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Berlin Brandenburg

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  • 1
    Language: English
    In: Injury, 2012, Vol.43(1), pp.33-37
    Description: A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups ( = 0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.
    Keywords: Wounds and Injuries ; Blood Coagulation Disorders ; Blood Transfusion ; Resuscitation
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 2
    Language: English
    In: Injury, October 2014, Vol.45(10), pp.1653-1658
    Description: Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union. An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury. 285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant. Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion. Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. Patients with delayed union or nonunion can expect poorer outcomes.
    Keywords: Trauma ; Outcomes ; Femur ; Tibia ; Fracture ; Nonunion ; Delayed Union
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 3
    Language: English
    In: Injury, October 2014, Vol.45(10), pp.1545-1548
    Description: To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. Retrospective review. Two level one trauma centres. Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, 〈 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, = 0.333). A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. Level III.
    Keywords: Distal Humerus Fracture ; Extra-Articular ; Approach ; Triceps Split ; Triceps Sparing ; Outcomes
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 4
    Language: English
    In: Injury, 2010, Vol.41(9), pp.894-898
    Description: The purpose of this study was to assess the role of decompressive craniectomy (DC) in patients with post-traumatic intractable intracranial hypertension (ICH) in the absence of an evacuable intracerebral haemorrhage. Retrospective study at LAC+USC Medical Centre including patients who underwent DC for post-traumatic malignant brain swelling or ICH without space occupying haemorrhage, during the period 01/2004 to 12/2008. The analysis included the effect of DC on intracranial pressure (ICP) and timing of DC on functional outcomes and survival. Of 106 patients who underwent DC, 43 patients met inclusion criteria. Of those, 34 were operated within the first 24 h from admission. DC decreased the ICP significantly from 37.8 ± 12.1 mmHg to 12.7 ± 8.2 mmHg in survivors and from 52.8 ± 13.0 to 32.0 ± 17.3 mmHg in non-survivors. Overall 25.6% died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). No tendency towards either increased or decreased incidence in favourable outcome was found relative to the time from admission to DC. Six of the 18 patients (33.3%) with favourable outcome were operated on within the first 6 h. DC lowers ICP and raises CPP to high normal levels in survivors compared to non-survivors. The timing of DC showed no clear trend, for either good neurological outcome or death. Overall, the survival rate of 74.4% is promising and 41.9% had favourable neurological outcome.
    Keywords: Decompressive Craniectomy ; Severe Traumatic Brain Injury ; Intractable Intracranial Hypertension ; Glasgow Outcome Score
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 5
    Language: English
    In: Injury, January 2018, Vol.49(1), pp.62-66
    Description: Higher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients. Retrospective observational study. Patients with isolated severe blunt TBI (AIS head ≥ 3, AIS extracranial 〈 3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution’s trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis. A total of 385 patients were included. Median age was 32 years (IQR 2–50), 71.4% were male, and 76.6% had an ISS ≥ 16. Plasma:PRBC transfusion ratios ≥ 1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22–0.81]). PLT:PRBC transfusion ratios ≥ 1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08–1.92]). This study revealed plasma to PRBC transfusion ratios ≥ 1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.
    Keywords: Brain Injury ; Blood Component Transfusion ; Transfusion Ratio ; Mortality ; Coagulopathy
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 6
    Language: English
    In: Injury, 1999, Vol.30(6), pp.431-437
    Description: There is a paucity of large cohort studies that address outcomes after acute orthopaedic trauma. The regional trauma registry is a powerful tool to study trends of large populations over long periods of time. We used such a regional trauma registry to review retrospectively a large subset of orthopaedic trauma patients over a long period of time and to evaluate the relationship between initial presentation, hospital course, hospital charges, and outcomes as a function of age. A retrospective review of 130,506 level I and II trauma admissions with acute orthopaedic injuries over 10 years (1985-1995) was conducted. Aggregate data were analyzed among five age groups. Descriptive analyses were conducted for mechanism of injury, mortality, time to death, injury type, injury severity score (ISS), Glasgow Coma Scale (GCS) on presentation, length of stay (LOS), discharge destination, and hospital charges. Forty-six percent of the patients were in the 18-35-year-old age group; however, 21% of all patients were older than 65 years of age at the time of injury. There were no differences in GCS or ISS on admission. Injury types were similar across all age groups, mostly extremity fractures. Younger patients were much more likely to be injured in a motor vehicle accident (MVA), whereas older patients were injured in a fall. Penetrating trauma was seen almost exclusively in the young. LOS in the hospital was longer in the elderly; however, LOS in the intensive care units were similar across all age groups. Time to death from initial presentation differed across age groups. Elderly patients who eventually died were much more likely to survive more than 24 h in the hospital as compared with young patients. Hospital charges per hospitalization increased with age, although the total charges to the youngest age group were higher due to the group's high volume. Younger American trauma patients with acute orthopaedic injuries are much more likely than their older counterparts to sustain penetrating trauma and pass the socioeconomic burden to society by way of large opportunity costs, lack of insurance, and high rates of recidivism. Elderly patients fared as well as younger patients after acute orthopaedic trauma, although their hospital stays were longer and resulted in increased hospital charges. The excessive costs of trauma, $100 billion and more than 150,000 deaths annually, necessitate study of general population trends. Indirect costs, including rehabilitation costs and opportunity costs, as well as direct costs, are incurred during the post-trauma hospitalization. Attention must focus on prevention of penetrating injuries in the young and falls in the elderly to reduce morbidity, mortality, and the costs of trauma.
    Keywords: Fractures, Bone -- Epidemiology;
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 7
    Language: English
    In: Injury, 2007, Vol.38(9), pp.993-1000
    Description: Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients’ outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems. Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) 〈90 mmHg) and early trauma fatality rate (i.e. death during the first 24 h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes. After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73–1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54–0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems. These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.
    Keywords: Emergency Medical Services (Ems) ; Trauma ; Injury ; International ; Mortality ; Clustered Study ; Shock Rate ; Intracluster Correlation Coefficient (ICC)
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 8
    Language: English
    In: Injury, 2007, Vol.38(9), pp.1001-1013
    Description: To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries. We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) 〉15 and the pre-hospital trauma care provided to these patients were compared among different countries. A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1 min) and Montreal, Canada (median 16.1 min) reported the shortest and Germany (median: 30 min) and Austria (median: 26 min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively). This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.
    Keywords: Pre-Hospital Trauma Care ; Emergency Medical Service (Ems) Systems ; Developed and Developing Countries ; Advanced Life Support ; Basic Life Support ; Intravenous Fluid Therapy ; Endotracheal Intubation
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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