. Emergency room patients. Unfallchirurg. 2003;106(5):380–6.

     
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    Kuhne CA, et al. Mortality in severely injured elderly trauma patients—when does age become a risk factor? World J Surg. 2005;29(11):1476–82.

     
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    Morris JA Jr, MacKenzie EJ, Edelstein SL. The effect of preexisting conditions on mortality in trauma patients. JAMA. 1990;263(14):1942–6.

     
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2.4 Thorax

Importance of the Medical History

Key recommendation:

2.9

Recommendation

2016

GoR B

An accurate medical history should be collected, if necessary from a third party.

2.10

Recommendation

2016

GoR B

High-speed trauma and motor vehicle accidents with lateral impact should be considered evidence for chest trauma/aortic rupture.

Explanation:

Although there are few studies on collecting the medical history in regard to thoracic trauma, it remains an indispensable requirement for the assessment of injury severity and pattern of injury, and is used to establish whether or not an accident actually occurred. Collection of the circumstantial details of the accident are essential for the history. For motor vehicle accidents (MVAs) involving passenger vehicles, questions regarding the speed of the vehicle at the time of impact and the direction of impact are particularly important. There are marked differences in the occurrence, pattern, and severity of chest injuries as well as overall injury severity depending on whether the impact is lateral or frontal [113].

Horton et al. [64] reported a sensitivity of 100% and a specificity of 34% for aortic rupture with a lateral collision and/or change in velocity (delta V) ≥ 30 km/h. In another study [33], high velocity injuries at speeds of > 100 km/h were graded as suspicious for aortic rupture. Richter et al [106] also found an increased risk of chest injury in lateral collisions. In this study, delta V correlated with the AIS (thorax), ISS, and clinical course. Ruchholtz et al. [110] diagnosed chest injury in 8 of 10 passenger vehicle accidents involving lateral collision.

In a study of 286 passenger vehicle occupants with ISS ≥ 16, the probability of aortic injury was twice as high after lateral versus frontal collision [98]. Impact in the region of the superior thoracic aperture and fractures of ribs 1-4 appear to be associated with an increased incidence of aortic injuries [115].

Children as well have a 5-fold higher risk of severe chest injury (AIS ≥ 3) and significantly higher overall injury severity when they are occupants of a passenger vehicle in a lateral versus frontal collision [96].

The effect of seatbelts on chest injuries appears unclear. In a retrospective study of 1124 patients with relatively minor overall injury severity (ISS 11.6), Porter and Zaho [100] did find increased incidence of sternum fractures (4 % vs. 0.7 %) in seat belted patients, but the proportion of patients with thoracic injuries were identical in both groups (21.8 vs. 19.1 %).

Importance of Physical Examination Findings

Key recommendation:

2.11

Recommendation

2016

GoR A

Clinical examination of the chest must be performed.

2.12

Recommendation

Modified 2016

GoR A

Auscultation must be carried out with the physical examination.

Explanation:

Although there are barely any studies on the importance of and required scope for physical examination, it remains an indispensable requirement for the recognition of symptoms and making (suspected) diagnoses. The physical examination serves to detect relevant, life-threatening, or potentially fatal disorders or injuries that require immediate and specific treatment. Even when an examination has already been performed in the pre-hospital phase and even when a chest tube has already been inserted, physical examination in the emergency department is to be performed, since a change in the constellation of findings could have occurred.

The initial physical examination should address the following objectives [81]:
  • Examination and securing of the airway

  • Respiratory rate/dyspnea

  • Inspection of the chest (skin and soft-tissue injuries, symmetry of the chest and respiratory excursion, paradoxical respiration, congestion, belt marks)

  • Palpation (subcutaneous emphysema, crepitus, points of tenderness)

  • Auscultation (presence and quality of breath sounds bilaterally)

  • Details regarding pain

The following immediately life-threatening injuries must be checked during the initial examination [3]:
  • Airway obstruction

  • Tension pneumothorax

  • Open pneumothorax

  • Flail chest/Lung contusion

  • Massive hemothorax

  • Pericardial tamponade

Auscultation findings are the leading indicators in the diagnosis of chest trauma. In addition, subcutaneous emphysema, palpable instability, crepitus, pain, dyspnea, and increased ventilatory pressures can indicate thoracic injuries.

In a prospective study, Bokhari et al. [9] examined 676 patients with blunt or penetrating chest injury for clinical signs and symptoms of hemopneumothorax. Of 523 patients with blunt trauma, only 7 had hemopneumothorax. In this group, auscultation had sensitivity and negative predictive values of 100 %. Specificity was 99.8 % and the positive predictive value was 87.5 %. In penetrating injuries, the sensitivity of auscultation was 50 %, specificity and positive predictive value were 100 %, and the negative predictive value was 91.4 %. In both injury mechanisms, pain and tachypnea are insufficient to diagnose hemopneumothorax.

In a retrospective study of 118 patients with penetrating trauma, Chen et al. [21] also found a sensitivity of only 58%, specificity and positive predictive value of 98%, and a negative predictive value of 61% for auscultation. In a prospective study of 51 patients with penetrating trauma, the combination of percussion and auscultation exhibited a sensitivity of 96%, specificity of 93%, and positive predictive value of 83% [61].

These studies show that in penetrating trauma, decreased or absent breath sounds generally indicate an underlying pneumothorax, and a chest drain should be inserted prior to x-ray.

In their search for a clinical decision-making tool to identify children with chest injuries, Holmes et al. [63] studied 986 patients, 80 of whom had a chest injury. This yielded an odds ratio (OR) of 8.6 for positive auscultation findings, OR of 3.6 for abnormal physical examination (reddening, skin lesions, crepitus, tenderness), and OR of 2.9 for elevated respiratory rate.

Importance of Diagnostic Equipment (chest radiograph, ultrasound, CT, angiography, ECG, laboratory tests) and Indications for Use

Key recommendations:

2.13

Recommendation

Modified 2016

GoR A

If thoracic trauma cannot be ruled out, radiological diagnostic studies must be performed in the emergency department.

2.14

Recommendation

2016

GoR B

Spiral CT of the thorax with contrast medium should be performed for any patient with clinical evidence or history suggestive of severe chest trauma.

Explanation:

As explained in points 1 and 2, both the mechanism of injury and the findings from the physical examination provide important information on the presence or absence of a chest injury. For this reason, a chest radiograph can be dispensed with if a trauma CT scan will be performed immediately and if a chest injury can be excluded based on the accident circumstances and at the same time there are no findings from the physical examination that make an intrathoracic injury probable.

Conversely, all patients with confirmed chest injury should undergo chest x-ray once immediately life-threatening injuries have been excluded and/or treated. The initial radiograph can enable diagnosis of pneumothorax and/or hemothorax, rib fractures, tracheobronchial injuries, pneumomediastinum, mediastinal hematoma, and pulmonary contusion [53]. For detailed diagnosis of the pattern of injury, computed tomography is the gold standard. If there is not enough time available, chest x-ray can be performed as primary diagnostic study, due to the low cost and good availability. Nevertheless, there is little evidence on sensitivity and specificity of the diagnosis of pulmonary or thoracic injuries.

A prospective study of 100 patients found that the most important thoracic injuries are evident on chest x-ray. The sensitivity of images with the patient standing upright was 78.7 % and supine was 58.3 % [58]. In a series of 37 patients who died within 24 hours of admission, McLellan et al. [83] identified 11 cases in which important injuries found at autopsy were not evident on chest x-ray. Of these, there were 11 cases of rib fractures, 3 sternum fractures, 2 diaphragmatic ruptures, and 1 intimal lesion of the aorta.

The chest x-ray gives sufficient accuracy, e.g. to establish a need for chest tube drainage. In a prospective study of 400 polytrauma patients, Peytel et al. [99] reported that all cases (n = 77) in which chest tubes were placed based on chest x-ray findings were correct.

However, numerous studies have found that intrathoracic injuries can be identified significantly more often on CT than on chest radiographs alone. It is especially superior for the detection of pneumothorax, hemothorax, lung contusion, and aortic injuries. Spiral CT with intravenous (I.V.) contrast is preferable [94]. With the use of multi-layer versus single-layer spiral CT, the average whole-body examination time decreased from 28 to 16 minutes, and the initial diagnostic information was taken from real-time images on the monitor [76] The NEXUS criteria can be helpful for the decision for or against radiological diagnostic studies [107].

In a series of 103 severely injured patients, Trupka et al. [122] found that compared to radiographs, additional information regarding the basic thoracic trauma was evident in 65 % of patients (lung contusion n = 33, pneumothorax n = 34, hemothorax n = 21). There were direct therapeutic consequences resulting from this extra information for 63 % of these patients, the majority of whom required new or correction of existing chest tube placement.

In patients with relevant trauma (motor vehicle accidents with accident speeds > 15 km/h, falls from a height > 1.5 m), Exadaktylos et al. [38] identified no thoracic injuries on conventional radiographs in 25 of 93 patients. However, CT showed some considerable thoracic injuries in 13 of these 25 patients, including two aortic lacerations. In a prospective study, Demetriades et al. [28] performed spiral CT examinations of the chest in 112 patients with deceleration trauma, of whom nine patients were diagnosed with aortic rupture. Four of these patients had normal chest x-rays. Eight cases of aortic rupture were identified on CT. One patient had an injury to the brachiocephalic artery. Local hematoma was evident on CT, but the vessel itself was not visualized on the CT cuts. Even in patients without clinical signs of thoracic injury and with negative radiographic findings, chest injuries were evident on CT in 39% of patients, and in 5% of cases this led to a change in treatment [95].

Blostein et al. [8] concluded that routine CT is not generally recommended in blunt chest trauma, since of 40 patients studied prospectively with defined chest injuries, 6 patients had changes in treatment (5x chest tubes, 1x aortogram with negative result). The authors admitted as well that CT yields findings not visible on conventional radiographs in patients who are intubated and ventilated. In patients with an oxygenation index (PaO2/FiO2) < 300, the CT can help estimate the extent of pulmonary contusion and to identify patients at risk for pulmonary failure. Moreover, patients in whom an incompletely decompressed hemothorax and/or pneumothorax could lead to further decompensation can be identified. In a retrospective study of 45 children [104] with 1) pathologic radiographic findings (n = 27), 2) abnormal physical examinations (n = 8), and 3) substantial impact to the chest wall (n = 33), CT identified additional injuries in 40%, leading to a change in treatment of 18%.

Although the supplementary diagnostic information of chest CT has become generally accepted for blunt thoracic trauma in the more recent literature [54], its benefit regarding clinical outcomes remains controversial and is not yet clear. A prospective study by Guerrero-Lopez et al. [56] found chest CT to be more sensitive in detecting hemo/pneumothorax, lung contusion, vertebral fractures, and chest tube misplacement, and led to changes in therapy in 29 % of cases. On multivariate analysis, no therapeutic correlation between CT and ventilation duration, intensive care stay, or mortality was established. The authors concluded that chest CT should be performed only for suspected severe injuries that can be confirmed or excluded.

Current studies have identified clear benefits from multi-layer CTs of the chest when there is a defined indication. Brink et al. [15] evaluated routine versus selective use in 464 and 164 patients, respectively. Indications for routine CT were high-energy trauma, threatening vital signs, and severe injuries such as pelvic or vertebral fractures. Indications for selective CT were abnormal mediastinum, more than three rib fractures, pulmonary shadowing, emphysema, and thoracolumbar spine fractures. Injuries not evident on conventional radiographs were found in 43 % of patients undergoing routine CT. This led to treatment changes in 17 %. Of 7.9 % of patients with normal chest x-rays, Salim et al. [111] found pneumothorax in 3.3 %, suspected aortic rupture in 0.2 %, lung contusion in 3.3 %, and rib fractures in 3.7 %.

Summarizing results in the literature, the following criteria are indications for chest CT:

Indication criteria for chest CT (summarized according to [15, 107, 111]):
  • Motor vehicle accident (MVA) Vmax > 50 km/h

  • Fall from > 3 m height

  • Patient ejected from vehicle

  • Rollover trauma

  • Substantial vehicle damage

  • Pedestrian hit at > 10 km/h

  • Bicyclist hit at > 30 km/h

  • Entrapment

  • Pedestrian hit by vehicle and flung > 3 m

  • GCS < 12

  • Vital/hemodynamic abnormalities (respiratory rate > 30/min, pulse > 120/min, systolic blood pressure < 100 mmHg, blood loss > 500 ml, capillary refill > 4 seconds)

  • Severe concomitant injuries (pelvic ring fracture, unstable vertebral fracture, or spinal cord compression)

A retrospective multicenter analysis using the DGU trauma registry database found improved survival probability for patients who had initially undergone a full-body CT scan [65]. The use of full-body CT leads to a relative reduction in mortality of 25 % in TRISS and of 13% in the RISC score. CT was an independent predictor for survival on multivariate analysis.

Key recommendation:

2.15

Recommendation

Modified 2016

GoR B

An initial ultrasound of the chest should be performed in any patient with clinical signs of thoracic trauma (according to the eFAST framework), unless an initial spiral CT chest with contrast has been performed.

Explanation:

In a prospective study of 27 patients, chest X-rays, ultrasound examinations, and CT were compared for diagnostic accuracy for pneumothorax. The ultrasound examination of the chest showed sensitivity and negative predictive value of 100 % and specificity of 94 % [108]. In another study comparing ultrasound with radiographs for the diagnosis of pneumothorax, ultrasound yielded sensitivity and positive predictive value of 95 % and a negative predictive value of 100 % [31]. However, emphysematous bullae, pleural adhesions, or extensive subcutaneous emphysema can distort ultrasound results.

As a retrospective study of 240 patients made clear, ultrasound ranks equally with the X-ray in diagnosing hemothorax. In 26 of these patients, hemothorax was confirmed by either chest tube or chest CT. Ultrasound and chest x-ray each showed sensitivity of 96%, specificity and negative predictive value of 100%, and positive predictive value of 99.5% [78].

In a prospective study of 261 patients with penetrating injuries, chest ultrasound had a sensitivity of 100% and specificity of 96.9% for detecting pericardial tamponade [109]. False negative ultrasound results occur, however, especially in patients with a larger hemothorax, which can conceal smaller hematomas of the pericardium [86]. Thus, ultrasound sensitivity was only 56% in this study.

A retrospective study of 37 patients with CT-confirmed pulmonary contusion found ultrasound sensitivity of 94.6%, specificity of 96.1%, and positive and negative predictive values of 94.6% and 96.1%, respectively [116].

Spiral CT chest with contrast excluded aortic injuries in patients without detected mediastinal hematoma, so that angiography was not necessary. Because of insufficient sensitivity, conventional CT examinations are less suited for exclusion of an aortic injury [32, 44, 87].

Aortogram is useful only in patients with inconclusive CT or with a periaortal hematoma without direct signs of aortic injury. There is now general consensus that spiral CT with contrast is suitable to exclude aortic rupture [18, 36, 85]. There is high probability that patients without detectable mediastinal hematoma have no aortic injury. Thus, the use of computed tomography can avoid a large number of unnecessary aortogram procedures. However, when brain CT scan is also necessary, it should be carried out before the chest CT as the use of contrast agent complicates the traumatic brain injury diagnosis.

As comparative studies on angiography have shown, CT showing no evidence of mediastinal hematoma has a negative predictive value of 100% for the injury of large intrathoracic vessels [103]. However, the study of Parker et al. [97] finds the specificity only 89 % because of 14 false positive results. It is thus recommended that angiography be performed for patients with CT scans showing para-aortic hematoma or blood collections around aortic branches as well as aortic contour irregularities. A negative CT scan with contrast definitively excludes aortic rupture [44, 91, 127].

In an analysis of 54 patients with surgically detected aortic ruptures, Downing et al. [30] showed sensitivity of 100% and specificity of 96% for spiral CT. In a prospective study of 1104 patients with blunt chest trauma, Mirvis et al. [90] found mediastinal bleeding in 118 cases, of which 25 patients had aortic ruptures. For aortic rupture, spiral CT yielded sensitivity and negative predictive value of 100%, specificity of 99.7%, and positive predictive value of 89%. In a retrospective study of chest CT, Bruckner et al. found a negative predictive value of 99%, positive predictive value of 15%, sensitivity of 95%, and specificity of 40%.

In another prospective study of 1009 patients, 10 patients had aortic injuries [34]. Spiral CT had sensitivity and negative predictive value of 100 %, specificity of 96 %, and positive predictive value of 40 % for direct signs of aortic injury.

In contrast to the prospective studies mentioned above, in a retrospective study of 242 patients, Collier et al. [25] found a sensitivity of only 90% and a negative predictive value of 99%; aortic injury was found during the autopsy of one patient with a normal CT who had subsequently died from the consequences of traumatic brain injury. In another retrospective study, angiography did not detect any aortic injury in 72 patients with intrathoracic hematoma but no evidence of a direct aortic or other intrathoracic vessel injury on CT scan [112].

Transesophageal echocardiography (TEE) is a sensitive screening test [16, 24, 126], but angiography was often also carried out afterwards [19, 89]. TEE requires an experienced examiner [51] and is generally not as rapidly available as CT or angiography. The benefit of TEE may lie in the visualization of small intimal tears [16] that might not be visible on angiography or helical CT. However, TEE cannot provide good images of the ascending aorta and the aortic branches, which thus elude diagnostic evaluation [92]. To date, only one prospective study compares spiral CT to TEE in the diagnosis of aortic injury. CT and TEE showed sensitivity of 73 and 93%, respectively, and negative predictive value of 95%.

Key recommendations:

2.16

Recommendation

2016

GoR A

A 3-lead ECG must be performed to monitor vital functions.

2.17

Recommendation

Modified 2016

GoR A

If blunt cardiac injury is suspected, a twelve lead ECG must be performed.

Explanation:

An initial ECG is essential for every severely injured patient. It is necessary particularly in the absence of palpable pulses, to differentiate rhythms that can and can’t be defibrillated in cardiac arrest. The ECG can also be used as a screening test for potential cardiac complications from blunt cardiac injury.

Patients with normal ECG, normal troponin-I value, normal hemodynamics, and no other relevant injuries do not require further diagnostic studies or treatment. Cardiac enzymes are irrelevant in predicting complications from blunt cardiac injury, although raised troponin I levels can predict abnormalities on echocardiography. A 12-lead ECG is performed for further diagnosis of patients with blunt chest trauma [23].

Echocardiography should not be used in the emergency department for the diagnosis of cardiac contusion, since this entity is not correlated with clinical complications. Echocardiography should be performed in hemodynamically unstable patients to diagnose pericardial tamponade or pericardial rupture. Transthoracic echocardiography should be the method of choice, as there is no clear evidence as yet that transesophageal echocardiography is superior in diagnosing blunt cardiac injury.

The ECG is a rapid, cost-effective, non-invasive examination that is always available in the emergency department. Meta-analysis of 41 studies found that ECG and creatine kinase MB (CK-MB) levels are more important than radionuclide examinations and echocardiogram in the diagnosis of clinically-relevant blunt cardiac injury (defined as a treatment-requiring complication) [79].

Fildes et al. [43] reported prospectively on 74 hemodynamically stable patients with normal initial ECG, no existing heart disease, and no other injuries. None of these patients developed cardiac complications. Another retrospective study of 184 children with blunt cardiac injury reported that patients with a normal ECG in the emergency department did not develop complications [29]. Meta-analysis of 41 studies correlated abnormal admission ECG with the development of treatment-requiring complications [79]. Conversely, a prospective study from Biffl et al. [7] identified contusion complications in 17 of 107 patients. Only two of 17 patients had abnormal ECG on admission, and three showed sinus tachycardia. In another retrospective study of 133 patients with clinical suspicion of myocardial contusion at two institutions, 13 patients (9.7 %) developed complications; however, no patients with normal initial ECGs showed other abnormalities [41]. In a study by Miller et al. [88] of 172 patients, four developed treatment-requiring arrhythmias, with all four patients having abnormal initial ECGs. Wisner et al. [134] studied 95 patients with suspected cardiac contusion. Of these, four patients developed clinically significant arrhythmias, and only one of these had a normal ECG on admission. In summary, the majority of authors recommend that asymptomatic, hemodynamically stable patients with normal ECG do not require any further diagnostic tests or treatment.

Key recommendation:

2.18

Recommendation

Modified 2016

GoR 0

Serum levels of troponin can be measured as an adjunct for the diagnosis of blunt cardiac injury.

Explanation:

The assessment of creatine kinase MB (CK-MB) levels is not indicated for the diagnosis of myocardial contusion [23]. In a retrospective study of 359 patients, of whom 217 were initially admitted to exclude myocardial contusion, 107 were diagnosed because of either abnormal ECG or elevated CK-MB levels 16% of patients developed complications requiring treatment (arrhythmias or cardiogenic shock). All of these patients had abnormal ECG, but only 41% had elevated CK-MB levels. Patients with normal ECG and increased CK-MB levels did not develop complications [7]. In a prospective study of 92 patients undergoing ECG, CK-MB analysis, and continuous monitoring, 23 patients developed arrhythmias requiring no specific treatment. This shows that the number of arrhythmias requiring therapy is low. 52% of patients with arrhythmias had elevated CK-MB levels, whereas 19% of patients without arrhythmias also had elevated CK-MK levels [39]. Other studies have found no correlation between elevated CK-MB levels and cardiac complications [45, 57, 59, 71, 88, 117, 134].

Troponin I and T are sensitive markers in the diagnosis of myocardial infarction and considerably more specific than CK-MB, as they are not present in skeletal muscle. In a study of 44 patients, the 6 patients with echocardiography-confirmed myocardial injury showed simultaneous elevations in CK-MB and troponin I. Of the 37 patients without cardiac injury, CK-MB levels were elevated in 26 patients, but troponin I was elevated in none [1]. Another study of 28 patients, 5 of whom with echocardiogram-confirmed myocardial contusion, reported 100 % specificity and sensitivity for troponin I. In a study of 29 patients, troponin T showed higher sensitivity (31%) than CK-MB (9%) in diagnosing myocardial injury. Troponin T showed a sensitivity of 27 % and a specificity of 91 % for predicting clinically significant ECG changes in 71 patients [46].

In a more current prospective study of 94 patients, 26 patients were diagnosed with myocardial contusion by either ECG or echocardiography. Troponin I and T showed sensitivity of 23 and 12%, respectively, sensitivity of 97 and 100%, respectively, and negative predictive value of 76.5 and 74%, respectively. The authors describe an unsatisfactory correlation between the two enzymes and the occurrence of complications [6]. In another prospective study, sensitivity, specificity, and positive and negative predictive values of troponin I are given as 63, 98, 40, and 98%, respectively, for detecting myocardial contusion [35]. Velmahos et al. carried out ECG tests and troponin I measurements prospectively in 333 patients with blunt chest trauma [124]. In 44 diagnosed cardiac injuries, the ECG and troponin I showed sensitivity of 89 and 73%, respectively, and negative predictive values of 98% and 94%, respectively. The combination of ECG and troponin I produced sensitivity and negative predictive values of 100% each. Rajan et al. [102] showed that a cTnI level below 1.05 µg/l at admission and after six hours excludes myocardial injury.

Patients with a normal ECG and Troponin I values do not have myocardial contusion, and therefore need monitoring. It is different when the ECG is normal but the troponin I value is elevated; monitored observation is then recommended [23].

A transthoracic echocardiography (TTE) is often carried out in the diagnosis of blunt cardiac injury but has hardly any importance in hemodynamically stable patients. In a prospective study, Beggs et al. carried out TTE in 40 patients with suspected blunt chest injury. Half of the patients had at least one pathologic finding on ECG, TTE, or in the cardiac enzyme levels. There was no correlation between TTE, enzymes, or ECG findings, and TTE did not predict the development of complications [5]. In another prospective study of 73 patients undergoing TTE, CK-MB measurements, and cardiac monitoring, 14 patients had abnormalities on echocardiography. However, only 1 patient, who had a pathologic ECG on admission, developed a complication, in the form of a ventricular arrhythmia [60]. A prospective study of 172 patients offered the conclusion that only abnormal ECG or shock have predictive value with reference to monitoring or to specific treatment. Patients with abnormalities on TTE or elevated CK-MB levels without pathologic ECG developed no complications requiring treatment [88]. Although there are a number of studies showing the advantages of TTE in the diagnosis of pericardial effusion or pericardial tamponade in penetrating trauma, the value of this study for blunt trauma is debatable [88, 93, 109].

There are a number of studies showing that the accuracy of transesophageal echocardiography (TEE) is greater than that of TTE in the diagnosis of cardiac injuries [16, 20, 22, 52, 130]. In addition, other cardiovascular changes such as aortic injuries, for example, can be diagnosed by TEE. In a prospective study of 95 patients with risk factors for aortic injury, Vignon et al. [125] performed spiral CT and then TEE in the intensive care unit. The sensitivity of TEE and CT was 93 and 73%, respectively, the negative predictive values were 99% and 95%, respectively, and the specificity and the positive predictive values were 100% for both examination methods. TEE proved superior in identifying intimal tears, whereas an aortic branch lesion was missed.

In summary, echocardiography should be carried out if a pericardial tamponade or pericardial rupture is suspected.

Additional Diagnostic Studies Available for Trauma Patients in the Emergency Department

Fabian et al. [40] state that patients with mediastinal hematoma and no direct evidence of aortic injury require no further assessment. This also applies to intimal tears and pseudo-aneurysms. However, patients with changes that cannot be classified in more detail should undergo angiography for further assessment. Gavant et al. [49] also stated that in the absence of a mediastinal hematoma or if a normal aorta is visualized despite mediastinal hematoma, spiral CT with contrast agent is sufficient for diagnosis and aortography is not necessary.

Mirvis et al. [90] and Dyer et al [34] suggest that aortic injury or injury to the main branches and a mediastinal hematoma detected on CT require either angiography or direct thoracotomy, depending on the experience of the treating establishment. Angiography is also necessary for mediastinal hematoma in direct contact with the aorta or the proximal great vessels without direct evidence of vascular injury or for abnormal aortic contours [97].

Downing et al. [30] conclude that surgical treatment can be carried out without further diagnostic tests if spiral CT clearly detects an aortic rupture. In contrast to the study by Dyer et al. [33] mentioned above, Fabian et al. [40] conclude that patients with mediastinal hematoma but no direct evidence of aortic injury require no further work-up.

To date, there are no comparative studies evaluating the need for angiography prior to a planned operation for an aortic injury detected on CT scan. Thus, the recommendations are based both on conclusions from studies evaluating angiography and CT in the diagnosis of aortic injury and on data from diagnostic tests performed prior to endovascular treatment.

Gavant et al. [49], recommend that aortography be carried out prior to surgical or endovascular treatment to confirm the injury and define the extent of damage. Parker et al. [97] also consider angiography necessary to confirm positive CT findings.

In patients with direct evidence of aortic injury and mediastinal hematoma, Mirvis et al. [90] and Dyer et al [34] suggest either angiography or direct thoracotomy, depending on the experience of the treating establishment.

Downing et al. [30] and Fabian et al. [40] hold the view that thoracotomy can be carried out with a clear CT diagnosis, also without additional angiography.

In a series of five patients with acute traumatic rupture of the thoracic aorta, CT scans and angiography were carried out on all patients prior to stent implantation [119].

Importance of Emergency Measures (chest tube drainage, intubation, pericardiocentesis, thoracotomy)

Key recommendations:

2.19

Recommendation

2016

GoR A

Clinically relevant or progressive pneumothorax must be primarily decompressed in ventilated patients.

2.20

Recommendation

2016

GoR B

For non-ventilated patients, progressive pneumothorax should be decompressed.

2.21

Recommendation

2016

GoR A

A chest tube must be inserted for this purpose.

2.22

Recommendation

Modified 2016

GoR B

Chest tubes sized 24 - 32 French should be favored.

Explanation:

A pneumothorax detected on x-ray is an indication to insert a chest tube, particularly when mechanical ventilation is necessary. This is general clinical practice, although there are no comparative studies examining this in the literature [2, 47, 50, 63, 129]. Because of the underlying pathophysiology, it has been upgraded to Grade of Recommendation A. Westaby and Brayley [132] recommend that a chest tube should always be inserted for pneumothorax larger than 1.5 cm at the level of the 3rd intercostal space. If it is smaller than 1.5 cm, the chest tube should only be placed if ventilation is necessary or if both sides are affected. Chest tube placement can be omitted in a small anterior pneumothorax detected on CT only, but close clinical monitoring is required.

Chest tubes should be placed in the emergency department since there is a risk of progression to tension pneumothorax, and the rapidity of this development cannot be estimated. The risk of a tension pneumothorax occurring should be considered markedly higher in ventilated patients versus non-ventilated patients. In non-ventilated patients, a small pneumothorax less than 1-1.5 cm wide can initially be treated conservatively with close clinical observation. If this is not possible because of logistics, decompression of the pneumothorax should also be performed here.

The benefits of a very large lumen chest tube 36-40 vs. 28-32 Fr have not been confirmed in polytrauma patients. This was investigated in a study of 293 patients [67]. On the contrary, smaller chest tubes (24 Fr) can be used without complications.

The increasing use of abdominal and chest CT in the diagnosis of blunt trauma has led to the detection of pneumothorax cases that would not have been detected on conventional supine radiographs. These cases of “occult pneumothorax,” usually lying anteriorly, are found in 2-25% of patients after severe multiple injuries [8, 95, 105, 121, 122, 128]. Based on the available literature, the initial insertion of a Bülau drain should be omitted in an occult pneumothorax diagnosed by CT if:
  • the patient is hemodynamically stable and has largely normal pulmonary function,

  • there are frequent clinical checks, with the possibility of interval x-rays,

and
  • a chest tube can be inserted at any time by a qualified physician [72].

In a prospective randomized study, Brasel et al. [14] also studied the need for chest tube insertion for an occult traumatic pneumothorax. Chest tubes were inserted in 18 patients, and 21 patients were observed only. Ventilation was necessary for nine patients of each group. In the chest tube group, the pneumothorax increased in 4 patients; in the control group without chest tubes, a Bülau drain was inserted in 3 patients, of whom 2 were then also ventilated.

In a prospective study of 36 patients with 44 cases of occult pneumothorax, cases were subdivided into minimal (< 1 cm visible on a maximum of 4 CT slices), anterior (> 1 cm but not extending laterally into the dorsal half of the chest), and anterolateral pneumothorax [135]. Fifteen cases of minimal pneumothorax were monitored closely, regardless of the need for ventilation. Two cases required secondary insertion of a chest tube. In patients requiring ventilation, anterior and anterolateral pneumothorax was always treated with chest tube placement. In a prospective study of children, Holmes et al. identified eleven patients with occult pneumothorax, classified according to the schema above [62]. Patients with minimal pneumothorax were treated conservatively regardless of need for ventilation.

In a retrospective study, 13 pneumothorax patients were treated with and 13 without chest tube insertion [26]. Of ten patients in whom mechanical ventilation was needed, two patients required secondary chest tube placement. However, there was no information regarding the size of the initial pneumothorax. In another retrospective study, the size of the occult pneumothorax was compared against the need to insert a chest tube, and it was suggested that pneumothorax less than 5 x 80 mm could be observed regardless of the need for mechanical ventilation [48]. In their retrospective study of 1199 patients (403 with traumatic pneumothorax), Weißberg et al. [131] stated that clinical observation is possible for cases of pneumothorax less than 20 % of the pleural space. There are no details regarding the possible effects of mechanical ventilation.

A score was proposed by de Moya to better define a “small” pneumothorax, comprised of two parts: 1) the largest diameter of the pneumothorax, and 2) its relationship to the pulmonary hilum. If the pneumothorax does not exceed the pulmonary hilus, 10 is added to the millimeter measure of the pneumothorax; if the hilus is exceeded, 20 is added. The score value is the sum of the individual values of each side. The positive predictive value for a chest tube with a score > 30 was around 78 % and the negative predictive value for a score < 20 was around 70 % [27]. In a randomized study of 21 ventilated patients, observation of occult pneumothorax was shown to be safe. In 13 patients treated initially without chest tube placement, emergency decompression was required in none, although two patients required evacuation of pleural effusion over the course of stay and one patient required decompression of a progressive pneumothorax after central venous catheter placement. A “wait and see” attitude regarding chest tube insertion for occult pneumothorax appears justified in ventilated and non-ventilated patients [4, 133].

In an analysis of patients with traumatic cardiac arrest, decompression of tension pneumothorax was identified as the most important factor leading to improved prognosis [66]. In addition, non-decompressed tension pneumothorax has been reported as the most frequent definitively avoidable cause of death after trauma [75]. For this reason, resuscitation after trauma should not be ended until the reversible cause “tension pneumothorax” is definitely excluded [74].

Key recommendations:

2.23

Recommendation

2016

GoR B

Pericardial decompression should be performed for confirmed cardiac tamponade and acute deterioration of vital parameters.

2.24

Recommendation

New 2016

GPP

For hemodynamically unstable patients with thoracic trauma, an eFAST examination should be performed to rule out pericardial tamponade.

Explanation:

Regardless of the patient’s condition, the diagnosis of pericardial tamponade should be rapidly and reliably made so that any necessary surgery can be carried out rapidly. Although the diagnosis of tamponade can be confirmed by the insertion of a pericardial window, this is an invasive procedure, particularly if there is only mild suspicion of cardiac injury. The ultrasound examination has proven itself as a sensitive study to diagnose pericardial effusion and is thus the current method of choice. In a prospective multicenter study of 261 patients with penetrating pericardial chest injuries, sensitivity was 100%, specificity 96.7%, and accuracy 97% [109]. There were no false negative results. In another study, ultrasound identified pericardial fluid in three of 34 patients. One patient was hemodynamically unstable and underwent thoracotomy, and the other two had negative pericardial windows [10].

Pericardiocentesis is now of lesser importance in the diagnosis of pericardial tamponade, having been replaced by ultrasound examination [23, 109, 120].

Key recommendation:

2.25

Recommendation

2016

GoR 0

Thoracotomy can be performed with initial blood loss > 1500 mL from the chest tube or with continuing blood loss > 250 mL/hour for more than 4 hours.

Explanation:

There was intensive debate within the guideline group regarding indications for thoracotomy depending on the initial or continuing blood loss through the chest tubes, not least because of the inconsistent quantities reported in the literature. These are almost exclusively cohort studies on penetrating trauma; randomized studies on this topic are not available. The evidence is much less clear for blunt trauma; thoracotomy is indicated in far fewer cases and generally later than for penetrating trauma. In certain conditions with corresponding blood loss, thoracotomy can be useful even in hemodynamically stable patients. There is no data regarding coagulation status as criterion for decision-making; however, body temperature can be taken into account.

In the 1970s, based on experience with penetrating trauma in the Vietnam War, McNamara et al. [84] reported reduced mortality after early thoracotomy. The indication criteria for thoracotomy were given as initial blood loss of 1000-1500 ml after chest tube insertion as well as blood loss of 500 ml in the first hour after tube placement.

Kish et al. [73] evaluated 59 patients in whom thoracotomy was necessary. Thoracotomy was performed 6-36 hours post-trauma when there was continuous bleeding of 150 ml/h over more than 10 hours or 1500 ml over a shorter time period in four of 44 cases of penetrating and two of 15 cases of blunt trauma. The strategy of thoracotomy for an initial blood loss > 1500 ml after chest tube placement or with continuous blood loss > 250 ml over 4 hours has been accepted for penetrating injuries [80].

A multicenter study of 157 patients undergoing thoracotomy for thoracic bleeding found an association of mortality with the level of thoracic blood loss [69]. Mortality risk increased 3.2-fold with a blood loss of 1500 ml versus 500 ml. The authors concluded that for patients with penetrating and blunt trauma, thoracotomy should be considered with a blood loss of 1500 ml in the first 24 hours after admission even when there are no signs of hemorrhagic shock.

In the current version of the NATO Handbook [11], initial blood loss of 1500 ml as well as drainage of 250 ml or more per hour over more than four hours are given as indications for thoracotomy. The various volumes reported as threshold values were gone over by the guideline group. Agreement was reached with the volume presented in the recommendation of > 1500 ml initially or > 250 ml/h over more than four hours.

Key recommendation:

2.26

Recommendation

2016

GoR B

Emergency thoracotomy should not be performed in the emergency department for blunt trauma patients with absence of vital signs at the accident scene.

Explanation:

When vital signs are absent at the accident scene in blunt trauma patients, emergency thoracotomy in the emergency department is not indicated. Vital signs include pupillary reaction to light, any type of spontaneous breathing, movement to pain stimuli, or supra-ventricular activity on ECG [12]. However, if cardiac arrest develops on admission to the hospital, immediate thoracotomy should be performed, especially in the case of penetrating trauma.

Boyd et al. carried out a retrospective study of 28 patients undergoing thoracotomy in the emergency department for resuscitation. Meta-analysis was also performed [12]. Survival rate was 2 of 11 patients with penetrating trauma and 0 of 17 blunt trauma patients. Survival rate (2 of 3 patients) was highest when vital signs were present both at the accident scene and in the emergency department. Meta-analysis of 2294 patients yielded a survival rate of 11 %, with survival significantly better in penetrating versus blunt trauma (14 % vs. 2 %). There were no survivors in the group of patients without vital signs at the accident scene, and of blunt trauma patients without vital signs in the emergency department, none survived without neurological deficits.

Velhamos et al. [123] performed a retrospective analysis of 846 patients who underwent emergency thoracotomy in the emergency department. All patients presented without vital signs at the time of admission or with cardiac arrest in the emergency department. Of 162 patients who were successfully resuscitated, 43 (5.1 %) were discharged from the hospital, and 38 of these had no neurological deficit. Of 176 patients with blunt trauma, only one patient survived (0.2 %) with significant neurological deficits.

Branney et al. [13] reported an overall survival rate of 4.4 % in 868 patients undergoing emergency thoracotomy. Eight of 385 (2 %) blunt trauma cases survived. Of these, four patients had no neurological deficits. Of blunt trauma patients without vital signs at the accident scene, two patients survived with severe neurological deficits. In contrast, patients with penetrating trauma and without vital signs at the accident scene fared markedly better with 12 of 355 surviving neurologically intact. This result is clearly different from that obtained by the meta-analysis of Boyd et al. [12] outlined above, and later studies by Esposito et al. [37], Mazzorana et al. [82], Brown et al. [17] and Lorenz et al. [77], who found no survivors among patients with penetrating trauma without vital signs at the accident scene.

Another retrospective study of 273 thoracotomies performed in the emergency department yielded ten survivors without neurological deficits [68]. They all had penetrating injuries and vital signs were present either at the accident scene or in the emergency department. Of 21 blunt trauma patients, none survived. The authors conclude thus, that thoracotomy should be performed in the emergency department only for patients with penetrating trauma and evidence of vital signs either at the accident scene or in the emergency department. Grove et al. [55] also found no survivors of 19 blunt trauma patients treated with emergency thoracotomy. At the time of admission, five of these patients had no vital signs and 14 patients had positive vital signs. All patients died within four days. The survival rate for penetrating trauma was 3 of 10 patients.

Based on a meta-analysis of 42 outcome studies with a collection of 7035 emergency department thoracotomies, the American College of Surgeons published a guideline on the indications and implementation of emergency department thoracotomy [118]. The resulting conclusions are based primarily on the finding that with an overall survival rate of 7.8 %, only 1.6 % of blunt trauma patients, but 11.2 % penetrating trauma patients survived. More recent studies have also confirmed that emergency thoracotomy performed during cardiopulmonary resuscitation (CPR) can improve prognosis, particularly in penetrating trauma, and appears to be particularly expedient when vital signs are initially present [42, 70, 101, 114].

The evidence table for this chapter is found on page 169 of the guideline report.

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2.5 Abdomen

Key recommendation:

2.27

Recommendation

2011

GoR A

The abdomen must be examined, although an unremarkable examination does not exclude a relevant intraabdominal injury, even in conscious patients.

Explanation:

In a prospective study of 372 hemodynamically stable patients after blunt abdominal trauma, Miller et al. reported that intra-abdominal injury was detected on CT in only 25.5 % of the 157 patients complaining of painful abdomen or pelvis. CT detected injury in only 20 % of patients with the “seatbelt sign” [20].

In a multicenter prospective study of 2299 patients with blunt abdominal trauma (exclusion criteria GCS ≤ 14, age ≤ 16 years, emergency laparotomy undergone), Livingston et al. [15] reported that a positive clinical examination related to signs of external injury or pain was present in 1406 (61 %) of patients. Evidence of abdominal injury on CT was present in only 26 % of these patients. Of patients with evidence of abdominal injury on CT, 11 % of patients had normal clinical examinations. Of 265 patients with free intra-abdominal fluid on CT, 212 (80 %) had abnormal clinical examinations. In this study, the sensitivity of the clinical examination for free fluid on CT was 85 %, the specificity 28 %, the positive predictive value 63 %, and the negative predictive value 57 %.

In a prospective study of 350 patients, Ferrara et al. investigated the predictive value of abdominal tenderness in association with the presence of an intra-abdominal lesion verified on CT or with diagnostic peritoneal lavage (DPL) [5]. They calculated a sensitivity of 82 %, a specificity of 45 %, and a positive predictive value of 21 %, with a negative predictive value of 93 %.

In a prospective study of 162 patients (2001-2003, Level I Trauma Center) after blunt trauma with clear level of consciousness (GCS ≥ 14) and unremarkable clinical abdominal examination (but requiring emergency extra-abdominal surgical intervention, 88 % trauma surgery, and CT scan of the abdomen), Gonzalez et al. [6] found that these patients do not need diagnostic CT prior to surgery, because the clinical examination is suitably reliable in this population. The diagnostic CT study provided pathological intraperitoneal findings in only two cases (1.2 %) that needed no further interventions (spleen injury, mesenteric hematoma).

Concomitant Injuries

In a study of 1096 patients with blunt abdominal trauma, Grieshop et al. [7] tried clinical options to identify patients not needing further diagnostic CT. Patients in shock with GCS < 11 or who had suffered spinal trauma were evaluated, but because of the limited clinical examination they were not included in the statistical evaluation (n = 140). The authors concluded that along with abnormal clinical examination (abdominal tenderness, guarding or other signs of peritonitis), the presence of macrohematuria or thoracic trauma (fractures of ribs 1 or 2, multiple rib fractures, sternum fracture, scapula fracture, widened mediastinum, hemo/pneumothorax) must also be considered risk factors. The risk of intra-abdominal injury increases by a factor of 7.6 with accompanying thoracic trauma and a factor of 16.4 with accompanying macrohematuria. All patients with relevant intra-abdominal injuries (n = 44) belonged either to the group with abnormal examination or to the group with one or both of the risk factors mentioned above (n = 253), corresponding to a sensitivity of 100 %. The authors continued that to exclude organ injuries, these cases must undergo additional diagnostic studies, for example with computed tomography of the abdomen. No abdominal injuries were evident in the remaining 703 patients with normal examinations and no risk factors. The calculated negative predictive value was 100 %, so that further diagnostic studies can be foregone in these cases. According to this study, associated bony pelvic injury, closed traumatic brain injury, spine injury, and fractured long bones of the lower extremity are not significant independent risk factors.

In contrast, in prospective studies, Ballard et al. and Mackersie et al. found that pelvis fractures are associated with increased risk of intra-abdominal organ injuries, so that diagnostic CT is needed for several reasons [2, 17].

Schurink et al. [34] evaluated the importance of the clinical examination in a retrospective study of 204 patients subdivided into four groups: patients with isolated abdominal trauma (n = 23), patients with lower rib fractures (ribs 7-12) (n = 30), patients with isolated head injury (n = 56), and patients with multiple injuries (ISS ≥ 18) (n = 95). All patients underwent abdominal ultrasound examinations. For the 20 patients with isolated abdominal trauma, clinical examination yielded sensitivity of 95 %, negative predictive value of 71 %, and positive predictive value of 84 % for the presence of intra-abdominal injury. For patients with rib fractures, the sensitivity and negative predictive value were 100 % with four abnormal clinical examinations.

Ultrasound

Key recommendations:

2.28

Recommendation

2011

GoR B

Initial focused abdominal ultrasound screening for free fluid, “Focused Assessment with Sonography for Trauma” (FAST), should be performed.

2.29

Recommendation

2011

GoR B

Ultrasound examinations should be repeated at intervals if computed tomography (CT) cannot be done in a timely manner.

2.30

Recommendation

2011

GoR 0

If CT can’t be performed, ultrasound examination focused on diagnosing parenchymal injuries in addition to FAST can be used as an alternative.

Explanation:

Stengel et al. performed a systematic review of four randomized, controlled studies on the value of ultrasound-based algorithms in the diagnosis of patients after blunt abdominal trauma; they found no evidence as yet to recommend ultrasound-based algorithms [39]. The same author previously carried out meta-analysis and systematic review on the diagnostic value of ultrasound as a primary investigative tool for detecting free fluid in the abdomen (FAST) (19 studies) or intra-abdominal organ injuries (11 studies) after blunt abdominal trauma. The 30 studies evaluated included investigations until July 2000 with 9047 patients and evidence levels IIb to IIIb [38]. One result was that abdominal ultrasound is only minimally sensitive in the diagnosis of free fluid and intra-abdominal organ injury. Every tenth organ lesion was not detected on primary ultrasound. Thus, ultrasound is considered insufficient as a primary diagnostic study after abdominal trauma, and other diagnostic studies (e.g. spiral CT) are recommended for both negative and positive findings [38, 39].

FAST

In a prospective study of 359 hemodynamically stable patients, Miller et al. assessed the importance of FAST using the hypothesis that a FAST examination leads to missed detection of intra-abdominal injuries after abdominal trauma [20]. As gold standard, abdominal CT was performed within one hour of the ultrasound in all patients. FAST was performed with four views and evidence of free fluid was considered a positive result. The FAST examination yielded 313 true-negative, 16 true-positive, 22 false-negative, and 8 false-positive results. This resulted in a sensitivity of 42 %, a specificity of 98 %, a positive predictive value of 67 %, and a negative predictive value of 93 %. Of the 22 false-negative diagnosed patients, 16 had parenchymal injuries to the liver or spleen, one each had mesenteric injury and gall bladder rupture, two had retroperitoneal injuries, and two other patients had free fluid without recognizable injury on CT. Six patients of this group required surgery and one underwent embolization with angiography. Among the 313 patients with true-positive FAST findings, the CT examination identified 19 additional hepatic and spleen injuries as well as eleven retroperitoneal injuries (including aortic wall hematoma, bleeding of the pancreatic head, kidney contusion). None of these patients required operative interventions. As a consequence, the authors call for further assessment with CT abdomen/pelvis for sufficiently hemodynamically stable patients, regardless of FAST examination findings [20].

In a systematic review by McGahan et al. of investigations assessing the importance of FAST as a diagnostic study after abdominal trauma, there was wide variation in the sensitivity of the examination for detection of free fluid, ranging from 63 to 100 %. McGahan et al. are critical of studies reporting high sensitivity and citing FAST as a suitable initial screening method, in which there are significant study design weaknesses (no standard reference, no consecutive inclusion) [19].

Soyuncu et al. reported on a prospective case series of 442 patients who had sustained blunt abdominal trauma. They found that FAST, performed by an examiner experienced in abdominal ultrasound (minimum one year experience), had a sensitivity of 86 % and a specificity of 99 % with 0.95 % false-positive and 1.1 % false-negative results (controls laparotomy, CT, autopsy) [37].

Ultrasound as Organ Diagnostic Study

In a prospective study of 55 hemodynamically stable patients, Liu et al. [14] compared the diagnostic value of ultrasound (with screening for free fluid and organ injury), computed tomography, and DPL on the same patients. DPL was performed after the imaging procedures so as not to distort the other studies. In the diagnosis of an intraabdominal injury (without differentiating between detection of free fluid and direct detection of organ injury), the authors found a sensitivity of 91.7 % and a specificity of 94.7 % for ultrasound, below the results of DPL and CT. The disadvantages of ultrasound are: (1) technical difficulty of ultrasound when subcutaneous emphysema is present, (2) prior to surgery, free fluid may not flow into the Douglas space and thus could elude diagnosis, (3) pancreas and hollow organ injuries might not be well assessed, and (4) poor ability to assess the retroperitoneal space. In conclusion, the authors recommended ultrasound because of its usability as a primary diagnostic tool in the examination of hemodynamically unstable patients. However, due to the limitations cited, they warned against overestimating its informative value.

In a study of 3264 patients, Richards et al. [29] evaluated the quality of abdominal ultrasound for the diagnosis of free fluid and organ parenchymal injuries after abdominal trauma. Distinct from the FAST examination, abdominal ultrasound in this study was explicitly focused on detecting parenchymal injuries of the liver, kidneys, and spleen. Results were verified using CT, laparotomy, DPL, or clinical observation. Free fluid was detected in 288 patients on ultrasound and controlled with CT and laparotomy. Sensitivity was 60 %, specificity 98 %, negative predictive value 95 %, and positive predictive value 82 % for the diagnosis of free fluid alone. Specific organ injuries were detected in 76 cases, 45 with concomitant free fluid. The contemporaneous targeted ultrasound for organ parenchymal injuries increased the sensitivity for diagnosis of intra-abdominal injury to 67 %.

Like Richards and Liu et al., Brown et al. [4] examined 2693 patients after abdominal trauma for free fluid and also targeted for parenchymal injuries. Of these, 172 had intra-abdominal injury verified with laparotomy, DPL, CT, the clinical course, or on autopsy. Hemoperitoneum was not detected on ultrasound in 44 patients (26 %), but organ lesions were diagnosed in 19 (43 %) of these patients. The authors conclude that by limiting an ultrasound to a short examination focused on detecting free fluid (FAST), organ injuries are overlooked. Thus, as an emergency diagnostic study, an ultrasound examination should be focused on detection of free fluid and injuries to the organ parenchyma.

In a prospective study of 800 patients, Healey et al. [8] found higher sensitivity (88 %) for the diagnosis of intra-abdominal injury. This study also screened for both free fluid and organ lesions, and the results were compared to CT, DPL, laparotomy, repeat ultrasound, or the progressive course.

Poletti et al. [28] used a comparable study design and reported higher sensitivity. They evaluated 439 patients after abdominal trauma. 222 of these patients underwent no further investigations after initial normal screening and were discharged with the instructions to return if they felt there was deterioration. The remaining 217 patients were assessed. Ultrasound showed sensitivity of 93 % (77 of 83 patients) for the detection of free fluid and sensitivity of 41 % (39 of 99 patients) for direct evidence of parenchymal organ injury, although hepatic injuries were diagnosed well compared to other organs. In a repeat examination in cases of primary negative findings, these values could be increased; however, pathology had already been identified on CT and was known by the examiner. Overall, 205 patients underwent CT follow up examinations.

McElveen et al. [18] evaluated 82 consecutive patients (for free fluid and organ lesions), performed controls for all patients with reference examinations (71 with CT, six with repeat ultrasound, three with DPL, and two with laparotomy) and followed up for one week after trauma, either in-hospital or as outpatient. With sensitivity of 88 % and specificity of 98 %, along with negative predictive value of 97 % for the diagnosis of intra-abdominal injury, they recommended ultrasound as the primary examination method after abdominal trauma.

Poletti et al. compared the diagnostic value of ultrasound (with and without intravenous contrast enhancement) with CT in a prospective study of 210 consecutive hemodynamically stable patients after blunt abdominal trauma. The patients first underwent conventional ultrasound (including targeted organ diagnosis) and then CT. Patients with false-negative findings on primary ultrasound initially underwent repeat conventional ultrasound and with renewed negative findings, an ultrasound enhanced with contrast agent. Poletti et al. [27] found that neither repeat conventional ultrasound nor contrast-enhanced ultrasound reached the quality of computed tomography for the detection of organ injuries. With computed tomography, 88 organ injuries (solid organs) were detected in 71 patients. Of 142 patients in whom CT did not detect free fluid (intra-abdominal or retroperitoneal), organ injuries (all organs) were evident in 33 (23 %). Four of these patients (12 %) required intervention (laparotomy/interventional angiography). Primary ultrasound recognized 40 % (35 of 88), the control ultrasound 57 % (50 of 88), and the contrast-enhanced ultrasound 80 % (70 of 88) of the solid organ injuries. The authors concluded that even contrast-enhanced ultrasound cannot replace CT in hemodynamically stable patients.

Repeat Examinations

Regarding the importance of repeat ultrasound monitoring of patients after abdominal trauma, Hoffmann et al. [10] found that of 19 (18 %) of 105 patients with initially unclear findings, free intra-abdominal fluid could only be detected on repeat ultrasound in the emergency department (after hemodynamic stabilization procedures). The authors point out that if possible, both ultrasounds should be performed by the same examiner to achieve optimal monitoring. The monitoring examination should be performed about 10-15 minutes after the primary ultrasound in patients with minimal evidence of fluid (1-2 mm border) or unclear findings on the initial exam. Compared to DPL, repeated ultrasound can document a possible increase in free fluid, and can also be used to diagnose retroperitoneal and intra-thoracic injuries.

In the study mentioned above, Richards et al. [29] reported an increase in ultrasound sensitivity.

In a prospective study of 156 patients after blunt or penetrating abdominal trauma, Numes et al. [25] found that the use of repeat ultrasound led to a 50 % reduction in the false-negative rate for free intra-abdominal fluid and with it, an increased sensitivity from 69 % (from a single scan) to 85 %.

Examiners

Regarding who must perform the investigation, Hoffmann et al. [10] believe that ultrasound screening for free abdominal fluid can be easily learned and can then be reliably carried out by a member of the emergency department trauma team. However, the type and amount of training necessary remains unclear.

A prospective study by Ma et al. [16] reported that a 10-hour theoretical introduction, coupled with implementation of 10-15 examinations on healthy subjects is sufficient to achieve diagnostic proficiency in emergency ultrasound of the abdomen, provided that this is restricted to detection/exclusion of free fluid.

McElveen et al. [18] make the same recommendation although it is not based on a study. They stipulate 15 examinations of normal patients and 50 monitored exams on trauma patients.

A retrospective study by Smith et al. [36] on the quality of the ultrasound by trained, experienced surgeons showed that extensive previous ultrasound experience is not required and there is no learning curve.

Although a comparative study is lacking, Brown et al. [4] call for screening to increase sensitivity of the ultrasound by including focus on specific organ lesions, and thus, recommend that the exam be carried out by an experienced practitioner.

Diagnostic Peritoneal Lavage (DPL)

Key recommendation:

2.31

Recommendation

2011

GoR A

Diagnostic peritoneal lavage (DPL) must only be performed for exceptional cases.

Explanation:

With a sensitivity of 100 % and a specificity of 84.2 %, DPL was the most sensitive method for detecting intra-abdominal injury in the study by Liu et al. [14] comparing it to CT and ultrasound. The authors argue, however, that the high sensitivity (e.g. by detection of blood on catheter insertion) leads to a relevant number of non-therapeutic laparotomies. Liu et al. are also critical of DPL in cases of retroperitoneal hematoma, since even small tears in the peritoneum yielded positive results, which then led to unnecessary laparotomies in half of the six patients with retroperitoneal hematoma.

Hoffmann [10] considers the indications for DPL only in exceptional cases of patients impossible to examine with ultrasound (e.g. extreme obesity or abdominal wall emphysema), since in comparison to ultrasound and CT, DPL permits no conclusions regarding retroperitoneal injuries. Waydhas states that DPL is contraindicated in patients with previous laparotomy. In a prospective study of 106 polytrauma patients, the authors found a markedly lower sensitivity for ultrasound (88 %) versus DPL (95 %). Despite the lower sensitivity, they recommend ultrasound as a non-invasive, never contraindicated, and capable of detecting specific organ injuries initial screening method for which the sensitivity can be increased in cases of hemodynamic instability with unclear or negative ultrasound findings by supplementing with DPL [41].

Primary use of DPL can be theoretically indicated in hemodynamically unstable patients and if other diagnostic tools (ultrasound) have failed.

Computed Tomography

Key recommendation:

2.32

Recommendation

2011

GoR A

Multi-slice spiral CT (MSCT) has high sensitivity and the highest specificity for detecting intra-abdominal injuries and therefore must be performed after abdominal trauma.

Explanation:

The prospective study from Liu et al. [14] compared the diagnostic predictive value of ultrasound (with screening for free fluid and organ injury), computed tomography, and DPL on 55 hemodynamically stable patients. For CT, there was a sensitivity of 97.2 % and a specificity of 94.7 %. Correspondingly good results have also been reported in more recent studies [12, 26] for the detection of hollow organ injury with CT (after administration of oral and intravenous contrast medium), which has been recognized in the past as a diagnostic weakness of CT [35]. Liu et al. also state the benefits of CT abdomen versus ultrasound and DPL in terms of the ability to reliably image the retroperitoneum. CT can easily distinguish hemoperitoneum versus fluid retention, and can localize fresh hemorrhage using contrast medium. In addition, CT abdomen (using bony windows) can also provide diagnostic imaging of the spine and pelvis (or a full body spiral according to the pattern of injury) [24]. Due to similar results previously reported above, Miller et al. and other authors recommend CT abdomen for hemodynamically stable patients regardless of the FAST ultrasound results, because CT appears to be more sensitive for the diagnosis of intra-abdominal injuries [20].

Regarding examination technicalities, Linsenmaier recommends a multi-layer spiral CT (MSCT) with regular venous contrast medium for abdominal trauma. Cuts should be at least 5-8 mm in the cranio-caudal scan direction at a pitch of 1.5. If genitourinary injury is suspected, a delayed scan (3-5 minutes after bolus administration) should be performed [13]. If possible, oral contrast can also be given for improved diagnosis of gut injuries [13, 24]. Novelline describes the administration of gastrografin via nasogastric tube first in the emergency department after insertion, shortly before transfer, and in the gantry. Normally this should allow visualization of the stomach, duodenum, and jejunum. Contrast can also be added to the rectum/sigmoid colon via rectal tube [24].

In a retrospective case-control study of 96 patients (54 consecutive patients with intestinal/mesenteric injury as well as 42 matched pairs without injury) undergoing laparotomy as well as preoperative CT (standardized with oral contrast administration via nasogastric tube in the emergency department) after abdominal trauma, Atri et al. [1] found that multilayer CT reliably detects relevant injuries to the intestines/mesentery and has a high negative predictive value. Three radiologists at varying training levels evaluated the CTs without knowledge of outcome. 38 (40 %) of the patients had surgically relevant injuries, and 58 (60 %) had either no or negligible injuries of the intestines or mesentery. Sensitivity ranged from 87-95 % for the three examiners. Only ten CTs were performed without oral contrast medium, because the patients were transferred directly to CT.

Conversely, in a retrospective study of 1082 patients (years 2001-2003), Stuhlfaut et al. concluded that multilayer CT abdomen/pelvis without contrast is sufficient to detect intestinal and mesenteric injuries requiring surgical intervention. After CT, 14 patients had suspected intestinal or mesenteric injury. Of these patients, four CTs showed pneumoperitoneum, two showed mesenteric hematoma and intestinal wall changes, and four each showed isolated mesenteric hematoma or intestinal wall thickening. Intestinal/mesenteric injuries were surgically confirmed in eleven of these patients. There were 1066 true-negative, 9 true-positive, 2 false-negative, and 5 false-positive results. The sensitivity was 82 % and the specificity was 99 %. The negative predictive value of the multilayer spiral CT (MSCT) without contrast was 99 % [40].

Although the survival advantage offered by multilayer spiral CT (MSCT) with regular venous contrast medium for rapid and reliable diagnosis of the extent of injury is clearly evident, the high radiation exposure should always be considered. For children, a good 70 % of the radiation exposure required to potentially induce thyroid malignancy is reached [32]. There is no reliable data regarding this for adult patients. Nevertheless, the potential for malignant induction must always be weighed against the indication.

In ambiguous cases (non-specific radiological findings) regarding possible intestinal/mesenteric injuries, Brofman et al. [3] recommend clinical reevaluation and repeat examination.

Experts are unanimous that the introduction of multilayer spiral CT is a step forward in spiral CT technology; in addition to better resolution, the scanning duration can be shortened considerably and motion artefacts are less disruptive [13, 24] [28, 30]. The same authors underscore the importance of using pre-programmed protocols for CT diagnosis of acute trauma (positioning, layer thickness, table advance, time and manner of contrast administration, bony/soft-tissue windows, reconstructions), since these can considerably shorten examination time. When considering concomitant injuries, some authors recommend full body MSCT after stabilization (during which abdominal ultrasound to detect/exclude free fluid should be performed). Full body MSCT enables diagnostic imaging of the skull, chest, skeletal trunk, and the extremities in a single investigation [30].

Computed tomography is the only diagnostic method for which injury scores are in place [21], on which basis treatment decisions can be made [33].

Hemodynamic status can restrict the implementation of MSCT (see the section “Influence of Hemodynamic Status on Diagnostic Studies”).

Influence of Hemodynamic Status on Diagnostic Studies

Key recommendation:

2.33

Recommendation

2011

GoR B

For patients who are hemodynamically unstable due an intra-abdominal lesion (free fluid), emergency laparotomy should be initiated immediately. The possibility of shock from a non-abdominal cause should also be kept in mind.

Explanation:

The diagnostic algorithm of a patient with blunt abdominal trauma is fundamentally influenced by the vital parameters. Thus, in the early phase of treatment, the immediate evaluation and stabilization of the vital signs have the highest priority. If adequate hemodynamic stability cannot be restored despite immediate volume replacement or mass transfusion, and there is positive history and suspicion for intra-abdominal injury, Nast-Kolb et al. call for immediate emergency laparotomy [23]. Even in cases of unstable vital signs, the indication for emergency laparotomy should be supported by an abdominal ultrasound that is performed parallel to polytrauma management. This basic diagnostic workup can be performed without further time delay [14, 28]. Nast-Kolb’s working group calls for early laparotomy for patients in shock as well as in polytrauma patients (ISS ≥ 29) even when only a small quantity of fluid is detected. The authors justify this with the fact that a retrospective non-therapeutic laparotomy is much less traumatic and risky than a secondary operation required for an organ injury that was initially overlooked [23].

CT abdomen should only be performed when there is sufficient hemodynamic stability [22, 23, 30, 31, 42], since therapeutic interventions, for example those needed to stabilize the patient, are limited within the CT gantry [23, 30, 31, 42]. This recommendation remains fundamentally valid [11, 43, 44]; however, Hilbert et al. [9] discuss the primary use of CT even in unstable patients.

References
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    Atri M, et al. Surgically important bowel and/or mesenteric injury in blunt trauma: accuracy of multidetector CT for evaluation. Radiology. 2008;249(2):524–33 (LoE 3b).

     
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    Brofman N, et al. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics. 2006;26(4):1119–31 (LoE 5).

     
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    Brown MA, et al. Importance of evaluating organ parenchyma during screening abdominal ultrasonography after blunt trauma. J Ultrasound Med. 2001;20(6):577–83 (quiz 585 [LoE 3b]).

     
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    Ferrera PC, et al. Injuries distracting from intraabdominal injuries after blunt trauma. Am J Emerg Med. 1998;16(2):145–9 (LoE 3b).

     
  6. 6.

    Gonzalez RP, et al. Screening for abdominal injury prior to emergent extra-abdominal trauma surgery: a prospective study. J Trauma. 2004;57(4):739–41 (LoE 4).

     
  7. 7.

    Grieshop NA, et al. Selective use of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma. 1995;38(5):727–31 (LoE 2b).

     
  8. 8.

    Healey MA, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma. 1996;40(6):875–83 [discussion 883–5 (LoE 2b)].

     
  9. 9.

    Hilbert P, et al. New aspects in the emergency room management of critically injured patients: a multi-slice CT-oriented care algorithm. Injury. 2007;38(5):552–8 (LoE 4).

     
  10. 10.

    Hoffmann R, et al. Blunt abdominal trauma in cases of multiple trauma evaluated by ultrasonography: a prospective analysis of 291 patients. J Trauma. 1992;32(4):452–8 (LoE 2b).

     
  11. 11.

    Kanz KG, et al. Priority-oriented shock trauma room management with the integration of multiple-view spiral computed tomography. Unfallchirurg. 2004;107(10):937–44 (LoE 4).

     
  12. 12.

    Killeen KL, et al. Helical computed tomography of bowel and mesenteric injuries. J Trauma. 2001;51(1):26–36 (LoE 3b).

     
  13. 13.

    Linsenmaier U, et al. Structured radiologic diagnosis in polytrauma. Radiologe. 2002;42(7):533–40 (LoE 4).

     
  14. 14.

    Liu M, Lee CH, P’Eng KF. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma. 1993;35(2):267–70 (LoE 2b).

     
  15. 15.

    Livingston DH, et al. Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy. Am J Surg. 2001;182(1):6–9 (LoE 2b).

     
  16. 16.

    Ma OJ, et al. Operative versus nonoperative management of blunt abdominal trauma: role of ultrasound-measured intraperitoneal fluid levels. Am J Emerg Med. 2001;19(4):284–6 (LoE 2b).

     
  17. 17.

    Mackersie RC, et al. Intra-abdominal injury following blunt trauma. Identifying the high-risk patient using objective risk factors. Arch Surg. 1989;124(7):809–13 (LoE 2b).

     
  18. 18.

    McElveen TS, Collin GR. The role of ultrasonography in blunt abdominal trauma: a prospective study. Am Surg. 1997;63(2):184–8 (LoE 3b).

     
  19. 19.

    McGahan JP, Richards J, Gillen M. The focused abdominal sonography for trauma scan: pearls and pitfalls. J Ultrasound Med. 2002;21(7):789–800 (LoE 2a).

     
  20. 20.

    Miller MT, et al. Not so FAST. J Trauma. 2003;54(1):52–9 (discussion 59-60 [LoE 2b]).

     
  21. 21.

    Moore EE, et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323–4.

     
  22. 22.

    Nast-Kolb D, Bail HJ, Taeger G. Current diagnostics for intra-abdominal trauma. Chirurg. 2005;76(10):919–26 (LoE 5).

     
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    Nast-Kolb D, et al. Abdominal trauma. Unfallchirurg. 1998;101(2):82–91 (LoE 5).

     
  24. 24.

    Novelline RA, et al. Helical CT in emergency radiology. Radiology. 1999;213(2):321–39 (LoE 5).

     
  25. 25.

    Nunes LW, et al. Diagnostic performance of trauma US in identifying abdominal or pelvic free fluid and serious abdominal or pelvic injury. Acad Radiol. 2001; 8(2):128–36 (LoE 3b).

     
  26. 26.

    Pal JD, Victorino GP. Defining the role of computed tomography in blunt abdominal trauma: use in the hemodynamically stable patient with a depressed level of consciousness. Arch Surg. 2002;137(9):1029–32 (discussion 1032–3 [LoE 3b]).

     
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    Poletti PA, et al. Blunt abdominal trauma: should US be used to detect both free fluid and organ injuries? Radiology. 2003; 227(1):95–103 (LoE 4).

     
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    Poletti PA, et al. Traumatic injuries: role of imaging in the management of the polytrauma victim (conservative expectation). Eur Radiol. 2002;12(5):969–78 (LoE 4).

     
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    Richards JR, et al. Sonographic assessment of blunt abdominal trauma: a 4-year prospective study. J Clin Ultrasound. 2002;30(2):59–67 (LoE 3b).

     
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    Rieger M, et al. Modern CT diagnosis of acute thoracic and abdominal trauma. Anaesthesist. 2002;51(10):835–42 (LoE 4).

     
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2.6 Traumatic Brain Injury

Acute Management in the Emergency Department

Once clinical findings have been reviewed and vital functions stabilized, the polytrauma patient with traumatic brain injury generally requires diagnostic imaging, with an overall body CT scan beginning with native (no contrast) scan of the head. Because the immediate elimination of intracranial bleeding can be life-saving, delay is not justified in cases where respiratory and hemodynamic functions are stable. This applies also to the patient who was responsive at the accident scene but sedated for intubation and transport, because only CT will differentiate between a developing intracranial bleed and medication-induced unconsciousness.

Monitoring Clinical Findings

Key recommendation:

2.34

Recommendation

2011

GoR A

Examinations of level of consciousness, with pupillary function and Glasgow Coma Scale (bilateral motor function) must be repeated at regular intervals and documented.

Explanation:

According to the literature, the only clinical findings with prognostic value are wide, fixed pupils [11, 23, 26] and deterioration in GCS score [11, 15, 23], both of which are correlated with poor outcomes. There are no prospective randomized controlled trials on the use of clinical findings to guide treatment. Since such studies would not be ethically justifiable, this guideline has upgraded the importance of clinical examination to grade of recommendation A, on the currently unconfirmed assumption that patient outcome can be improved by detecting life-threatening conditions with therapeutic consequences as soon as possible (see the following recommendations).

Despite various difficulties [3], the Glasgow Coma Scale (GCS) has established itself internationally as an assessment of the momentary severity of brain dysfunction. It enables standardized assessment of eye-opening, verbal and motor response. The neurological findings, documented with the time of examination, are essential for the course of further treatment. Frequent neurological checks must be carried out to detect any deterioration [11, 13].

However, the use of GCS alone risks a diagnostic gap, particularly if only total values are considered. This applies to early onset of mid-brain syndromes, which can manifest as spontaneous decerebrate rigidity, which is not recorded on GCS, or to associated injuries of the spinal cord. Thus, motor function of the extremities must be examined and recorded, with lateral differentiation of the arms and legs - whether complete, incomplete, or no paralysis is present. The presence of decorticate or decerebrate rigidity should be noted. If voluntary movements are not possible, all extremities should be examined for reactions to painful stimuli.

If the patient is conscious, then orientation, cranial nerve function, coordination, and speech must also be noted.

Vital Functions

Key recommendations:

2.35

Recommendation

2011

GoR A

The goals should be normal oxygen, carbon dioxide, and blood pressure levels. Arterial oxygen saturation falling below 90% must be avoided.

2.36

Recommendation

2011

GoR A

Unconscious patients (GCS ≤ 8) must be intubated with adequate ventilation (according to capnometry and blood gas analysis).

2.37

Recommendation

Modified 2016

GoR B

In adults, the goal should be normal arterial pressure with systolic blood pressure not falling below 90 mmHg (age-adapted for children).

Explanation:

Due to ethical considerations, prospective randomized controlled trials examining the effects of hypotension and/or hypoxia on treatment outcomes are not justifiable. However, there are many retrospective studies [11, 25] that provide evidence of markedly worse outcomes when hypotension or hypoxia are present. The absolute priority is to eliminate all conditions associated with decreased blood pressure or blood oxygen saturation. However, aggressive therapy to increase blood pressure and oxygen saturation has not always been supported, due to adverse effects. The goals should be normal oxygen, carbon dioxide, and blood pressure levels.

Intubation is indicated for insufficient spontaneous respiration but also for unconscious patients even with adequate spontaneous breathing. Unfortunately, here as well the literature does not offer high-quality evidence that proves a clear benefit. The major argument for intubation is the efficient prevention of secondary brain injury through hypoxia. This is a threat in unconscious patients even when there is adequate spontaneous breathing, since impaired reflexes can result in aspiration. The major argument against intubation is the hypoxic injury that can occur during an unsuccessful intubation. However, it can be assumed that the conditions of the emergency department will allow immediate detection of failed intubation that can then be corrected. Ventilation is frequently required after intubation, and this must be monitored for effectiveness with capnography and blood gas analyses.

Interventions to support hemodynamic functions are the elimination of obvious bleeding (if not yet done), monitoring of blood pressure and pulse, as well as volume replacement, as described within this guideline. Specific recommendations cannot be made regarding the infusion solution to be used for volume replacement in multiply injured patients with traumatic brain injury [11].

Diagnostic Imaging

Key recommendations:

2.38

Recommendation

2011

GoR A

In cases of polytrauma with suspected traumatic brain injury, head CT must be performed.

2.39

Recommendation

2011

GoR A

In cases of neurological deterioration, (control) CT must be performed.

2.40

Recommendation

2011

GoR B

For unconscious patients and/or signs of injury on the initial CT head, follow-up CT head should be performed within 8 hours.

Explanation:

High quality evidence regarding which situations call for cranial imaging when traumatic brain injury is suspected is not currently available in the literature. In isolated TBI, the following findings are associated with increased risk of intracranial bleed (absolute indication [16]):
  • Coma,

  • Decreased level of consciousness,

  • Amnesia,

  • Other neurological abnormalities,

  • Vomiting, when it occurs soon after the impact,

  • Seizure,

  • Clinical signs or x-ray evidence of skull fracture,

  • Suspected impression fracture and/or penetrating injuries,

  • Suspected cerebrospinal fluid fistula,

  • Evidence of coagulation disorder (third-party medical history, anticoagulant therapy, antiplatelet agents, incessant bleeding from superficial injuries, etc.).

Noncompulsory indications that require close clinical monitoring as an imaging alternative include:
  • Unclear accident history,

  • Severe headache,

  • Drug or alcohol intoxication,

  • Evidence of high-energy trauma. These include [1] vehicle speed > 60 km/h, severe vehicle damage, intrusion > 30 cm into the passenger compartment, time required to rescue from vehicle > 20 min, fall from > 6m, vehicle roll-over trauma, pedestrian or motorcycle collision with > 30 km/h or rider thrown from motorcycle.

Since great impact force can be assumed in patients with multiple injuries, there was consensus during the development of this guideline that head CT imaging must be performed when there are symptoms of brain injury. If symptoms first occur or increase in severity during the course of treatment, control imaging is necessary, since intracranial bleeding can have delayed onset and/or increase in size. Detection of intracranial bleeding causing compression (see Chapter 3.5) requires immediate surgery.

This recommendation is based on the clinical observation that compressive intracranial bleeding can develop in patients with an initially unremarkable CT, and that initially smaller findings not requiring intervention can increase markedly in size and thus require surgery. The appearance of neurological symptoms can take several hours and/or can be masked by the intensive care treatment of unconscious patients. For this reason, there was agreement that in such cases control CT head scans should be performed at regular intervals.

Computed tomography is the gold standard of cranial imaging because of its generally rapid availability and easier examination procedure compared to magnetic resonance imaging [28]. Magnetic resonance imaging has a higher sensitivity for circumscribed tissue lesions [10]. For this reason, it is recommended particularly for patients with neurological abnormalities without pathologic CT findings.

Neuroprotective Therapy

Key recommendation:

2.41

Recommendation

2011

GoR A

For treatment of TBI, glucocorticoid administration must be avoided.

Explanation:

Replacement of disordered functions (respiration, nutrient intake [17, 25], etc.) is necessary in brain-injured patients. According to current scientific understanding, the goals are to achieve homeostasis (normoxia, normotension, prevention of hyperthermia) and to avert threatening (e.g. infectious) complications. Sepsis, pneumonia, and coagulation disorders are independent predictors of poor clinical outcomes [18]. The goal of these measures is to limit secondary brain injury and to provide optimal conditions for functional regeneration of damaged but intact brain cells. This applies equally when multiple injuries are present.

There is continued debate regarding the need for antibiotic prophylaxis in frontobasal fractures with liquorrhea. However, there is no evidence for the administration of antibiotics [5, 27].

Physical thromboprophylaxis measures (e.g. compression stockings) are undisputed as means to prevent secondary complications. Regarding administration of heparin or heparin derivatives, the benefits must be weighed against the risks of increased intracranial bleeding. These drugs are not approved for brain injuries and thus, this “off-label” use must be approved by the patient or a legal representative.

Anticonvulsant therapy prevents the manifestation of epileptic seizures in the first week after trauma. However, the incidence of seizures in the early phase does not lead to worse clinical outcomes [22, 25]. Administration of anticonvulsant therapy extended more than 1-2 weeks is not associated with a reduction in late traumatic seizures [6, 22, 25].

To date, there has been no published evidence confirming the benefits derived from more extensive treatment regimens focused solely on neuroprotection. At present, no recommendation can be given for hyperbaric oxygen [4], therapeutic hypothermia [12, 21], administration of 21-aminosteroids, calcium antagonists, glutamate receptor antagonists, or tris-buffers [11,14,20,30].

The administration of glucocorticoids is no longer indicated due to a significantly increased 14-day mortality [2, 7] without improvements in clinical outcomes [8].

Therapy for Increased Intracranial Pressure

Key recommendation:

2.42

Recommendation

2011

GoR 0

In cases where severely increased intracranial pressure is suspected, particularly with symptoms of transtentorial herniation (pupillary dilation, extensor synergy, extensor reflex to pain stimulation, progressive disorientation), the following measures can be applied:

 •Hyperventilation

 •Mannitol

 •Hypertonic saline

Explanation:

In cases where transtentorial herniation is suspected and there are signs of acute midbrain syndrome (pupillary dilation, decerebrate rigidity, extensor reaction to painful stimuli, progressive disorientation), hyperventilation can be initiated in the early phase after trauma [11, 25]. The reference value is 20 breaths/min in adults. Hyperventilation, used in the past because of its often impressive effects in reducing intracranial pressure, has the consequence of reduced cerebral perfusion because of induced vasoconstriction. Thus, aggressive hyperventilation involves a risk of cerebral ischemia and with it, worsening in clinical outcomes [25].

Administration of mannitol can reduce intracranial pressure (ICP) for a short time (up to one hour) [25]. Monitoring of therapy with ICP measurements is preferred [29]. When transtentorial herniation is suspected, it can be given without ICP measurement. Serum osmolarity and renal functions must also be monitored.

To date, there is no evidence for the neuroprotective effects of hypertonic saline solutions. Compared to mannitol, mortality appears somewhat less. However, the effect is based on a small case number and is not statistically significant [29].

Upper body elevation to 30° is often recommended, although this does not affect the CPP. However, extremely high ICP values are reduced.

(Analgesic) sedation itself has no ICP-lowering effect. However, it can favorably influence agitation associated with abnormal independent respiration, which can lead to ICP increases. Improved ventilation also allows better oxygenation. Although barbiturates have been recommended in previous guidelines for otherwise-uncontrollable increases in ICP [23], there is insufficient evidence for their use [19]. When barbiturates are administered, attention must be given to the negative inotropic effects, possible hypotension, and impaired neurological assessment.

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    CRASH trial collaborators. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury—outcomes at 6 months. Lancet. 2005;365:1957–59 (LoE 1b).

     
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    Firsching R, Messing-Jünger M, Rickels E, Gräber S und Schwerdtfeger K. Leitlinie Schädelhirntrauma im Erwachsenenalter der Deutschen Gesellschaft für Neurochirurgie. AWMF online. 2007. http://www.uni-duesseldorf.de/AWMF/ll/008-001.htm

     
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    Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, Walters BC, Brain Trauma Foundation. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma. 2002;19:111–74 (Evidenzbasierte Leitlinie).

     
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    Harris OA, Colford JM Jr, Good MC, Matz PG. The role of hypothermia in the management of severe brain injury: a meta-analysis. Arch Neurol. 2002;59:1077–83.

     
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    Karimi A, Burchardi H, Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI) Stellungnahmen, Empfehlungen zu Problemen der Intensiv- und Notfallmedizin, 5. Auflage. Köln, asmuth druck + crossmedia. 2004.

     
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    Langham J, Goldfrad C, Teasdale G, Shaw D, Rowan K. Calcium channel blockers for acute traumatic brain injury (Cochrane Review). In: The Cochrane Library, issue 1. Chichester: Wiley; 2004.

     
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    Marmarou A, Lu J, Butcher I, McHugh GS, Murray GD, Steyerberg EW, Mushkudiani NA, Choi S, Maas AI. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre‐hospital and on enrollment: an IMPACT analysis. J Neurotrauma. 2007;24(2):270–80 (LoE 3a).

     
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    Mendelow AD, Teasdale G, Jennett B, Bryden J, Hessett C, Murray G. Risks of intracranial haematoma in head injured adults. Br Med J (Clin Res Ed). 1983;287:1173–6.

     
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    Perel P, Yanagawa T, Bunn F, Roberts IG, Wentz R. Nutritional support for head-injured patients. Cochrane Database Syst Rev. 2006;4.

     
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    Piek J, Chesnut RM, Marshall LF, van Berkum-Clark M, Klauber MR, Blunt BA, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA. Extracranial complications of severe head injury. J Neurosurg. 1992;77:901–7.

     
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    Roberts I. Barbiturates for acute traumatic brain injury (Cochrane Review). In: The Cochrane Library, issue 1. Chichester: Wiley; 2004.

     
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    Roberts I. Aminosteroids for acute traumatic brain injury (Cochrane Review). In: The Cochrane Library, issue 1. Chichester: Wiley; 2004.

     
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2.7 Pelvis

Importance of the Initial Clinical Evaluation of the Pelvis

Key recommendations:

2.43

Recommendation

2016

GoR A

Acute life-threatening pelvic injury must be excluded upon patient arrival to the hospital.

2.44

Recommendation

2016

GoR A

The pelvis must be physically examined for stability.

Explanation:

Massive pelvic bleeding in hemodynamically unstable polytrauma patient is an acute life-threatening situation. There is no alternative to immediate surgical hemostasis and accelerated blood replacement (expert opinion with strong evidence from overall national and international clinical experience). Thus, life-threatening pelvic injury must be excluded or recognized and treated within the first minutes of arrival to the emergency department [1].

Essential components of making the diagnosis include clinical examination of the pelvis, inspection for external signs of injury, abdominal ultrasound, as well as consideration of mechanism of injury. Approximately 80 % of roll-over trauma cases are associated with pelvic fractures and often lead to significant soft-tissue injuries.

The following definitions are commonly used for the most severe types of life-threatening pelvic fractures:

“In extremis” pelvic injury: massive external bleeding, e.g. in a traumatic hemipelvectomy or crush injuries after severe roll-over trauma,

Complex trauma of the pelvis and/or acetabulum: fractures/fracture-dislocations with additional peri-pelvic injuries of the soft-tissue mantle, the genitourinary system, the intestines, the great vessels and/or nerve bundles. The modification according to Pohlemann et al. [45, 47] includes bleeding from torn pelvic veins and/or the pre-sacral plexus, which are the cause of bleeding in approximately 80 % of cases.

Traumatic hemipelvectomy: unilateral or bilateral avulsion of the bony pelvis combined with tears of the large intra-pelvic neurovascular pathways,

Pelvic-mediated hemodynamic instability (importance of the initial blood loss, e.g. > 2000 ml according to Bone [6] or > 150 ml/min according to Trunkey [65]).

If the clinical assessment suggests an “in extremis” complex pelvic trauma situation (complex trauma with hemodynamic instability), the pelvic ring must be closed as soon as possible, if not already performed in the pre-hospital setting, if necessary in a non-invasive manner e.g. with a “pelvic binder.”

When multiple injuries are present, the priorities of each individual injury should be weighed against each other. If one or more injuries are equally life-threatening, only emergency pelvic stabilization takes precedence.

Primary Diagnostic Studies for Suspected Pelvic Injuries

Key recommendation:

2.45

Recommendation

2016

GoR A

During the diagnostic survey, pelvic radiographs and/or computer tomography (CT) must be performed.

Explanation:

Clinical Examination:

If the patient is not “in extremis,” a more detailed physical examination can be performed. This consists of a complete external inspection and palpation of the pelvic area. It includes inspection for external wounds, bruising, or hematomas, as well as internal inspection and examination of the vaginal and rectal cavities. Clinical testing of pelvic stability is increasingly debated; however, current publications have as yet insufficient evidence to change the recommendations. Shlamovitz et al. reported low sensitivity of clinical pelvic examination for the detection of a mechanically unstable pelvic ring fracture as defined [54]. In a multicenter observational study, the working group of Schweigkofler found a sensitivity of 31.6 % and specificity of 92.2 % for the detection of unstable pelvic ring fractures. The positive predictive value was 72 % and the negative predictive value was 68 % [70].

In a study from Essen, the sensitivity and specificity of the clinical pelvic exam were 44 % and 99 %, respectively. However, approximately one fifth of unstable pelvic injuries are first diagnosed using survey radiographs [40]. In contrast to Kessel et al. [34] and Their et al. [60], who question the need for emergency pelvic survey radiographs when emergency CT is available, Pehle states that they should remain part of the emergency department diagnostic protocol for polytrauma [40]. This also corresponds with the current recommendation of the ATLS® algorithm. The hemodynamic situation must be given decision-making priority. According to the data from Miller et al. [37], blood pressure not responding to volume replacement has 30 % specificity for relevant intra-pelvic bleeding. Conversely, relevant bleeding can be excluded with a high degree of certainty when blood pressure is over 90 mmHg (negative predictive value 100 %).

During the clinical examination, special attention should be given to women of child-bearing age. A pregnancy test should be performed in these patients during the diagnostic survey in the emergency department. At the same time, the possibility of miscarriage/abortion induced by the trauma should be considered in the case of vaginal bleeding and pelvic trauma. Early consultation and close cooperation with the gynecology department is indispensable in this case.

Diagnostic Imaging:

Regarding diagnostic radiographs in the emergency department, the use of whole-body CT (aka “trauma scan”) is considered in many modern emergency department trauma care algorithms. Whole-body CT as the primary and possibly only diagnostic imaging in the trauma care area of the emergency department can be supplemented as needed with a preceding or subsequent anterior-posterior (AP) image. 28.6 % of surveyed DGU members reported that they perform conventional pelvic survey radiographs despite a planned trauma scan [69]. Further radiographs such as inlet/outlet or Judet views are assigned according to the particular case. Young et al. [71] state that 94 % of all pelvic fractures are correctly classified with the AP pelvis film alone. Edeiken-Monroe [19] found a success rate of 88 % for the AP pelvis x-ray. Several studies have compared CT and x-ray for diagnosis of pelvic fractures. In one retrospective study, Berg [4] detected 66 % of all pelvic fractures on the AP pelvis, and 86 % of all pelvic fractures on CT with 10 mm axial cuts. Harley [30] also found higher sensitivity for diagnostic CT, especially in detecting fractures of the sacrum and acetabulum. Resnik [48] also reported that plain x-ray misses 9 % of fractures, but noted that these fractures had no clinical relevance. Stewart [58] recommends that plain radiographs should be avoided when CT is planned. Kessel et al. [34], Their et al. [60], and Duane et al. [18] also question the need for emergency pelvic survey films when emergency CT is planned. For emergency CT, Stengel et al. [57] found a sensitivity of 86.2 % and specificity of 99.8 % for pelvic injuries after blunt trauma. However, they fear that a negative CT might have another explanation.

The increasing re-thinking of pre-hospital care as well as already improved technical equipping of rescue services (high availability of non-invasive stabilization tools such as e.g. pelvic binders) have marked influence on the results of diagnostic imaging. For example, when a pelvic binder is correctly applied, a pelvic B1 injury (pure ligamentous open book injury) can be so “concealed” that it is not detected on CT. A working group in the Emergency, Intensive, and Severely Injured Care section of the DGU (NIS) is currently working on a “clear the pelvis” algorithm with conventional radiographs/dynamic imaging under image intensification with an open pelvic binder (prior to and after CT) to address this problem.

When there is no fracture detected on x-ray, pelvic bleeding can be excluded with higher probability. Individual studies have examined the extent to which a fracture classification using conventional diagnostic x-ray can be used to assess vascular injury. Dalal et al. [15] found a significantly higher volume requirement especially in the most severe anterior-posterior pelvic fractures; however, that can also be explained by intra-abdominal injuries.

In addition, there are numbers comparing CT and angiography for the diagnosis of relevant pelvic bleeding. Pereira [41] reported accurate detection of pelvic bleeding by dynamic spiral CT in over 90 % of cases requiring embolization. Similarly, Miller [37] found a sensitivity of 60 % and specificity of 92 %. Kamaoui also found the CT pelvis examination with or without contrast helpful in identifying patients who require angiography [33].

Brown et al. [9] found relevant bleeding on subsequent angiography in 73 % of patients with pelvic fractures and contrast evidence of bleeding on CT. Conversely, close to 70 % of patients with negative CT showed a source of bleeding on angiography; thus, the relevance of bleeding must be questioned. Brasel et al. reported contrast extravasation on CT as a marker for pelvic injury severity; however, it does not mean that angiography is required. Like Brown, they found 33 % of cases with negative CT had pelvic bleeding that benefited from angiography and embolization [8].

Blackmore [5] suggested that contrast extravasation of 500 ml or more on CT indicates intra-pelvic bleeding. Analysis of 759 patients yielded highly significant association of these two with a RR of 4.8 (95% CI: 3.0-7.8). With extravasation over 500ml, then, bleeding is present in almost half of cases. When less than 200ml of extravasate is evident, there is a 95 % certainty that there is no bleeding. Sheridan [53] reports that bleeding can also be estimated on native (non-contrast) CT, because there is a correlation between hematoma development and bleeding when the size is greater than 10cm2.

A study from 2007 [24] investigated the sensitivity and specificity of the FAST (ultrasound) examination as an alternative to CT in patients with pelvic-mediated fractures, to help decide between emergency laparotomy and emergency angiography. Sensitivity of the FAST was 26 %, and specificity was 96 %. However, a negative result did not help with the decision regarding the need for laparotomy and/or angiography in patients with pelvic fractures [24]. CT abdomen was required for this decision, because ultrasound alone, in the eFAST context, is not considered adequate [8].

Classification of Injuries:

Bony pelvic injuries should be classified using diagnostic imaging. An exact classification of pelvic fractures is the basis for prioritized management [19]. This classification should also be undertaken as soon as possible in patients with compromised vital functions.

The AO (Arbeitsgemeinschaft Osteosynthese) classification is generally used, which distinguishes three fracture types:
  • Stable A type injuries with osteoligamentous integrity of the posterior pelvic ring, intact pelvic floor; the pelvis will not displace with physiological forces,

  • Rotationally unstable B type injuries with partially retained stability of the posterior pelvic ring,

  • Translationally unstable C type injuries with disruption of all posterior osteoligamentous structures as well as the pelvic floor. The direction of displacement (vertical, posterior, distraction, excess rotation) plays a subordinate role. The pelvic ring is disrupted anteriorly and posteriorly, and the affected side is unstable.

The concept of a complex pelvic fracture applies for all bony injuries of the pelvis with concomitant severe peri-pelvic soft tissue injury e.g. hollow organ injury of the pelvis, neurovascular injuries and/or urinary tract injuries.

It is also helpful to differentiate between open and closed pelvic injuries. The following pelvic injury situations would be deemed open:
  • Primary open pelvic fracture: according to the typical definition with communication between the fracture site and the skin and/or the vaginal or anorectal mucosa,

  • Closed pelvic fracture with packing inserted for hemostasis,

  • Closed pelvic lesions with documented contamination of the retroperitoneum from an intra-abdominal injury [32].

In contrast, pelvic fractures with isolated lesions of the bladder or urethra should be considered complex injuries, but not open. Open pelvic injuries have high mortality (approximately 45 %) due to the concomitant abdominal injuries with risks of acute exsanguination as well as delayed sepsis [17].

Detection of Unstable Pelvic Fractures

Instability, particularly of the posterior pelvic ring, is accompanied by a tendency for profuse bleeding from the pre-sacral venous plexus. It is important here to distinguish between isolated mechanical instability and hemodynamic instability, although both can also occur together. Evidence of instability should promote increased awareness of the hemodynamic situation. Instability should be differentiated according to iliac wing hinging inwards or outwards, internal and external rotation. In cases of translational instability, there can be craniocaudal instability in the horizontal plane or anterior-posterior instability in the sagittal plane. In addition to the increased bleeding risk, instability can lead to further complications such as thrombosis and secondary nerve, vascular, and organ injuries. The latter can be primary injuries and must be excluded during the primary diagnostic survey in unstable pelvic injuries. Pelvic instability should be managed with early surgery. Depending on patient condition, this can be a quick damage control procedure, or direct definitive treatment (more time intensive). There is consensus, however, that mechanical stabilization (regardless of method) has highest priority and should ideally be performed at the scene of the accident. Hemostasis has a similarly high priority and should be implemented according to the available alternatives.

Signs of pelvic instability can be identified on diagnostic imaging. These include, for example, widening of the public symphysis or the SI joints. Displacement of the iliac wings horizontally or vertically should also be considered a sign of instability. It should be kept in mind that displacement is frequently much greater at the time of trauma than at the time of diagnosis. Thus, a fracture of the transverse process of the L5 vertebra should be evaluated as a sign of instability if there is concomitant pelvic injury, even if there is no iliac wing displacement. It should also be kept in mind that a correctly placed pelvic girdle or pelvic binder can mask pelvic instability.

The vector of pelvic instability is important for classification. If there is rotational instability only of the pelvis over the vertical axis of the posterior pelvic ring, this is a Group B injury. If there is translational instability in the vertical or horizontal plane, it is a Group C injury.

Emergency Stabilization of the Pelvis

Key recommendation:

2.46

Recommendation

Modified 2016

GoR A

In cases of an unstable pelvis and hemodynamic instability, emergency mechanical stabilization must be carried out.

Explanation:

Only simple and rapid procedures are suitable for emergency stabilization of the pelvis. Use of a sheet or pneumatic or other industrial pelvic girdles is clearly inferior to an anterior external fixator and the pelvic C-clamp in terms of mechanical stability. Nevertheless, both procedures are effective as emergency measures at least temporarily in an urgent situation [16]. On the other hand, mechanical stability of the Ganz C-clamp or external fixator are dependent on fracture type. The exact timeline of the injury must be observed. Early stabilization with a cloth sling or a pelvic girdle (pelvic binder) can be better for patient outcome than a later stabilization with a supra-acetabular fixator and pelvic clamp.

There is continued debate whether the anterior external fixator (supra-acetabular) or the pelvic C-clamp should be used. For unstable pelvic fractures type C (AO or CCF), the pelvic C-clamp is preferred over the anterior fixator as evidenced by biomechanical studies [46]. For unstable type B injuries, there were no noteworthy differences between the two. There have been no studies on the question of which emergency stabilization technique has the best effect on hemostasis [10, 14].

Overall, the pelvic C-clamp is used less often, since it is a less definitive solution compared to the external fixator and has special contraindications. For example, trans-iliac fractures are a contraindication, because with compression, the spine of the clamp could pass through the fracture and result in lesser pelvic organ injury. On the other hand, reliable stabilization with an external fixator is not always possible when there is posterior instability. Siegmeth et al. [55] theorize that an external fixator is sufficient for instability of the anterior pelvic ring, but that injuries to the posterior pelvic ring need additional compression in an emergency. Trafton et al. called for the same already in the late 1980s [64]. Studies of a commercial pelvic girdle (non-invasive pelvic stabilization) have yielded contradictory results regarding reductions in mortality, pRBC transfusions, and duration of trauma-related hospital admission. Although Croce [13] reported benefits of the pelvic girdle in his study, these findings were not confirmed by Ghaemmaghami et al. [25]. One important change, however, is that in recent years, the use of pelvic girdles and other non-invasive external stabilization techniques has increasingly established itself in the pre-hospital setting. The consequence of this is that effective emergency stabilization is begun markedly earlier. The initiation of non-invasive stabilization occurs generally based on accident kinematics and can stabilize and manage the patient with pelvic bleeding much sooner.

The widespread use of pelvic girdles has also changed emergency stabilization within the trauma care area of the emergency department. In a retrospective study, Pizanis et al. [44] investigated the effects of three different emergency stabilization techniques mainly on mortality. A time advantage was identified for the use of cloth slings and pelvic binders. The sequential procedure used in current practice, with pre-hospital application of a pelvic girdle followed by in-hospital change to a C-clamp when necessary was discussed, but the effects could not be analyzed based on the study design. Commercial pelvic binders appear to have benefits over cloth slings. This is because of the implementation, particularly in the positioning of the device. Similar to Bonner et al. [6], the unpublished results of a retrospective analysis of over 500 trauma scans with some 200 applied pelvic girdles by Schweigkofler from Frankfurt found that a correct position within a corridor ± 5 cm around the ideal position was reached in only 62 % of cases.

The data regarding frequency of use of pelvic C-clamps, pelvic binders, and cloth slings showed discrepancies. In a survey on emergency management of the pelvis, Wohlrath et al. [69] found that a pelvic C-clamp was used in only 47.7 % of cases as an emergency stabilization device, while it was used in 69 % of cases in the Pizanis et al. [44] study.

Today, the pelvic C-clamp is used less often within the emergency department, but increasingly in the “safe” operating room environment [44].

Procedures for Hemodynamic Instability Associated with Pelvic Fractures

Key recommendation:

2.47

Recommendation

Modified 2016

GoR B

In cases of persistent bleeding, surgical hemostasis and/or selective angiography with angioembolization should be performed.

Explanation:

Unstable pelvic fractures often lead to profuse bleeding, depending on the degree of posterior pelvic ring displacement. If an unstable pelvic fracture is diagnosed in combination with hemodynamic instability, the pelvic fracture should be considered a possible cause of the hemodynamic instability. Except in cases of severe pelvic roll-over trauma, emergency stabilization of the pelvis using the methods already described here in combination with volume replacement infusion therapy can lead to persistent hemodynamic stabilization, so that the need for surgical hemostasis can be reevaluated. The ATLS©-compliant classification as “responder” and “non-responder” can be a useful decision aid in this case.

If the patient continues to be a “non-responder,” with persistent hemodynamic instability despite these measures, additional measures must be undertaken. There are basically two possibilities: surgical tamponade and embolization. When selecting one of these procedures, it should be noted that only arterial bleeding can be embolized, and that this is estimated to account for only 10-20 % of cases of bleeding in severe pelvic injuries. The remaining 80 % are of venous origin [38].

In view of this, surgical tamponade of the lesser pelvis appears reasonable and, in the German-speaking world at least, is considered the method of first choice in such cases ([20], prospective study with 20 patients). Similarly, in a prospective study of 150 patients, Cook [11] found an advantage for rapid mechanical stabilization followed by surgical hemostasis or tamponade. Pohlemann et al. [45] made similar recommendations based on a prospective study of 19 patients, and Bosch [7] after a retrospective analysis of 132 patients. However, prior mechanical stabilization of the pelvic ring is imperative.

At the same time, embolization must also be considered. Miller [37] considers angiography and embolization even more valuable than mechanical stabilization. Operative stabilization merely delays efficient hemostasis and also represents avoidable surgical trauma. According to Hagiwara, patients with hypotension and “partial responders” receiving two liters of fluid after blunt abdominal trauma and injury to the pelvis and/or liver and/or spleen, etc. benefit from angiography and subsequent embolization. After embolization, volume requirements decreased significantly and the shock index normalized [28, 29].

In a retrospective study for the years 2007-2012, Marzi investigated 173 severely injured patients with pelvic ring fractures. The following algorithm was applied: angioembolization as hemostasis was used only in hemodynamically stable “responder” patients. In contrast, hemodynamically unstable patients underwent mechanical and surgical hemostasis in the operating room as soon as possible prior to angioembolization [36].

Agolini [2] writes that only a small percentage of patients with pelvic fractures require embolization. When applied, however, it can be close to 100 % effective. Patient age, time of embolization, and the extent of initial hemodynamic instability influence survival rate; for example, angiography performed three hours after trauma resulted in 75 % mortality versus 14 % when it was performed less than three hours after the accident. Pieri et al. found 100 % effectiveness of emergency angiography with embolization in pelvic-mediated hemodynamic instability and bleeding from the obturator as well as the gluteal arteries [43]. Tottermann found significant arterial bleeding from the internal iliac artery in 2.5 % of patients with pelvic injuries. With an all-cause mortality of 16 % in the patient population, he identified an inverse proportionality between age and survival probability [62].

Panetta [39] postulated that early embolization with a range of 1-5.5 hours (average 2.5 hours), but found no correlation between time of procedure and mortality. Outcome reports identified no benefits for embolization, with success rates of approximately 50 % when performed within six hours after the accident [41]. The groups of Kimbrell [35] and Velmahos [66] are in favor of liberal use of embolization for abdominal and pelvic injuries with confirmed arterial bleeding even in patients without initial signs of hemodynamic instability.

Gourlay et al. [26] describe angiography as the gold standard for arterial bleeding in pelvic fractures. A special subpopulation of approximately 7-8 % even needed follow up angiography because of persistent hemodynamic instability. A study by Shapiro [52] gave indication for re-angiography as persistent shock symptoms (SBP < 90 mmHg), lack of other intra-abdominal injuries, and sustained base excess < -10 for more than six hours after admission. In the subsequent re-angiography, there was pelvic-mediated bleeding in 97 % of cases.

In a study by Fangio, some 10 % of patients with pelvic injuries were hemodynamically unstable. The subsequent angiography was successful in 96 % of cases. Angiography enabled the diagnosis and treatment of non-pelvic bleeding in 15 % of cases. This decreased the rate of false positive emergency laparotomy procedures [23]. Sadri et al. [49] also discovered that a specific subgroup of pelvic injuries (approximately 9 %) with persistent volume requirements benefited from emergency mechanical C-clamp stabilization of the pelvic ring and subsequent angiography/embolization.

On the other hand, Perez [42] also considers embolization a fundamentally reliable procedure, but sees a need for clarification of the parameters defining indications and effectiveness for use. Salim et al. reported the following parameters with significant predictive values to identify the group of patients who benefit from angioembolization: SI joint disruption, female gender, and persistent hypotension [50].

According to Euler [21], interventional radiological procedures like embolization or balloon catheter occlusion are more important in the later, post-primary treatment phase and not during polytrauma management. Only 3-5 % of hemodynamically unstable patients with pelvic injury require and/or benefit from embolization [3, 22, 38].

As characterized above, there are divergent opinions in the literature. These differences can be explained to some extent by the considerable differences in patient collectives and injury severity.

No definitive recommendation can be given due to the lack of high quality evidence for both packing and embolization. Rather, it is crucial that a stabilizing intervention must be applied, since unnecessary delay worsens patient outcome. In the end, surgical hemostasis (packing and external stabilization) and angioembolization are not competing, but complementary procedures with different foci. The preferred method will also certainly depend on local circumstances. In addition to the availability of embolization, particular consideration should be given to the fact that no other measures can be performed in parallel for the patient during the procedure. Finally, there is the need for strict time management, which must be adhered to in any case.

Data from the Pelvic Registry III of the DGU showed an increase in emergency angiography procedures performed in Germany from approximately 2 % to 4 %. In 2008, Westhoff recommended early clinical integration of interventional emergency embolization for pelvic fractures in cases when the appropriate infrastructure is in place [68]. Until 2007, the Anglo-American literature in particular seemed to emphasize the angiography approach. The results of the following two studies from 2007 might be interpreted as the beginning of a paradigm shift.

Tottermann reported a significant blood pressure increase after surgical packing. In the subsequent angiography, there was still evidence of arterial bleeding in 80 % of cases, so that he suggests a stepwise approach with surgical packing followed by embolization [63]. The study of Cothren found a significant reduction in the need for packed red blood cell (pRBC) transfusions within 24 hours of hospital admission for the patients receiving pelvic packing only compared to the angiography group (approximately 12 versus 6 units pRBCs; [12]). Sufficient training of operating personnel is essential to adequate patient stabilization with surgical packing. Packing is a sufficient method of hemostasis only when surgeons are adequately trained in the metho