Biomedical subjects

Christian Waydhas

Publications and source records attributed to Christian Waydhas.

15 recordsLinked to original sources

PubMed2006

Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review.

Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors' perspective.

Chest Tubes↗

PubMed2005

Nonoperative management of tracheobronchial injuries in severely injured patients.

PURPOSE: A rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure. METHODS: We retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR). RESULTS: Five (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury. CONCLUSION: We believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.

Adolescent↗

PubMed2005

Long-term follow-up after severe suicide attempt by multiple blunt trauma.

OBJECTIVE: After parasuicide there is a high risk of reattempts. However, it seems that patients who survived severe suicidal trauma recover well. Therefore, the outcome of patients with severe multiple blunt trauma as a result of a suicide attempt was investigated with respect to psychiatric and somatic health, quality of life (QOL) and suicide reattempt rates. METHODS: Patients who underwent a suicide attempt were isolated from a prospectively collected sample of trauma patients from a level I University Trauma Centre. Follow-up examination was performed 6.1 +/- 3 years after the trauma. A physical and psychiatric examination was performed, using established psychiatric scales. RESULTS: Twelve percent of severely injured patients were identified as suicide attempters (male/female: 37/28, mean age 38 +/- 18 years, mean Injury Severity Score (ISS) 40 +/- 15 points). A psychiatric diagnosis was present in 90% at the time of the suicide attempt. Twenty-one patients died during the hospital stay (32%) and six subjects died thereafter, none due to suicide. Thirty-five individuals were eligible for examination. None of them had reattempted suicide. Seventeen (48%) had good outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings and good psychosocial ability. An indeterminate outcome was determined in 24%. Predictive variables for an adverse outcome (10 patients, 28%) were found to be a diagnosis of schizophrenia, continued psychiatric treatment and being without employment. CONCLUSION: Despite the seriousness of the suicide attempt, survivors recovered well in about half the cases with no further suicide attempt in any patient. An early psychiatric consultation already on the Intensive Care Unit (ICU) is recommended.

Adaptation, Psychological↗

PubMed2005

Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe.

BACKGROUND: Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety. METHODS: In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients. RESULTS: Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 +/- 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3-46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 +/- 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by TRISS (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%). CONCLUSION: DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.

Adult↗

PubMed2005

Prone positioning improves oxygenation in post-traumatic lung injury--a prospective randomized trial.

BACKGROUND: In a prospective randomized trial the effect of prone positioning on the duration of mechanical ventilation was evaluated in multiple trauma patients and was compared with patients ventilated in supine position. METHOD: Multiple trauma patients of the intensive care units of two university hospitals were considered eligible if they met the criteria for acute lung injury or the acute respiratory distress syndrome. Patients in the prone group (N = 21) were kept prone for at least eight hours and a maximum of 23 hours per day. Prone positioning was continued until a PaO2:FiO2 ratio of more than 300 was present in prone as well as supine position over a period of 48 hours. Patients in the supine group (N = 19) were positioned according to standard care guidelines. RESULTS: The duration of ventilatory support did not differ significantly (30 +/- 17 days in the prone group and 33 +/- 23 days in the supine group). Worst case analysis (death and deterioration of gas exchange) displayed ventilatory support for 41 +/- 29 days in the prone group and 61 +/- 35 days in the supine group (p = 0.06). The PaO2:FiO2 ratio increased significantly more in the prone group in the first four days (p = 0.03). The prevalence of Acute Respiratory Distress Syndrome (ARDS) following acute lung injury (p = 0.03) and the prevalence of pneumonia (p = 0.048) were reduced also. One patient in the prone and three patients in the supine group died due to multi organ failure (p = 0.27). CONCLUSIONS: Intermittent prone positioning was not able to reduce the duration of mechanical ventilation in this limited number of patients. However the oxygenation improved significantly over the first four days of treatment, and the prevalence of ARDS and pneumonia were reduced.

Adult↗

PubMed2004

Improved student preparation from implementing active learning sessions and a standardized curriculum in the surgical examination course.

Students' knowledge before and preparation for courses with practical skills training or bedside teaching may be insufficient and reduce efficiency of teaching time at the bedside and in skills training. To study the effect of a new curriculum on students' preparation for courses, a quasi-randomized study was conducted. All medical students were included who participated in the surgical examination course during a period of four semesters. In the intervention group, specified topics for every session, a course book describing only those procedures relevant for the course and a foregoing case-based active learning session were introduced as compared to the traditional way of teaching the surgical examination course. For evaluation a questionnaire for the students was used. A total of 614 questionnaires (return rate 79.6%) were included in the analysis. Student as well as teacher preparation significantly improved in the intervention group from 34.8 to 73.6% and 46.1 to 73.0%, respectively. The case-based learning session and the course book were considered helpful by 77.7 and 96.4% of the students, respectively. The introduction of a timetable with specified topics for every session, a course book and a foregoing case-based learning session significantly improved student preparation for the surgical clinical examination course.

Competency-Based Education↗

PubMed2004

Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary?

BACKGROUND: In unstable pelvic ring fractures free abdominal fluid on ultrasound (US) may be caused by retroperitoneal hematoma that passes into the abdominal cavity or by an additional intraabdominal lesion. In this study a clinical pathway for the therapy of potentially combined lesions was analyzed. PATIENTS AND METHODS: All patients treated in the ED for severe trauma underwent basic sonographical and radiologic diagnostics within 15 minutes. of admission. Data were prospectively documented. According to the treatment protocol unstable pelvic ring fractures with initial free fluid on US received laparotomy. Patients with stable vital conditions had abdominal CT-Scan before surgery. RESULTS: 1472 consecutive severely injured patients (ISS 20, age: 39 years) were included. Eighty subjects had sustained type B (47) or C (33) pelvic ring fracture. Early free abdominal fluid on US was absent in 49 cases. Three patients in this group required celiotomy later on, during ICU treatment. In 31 patients free fluid was present. All of them had laparotomy. Only one patient showed retroperitoneal hematoma alone, while all others had one or more significant lesions (rupture) that required surgical repair. Simultaneously with laparotomy pelvic stabilization was performed by external (19) or internal (6) fixation. In all cases with massive pelvic hemorrhage and free fluid in US bleeding was controlled by internal tamponade and external fixation. CONCLUSION: The finding of intraperitoneal fluid on US in the emergency department strongly correlates with significant intraabdominal lesions requiring surgical intervention. Early laparotomy appears indicated in these cases. Shock control in pelvic bleeding can be sufficiently achieved by internal tamponade and external fixation.

Abbreviated Injury Scale↗

PubMed2003

Influence of surgical intervention in the immune response of severely injured patients.

OBJECTIVE: Primary events such as severe injury and elective surgery cause a deterioration of the immune response measurable by reduction of expression of HLA-DR on monocytes or ex vivo LPS-induced TNFalpha production. The further influence of secondary surgery after severe injury on the immune response remains unresolved. DESIGN: Prospective observation study. SETTING: Surgical intensive care unit of an university hospital. PATIENTS: Sixteen severely injured patients with an ISS >25 points. MEASUREMENTS AND RESULTS: On day 1 after trauma and immediately before secondary surgery, mean fluorescence intensity (MFI) of HLA-DR expression on monocytes and TNFalpha ex vivo synthesis was significantly reduced compared to healthy donors. Overall, surgical intervention during the second week after trauma caused no further reduction of HLA-DR expression on monocytes and of the ex vivo TNFalpha-synthesis. However, major surgery such as intramedullary nailing or pelvic osteosynthesis caused reduction of the HLA-DR expression and TNFalpha-synthesis, whereas, minor surgical interventions such as osteosynthesis on peripheral joints exhibited no significant effects on the immune response. Surgical intervention performed to clear septic foci normalised immune response by elevating HLA-DR expression on monocytes and ex vivo TNFalpha synthesis. Severe injury caused elevated serum IL-10 levels, whereas secondary surgery did not induce a further increase in serum IL-10 levels. CONCLUSION: This study shows that initial trauma as well as major secondary surgery causes a suppression of immune functions, whereas minor secondary surgery does not cause significant immune disturbance.

Adult↗

PubMed2003

Guideline validation in multiple trauma care through business process modeling.

Clinical guidelines can improve the quality of care in multiple trauma. In our Department of Trauma Surgery a specific guideline is available paper-based as a set of flowcharts. This format is appropriate for the use by experienced physicians but insufficient for electronic support of learning, workflow and process optimization. A formal and logically consistent version represented with a standardized meta-model is necessary for automatic processing. In our project we transferred the paper-based into an electronic format and analyzed the structure with respect to formal errors. Several errors were detected in seven error categories. The errors were corrected to reach a formally and logically consistent process model. In a second step the clinical content of the guideline was revised interactively using a process-modeling tool. Our study reveals that guideline development should be assisted by process modeling tools, which check the content in comparison to a meta-model. The meta-model itself could support the domain experts in formulating their knowledge systematically. To assure sustainability of guideline development a representation independent of specific applications or specific provider is necessary. Then, clinical guidelines could be used for eLearning, process optimization and workflow management additionally.

Humans↗

PubMed2003

Effect of granulocyte-macrophage colony-stimulating factor on the immune response of circulating monocytes after severe trauma.

OBJECTIVE: Severe injury compromises functions of the antigen-presenting immune cells, resulting in an increased vulnerability toward bacterial sepsis. Support of the immune capabilities contributes a desirable therapeutic option in high-risk patients. Factors possessing immunostimulating properties such as granulocyte-macrophage colony-stimulating factor (GM-CSF) may serve as potential tools to compensate immunosuppression caused by severe trauma. In the present study, therefore, GM-CSF was examined with regard to its capacity to overcome trauma-induced down-regulation of immune functions. DESIGN: Prospective clinical experimental study. SETTING: University hospital intensive care unit and research facility. PATIENTS: Severely injured patients with >25 points on the Injury Severity Score. INTERVENTIONS: Blood samples of severely injured patients were incubated in vitro with 10 ng/mL GM-CSF for 6 hrs. MEASUREMENTS: Human leukocyte antigen (HLA)-DR expression on monocytes was analyzed by flow cytometry, lipopolysaccharide-induced tumor necrosis factor (TNF)alpha and interleukin-10 production of blood samples was measured by means of enzyme-linked immunoabsorbent assay. MAIN RESULTS: Compared with blood specimens of healthy donors, ex vivo endotoxin-induced TNF alpha production and HLA-DR expression on monocytes were significantly reduced in blood of trauma patients. Ex vivo treatment of blood specimens with GM-CSF increased HLA-DR expression and TNF alpha production stimulated by lipopolysaccharides in both healthy volunteers and patients on day 1 after trauma. Blood samples of patients with an uneventful recovery showed nearly normal TNF alpha synthesis and HLA-DR expression after 2-3 wks, whereas TNF alpha production and HLA-DR expression of patients with sepsis and multiple organ failure remained at low levels. In the sepsis/multiple organ failure group, GM-CSF also enhanced HLA-DR expression and TNF alpha production, although the levels of the volunteers' blood were not reached. CONCLUSIONS: The presented data show that trauma- and sepsis-induced depression of monocyte functions can be counteracted by GM-CSF in vitro, suggesting that this substance may serve as support of immune functions in severely injured patients.

Adult↗

PubMed2003

Quality of multiple trauma care in 33 German and Swiss trauma centers during a 5-year period: regular versus on-call service.

BACKGROUND: The purpose of this study was to evaluate process and outcome quality of severely injured patients admitted during on-call (OC) versus regular trauma service (RS). METHODS: This was a prospective and multicentric analysis of the Trauma Registry of the German Trauma Society. Patients were evaluated if directly admitted from the scene of accident with an Injury Severity Score of > 15 and if alive on arrival at the emergency department. RESULTS: Seventy percent of patients were admitted during OC; these patients were significantly younger. Blunt trauma predominated, with a 95% incidence. Falls from great heights were significantly more frequent during RS, whereas motor vehicle crashes predominated during OC. No differences were found for emergency department management (e.g., time to abdominal ultrasound, chest radiograph, or cranial computed tomography). However, time to admission to the intensive care unit was substantially longer during RS. No significant differences were found for outcome parameters such as length of intensive care unit stay, hospitalization time, incidence of organ failure, or mortality. CONCLUSION: This study demonstrates a constant quality of care provided 24 hours per day, 7 days per week in the participating hospitals. Differences within individual trauma centers were not compared and need to be assessed by internal quality management.

Germany↗

PubMed2002

A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers.

OBJECTIVE: The impact of a multidisciplinary quality management system (MQMS) on the early treatment of severely injured patients was tested. DESIGN AND SETTING: Prospective clinical study in two level 1 trauma centers. METHODS AND MATERIALS: MQMS comprised a protocol for documentation, 20 assessment criteria, and the judgement of data by a quality circle. After implementation in Munich (1st period, n=90; 2nd period, n=77) the validation took place in Essen (1st period, n=175; 2nd period, n=150). RESULTS: Improvements in diagnostics were shown by significant time savings in radiological diagnostics and before computed tomography in severe traumatic brain injury. In patients with hemorrhagic shock there was a reduction in time before transfusion (49 to 14 min in Munich; 31 to 22 min in Essen) and before emergency operation (74 to 43 min in Munich; 69 to 45 min in Essen). The time before craniotomy was reduced from 97 to 67 min in Munich. The incidence of delayed diagnosis of life-threatening lesions was diminished from 6% to 3% in Munich (not found in Essen). The TRISS technique showed a reduction in mortality in both hospitals in the second period (Munich: 15.4% TRISS vs. 9.1% observed mortality; Essen: 17.8% vs. 11.3%). CONCLUSIONS: MQMS improved early clinical treatment in severe injury with respect to therapeutic effectiveness and outcome. The effectiveness of the MQMS was shown at two different hospitals

Germany↗

PubMed2002

Prehospital intubation in severe thoracic trauma without respiratory insufficiency: a matched-pair analysis based on the Trauma Registry of the German Trauma Society.

OBJECTIVE: On the basis of the data of a multicenter study, the impact of prehospital intubation and ventilation in the therapy of severe thoracic trauma without manifest respiratory insufficiency was analyzed. METHODS: Data were collected prospectively in the Trauma Registry of the German Trauma Society. In a matched-pair analysis, patients with severe thoracic trauma (Abbreviated Injury Scale score of 4) with and without prehospital intubation were compared. Patients were paired with respect to age, injury severity, and prognosis (according to the TRISS method). RESULTS: From a total of 3,814 patients, two groups (with/without prehospital intubation) of 44 matched patients each with comparable average age (36 vs. 36 years), Injury Severity Score (29 vs. 29), and TRISS (95.2 vs. 95.3) were identified. No patient was unconscious at the scene (all Glasgow Coma Scale scores > or = 8) or presented with severe respiratory insufficiency (all > or = 10 breaths/min). Time between injury and hospital admission was significantly longer (73 minutes; p < 0.05) in the group with prehospital intubation compared with the nonintubated group (47 minutes). Furthermore, fluid requirements in the prehospital period were significantly higher in the intubated patients (3,000 mL vs. 1,000 mL). In the prehospital intubation group, the number of patients with mass transfusion (9 vs. 4) as well as with emergency operations (10 vs. 4) were not significantly different from the nonintubated group. The prehospital intubation group showed a similar incidence of lung failure (17 vs. 14), kidney failure (6 vs. 2), and circulation failure (13 vs. 5). Except for two of the primarily nonintubated patients, all were intubated during their stay in the emergency room or on the intensive care unit. Days of ventilation (median, 7 days) as well as the length of stay on the ICU (median, 11 days) were comparable in both groups. Mortality in the prehospital intubation group was not significantly different between groups (six vs. two deceased). CONCLUSION: Prognosis with respect to organ failure, treatment time, and mortality is not adversely affected in the German trauma system, if patients with severe thoracic trauma without manifest respiratory insufficiency and without other indications for intubation are not treated with prehospital intubation.

Adult↗

PubMed2002

Guideline validation in multiple trauma care through business process modeling.

Clinical guidelines can improve the quality of care in multiple trauma. In our Department of Trauma Surgery a specific guideline is available paper-based as a set of flowcharts. This format is appropriate for the use by experienced physicians but insufficient for electronic support of learning, workflow and process optimization. A formal and logically consistent version represented with a standardized meta-model is necessary for automatic processing. In our project we transferred the paper-based into an electronic format and analyzed the structure with respect to formal errors. Several errors were detected in 7 error categories. The errors were corrected to reach a formal and logically consistent process model. In a second step the clinical content of the guideline was revised interactively using a process modeling tool. Our study reveals that guideline development should be assisted by process modeling tools, which check the content in comparison to a meta-model. The meta-model itself could support the domain experts in formulating their knowledge systematically. To assure sustainability of guideline development a representation independent of specific applications or specific provider is necessary. Then clinical guidelines could be used for training, process optimization and workflow management additionally.

Germany↗

PubMedDate not supplied

Incidence of posttraumatic stress disorder after prolonged surgical intensive care unit treatment.

The purpose of the study was to investigate the prevalence of posttraumatic stress disorder (PTSD) after prolonged intensive care unit (ICU) treatment and to study the differences between trauma patients and patients who were admitted with other diagnoses. Survivors of surgical intensive care of at least 30 days' duration underwent follow-up examination at about 35 months after discharge from the ICU. Thirty-seven patients were investigated. Seven patients met full DSM-IV criteria for diagnosis of PTSD. All of them had sustained severe multiple injuries. Patients with trauma were at significantly higher risk for developing PTSD than were non-trauma patients. After prolonged ICU treatment, PTSD seems more likely to occur when the reason for admission to the ICU was severe physical injury. The prevalence of PTSD does not seem to be related to injury severity or duration of ICU treatment.

Adult↗