IntroductionIsolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters.MethodsBetween 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU® database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock.ResultsWorsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick’s values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock.ConclusionSI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.

BackgroundIn order to match the challenges of quickly recognizing and treating any life-threatening injuries, the ABCDE principles were established for the assessment and treatment of trauma patients. The high priority of spine protection is emphasized by the fact that immobilization of the cervical spine is performed at the very first step in the ABCDE principles. Immobilization is typically performed to prevent or minimize secondary damage to the spinal cord if instability of the spinal column is suspected. Due to increasing reports about disadvantages of spinal immobilization, the indications for performing spinal immobilization must be refined.The aim of this study was (i) to develop a protocol that supports decision-making for spinal immobilization in adult trauma patients and (ii) to carry out the first applicability test by emergency medical personnel.MethodsA structured literature search considering the literature from 1980 to 2014 was performed. Based on this literature and on the current guidelines, a new protocol that supports on scene decision-making for spinal immobilization has been developed. Parameters found in the literature concerning mechanisms and factors increasing the likelihood of spinal injury have been included in the new protocol. In order to test the applicability of the new protocol two surveys were performed on German emergency care providers by means of a questionnaire focused on correct decision-making if applying the protocol.ResultsBased on the current literature and guidelines, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients was developed. Following a fist applicability test involving 21 participants, the first version of the E.M.S. IMMO Protocol has to be graphically re-organized. A second applicability test comprised 50 participants with the current version of the protocol confirmed good applicability. Questions regarding immobilization of trauma patients could be answered properly using the E.M.S. IMMO Protocol.DiscussionCurrent literature increasingly reports of disadvantages that may be associated with immobilization. Based on the requirements of the current guidelines, a new protocol that supports decision-making for indications for out-of-hospital spinal immobilization has been developed in this study. In contrast to established protocols, the new protocol offers different options for immobilization as well as a decicion-support.ConclusionsThe E.M.S. IMMO protocol provides a decision-support tool for indications for spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization method in particular.

Background/ObjectiveThe application of a cervical collar is a standard procedure in trauma patients in emergency medicine. It is often observed that cervical collars are applied incorrectly, resulting in reduced immobilization of the cervical spine. The objective of this study was to analyze the practical skills of trained professional rescue personnel concerning the application of cervical collars.Material and MethodsWithin emergency medical conferences, n = 104 voluntary test subjects were asked to apply a cervical collar to a training doll, wherein each step that was performed received an evaluation. Furthermore, personal and occupational data of all study participants were collected using a questionnaire.ResultsThe test subjects included professional rescue personnel (80.8%) and emergency physicians (12.5%). The average occupational experience of all study participants in pre-clinical emergency care was 11.1±8.9 years. Most study participants had already attended a certified training on trauma care (61%) and felt "very confident" in handling a cervical collar (84%). 11% applied the cervical collar to the training doll without errors. The most common error consisted of incorrect adjustment of the size of the cervical collar (66%). No association was found between the correct application of the cervical collar and the occupational group of the test subjects (trained rescue personnel vs. emergency physicians) or the participation in certified trauma courses.ConclusionDespite pronounced subjective confidence regarding the application of cervical collars, this study allows the conclusion that there are general deficits in practical skills when cervical collars are applied. A critical assessment of the current training contents on the subject of trauma care must, therefore, be demanded.

Introduction: Conventional non-vascularized bone grafts as well as vascularized bone grafts are used to treat scaphoid non-union (SN). Due to limited available studies, the field of application using both grafts for SN still remains controversial. The aim of this study was to evaluate a treatment algorithm for the use of both vascularized versus non-vascularized bone grafts based on clinical outcomes and quality of life (QoL) to improve the level of evidence. Materials and Methods: Based on a retrospective cohort study, including 28 patients with vascularized and 45 patients with conventional bone grafts, functional parameters, radiological outcome, Mayo-wrist-score, and QoL by SF-36 were applied to statistically compare the outcome of these two techniques. Results: Time between last procedure or trauma and study group scaphoid reconstruction was almost double in the vascularized bone grafting group. Comparable union rates were achieved with vascularized as well as non-vascularized bone grafts. Significant differences were observed between both groups for grip strength and radial-ulnar active range of motion. Further functional outcomes, radiological outcomes as well as QoL were found similar for both techniques in patients with surgical union. Discussion and conclusions: In order to achieve comparable and appropriate treatment results, vascularized bone grafts are recommended for patients with delayed treatment, impaired scaphoid vascularity, and revision surgery. Even in preselected, complex cases, the results are comparable to conventional grafts, which are the basis for further patient education and approve the powerful role of surgical angiogenesis of vascularized bone grafts.