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S Ruchholtz

Publications and source records attributed to S Ruchholtz.

At least 37 records · Page 2Linked to original sources
PubMed2003

[Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room].

AIM: Physical examination and radiography of the pelvis is part of most routine protocols in the emergency room (ER) management of blunt trauma patients. The purpose of this study was to determine the usefulness of these diagnostic tests with respect to diagnostic accuracy, therapeutic consequences, and prognosis in severely injured patients. METHOD: In a prospective study including all trauma patients admitted to the ER, physical examination and clinical management were evaluated. All patients underwent physical examination of the pelvis and were grouped into two categories: patients without (group I) and with (group II) clinical pelvic instability. A comparison between these two groups was made for standard demographic data, indices of shock, diagnostic and therapeutic procedures, and results. RESULTS: During a 45-month period a total of 1160 patients were enrolled: 979 subjects (ISS 21+/-16) with blunt trauma were included in this analysis. Of these, 929 patients had negative (group I) and 51 (group II) positive examination results for clinical stability of the pelvis. When comparing these two groups, group II patients had a higher injury severity score, higher incidence of shock with a lower initial systolic blood pressure, a lower initial hemoglobin, and a higher rate of associated severe chest and abdominal injuries (AIS > or = 3). Among the 51 patients with abnormal pelvis instability, there were 6 type A, 16 type B, and 27 type C fractures, whereas in two cases no pelvic fracture could be found. Of the 928 patients without positive clinical signs, 866 (93%) had no pelvic fracture. There were 40 type A, 19 type B, and 3 type C fractures missed on clinical examination. The physical examination had a sensitivity of 44% and specificity of 99% for detecting pelvic fracture. A comparison between groups I and II showed the patients with positive physical pelvic examination to have greater transfusion requirements and a higher rate of surgical intervention for pelvic stabilization and blood control. CONCLUSION: The clinical diagnosis of pelvic instability should result in an immediate order for blood products, taking surgical intervention into account. Pelvic radiographs in the ER are required for early surgical management. In patients with negative pelvis examination results, a routine pelvic radiograph is recommended because clinical examination cannot reliably rule out surgically significant pelvic fractures (20%) in the severely injured and intubated blunt trauma patient.

Adult↗
PubMed2003

[The value of subjective estimation of the severity of thoracic injuries by the emergency surgeon].

INTENTION: Thorax trauma (TT) is associated with a high rate of pulmonary failure and increased mortality. To prevent these complications, the German trauma system recommends intubation and chest tube insertion at the scene of the accident, even in cases without acute respiratory dysfunction. Due to the possible life threatening complications of the therapy, the emergency surgeon should be able to correctly identify a TT at the scene. Therefore, we retrospectively compared the evaluation of chest trauma by the emergency surgeon with objective injury severity according to the Abbreviated Injury Scale (AIS). METHOD: Data from 2,392 patients (aged 39+/-1 years, Injury Severity Score 27+/-0.3) were taken from the multiple trauma database of the German Trauma Society. The evaluation of TT (absent, light, medium, severe) by the emergency surgeon was compared with objective injury severity (AIS=0: absent, 0>AIS<3: light, AIS=3: medium, AIS>3: severe). If the difference between the subjective and objective injury severity increased or decreased two and more levels, a substantial misclassification was assumed. The influence of the estimate on outcome was tested by comparing the predicted (TRISS-method) with the observed fatalities. RESULTS: Absence of TT was estimated correctly in 62%, light in 24%, medium in 40% and severe TT in 46% of cases. Thus a correct estimate of TT was made for 49% of the patients. The chest injury severity was substantially overrated by the emergency surgeon in 20% and substantially underestimated in 17% of cases. In patients with the correct classification at the scene, a total of 81% received a chest tube. Of these patients, only 50% received their chest tube at the scene. Of the patients with an initially overlooked TT, only 37% received a chest tube and nearly all were placed in the emergency room. The number of fatalities was lower than predicted in all groups, even in patients with correctly estimated severe TT (observed: 34%, estimated: 42+/-2%), and also in patients with initially overlooked TT (observed: 16%, estimated: 24+/-2%). CONCLUSION: Due to the high rate of misclassification and possible severe complications caused by therapy, and without having any benefit in terms of outcome, intubation and chest tube insertion should not be carried out in vital, stable patients.

Adult↗
PubMed2003

[Craniocerebral trauma].

In cases of craniocerebral trauma there may be primary and secondary cerebral lesions. The principal goal of treatment is to minimize secondary cerebral trauma by optimized therapy. In the primary treatment phase monitoring of vital signs (blood pressure and respiration) is of crucial importance. CT diagnosis is followed by treatment of any increase in intracranial pressure by relief of hematomas, CSF drainage and appropriate intensive care measures.

Abbreviated Injury Scale↗
PubMed2002

[The value of computed tomography in the early treatment of seriously injured patients].

BACKGROUND: The availability of newer, faster computed tomography (CT) technology has engendered discussion about whole-body CT-scanning for primary radiological diagnostics of seriously injured patients. METHOD: Within a quality management system, the scaled, priority-oriented scheme of conventional radiological and CT-diagnostics used in each institution was analysed and compared with the possible benefit of whole-body CT-scanning. Every patient with severe trauma admitted directly from the scene of an accident, underwent basic radiological and sonographic diagnostics in the emergency room (ER). According to the findings, patients in a stable vital condition had CT-scans when indicated by the guidelines of the particular institution. RESULTS: From 5/1998 until 12/2000, a total of 832 patients were treated in the ER. Of those, 480 patients (average ISS 20) were admitted directly from the scene of the accident. Basic radiological - sonographic diagnostics (radiographs of cervical spine, chest, and abdomen, as well as abdominal sonography) took 15+/-8 min. Twenty-two (5%) of the patients in hemorrhagic shock needed emergency operations after 57+/-43 min. The remaining patients underwent further radiological diagnostics (spine, extremities etc.) after 44+/-27 min. In 79% (379) of patients, CT was indicated. Cranial CT for traumatic brain injury prevailed clearly with 74% of cases. Spine (24%), chest (18%), abdomen (5%) and pelvis (5%) were indicated comparatively less frequently. The incidence of delayed diagnoses (after ICU-admission) was 4% (22). In 2% (nine) of patients the lesions possibly could have been detected by a primary CT-scan. In the three cases with thoracic lesions, there was a deviation from the indication guidelines for thoracic CT as normally used in the institution. There were three cases of delayed diagnoses in both the cerebral (small contusion haematomas) region and the abdominal region. The abdominal lesions were detected by sonographic control examinations. No patient died because of a delayed diagnosis. The average X-ray dose was five times lower with the scaled diagnostic management comprising indicated CT when compared to the doses calculated for routine whole-body CT. CONCLUSION: While 74% of patients had cranial CT, only 25% needed CT for the trunk regions. Delayed diagnoses were rare and without severe consequences for the patient. Considering the five times higher X-ray doses combined with the possible time loss in patients with unstable conditions, primary whole-body CT-scanning should not be performed routinely when serious injury is suspected.

Adult↗
PubMed2002

[Primary external fixation with consecutive procedural modification in polytrauma].

AIM OF STUDY: It is the purpose of the current investigation to determine whether immediate external fixation of fractures, which is a simple and fast procedure, followed by secondary planned conversion represents a safe and reliable procedure without additional trauma in multiply injured patients (ISS > 15). METHODS: With a prospective protocol, all data of multiply injured patients with fractures which required immediate osteosynthesis were registrated. Demographic data, severity of injury (AIS and ISS), data of primary surgery and osteosyntheses, course of intensive care (organ failure, local/systemic complications, infectious protocol), secondary conversion (time, duration, osteosynthesis related complications) and further course were analysed. RESULTS: Out of 679 mulitiply injured patients (ISS 22), 118 required immediate surgical procedures for intracranial injury and 175 for further indications. In 45 multiply injured patients (ISS 37), 83 external fixations were performed. According to 59 planned secondary conversions (13 days), one patient developed deep infection, no other local complication was registrated. The average time for conversion procedures lasted three times longer as in immediate external fixation (43 vs. 139 min). CONCLUSIONS: Immediate external fixation in multiply injured patients is fast and poor of complications. It is a expedient procedure which is safe and careful for critically ill patients. The required conversion procedure shows no raised rate of complications.

Adolescent↗
PubMed2001

[Interdisciplinary quality management in the treatment of severely injured patients. Validation of a QM system for the diagnostic and therapeutic process in early clinical management].

A multidisciplinary quality management system (QMS) for the early treatment of severely injured patients was validated in a trauma center in Germany. In the presented prospective study a QMS developed at another trauma center was implemented at the department of trauma surgery of the University of Essen for the presented study. The essential elements of the QMS were the establishment of (1) an adequate protocol for documentation, (2) 20 criteria for the assessment of treatment quality, (3) regular statistical analysis of treatment quality and (4) a quality circle comprising all medical specialties for data discussion. From 5/98-9/99 a cohort of 447 patients with an average injury severity score (ISS) of 22 +/- 17 was treated in the emergency department. The impact of the QMS was assessed in 4 periods (1: 5/1998-8/1998; 2: 9-12/1998; 3: 1-4/1999; 4: 5-8/1999). The quality circle met 8 times. For the improvement of the process 16 long-term changes were introduced. In 60% (n = 12) of the 20 assessment criteria significant improvements were detected. In diagnostics there were significant reductions of the time needed for basic radiological and sonographic check-up (from 24 +/- 12 min in the first to 14 +/- 8 min in the last period) and of the duration until performance of a cranial computed tomography in severe traumatic brain injury (sTBI; from 45 +/- 22 to 28 +/- 8 min). The rate of delayed diagnoses remained low (4% in the first, 5% in the last period). Further positive changes were the time savings in transfusion (from 35 +/- 20 to 20 +/- 4 min) and emergency operations (from 67 +/- 20 to 48 +/- 4 min) in hemorrhagic shock as well as for craniotomies (77 +/- 41 to 54 +/- 19 min) in sTBI. Apart from the significant time reductions other improvements were found. Overall mortality was diminished from 17% in the first to 10% in the last observation period. In conclusion the study revealed that the quality of the early therapy of severely injured patients was significantly improved by implementation of a multidisciplinary quality management system especially with respect to treatment efficiency.

Adolescent↗
PubMed2001

[Postoperative morbidity in surgically treated extension fractures of the distal radius. A comparative study of dorsal and volar approach].

The aim of this study was to investigate perioperative morbidity in operative interventions in distal radiusfractures, comparing the operative approach from volar and dorsal. Only problems, resulting from the operative approach towards the distal aspect of the radius, were examined. In a Case-Control-Study, we investigated patients with operative by plate-osteosynthesis treated distal radius-extensions-fractures. During 3 years we investigated 92 patients. 49 were operated with a volar approach, and after changing the operative management, consecutive 43 patients with a dorsal approach to the distal radius. Indications for operative treatment were not changed. The approach to the distal aspect of the radius corresponded to the recent guidelines. Further perioperative procedures were identical, including procedures in anesthesiology. Datas of patients have been investigated for epidemiology, kind of operations, point of time in treatment, duration of operation, X-Ray, immobilisation and time of inhospital stay as well as all documented complications. It has been shown, that in respect of all criterias, concerning length of operation (106 vs. 83 min), intraoperative X-Ray (3.0 vs. 1.65 min) as well as postoperative immobilisation (33 vs. 25 days), and documented incidences of complications like secondary wound-healing (19/49 vs. 0/43) or nerval irritations (13/49 vs. 1/43), the dorsal osteosynthesis is definitively to be favored.

Adolescent↗
PubMed2000

[The Trauma Registry of the German Society of Trauma Surgery as a basis for interclinical quality management. A multicenter study of the German Society of Trauma Surgery].

Based on the "Trauma Registry" of the German Society of Trauma Surgery, an interclinical quality management (QM) system was implemented. The principles of the QM system as well as the differences in the quality of outcome and treatment are presented. The analysis uses the data on 2,069 severely injured (ISS = 22 +/- 14) patients from 20 hospitals collected prospectively and anonymously between 2/93 and 12/97. Outcome quality was analyzed by the TRISS method and Z-statistics. The Z-value of the whole series was -0.24. There were three hospitals with more than 150 patients that had a Ps value calculated by the TRISS method. Clinic A had a good (-2.49), clinic B an average (-0.3) and clinic C (3.62) an adverse Z-value. The assessment of treatment quality was performed by criteria concerning both preclinical and acute clinical phases. Clinic C had a prolonged preclinical treatment time (90 min vs 62 min in clinic A) for severely injured (ISS > 15) patients. At the same time, the preclinical intubation rate for severe thoracic trauma (AIS > 3) was lower (44 %) in clinic C than in A (62 %). With 14 min clinic A had the shortest time until basic radiological and ultrasound diagnostics were completed (X-rays of chest and pelvis and abdominal ultrasound) in cases of severe blunt trauma (ISS > 15), compared to 54 min in clinic B or 31 min in clinic C. Also, cranial computed tomography for severe traumatic brain injury (GCS < 9) was applied significantly faster in clinic A (after 36 min) than in clinic C (after 62 min). Delayed diagnoses were defined as the difference between the ISS at discharge and the ISS at completion of diagnostics in the emergency department; this criterion was met best by clinic A with an ISS difference of two patients compared to five in clinic B and four in clinic C. The hospitals participating in the Trauma Registry receive an annual analysis of their preclinical and acute clinical performance. Thus, every hospital can analyze and improve the quality of treatment based on reliable data that show which parts of the process have to be optimized. Furthermore, the data allow a comparison of the average and optimal results of the whole series.

Efficiency, Organizational↗
PubMed1999

[Quality management of early clinical treatment of severely injured patients].

The early clinical treatment of severely injured patients of today is based on modern technical resources as well as on refined therapeutic strategies involving a multidisciplinary team. In the meantime the requirements for and expectations towards best major trauma care have both increased considerably. In spite of a decline in mortality after major trauma during the last two decades still clinical deviations from actual treatment guidelines with proven influence on negative outcome are to be found. In order to improve the therapeutic process it proved effective to introduce the main principles of quality assurance (QA) and quality management (QM) that were used successfully in industry into major trauma treatment. In QA an analysis of 'process', 'structure' and 'outcome' of the clinical treatment is performed. For these components of QA important tools such as treatment-guidelines (polytrauma-algorithms), guidelines by the German Society of Trauma Surgery for the equipment of a trauma center and score systems for the classification of injury severity were elaborated and implemented in major trauma care. Further optimization of outcome quality may be achieved by integrating the QA- components in a QM-system. QM means introducing relevant feed-back-pathways of procedural data for the improvement of the (treatment-) process and of outcome data for decisions about structural (and organizational) changements. The presented clinical QM-system is based on adequate documentation, analysis and assessment of treatment data within a quality committee. The treatment of severely injured patients was significantly improved by implementation of the QM-system in clinical routine with respect to the effectivity of the treatment process. Furthermore, by transferring the QM-system to another trauma center, we were able to show that the effects of the system in major trauma care are reproducible. Besides the internal efforts for quality optimization an external quality assessment comparing the own treatment results with other trauma centers should take place. For this purpose joining a multicentered trauma registry (i.e. the trauma registry of the German Society of Trauma Surgery for the German speaking countries) is recommended.

Germany↗
PubMed1999

Long-term results and quality of life after parasuicidal multiple blunt trauma.

OBJECTIVE: This study evaluates the somatic, socioeconomic, and psychiatric long-term results, as well as the factors for adverse outcome, in a significant subset of patients with severe multiple injuries resulting from attempted suicide. DESIGN: The follow-up study 6.1 +/- 3 (SD) yrs after trauma was based on prospectively documented data of patients with multiple injuries. SETTING: Level I university trauma center in a major German city. MEASUREMENTS AND MAIN RESULTS: Data derived from thorough physical and psychiatric evaluations. The Brief Psychiatric Rating Scale and the Global Assessment of Functioning Scale served to describe psychiatric outcome. PATIENTS: In a series of 539 severely injured patients (Abbreviated Injury Score in two regions > or = 3), 65 (12%) attempted suicides were reported (Injury Severity Score, 40 +/- 15; age, 38 +/- 18 yrs). Twenty-one patients of the study cohort died during the hospital stay, and six subjects died thereafter, none because of suicide. Three patients were lost to follow-up, resulting in 35 individuals eligible for examination. None of the latter had reattempted suicide. Seventeen (48%) had good or satisfactory outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings (Brief Psychiatric Rating Scale), and good psychosocial ability (Global Assessment of Functioning Scale). For eight patients (24%), the result was indeterminate. The adverse outcomes in ten patients (28%) were mainly influenced by the presence of chronic schizophrenia (n = 4), affective disorder (n = 2), or severe traumatic brain injury (n = 3). CONCLUSIONS: Despite the parasuicidal origin, the long-term results after severe trauma were good or satisfactory in approximately half the cases and without further suicide attempts in any of the patients. Good recovery of the parasuicidal patients in our study is approximately 20% lower than in an unselected group of patients with multiple injuries and may be attributed mainly to the underlying chronic psychiatric disease.

Adult↗
PubMed1998

[Abdominal trauma].

While a great part of the Anglo-American medical literature addresses the topic of penetrating trauma the German speaking countries rather publish on blunt abdominal injury. The presented paper discusses the strategic principles of acute clinical management of abdominal trauma on the combined basis of own research results and a comprehensive review of the literature. Blunt abdominal injuries in most cases from a part in the pattern of multiple trauma. The early, first-hours mortality is most often caused by severe traumatic brain injury or abdominal trauma with massive hemorrhage. The prehospital management of penetrating injuries is characterized rather by the concept of 'load and go', whereas the onscene stabilization of the patient with blunt abdominal injury should precede transport to the adequate hospital. On arrival in the accident and emergency room an immediate blood transfusion is recommended for hemodynamically unstable patients. If then a stabilization is not achieved, an emergency laparotomy should follow. Abdominal stab injuries should be explored by laparoscopy if an intraperitoneal lesion is suspected. If then the possibility of an intestinal lesion is present a laparotomy should be performed directly thereafter. Firearm injuries require open revision in almost all cases. The standard diagnostic technique in blunt abdominal trauma is sonography, assisted by computed tomography and, if indicated, angiography in hemodynamically stable patients. Isolated abdominal injuries without hemodynamic or coagulation disorders allow conservative treatment in the intensive care setting. In severe multiple trauma as well as in manifest shock even the smallest fluid detection should lead to laparotomy. The surgical treatment of splenic rupture is still a matter of discussion. Splenectomy is indicated in patients with severe concomitating injuries or shock whereas in the remainder of cases the total or partial preservation of the spleen should be pursued. Hepatic injuries offer a broad spectrum of operative interventions, ranging from superficial hemostatic measures over compression techniques like 'packing' and 'mesh-wrapping' to atypical and anatomical resections and to liver transplantation in exceptional cases. Lesions of tubular organs and the pancreas pose especially difficult diagnostical problems but regularly allow a rather easy operative treatment.

Abdominal Injuries↗
PubMed1998

[Effect of kinetic therapy on the treatment outcome in patients with post-traumatic lung failure].

Intermittent prone positioning (PP) is a promising therapy of patients with severe respiratory failure. Evaluations of patient outcomes can not, to dare, be found in the literature. This study was conducted to investigate the effects of intermittent PP on patients with posttraumatic respiratory failure (PaO2/FiO2 < 280 mmHg) in comparison with conventional therapy in suspine position. The collected data is part of our prospective polytrauma study. 136 polytraumized patients (mean ISS 23.4) were included and evaluated. 77 patients had a severe chest trauma with an AIS > or = 3. Of these, 47 patients developed a respiratory failure. 19 of these patients were treated conventionally in suspine position, 28 patients were intermittently turned prone. Having similar AIS (3.6 vs. 33), the PP-patients had a significantly severer trauma (ISS 35.8 vs. 24.5). Though the injury severity of the PP-patients was much higher, the time of ventilation (32 vs. 31 d) and the ICU stay (39 vs. 36 d) was similar to the patients treated in suspine position. The mortility of PP-patients was 0%, of suspine positioned patients 26%. After the first PP the PaO2/FiO2 ratio increased with an average of 82 mmHg (26-151 mmHg). The FiO2 was reduced from 0.45 (0.35-1.0) to 0.26 (0.21-0.35). Beside the beneficial effect of PP on the oxygenation we have, for the first time evidence that PP improves the outcome of patients with posttraumatic respiratory failure.

Adolescent↗