[Interruption of the diagnostic algorithm and immediate surgical intervention after major trauma--incidence and clinical relevance. Analysis of the Trauma Register of the German Society for Trauma Surgery].
BACKGROUND
Life-threatening situations after multiple trauma which require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. The purpose of this study was to evaluate the incidence, causes, implications and relevance of life-threatening situations for major trauma patients after admission to trauma centers.


METHODS
Data of 12,971 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) > 16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to patients where the diagnostic algorithm in the resuscitation room was interrupted to perform emergency surgery (group Notop, n = 713, 5.5%) and patients who received early surgical care after completed diagnostics (group Frühop, n = 5,515, 42.5%). Comparative parameters were the pattern and severity of injury, physiological state and clinical outcome.


RESULTS
Patients receiving emergency surgery showed an average ISS score of 39 ± 15 points, whereas patients receiving early surgery showed an average ISS of 31 ± 12 points. On admission patients in the emergency surgery group (44%) suffered from hemodynamic shock considerably more often than patients in the early surgery care group (15%, p < 0.001). This was indicated by the significant differences in systolic blood pressure on admission, amount of preclinical substituted volume, base excess on admission and substituted erythrocyte concentrates in early clinical course. Mortality was 46% in the emergency surgery group and 13% in the early surgical care group (p < 0.001). Severe injuries (AIS ≥ 4) of the thorax, abdomen and extremities (including the pelvis) were encountered considerably more often in the emergency surgery group. There was no statistical difference in occurrence of severe head injuries between the groups. Emergency surgery consisted of 50.5% laparatomy, 19.8% craniotomy, 10.0% thoracotomy and 9.3% pelvic surgery.


CONCLUSIONS
Life-threatening situations after major trauma which require immediate surgical intervention in the resuscitation room rarely occur in Germany. Nevertheless, they are associated with a high mortality and prolonged and complex clinical course if primarily survived. Indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms and should be considered for the future education of orthopedic surgeons in Germany.
Lögters
T
T
Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf.
Lefering
R
R
Schneppendahl
J
J
Alldinger
I
I
Witte
I
I
Windolf
J
J
Flohé
S
S
D000328:Adult; D000465:Algorithms; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D009104:Multiple Trauma / Q000453:epidemiology* / Q000601:surgery*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012042:Registries / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors
Resuscitation. 2007 Nov;75(2):276-85
17574721
J Trauma. 2008 Jun;64(6):1459-63; discussion 1463-5
18545109
J Trauma. 1993 Sep;35(3):375-82; discussion 382-3
8371295
Unfallchirurg. 2002 Nov;105(11):1027-32
12528671
Unfallchirurg. 2002 Nov;105(11):1007-14
12402127
J Trauma. 1997 May;42(5):857-61; discussion 861-2
9191667
Unfallchirurg. 2008 Apr;111(4):232-9
18351314
J Trauma. 2009 Jan;66(1):41-8; discussion 48-9
19131804
Intensive Care Med. 2002 Oct;28(10):1395-404
12373463
Unfallchirurg. 2004 Oct;107(10):903-10
15452651
Crit Care. 2005;9 Suppl 5:S1-9
16221313
Unfallchirurg. 1998 Oct;101(10):742-9
9847700
J Trauma. 2008 Jun;64(6):1638-50
18545134
J Trauma. 2003 Dec;55(6):1095-108; discussion 1108-10
14676657
J Trauma. 2007 Apr;62(4):834-9; discussion 839-42
17426537
Unfallchirurg. 2004 Oct;107(10):871-80
15565425
J Trauma. 2000 Nov;49(5):969-78
11086798
Unfallchirurg. 2003 Apr;106(4):348-57
12719857
Chirurg. 2006 Sep;77(9):861-72; quiz 873
16932931
Injury. 2009 Jan;40(1):11-20
19135193
Injury. 2007 Mar;38(3):298-304
17214989
J Trauma. 1985 Jan;25(1):60-4
3965737
Unfallchirurg. 2004 Oct;107(10):881-91
15459808
Unfallchirurg. 2004 Oct;107(10):851-61
15459805
J Trauma. 2001 Aug;51(2):261-9; discussion 269-71
11493783
Unfallchirurg. 2004 Oct;107(10):844-50
15452655
Unfallchirurg. 2006 Jun;109(6):437-46
16583190