20110720_S3-LL Polytrauma DGU_final_eng_cleaned_mc_korrigiert

S3 – Guideline 

on Treatment of Patients with 

Severe and Multiple Injuries 

English Version of the German Guideline S3 – Leitlinie Polytrauma/Schwerverletzten-Behandlung 

(AWMF-Registry No. 012/019) 

Publisher: German Trauma Society (DGU) (lead) 

Office in Langenbeck-Virchow House 

Luisenstr. 58/59 

10117 Berlin 

German Society of General and Visceral Surgery 

German Society of Anesthesiology and Intensive Care Medicine 

German Society of Endovascular and Vascular Surgery 

German Society of Hand Surgery 

German Society of Oto-Rhino-Laryngology, Head and Neck Surgery 

German Society of Oral and Maxillofacial Surgery 

German Society of Neurosurgery 

German Society of Thoracic Surgery 

German Society of Urology 

German Radiology Society 

Addresses for correspondence: Prof. Dr. Klaus Michael Stürmer 

Head of the Guidelines Committee at the DGU 

Director of the Clinic for Trauma Surgery, Plastic and Reconstructive 

Surgery 

University Hospital Göttingen – Georg-August-Universität 

Robert-Koch Str. 40 

37075 Göttingen 

Prof. Dr. Prof. h.c. Edmund Neugebauer 

Head of the Steering Group for the S3 Guideline on Polytrauma 

Chair of Surgical Research 

Institute for Research in Operative Medicine (IFOM) 

University of Witten, Herdecke 

Ostmerheimerstr. 200 

51109 Cologne

S3 Guideline on Treatment of Patients with Severe and Multiple Injuries 

Overall coordination 

Prof. Dr. rer. nat. Prof. h.c. Edmund Neugebauer 

Institute for Research in Operative Medicine (IFOM) 



51109 Cologne 

Coordination of sections 

Prehospital 

Prof. Dr. med. Christian Waydhas 

University Hospital Essen 

Clinic for Trauma Surgery 

Hufelandstr. 55 

45147 Essen 

Emergency room 

PD Dr. med. Sven Lendemans 




45147 Essen 

Emergency surgery phase 

Prof. Dr. med. Bertil Bouillon 

Cologne City Hospitals gGmbH 

Merheim Hospital 

Clinic for Trauma Surgery, Orthopedics & 

Sports Injuries 

51058 Cologne 

Prof. Dr. med. Steffen Ruchholtz 

University Hospital Giessen/Marburg 

Clinic for Trauma, Hand & Reconstructive 

Surgery 

Baldingerstrasse 

35043 Marburg 

Prof. Dr. med. Dieter Rixen 

Clinic for Trauma Surgery & Orthopedics 

BG Trauma Hospital Duisburg 

Grossenbaumer Allee 250 

47249 Duisburg 

- ii -


Organization, methods advice and support 

Dr. med. Michaela Eikermann (from 07/2010) 

Institute for Research in Operative Medicine 

(IFOM) 



51109 Cologne 

Christoph Mosch 


(IFOM) 



51109 Cologne 

Ulrike Nienaber 


(IFOM) 



51109 Cologne 

PD Dr. med. Stefan Sauerland (until 12/2009) 


(IFOM) 



51109 Cologne 

Dr. med. Martin Schenkel 





51058 Cologne 

Maren Walgenbach 


(IFOM) 



51109 Cologne 

- iii -


Medical societies and their delegates who participated in the consensus process 

Dr. med. Michael Bernhard 

(German Society of Anesthesiology and 

Intensive Care Medicine) 

Fulda Hospital gAG 

Central Accident & Emergency 

Pacelliallee 4 

36043 Fulda 

Prof. Dr. med. Bernd W. Böttiger 



University Hospital Cologne 

Clinic for Anesthesiology and Operative 

Intensive Care 

Kerpener Str. 62 

50937 Cologne 

Prof. Dr. med. Thomas Bürger 

(German Society of Endovascular and Vascular 

Surgery) 

Kurhessisches Diakonissenhaus 

Department of Vascular Surgery 

Goethestr. 85 

34119 Kassel 

Prof. Dr. med. Matthias Fischer 



Klinik am Eichert Göppingen 


Intensive Care, Emergency Treatment & Pain 

Therapy 

Eichertstr. 3 

73035 Göppingen 

Prof. Dr. med. Dr. med. dent. Ralf Gutwald 

(German Society of Oral and Maxillofacial 

Surgery) 

University Hospital Freiburg 

Clinic for Oral and Maxillofacial Surgery 

Hugstetterstr. 55 

79106 Freiburg 

Prof. Dr. med. Markus Hohenfellner 

(German Society of Urology) 

University Hospital Heidelberg 

Urology Clinic 

Im Neuenheimer Feld 110 

69120 Heidelberg 

Prof. Dr. med. Ernst Klar 

(German Society of General and Visceral 

Surgery) 

University Hospital Rostock 

Department of General, Thoracic, Vascular & 

Transplantation Surgery 

Schillingallee 35 

18055 Rostock 

Prof. Dr. med. Eckhard Rickels 

(German Society of Neurosurgery) 

Celle General Hospital 


Neurotraumatology 

Siemensplatz 4 

29223 Celle 

Prof. Dr. med. Jürgen Schüttler 



University Hospital Erlangen 

Clinic for Anesthesiology 

Krankenhausstr. 12 

91054 Erlangen 

Prof. Dr. med. Andreas Seekamp 

(German Trauma Society) 

University Hospital Schleswig-Holstein (Kiel 

Campus) 


Arnold-Heller-Str. 7 

24105 Kiel 

Prof. Dr. med. Klaus Michael Stürmer 

(German Trauma Society) 

University Hospital Göttingen – Georg- 

August University 

Department of Trauma Surgery, Plastic and Reconstructive 

Surgery 



Prof. Dr. med. Lothar Swoboda 


Eissendorfer Pferdeweg 17a 

21075 Hamburg 

- iv -


Prof. Dr. med. Thomas J. Vogl 

(German Radiology Society) 

University Hospital Frankfurt 

Institute of Diagnostic & Interventional 

Radiology 

Theodor-Stern-Kai 7 

60590 Frankfurt/Main 

Dr. med. Frank Waldfahrer 

(German Society of Oto-Rhino-Laryngology, 

Head and Neck Surgery) 


Oto-Rhino-Laryngology Clinic 

Waldstrasse 1 


Prof. Dr. med. Margot Wüstner-Hofmann 

(German Society of Hand Surgery) 

Klinik Rosengasse GmbH 

Rosengasse 19 

89073 Ulm/Donau 

- v -


Authors/co-authors of individual chapters 

Dr. med. MSc. Ulf Aschenbrenner 

University Hospital Dresden 


Surgery 

Fetscherstr. 74 

01307 Dresden 

Ch. 1.9, 2.15 

PD Dr. med. Hermann Bail 

South Nuremberg Hospital 

Clinic for Trauma & Orthopedic Surgery 

Breslauer Str. 201 

90471 Nuremberg 

Ch. 1.4, 1.7, 2.5 

Dr. med. Marc Banerjee 





51058 Cologne 

Ch. 3.10 

Dr. med. Mark Bardenheuer 

Landshut Hospital gGmbH 

Clinic for Orthopedics & Trauma Surgery 


84034 Landshut 

Ch. 1.4 

Dr. med. Christoph Bartl 

University Hospital Ulm 

Clinic for Trauma, Hand, Plastic & 

Reconstructive Surgery 

Steinhövelstr. 9 

89070 Ulm 

Ch. 3.2 

Dr. med. Michael Bayeff-Filloff 

Rosenheim Hospital 


Pettenkoferstr. 10 

83022 Rosenheim 

Ch. 1.4, 1.6, 2.10, 3.8 

Prof. Dr. med. Alexander Beck 

Juliusspital Würzburg 

Department of Orthopedics, Trauma & 


Juliuspromenade 19 

97070 Würzburg 

Ch. 1.4, 1.6, 1.10 

Dr. med. Michael Bernhard 

Fulda Hospital gAG 


Pacelliallee 4 

36043 Fulda 

Ch. 1.2, 2.15, 2.16 

PD Dr. med. Achim Biewener 


Clinic for Trauma & Reconstructive Surgery 


01307 Dresden 

Ch. 1.4, 1.9 

Prof. Dr. med. Jochen Blum 

Worms Hospital 


Gabriel-von-Seidl-Strasse 81 

67550 Worms 

Ch. 3.8 

Prof. Dr. med. Bernd W. Böttiger 





50937 Cologne 

Ch. 1.2, 2.15, 2.16 

Prof. Dr. med. Bertil Bouillon 





51058 Cologne 

Ch. 1.4, 3.10 

- vi -


Dr. med. Jörg Braun 

DRF Stiftung Luftrettung gemeinnützige AG, 

Medical Division 

Rita-Maiburg-Str. 2 

70794 Filderstadt 

Ch. 1.9 

Prof. Dr. med. Volker Bühren 

BG Trauma Hospital Murnau 

Department of Trauma Surgery & Sports 

Orthopedics 

Prof. Küntscher-Str. 8 

82418 Murnau am Staffelsee 

Ch. 2.9, 3.7 

Dr. med. Markus Burkhardt 

University Hospital of the Sauerland 


Surgery 

Kirrberger Strasse 100 

66424 Homburg/Saar 

Ch. 2.7 

Prof. Dr. med. Klaus Dresing 



Clinic for Trauma, Plastic & Reconstructive 

Surgery 



Ch. 2.2 

Prof. Dr. med. Axel Ekkernkamp 

Trauma Hospital Berlin 


Warener Str. 7 

12683 Berlin 

Ch. 3.3, 3.4 

Christian Fiebig 



Radiology 



Ch. 2.17 

Dr. med. Marc Fischbacher 




45147 Essen 

Ch. 1.2, 1.4 

Prof. Dr. med. Markus Fischer 

ATOS Clinic Practice 

Bismarckstr. 9-15 


Ch. 2.14 

Prof. Dr. med. Matthias Fischer 

Klinik am Eichert Göppingen 


Intensive Care, Emergency Treatment & Pain 

Therapy 

Eichertstr. 3 

73035 Göppingen 

Ch. 1.2, 2.15 

Dr. med. Mark D. Frank 


Clinical for Anesthesiology & Intensive 

Treatment 


01307 Dresden 

Ch. 1.9 

Prof. Dr. med. Florian Gebhard 





89070 Ulm 

Ch. 3.2 

Prof. Dr. med. Dr. med. dent. Ralf Gutwald 





Ch. 2.13, 3.12 

Prof. Dr. med. Norbert P. Haas 

Charité – Campus Virchow Clinic 


Augustenburger Platz 1 

13353 Berlin 

Ch. 2.5 

Dr. med. Sebastian Hentsch 

German Federal Military Hospital Koblenz 

Department of Trauma & Reconstructive 

Surgery 

Rübenacher Str. 170 

56072 Koblenz 

Ch. 1.4 

- vii -


Prof. Dr. med. Karl Hörmann 

University Hospital Mannheim 

Oto-Rhino-Laryngology Clinic 

Theodor-Kutzer-Ufer 1-3 

68167 Mannheim 

Ch. 2.14, 3.13 

Prof. Dr. med. Markus Hohenfellner 

University Hospital Heidelberg 

Urology Clinic 

Im Neuenheimer Feld 110 


Ch. 1.8, 2.8, 3.6 

PD Dr. med. Dr. med. dent. Bettina 

Hohlweg-Majert 





Ch. 2.13, 3.12 

Dr. med. Ewald Hüls 





29223 Celle 

Ch. 1.4 

Dr. med. Björn Hußmann 




45147 Essen 

Ch. 2.10 

Prof. Dr. med. Christoph Josten 

University Hospital Leipzig 

Clinic & Outpatient Clinic for Trauma & 


Liebigstr. 20 

04103 Leipzig 

Ch. 2.15 

PD Dr. med. Karl-Georg Kanz 

Munich University Hospital 

Surgery Clinic & Outpatient Clinic 

Nussbaumstr. 20 

80336 Munich 

Ch. 1.2, 1.4 

Prof. Dr. med. Lothar Kinzl 





89070 Ulm 

Ch. 3.2 

Dr. med. Christian Kleber 




13353 Berlin 

Ch. 1.7 

Prof. Dr. med. Markus W. Knöferl 





89070 Ulm 

Ch. 3.2 

PD Dr. med. Christian A. Kühne 



Surgery 


35043 Marburg 

Ch. 2.2, 2.3 

Prof. Dr. med. Christian K. Lackner 

Munich University Hospital 

Institute for Emergency Medicine & 

Medicine Management 

Schillerstr. 53 

80336 Munich 

Ch. 1.4 

PD Dr. med. Sven Lendemans 




45147 Essen 

Ch. 2.1, 2.10 

Dr. med. Dr. med. dent. Niels Liebehenschel 





Ch. 2.13, 3.12 

- viii -


PD Dr. med. Ulrich C. Liener 

Marienhospital Stuttgart 

Clinic for Orthopedics & Trauma Surgery 

Böheimstr. 37 

70199 Stuttgart 

Ch. 3.2 

Dr. med. Heiko Lier 





50937 Cologne 

Ch. 2.16 

Dr. med. Tobias Lindner 




13353 Berlin 

Ch. 1.7, 2.5 

Thomas H. Lynch 

St. James’s Hospital 

Trinity College 

James’s Street 

Dublin 8 (Ireland) 

Ch. 1.8, 2.8, 3.6 

Prof. Dr. med. Martin G. Mack 



Radiology 



Ch. 2.17 

Dipl.-Med. Ivan Marintschev 

University Hospital Jena 


Surgery 

Erlanger Allee 101 

07747 Jena 

Ch. 1.4 

PD Dr. med. Gerrit Matthes 




12683 Berlin 

Ch. 1.2, 1.4, 3.3, 3.4 

Dr. med. Hubert Mayer 

Surgical Group Practice am Vincentinum 

Franziskanergasse 14 

86152 Augsburg 

Ch. 1.4 

Dr. med. Yoram Mor 

Dept. of Urology 

The Chaim Sheba Medical Center 

Tel Hashomer, Ramat Gan, 52621 (Israel) 

Ch. 1.8, 2.8, 3.6 

Prof. Dr. med. Udo Obertacke 

University Hospital Mannheim 

Orthopedics Trauma Surgery Center 

Theodor-Kutzer-Ufer 1-3 


Ch. 2.4 

Prof. Dr. med. Hans-Jörg Oestern 





29223 Celle 

Ch. 3.10 

Prof. Dr. med. Jesco Pfitzenmaier 

Protestant Hospital Bielefeld 

Clinic for Urology 

Schildescher Strasse 99 

33611 Bielefeld 

Ch. 1.8, 2.8, 3.6 

Luis Martínez-Piñeiro 

University Hospital La Paz 

Paseo de la Castellana, 261 

28046 Madrid (Spain) 

Ch. 1.8, 2.8, 3.6 

Eugen Plas 

City Hospital Lainz 

Wolkersbergenstrasse 1 

1130 Vienna (Austria) 

Ch. 1.8, 2.8, 3.6 

Prof. Dr. med. Tim Pohlemann 



Surgery 

Kirrberger Strasse 100 


Ch. 2.7 

- ix -


PD Dr. med. Stefan Rammelt 





01307 Dresden 

Ch. 2.12, 3.11 

Dr. med. Marcus Raum 

Helios Clinic Siegburg 

Department of Orthopedics & Traumatology 

Ringstr. 49 

53721 Siegburg 

Ch. 1.3, 1.4 

Prof. Dr. med. Gerd Regel 

Rosenheim Hospital 


Surgery 

Pettenkoferstr. 10 

83022 Rosenheim 

Ch. 2.10 

Dr. med. Alexander Reske 


Clinic & Outpatient Clinic for 

Anesthesiology & Intensive Treatment 


01307 Dresden 

Ch. 2.15 

Dr. med. Andreas Reske 


Clinic & Outpatient Clinic for 

Anesthesiology & Intensive Treatment 


01307 Dresden 

Ch. 2.15 

Prof. Dr. med. Eckhard Rickels 





29223 Celle 

Ch. 1.5, 2.6, 3.5 

Prof. Dr. med. Dieter Rixen 


BG Trauma Hospital Duisburg 

Grossenbaumer Allee 250 

47249 Duisburg 

Ch. 3.1, 3.10 

Prof. Dr. med. Steffen Ruchholtz 



Surgery 


35043 Marburg 

Ch. 2.2 

Richard A. Santucci 

Detroit Receiving Hospital 

Wayne State University School of Medicine 

Detroit, Michigan (USA) 

Ch. 1.8, 2.8, 3.6 

PD Dr. med. Stefan Sauerland 


(IFOM) 



51109 Cologne 

Ch. 1.4, 1.8, 2.8, 2.15, 3.6, 3.10 

Dr. med. Ulrich Schächinger 

University Hospital Regensburg 

Department of Trauma Surgery 

Franz-Josef-Strauss-Allee 11 

93053 Regensburg 

Ch. 1.4 

Prof. Dr. med. Michael Schädel-Höpfner 

University Hospital Dusseldorf 

Clinic for Trauma & Hand Surgery 

Moorenstrasse 5 

40225 Düsseldorf 

Ch. 2.11, 3.9 

Dr. med. Bodo Schiffmann 

Muthstrasse 22 

74889 Sinsheim 

Ch. 2.14, 3.13 

Mechthild Schiffmann 

St.Maria Hospital Frankfurt 

Richard-Wagner-Str. 14 


Ch. 2.14, 3.13 

Prof. Dr. med. Thomas Schildhauer 

BG Trauma Hospital Bergmannsheil 

Surgical University Hospital and Outpatient 

Clinic 

Bürkle-de-la-Camp-Platz 1 

44789 Bochum 

Ch. 1.4 

- x -


Prof. Dr. med. Dr. med. dent. Rainer 

Schmelzeisen 





Ch. 2.13, 3.12 

Dr. med. Dierk Schreiter 


Clinic for Visceral, Thoracic and Vascular 

Surgery 


01307 Dresden 

Ch. 1.9, 2.15 

PD Dr. med. Karsten Schwerdtfeger 


Clinic for Neurosurgery 

Kirrbergerstrasse 


Ch. 1.5, 2.6, 3.5 

Prof. Dr. med. Andreas Seekamp 

University Hospital Schleswig-Holstein (Kiel 

Campus) 


Arnold-Heller-Str. 7 

24105 Kiel 

Ch. 1.4, 2.7 

PD. Dr. med. Julia Seifert 




12683 Berlin 

Ch. 3.3, 3.4 

Dr. med. Daniel Seitz 





89070 Ulm 

Ch. 3.2 

Efraim Serafetinides 

417 NIMTS 

Athens (Greece) 

Ch. 1.8, 2.8, 3.6 

Prof. Dr. med. Hartmut Siebert 

Diakonie Hospital Schwäbisch-Hall 

Department of Surgery II 

Diakoniestr. 10 

74523 Schwäbisch-Hall 

Ch. 2.11, 3.9 

PD Dr. med. Christian Simanski 





51058 Cologne 

Ch. 3.10 

PD Dr. med. Dirk Stengel 


Center for Clinical Research 


12683 Berlin 

Ch. 3.3, 3.4 

Dr. med. Erwin Stolpe 

Gartenseeweg 8 

82402 Seeshaupt 

Ch. 1.4 

Prof. Dr. med. Johannes Sturm 

Schlüterstr. 32 

48149 Münster 

Ch. 1.4 

Prof. Dr. med. Klaus Michael Stürmer 



Department of Trauma Surgery, Plastic and 




Ch. 2.2 

Prof. Dr. med. Lothar Swoboda 


Eisendorfer Pferdeweg 17a 

21075 Hamburg 

Ch. 3.2 

PD Dr. med. Georg Täger 




45147 Essen 

Ch. 2.10 

- xi -


Dr. med. Thorsten Tjardes 





51058 Cologne 

Ch. 3.10 

Levent Türkeri 

Marmara University School of Medicine 

Department of Urology 

34688 Haydarpaşa – Istanbul (Turkey) 

Ch. 1.8, 2.8, 3.6 

Prof. Dr. med. Gregor Voggenreiter 

Kösching Clinic 

Orthopedic Traumatological Center, Hospital 

im Naturpark Altmühltal 

Ostenstr. 31 

85072 Eichstätt 

Ch. 2.4 

Prof. Dr. med. Thomas J. Vogl 



Radiology 



Ch. 2.17 

PD Dr. med. Felix Walcher 



Surgery 


60590 Frankfurt 

Ch. 1.4 

Dr. med. Frank Waldfahrer 


Oto-Rhino-Laryngology Clinic, Head & 

Neck Surgery 

Waldstrasse 1 


Ch. 2.14, 3.13 

Prof. Dr. med. Christian Waydhas 




45147 Essen 

Ch. 1.1, 1.2, 1.4 

Dr. med. Michael Weinlich 

Medconteam GmbH 

Gerhard-Kindler-Str. 6 

72770 Reutlingen 

Ch. 1.4 

Dr. med. Christoph Georg Wölfl 

BG Trauma Hospital Ludwigshafen 


Ludwig-Guttmann-Str. 13 

67071 Ludwigshafen 

Ch. 1.4 

Prof. Dr. med. Alexander Woltmann 

BG Trauma Hospital Murnau 

Department of Trauma Surgery 

Prof. Küntscher-Str. 8 

82418 Murnau am Staffelsee 

Ch. 2.9, 3.7 

Dr. med. Nedim Yücel 

Practice for Orthopedics & Trauma Surgery 

Dülmener Str. 60 

48653 Coesfeld 

Ch. 3.10 

Prof. Dr. med. Gerald Zimmermann 

Theresienkrankenhaus Mannheim 

Trauma Surgery 

Bassermannstr. 1 


Ch. 1.4 

Prof. Dr. med. Hans Zwipp 





01307 Dresden 

Ch. 1.9, 2.12, 3.11 

- xii -


Contents 

Contents...................................................................................................................................xii 

List of tables........................................................................................................................... xiv 

List of figures .......................................................................................................................... xv 

List of abbreviations.............................................................................................................. xvi 

A Rationale und goals .......................................................................................................... 1 

A.1 Publisher/experts/medical associations/authors............................................ 4 

A.2 Target user group............................................................................................. 6 

B Methods............................................................................................................................. 7 

B.1 Literature search and selection of evidence................................................... 7 

B.2 Formulating the recommendation and finding consensus............................ 9 

B.3 Distribution and implementation.................................................................. 10 

B.4 Quality indicators and evaluation................................................................. 10 

B.5 Validity and updating of guideline ............................................................... 11 

B.6 Funding of the guideline and disclosure of potential conflicts of interests11 

1 Prehospital ...................................................................................................................... 14 

1.1 Introduction .................................................................................................... 14 

1.2 Airway management, ventilation and emergency anesthesia..................... 17 

1.3 Volume replacement ...................................................................................... 40 

1.4 Thorax ............................................................................................................. 51 

1.5 Traumatic brain injury.................................................................................. 86 

1.6 Spine ................................................................................................................ 93 

1.7 Extremities .................................................................................................... 104 

1.8 Genitourinary tract ...................................................................................... 114 

1.9 Transport and designated hospital ............................................................. 116 

1.10 Mass casualty incident (MCI) ..................................................................... 122 

2 Emergency room .......................................................................................................... 131 

2.1 Introduction .................................................................................................. 131 

2.2 The emergency room - personnel and equipment resources.................... 135 

2.3 Criteria for emergency room activation..................................................... 144 

2.4 Thorax ........................................................................................................... 152 

2.5 Abdomen ....................................................................................................... 176 

2.6 Traumatic brain injury................................................................................ 189 

2.7 Pelvis.............................................................................................................. 197 


Page 

- xii -


2.9 Spine .............................................................................................................. 226 

2.10 Extremities .................................................................................................... 240 

2.11 Hand .............................................................................................................. 248 

2.12 Foot ................................................................................................................ 251 

2.13 Mandible and midface ................................................................................. 253 

2.14 Neck ............................................................................................................... 256 

2.15 Resuscitation................................................................................................. 260 

2.16 Coagulation system ...................................................................................... 269 

2.17 Interventional control of bleeding .............................................................. 291 

3 Emergency surgery phase............................................................................................ 297 

3.1 Introduction .................................................................................................. 297 

3.2 Thorax ........................................................................................................... 300 

3.3 Diaphragm .................................................................................................... 309 

3.4 Abdomen ....................................................................................................... 311 

3.5 Traumatic brain injury................................................................................ 336 


3.7 Spine .............................................................................................................. 354 

3.8 Upper extremity............................................................................................ 363 

3.9 Hand .............................................................................................................. 368 

3.10 Lower extremity ........................................................................................... 382 

3.11 Foot ................................................................................................................ 402 

3.12 Mandible and midface ................................................................................. 412 

3.13 Neck ............................................................................................................... 418 

- xiii -


List of tables 

Table 1: AWMF table of levels for guideline development [4]......................................................1 

Table 2: CEBM evidence classification [9] ....................................................................................8 

Table 3: Prehospital volume replacement - mortality ...................................................................41 

Table 4: Diagnostic valency of a pathologic auscultation finding with regard to a 

hemo/pneumothorax ................................................................................................54 

Table 5: Diagnostic valency of dyspnea and tachypnea with regard to hemo/pneumothorax......54 

Table 6: Diagnostic valency of thoracic pain with regard to hemo/pneumothorax ......................55 

Table 7: Statistical probabilities for the presence of a clinically relevant hemopneumothorax in 

various combinations of findings after blunt chest injury (basic assumption: 10% 

prevalence as pretest probability and independence of test) ...................................55 

Table 8: Incidence of pneumothorax in the presence of chest injury............................................56 

Table 9: Complication rates for pleural drains inserted in the prehospital versus in-hospital phase 

.................................................................................................................................64 

Table 10: Complications when inserting a pleural drain...............................................................83 

Table 11: Composition and presence of specialist grade physicians in the enlarged emergency 

room team in relation to the care level ..................................................................141 

Table 12: Glasgow Outcome Scale (GOS) [8]:...........................................................................260 

Table 13: Drug options for coagulation therapy .........................................................................285 

Table 14: Midline laparotomy versus transverse upper abdominal laparotomy in abdominal 

trauma ....................................................................................................................312 

Table 15: Damage Control versus definitive management .........................................................314 

Table 16: Methods for abdominal wall closure...........................................................................316 

Table 17: Second look after packing...........................................................................................318 

Table 18: Angioembolization......................................................................................................321 

Table 19: Angiography................................................................................................................322 

Table 20: Interventions after blunt splenic injuries.....................................................................323 

Table 21: Interventions after blunt or penetrating splenic injuries .............................................326 

Table 22: Primary anastomosis versus ileostomy after penetrating colon injury .......................329 

Table 23: Hand suture versus stapler after penetrating colon injury...........................................330 

Table 24: Hand suture versus stapler after penetrating colon injury...........................................331 

Table 25: Grading classification of renal trauma according to the American Association for the 

Surgery of Trauma (AAST) [117].........................................................................342 

- xiv -


List of figures 

Figure 1: Operational algorithm for mass casualty incident (MCI) [7] ......................................125 

Figure 2: Triage of injured persons at mass casualty incident [7] ..............................................127 

Figure 3: Treatment algorithm for complex pelvic trauma [49] .................................................206 

Figure 4: CPR algorithm according to the ERC Guidelines [36]................................................264 

Figure 5: Algorithm on the diagnostic and therapeutic procedure for suspected renal injuries..347 

- xv -


List of abbreviations 

A. Artery 

a. p. Anteroposterior 

AAST American Association for the Surgery of Trauma 

ABC Assessment of blood consumption 

ABCD Airway/Breathing/Circulation/Disability 

ACS Abdominal compartment syndrome 

ACS COT American College of Surgeons Committee on Trauma 

ACTH Adrenocorticotropic hormone 

AIS Abbreviated Injury Scale 

AJ Ankle joint 

ALI Acute lung injury 

ALS Advanced Life Support 

APC Apheresis platelet concentrate 

aPTT Activated partial thromboplastin time 

ArbStättV Workplace Regulation 

ARDS Acute respiratory distress syndrome 

ASIA-IMSOP American Spinal Injury Association – International Medical Society 

of Paraplegia 

ASR Workplace Directive 

ASS Acetyl salicylic acid 

AT Antithrombin 

ATLS ® Advanced Trauma Life Support 

AUC Area under the curve 

AWMF Association of Scientific Medical Societies in Germany 

ÄZQ Medical Center for Quality in Medicine 

BÄK German Medical Association 

BE Base excess, base deviation 

BG Berufsgenossenschaftliches [Statutory Accident Insurance Company] 

BGA Blood gas analysis 

BLS Basic Life Support 

BP Blood pressure 

BS Body surface 

BW Body weight 

C 1-7 Cervical spine 

CA Contrast agent 

- xvi -


Ca ++ Calcium 

CCT Cranial computed tomography/tomogram 

CEBM Oxford Centre for Evidence Based Medicine 

CI Confidence interval 

CK-MB Creatine kinase MB 

COPD Chronic obstructive pulmonary disease 

CPAP Continuous positive airway pressure 

CPP Cerebral perfusion pressure 

CPR Cardiopulmonary resuscitation 

CRASH Clinical Randomization of Antifibrinolytics in Significant 

Hemorrhage 

CS Cervical spine 

CST Cosyntropine stimulation test 

CT Computed tomography/tomogram 

CTA CT angiography 

DC Damage control 

DDAVP Desmopressin 

DGAI German Society of Anesthesiology and Intensive Care Medicine 

DGNC German Society of Neurosurgery 

DGU German Trauma Society 

DIC Disseminated intravasal coagulopathy 

DIVI German Interdisciplinary Association for Intensive and Emergency 

Care 

DL Definitive laparotomy 

DO2I Oxygen delivery index 

DPL Diagnostic peritoneal lavage 

DSA Digital subtraction angiography 

DSTC Definitive surgical trauma care 

EAES European Association for Endoscopic Surgery 

EAST Eastern Association for the Surgery of Trauma 

ECG Electrocardiogram 

EL 

EMS 

Evidence level 

Emergency medical systems 

EMT Emergency Medical Technician 

ENT Otorhinolaryngology therapy 

ER Emergency room 

ERC European Resuscitation Council 

- xvii -


ERG Electroretinogram 

ETC European Trauma Course 

FÄ/FA Specialist physician 

FAST Focused assessment with ultrasonography for trauma 

FFP Fresh frozen plasma 

FR French (equals 1 Charrière [CH] and thus ⅓ mm) 

GCS Glasgow Coma Scale/Score 

GoR Grade of Recommendation 

GOS Glasgow Outcome Scale 

h Hour 

Hb Hemoglobin 

HES Hydroxy ethyl starch 

HFS Hannover fracture scale 

ICP Intracranial pressure 

ICU Intensive care unit 

IFOM Institute for Research in Operative Medicine (IFOM) 

INR International Normalized Ratio (subsequent standardization for 

Quick value) 

INSECT Interrupted or Continuous Slowly Absorbable Sutures – Evaluation 

of 

Abdominal Closure Techniques 

ISS Injury severity score 

ICU Intensive care unit 

IU International unit 

IVP Intravenous pyelography 

L 1-5 Lumbar spine 

LÄK German regional medical association 

LEAP Lower Extremity Assessment Project 

LISS Less invasive stabilization system 

LoE Level of Evidence 

LS Lumbar spine 

LSI Limb Salvage Index 

MAL Mean axillary line 

MCI Mass casualty incident 

MCL Medioclavicular line 

MESS Mangled Extremity Severity Score 

MILS Manual in-line stabilization 

- xviii -


MPH Miles per hour 

mrem Millirem (equals 0.01 millisievert) 

MRI Magnetic resonance imaging 

MRT Medical radiologic technologist 

MSCT Multi-slice helical computed tomography 

NaCl Sodium chloride 

NASCIS National Acute Spinal Cord Injury Study 

NASS CDS National Automotive Sampling System Crashworthiness Data 

System 

NEF Emergency physician vehicle 

NISSSA Nerve injury, Ischemia, Soft-tissue injury, Skeletal injury, Shock and 

Age of patient 

NS 

n. s. 

Paranasal sinuses 

Not significant 

OMS Oral and maxillofacial surgery 

OP Operation/surgery 

OPSI Overwhelming Postsplenectomy Syndrome 

OR Odds ratio 

pAOD Peripheral arterial occlusive disease 

PASG Pneumatic anti-shock garment 

PC Platelet concentrate 

PCC Prothrombin complex concentrate 

PHTLS ® Prehospital Trauma Life Support 

PMMA Polymethyl methacrylate 

POVATI Postsurgical Pain Outcome of Vertical and Transverse Abdominal 

Incision 

PPV Positive predictive value 

PRBC Packed red blood cells 

PSI Predictive Salvage Index 

PTFE Polytetrafluorethylene 

PTS Polytrauma Score 

PTT Partial thromboplastin time 

QM Quality management 

RCT Randomized controlled trial 

RISC Revised Injury Severity Classification 

ROSC Return of spontaneous circulation 

ROTEM Rotational thromboelastometry 

- xix -


RöV German X-ray Ordinance 

RR Relative risk 

RSI Rapid sequence induction 

RTA Road traffic accident 

RTH Rescue helicopter 

RTS Revised trauma score 

RTW Ambulance 

RX X-ray 

S Spine 

SAGES Society of American Gastrointestinal and Endoscopic Surgeons 

SBP Systolic blood pressure 

SCIWORA Spinal Cord Injury Without Radiographic Abnormality 

SIRS Systemic inflammatory response syndrome 

START Simple Triage And Rapid Treatment 

T 1-12 Thoracic vertebrae 

TARN Trauma audit and research network 

TASH-Score Trauma Associated Severe Hemorrhage Score 

TBI Traumatic brain injury 

TEE Transthoracic/transesophageal echocardiography 

TEG Thromboelastography 

TIC Trauma-induced coagulopathy 

tPA Tissue-specific plasminogen activator 

Trali Transfusion-associated acute lung failure 

TRGS Technical Rules for Hazardous Substances 

TRIS Tris(hydroxymethyl)aminomethane 

TRIS Trauma Injury Severity Score Method 

TS Thoracic spine 

TTAC Trauma Team Activation Criteria 

i. v. Intravenous 

VEP Visually evoked potential 

WMD Weighted mean difference 

- xx -


A Rationale und goals 

Introduction 

Medical guidelines are systematically developed decision aids for service providers and patients 

on the appropriate method applicable in specific health problems [1]. Guidelines are important 

tools for providing a rational and transparent basis for decisions in medical care [2]. Through 

imparting knowledge, they are intended to contribute towards improving care [3]. 

The process of developing guidelines must be systematic, independent and transparent [2]. 

Guideline development for Level 3 guidelines follows the criteria according to the AWMF/ÄZQ 

[German Medical Center for Quality in Medicine] specifications including all elements of 

systematic development [4]. 

Table 1: AWMF table of levels for guideline development [4]. 

Level 1 Experts group: 

A representatively formed group of experts from the Scientific Medical Society 

draws up a guideline in informal consensus, which is approved by the board of 

the society. 

Level 2 Formal evidence research or formal consensus finding: 

Guidelines are developed from formally assessed statements in scientific 

literature or discussed and approved in one of the proven formal consensus 

processes. Formal consensus processes consist of the nominal group process, the 

Delphi method and the consensus conference. 

Level 3 Guideline including all elements of systematic development: 

Formal consensus finding, systematic literature search and evaluation, and 

classification of studies and recommendations according to the criteria of 

evidence-based medicine, clinical algorithms, outcome analysis, decision 

analysis. 

The present guideline is a Level 3 guideline. 

Starting position 

Accidents are the most common cause of death in children and young adults [5]. In 2007, 8.22 

million people were injured in accidents and 18,527 people suffered a fatal accident according to 

statistics from the German Federal Institute for Occupational Safety and Health (Bundesanstalt 

für Arbeitsschutz und Arbeitsmedizin) [6]. The management of a severely injured person is 

typically an interdisciplinary task. It presents a major challenge to those involved in the 

provision of care because of the sudden occurrence of the accident situation, the unpredictability 

of the number of injured persons and the heterogeneity of the patient population [7]. 

An S1 guideline was issued by the German Society of Trauma Surgery in 2002 on the 

management of multiply injured patients and those with severe injuries. However, there is no upto-date, 

general, comprehensive, evidence-based guideline. This was the rationale for drawing up 

- 1 -


an interdisciplinary guideline for the management of multiply injured patients and those with 

severe injuries. 

Requirements of the guideline 

The guideline must meet the following fundamental requirements: 

� Guidelines for the treatment of polytrauma and patients with severe injuries are aids in 

decision-making in specific situations, based on the current state of scientific knowledge and 

on procedures proven in practice. 

� Due to its complexity, there is no single ideal concept for the treatment of polytrauma and 

patients with severe injuries. 

� Guidelines need to be constantly monitored and adapted to the current state of knowledge. 

� Using the recommendations in this guideline, it should be possible to treat the vast majority 

of severely injured/multiply injured patients. 

� Routine monitoring of treatment and monitoring the effect of treatment are necessary. 

� Regular discussion with all involved (physicians, nursing staff, patients, if possible patients’ 

families) should make the goals and methods of treatment of polytrauma and patients with 

severe injuries transparent. 

Aims of the guideline 

This interdisciplinary S3 guideline is an evidence-based and consensus-based tool with the aim 

of improving the management of multiply injured patients and those with severe injuries. The 

recommendations are intended to contribute towards the optimization of structural and process 

quality in hospitals and in prehospital management and, through their implementation, help to 

improve outcome quality in terms of case fatality rate or quality of life. 

The guideline, which is based on the current state of scientific knowledge and on procedures 

proven in practice, is intended to provide a decision-making aid in specific situations. The 

guideline can be used not only in the acute treatment situation and in the debriefing but also in 

discussions about local protocols by the quality circles in individual hospitals. Legal (and 

insurance) aspects and those relevant to billing are not explicitly dealt with in this guideline. The 

regulations of the German Social Code Book (Sozialgesetzbuch) (SBG VII) apply. 

The guideline should be an interdisciplinary decision-making aid. For this reason, it is also 

suitable for drawing up new treatment protocols in individual hospitals and for revising protocols 

already in existence. 

The aim of the guideline is to support the care of the vast majority of severely injured persons. 

Individual patients with defined pre-existing concomitant diseases or specific injury patterns may 

not all be adequately covered due to their specific problems. 

- 2 -


The guideline is intended to stimulate further discussion to optimize the care of severely injured 

persons. Constructive criticism is therefore expressly welcomed. Ideally, any amendments 

should be briefly summarized, backed up by references and forwarded to the publisher. 

Apart from the terms of reference of this guideline, it is intended to draw up interdisciplinary 

recommendations on the ongoing process management of severely injured persons during the 

acute and post-acute phase. 

- 3 -


A.1 Publisher/experts/medical societies/authors 

The responsibility for this guideline lies with the German Trauma Society (Deutsche 

Gesellschaft für Unfallchirurgie e. V.). 

The following medical societies were involved in drawing up the guideline: 

German Society of General and Visceral Surgery (Deutsche Gesellschaft für Allgemein- und 

Viszeralchirurgie e. V.) 

German Society of Anesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für 

Anästhesiologie und Intensivmedizin e. V ) 

German Society of Endovascular and Vascular Surgery (Deutsche Gesellschaft für 

Gefäßchirurgie und Gefäßmedizin e.V.) 

German Society of Hand Surgery (Deutsche Gesellschaft für Handchirurgie e.V.) 

German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (Deutsche Gesellschaft für 

HNO-Heilkunde, Kopf- und Hals-Chirurgie e.V.) 

German Society of Oral and Maxillofacial Surgery (Deutsche Gesellschaft für Mund-, Kiefer- 

und Gesichtschirurgie e.V.) 

German Society of Neurosurgery (Deutsche Gesellschaft für Neurochirurgie e.V.) 

German Society of Thoracic Surgery (Deutsche Gesellschaft für Thoraxchirurgie e.V.) 

German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie e.V.) 

German Society of Urology (Deutsche Gesellschaft für Urologie e.V.) 

German Radiology Society (Deutsche Röntgengesellschaft e.V.) 

Moderation, coordination and project management 

The German Trauma Society as the lead medical association has devolved central coordination 

for this guideline to the Institute for Research in Operative Medicine (Institut für Forschung in 

der Operativen Medizin) (IFOM). The tasks were: 

� coordination of the project group 

� methods support and quality assurance 

� systematic literature search 

� procurement of literature 

� data administration 

� structural and editorial harmonization of the guideline texts 

- 4 -


� coordination of necessary discussions, meetings, and consensus conferences 

� administration of financial resources 

- 5 -


Main treatment phase responsibilities 

The guideline was divided into 3 main treatment phases: prehospital, emergency room, and 

emergency surgery. Coordinators were assigned responsibility for each of these treatment 

phases. The tasks were: 

� establishing the contents of the guideline 

� screening and evaluating the literature on the different treatment strategies for multiply 

injured patients and those with severe injuries, drawing up and coordinating the guideline 

texts 

The AWMF, represented by Professor I. Kopp, provided methods guidance in drawing up the 

guideline. 

A.2 Target user group 

The guideline’s target user group is primarily the physicians and all other medical professionals 

involved in the management of a multiply injured patient or one with severe injuries. The 

recommendations relate to adult patients. Recommendations on the care of children and 

adolescents are only given occasionally in the guideline. 

- 6 -


B Methods 

The guideline project was first announced in December 2004 and again in May 2009. 

The guideline on the “Treatment of multiply injured patients and those with severe injuries” was 

developed according to a binding process with a structured plan. It is the result of a systematic 

literature search and critical evaluation of the evidence from available data using scientific 

methods as well as discussion with experts in a formal consensus procedure. 

B.1 Literature search and selection of evidence 

The key questions for the systematic literature search and evaluation were formulated on the 

basis of preliminary work during 2005. The literature searches were carried out in the MEDLINE 

database (via PubMed) using medical keywords (Medical Subject Headings/MeSH), partly 

supplemented by a free text search. The filter recommended in PubMed was used to identify 

systematic reviews. Supplementary searches were conducted in the Cochrane Library 

(CENTRAL) (in this case with keywords and text words in the title and abstract). The 

publication period selected was 1995-2010, and German and English as the publication 

languages. 

The literature searches were carried out partly by the Institute for Research in Operative 

Medicine (IFOM) and partly by the authors themselves. The results of the literature searches, 

sorted according to topic, were forwarded to the individual authors responsible for each topic. 

The underlying key questions, the literature searches carried out with date and number of hits 

and, if applicable, search limitations were documented and can be found in the appendix to the 

separate Methods Report. 

Selection and evaluation of the relevant literature 

The authors of each chapter selected and evaluated the literature included in the guideline. This 

was carried out according to the criteria of evidence-based medicine. Sufficient randomization, 

allocation concealment, blinding and the statistical analysis were taken into account. 

The evidence statement for the recommendations was based on the evidence classification of the 

Oxford Center of Evidence-Based Medicine (CEBM), March 2009 version. In formulating the 

recommendations, priority was given to studies with the highest level of evidence available 

(LoE). 

- 7 -


Table 2: CEBM evidence classification [9] 

Level Studies on therapy/prevention/etiology 

1a 

1b 

1c 

2a 

2b 

2c 

3a 

3b 

Systematic review of randomized controlled trials (RCT) 

An RCT (with narrow confidence interval) 

All or none principle 

Systematic review of well-planned cohort studies 

A well-planned cohort study or a low-quality RCT 

Outcome studies, ecological studies 

Systematic review of case-control studies 

Individual case-control study 

4. Case-series or low-quality cohort/case-control studies 

5. Expert opinion without explicit critical appraisal of the evidence or based on 

physiology/bench research 

Three grades of recommendation (GoR) were possible (A, B, O). The wording of the key 

recommendation employs “must” “should” or “can” as appropriate. In determining the GoR, in 

addition to the underlying evidence, benefit-risk evaluations were also taken into account, as 

were the directness and homogeneity of the evidence along with clinical expertise [2]. 

- 8 -


B.2 Formulating the recommendation and finding consensus 

The medical societies involved each nominated at least one delegate who, as a representative of 

that subject discipline, participated in drawing up the guideline. Each medical society had a vote 

in the consensus process. 

The recommendations and the grades of recommendation were approved in 5 consensus 

conferences (April 18-19, 2009, June 30, 2009, September 8, 2009, November 26-27, 2009 and 

February 01, 2010): 

The course of action at these conferences, assisted by the TED (electronic voting) system, was in 

6 steps: 

� the opportunity to review the guideline manuscript before the conference and to compile 

notes on the proposed recommendations and grades; 

� presentation and explanation from each author responsible on the pre-formulated proposals 

for recommendations; 

� registration via moderators of participants’ opinions and alternative proposals on all 

recommendations, with speaker contributions solely for clarification; 

� voting on all recommendations and grades of recommendation and on the cited alternatives; 

� discussion of the points on which no “strong consensus” could be reached in the first round; 

� final voting. 

Most of the recommendations were approved with “strong consensus” (agreement of > 95% of 

participants). Areas in which no strong consensus could be reached are marked in the guideline 

and the various positions are expounded. In classifying the consensus strength, the following 

consensus grades were decided on in advance [9]: 

� strong consensus: > 95% of participants agreed 

� consensus: > 75-95% of participants agreed 

� majority consensus: > 50–75% of participants agreed 

� no consensus: < 50% of participants agreed 

The records of the meetings can be viewed at the Institute for Research in Operative Medicine 

(IFOM). The Delphi method was then applied to recommendations for which no consensus could 

be reached in the consensus conferences. A detailed methods report is available for viewing on 

the AWMF website and has been filed at the Institute for Research in Operative Medicine 

(IFOM). 

- 9 -


B.3 Distribution and implementation 

The guideline is to be distributed in the following ways: 

� via the internet: AWMF website (http://www.awmf-online.de) and the websites of the 

medical societies and professional organizations involved in the guideline 

� via printed media: 

− Publication of the guideline as a manual/book by the DGU. A copy will be made 

available to all hospitals involved in the DGU Trauma Network. In addition, all 

hospitals involved will be notified in writing about where and how the guideline 

can be viewed on the AWMF homepage. 

− Publication of extracts of the guideline and of implementation strategies in 

journals of the medical societies involved. 

− To simplify use of the guideline, a summary of the guideline containing the key 

recommendations is also to be published in the Deutsches Ärzteblatt [German 

medical journal]. 

� via conferences, workshops, professional training courses offered by the medical societies 

involved. 

Various complementary measures are to be implemented in this guideline. In addition to the 

presentation of the recommendations at conferences, a link to topic-specific professional training 

courses is planned. 

In addition, implementation at all the German hospitals involved in the trauma network is to be 

evaluated approximately one year after publication of the guideline. In particular, it should be 

recorded how the guideline has been used and what practical suggestions the participants have 

gained from their experience to pass on to other users. 

B.4 Quality indicators and evaluation 

The audit filters were developed as criteria for quality management for the DGU Trauma 

Registry. Based on the available audit filters, the following criteria were established for this 

guideline: 

Process quality for evaluation in the prehospital phase: 

� duration of prehospital time between accident and hospital admission for severely injured 

patients with ISS ≥ 16 [∅min ± SD] 

� intubation rate in patients with severe chest injury (AIS 4-5) by the emergency physician 

[%, n/total] 

� intubation rate in patients with suspected traumatic brain injury (unconscious, Glasgow 

Coma Scale [GCS] ≤ 8) [%, n/total] 

- 10 -


Process quality for evaluation of emergency room management: 

� time between hospital admission and performance of a chest X-ray in severely injured 

patients (ISS ≥ 16) [∅ min ± SD] 

� time between hospital admission and performance of an ultrasound scan of the 

abdomen/chest in cases of severe trauma (ISS ≥ 16) [∅ min ± SD] 

� time until performance of a computed tomography (CT) scan of the cranium (CCT) in prehospital 

unconscious patients (GCS ≤ 8) [∅ min ± SD] 

� time until performance of a full-body CT scan on all patients, if carried out [∅ min ± SD] 

� time from emergency admission arrival to completion of diagnostic study in severely injured 

persons if this has been completed normally (ISS ≥ 16) [∅ min ± SD] 

� time from emergency admission arrival to completion of diagnostic study in severely injured 

persons if this has been interrupted due to emergency (ISS ≥ 16) [∅ min ± SD] 

Outcome quality for overall evaluation: 

� standardized mortality rate: observed mortality divided by the expected prognosis based on 

RISC (Revised Injury Severity Classification) in severely injured persons (ISS ≥ 16) 

� standardized mortality rate: observed mortality divided by the expected prognosis based on 

TRISS (Trauma Injury Severity Score Method) in severely injured persons (ISS ≥ 16) 

The routine recording and evaluation of these data offer a vital opportunity to monitor 

improvements in quality in the management of multiply injured patients and those with severe 

injuries. It is not possible to ascertain from this which effects are due to the guideline. Quality 

indicators should continue to be developed based on the aforementioned criteria. 

B.5 Validity and updating of guideline 

This guideline is valid until December 2014. The German Trauma Society is responsible for 

introducing an updating process. The cooperation of the German Society of Plastic, 

Reconstructive and Esthetic Surgeons (Deutsche Gesellschaft der Plastischen, Rekonstruktiven 

und Ästhetischen Chirurgen) and of the German Society of Burns Medicine (Deutsche 

Gesellschaft für Verbrennungsmedizin) and the thematic inclusion of burns, large skin/soft tissue 

defects and nerve defect injuries (including plexus injuries) is additionally planned for this 

updating. 

B.6 Funding of the guideline and disclosure of potential conflicts of interests 

Reimbursement monies for the methods support, costs for literature acquisition, costs for 

organizing the consensus conferences, and costs of materials were provided by the German 

Trauma Society and the Institute for Research in Operative Medicine (IFOM) of the University 

of Witten/Herdecke. The participants’ travel costs arising from the consensus process were 

- 11 -


covered by those medical societies/organizations sending representatives or by the participants 

themselves. 

All participants in the consensus conference disclosed potential conflicts of interest in writing. A 

summary of declarations of potential conflicts of interest from all coordinators, medical society 

delegates, draft authors, and organizers can be found in the appendix to the separate Methods 

Report of this guideline. Furthermore, the forms used to disclose potential conflicts of interest 

can be requested from the Institute for Research in Operative Medicine (IFOM). 

Grateful thanks are extended to the coordinators of the individual subsections, the authors and 

participants in the consensus process for their wholly voluntary work. 

- 12 -


References 

1. Field, M.J. and K.N. Lohr, eds. Clinical Practice 

Guidelines: Directions for a New Program. 1990, 

National Academy Press: Washington, D.C. 

2. Council of Europe, Developing a Methodology for 

drawing up Guidelines on Best Medical Practices: 

Recommendation Rec(2001)13 adopted by the 

Committee of Ministers of the Council of Europe on 

10 October 2001 and explanatory memorandum. 

2001, Strasbourg Cedex: Council of Europe. 

3. Kopp, I.B., [Perspectives in guideline development 

and implementation in Germany.]. Z Rheumatol, 

2010. 

4. Arbeitsgemeinschaft der Wissenschaftlichen 

Medizinischen Fachgesellschaften. 3-Stufen-Prozess 

der Leitlinien-Entwicklung: eine Klassifizierung. 

2009; Available from: http://www.uniduesseldorf.de/AWMF/ll/ll_s1-s3.htm. 

5. Robert Koch-Institut, ed.; Gesundheit in Deutschland. 

Gesundheitsberichterstattung des Bundes. 2006, 

Robert Koch-Institut: Berlin. 

6. Bundesanstalt für Arbeitsschutz und Arbeitsmedizin. 

Unfallstatistik: Unfalltote und Unfallverletzte 2007 in 

Deutschland. 2007; Available from: 

www.baua.de/cae/servlet/content 

blob/672542/publicationFile/49620/Unfallstatistik- 

2007.pdf;jsessionid=CC8B45BA699EE9E4E11AC1E 

AD359CB34. 

7. Bouillon, B., et al., Weißbuch Schwerverletzten- 

Versorgung. Empfehlungen zur Struktur, Organisation 

und Ausstattung stationärer Einrichtungen zur 

Schwerverletzten-Versorgung in der Bundesrepu-blik 

Deutschland., ed. D.G.f.U.e.V. (DGU). 2006, Berlin: 

Dt. Gesellschaft für Unfallchirurgie e.V. 

8. Oxford Centre of Evidence-based Medicine (CEBM): 

Levels of Evidence (March 2009); Available from: 

www.cebm.net/index.aspx?o=1025. 

9. Schmiegel, W., et al.: S3-Leitlinie “Kolorektales 

Karzinom: Available from: 

www.krebsgesellschaft.de/download/s3_ll_kolorektal 

es_karzinom_2008.pdf. 

- 13 -


1 Prehospital 

1.1 Introduction 

Within the structured emergency services, the professional treatment of severely injured patients 

starts right at the accident scene. The subsequent course can be set at this stage. So, even for this 

initial treatment phase, it is expedient and necessary to develop the clearest priorities and 

strategies for dealing with the situation. Due to the difficult environmental conditions in the 

prehospital emergency situation, the evidence level is low yet the full diversity of experience and 

expert knowledge is considerable. Moreover, the benefit-risk evaluation is disputed in a number 

of interventions, not least in considering the point at which an essentially indicated intervention 

should be carried out, for example, in the prehospital phase or only once admitted to hospital. 

Finally, the polarization between “stay and treat” and “load and go” also plays a role here. In 

addition, a large amount of scientific knowledge has been gained from different emergency 

systems and its transferability to specific situations in Germany is often ambiguous. 

Those active on the spot want a highly specific recommendation with broad validity but this 

desire is in conflict with the unfortunately often weak data available and the resulting unreliable 

conclusions. This desire can only be met by achieving a consensus among the experts, on the 

understanding that scientific uncertainty continues to exist in such areas and that there are 

differences between different emergency systems and cultures. 

The structuring of the prehospital guideline section is based on several considerations. Basically, 

the management of a (potentially) severely injured patient involves a sequence of actions that 

follow certain priorities. Every detail and individual step of the sequence itself cannot be 

evidence-based with proof of general validity. Moreover, many individual circumstances relating 

to the actual patient have to be considered so that not all possible sequence models can be 

depicted. The contents of the guideline were therefore not oriented to a specific sequence 

algorithm but focused instead on individual aspects. These sections concentrate on anatomic 

regions (head, chest, abdomen, spine, extremities, and pelvis). In the prehospital phase, very few 

invasive interventional options are available; of these the most important (volume replacement, 

airway management, chest drain) are dealt with in terms of indications and implementation. 

The individual aspects, interventions, and guidelines must be embedded in a general pathway of 

action that sets priorities and prescribes action pathways and sequences. A framework of this 

kind can be provided by programs such as Prehospital Trauma Life Support (PHTLS), Advanced 

Trauma Life Support (ATLS), European Trauma Course (ETC), and others. As such programs 

already exist and the individual steps cannot be individually scientifically proven, as indicated 

above, the attempt was not made to develop such a program in this guideline package. The 

individual guidelines are not intended to replace these programs but to represent the aspects 

embedded in them. 

Besides directly treating the individual patient, general aspects also play a role in the prehospital 

phase. On the one hand, a decision must be made about the designated hospital. It must be able 

to treat all acute, life-threatening injuries immediately and independently. The initial-treating 

hospital must have clear, well-ordered transfer strategies for injuries which require a special 

structure or expertise. In addition to the increasing number of trauma networks being set up, the 

Prehospital - Introduction 14


recommendations in the White Paper of the German Trauma Society [1] may be of great benefit 

here [2]. The resulting local and regional regulations can provide the emergency physician with 

additional support when selecting a suitable designated hospital. Besides the hospital structure, 

however, organizational and logistical circumstances, weather and road conditions or the time of 

day can also be significant in addition to purely medical considerations. Inextricably linked to 

this is the question of whether the patient is in fact severely injured. Criteria for this purpose are 

defined which are aligned to actual detected or suspected injuries, impairment of vital functions 

or mechanisms of injury. Finally, a balance must be found between the desire to underestimate as 

few patients as possible and the consequence of classifying too many patients unnecessarily as 

severely injured (overtriage). Conversely, although undertriage reduces the number of 

unnecessary emergency room alerts, it is at the cost of having underestimated more genuinely 

severely injured patients. The latter is viewed by many as the more critical model. Every trauma 

center should come to an agreement about this within its network or with the emergency services 

in its area. 

The mass casualty incident represents a rare yet particularly challenging situation. Until the 

arrival of the on-duty lead emergency physician, the emergency physician who arrives on the 

scene first must take over this function. The switch from individual medical care to triage 

represents a special challenge and the algorithm should provide support here. 

Many important, central domains are dealt with in the present edition of the prehospital 

polytrauma guideline. But some major topics, for example, pain therapy or prehospital 

management of traumatic brain injury, are not included. These are to be drawn up in future 

stages of guideline development, as well as other topics that are requested by the users. 

Overall, the rapid, smoothly running medical care of (severely) injured patients is the focus of all 

action. In this context, the emergency services must work hand-in-hand with the hospitals. To 

this end, the 2008 Key Points Paper [3] on emergency medical management of patients in 

hospital and prehospital demands that definitive clinical treatment shall be achieved within 90 

minutes for major emergency medical clinical pictures such as a severely injured patient. To 

make this possible, a time of 60 minutes from emergency call to hospital admission must be 

achieved. The scope of emergency physician care must be aimed at these targets. 



References 

1. Bouillon, B., V. Bühren, et al. (2006). Weißbuch 

Schwerverletzten-Versorgung. Empfehlungen zur 

Struk-tur,Organization und Ausstattung stationärer 

Einrichtungen zur Schwerverletzten-Versorgung in 

der Bundesrepublik Deutschland. German Society for 

Trauma Surgery e.V. 

2. Eckpunktepapier zur notfallmedizinischen 

Versorgung der Bevölkerung in Klinik und Präklinik 

(2008) Arbeitsgemeinschaft Südwestdeutscher 

Notärzte (agswn), Institut für Notfallmedizin und 

Medizinmanagement (INM), Bundesärztekammer 

(BÄK), Bundesvereinigung der 

Arbeitsgemeinschaften der Notärzte Deutschlands 

(BAND), Deutsche Gesellschaft für Anästhesiologie 

und Intensivmedizin (DGAI), Deutsche Gesellschaft 

für Chirurgie (DGCH), Deutsche Gesellschaft für 

Kardiologie (DGK), Deutsche Gesellschaft für 

Neurochirurgie (DGNC), Deutsche Gesellschaft für 

Unfallchirurgie (DGU), Deutsche Gesellschaft für 

Neonatologie und Pädiatrische Intensivmedizin 

(GNPI), Arbeiter Samariter Bund (ASB), 

Unternehmerverband privater Rettungsdienste (BKS), 

Deutsches Rotes Kreuz (DRK), Johanniter-Unfall- 

Hilfe (JUH), Malteser Hilfsdienst (MHD), Ständige 

Konferenz für den Rettungsdienst (SKRD). Notfall 

und Rettungsmedizin 11:421-422 



1.2 Airway management, ventilation and emergency anesthesia 

Summary 

Endotracheal intubation and ventilation, and hence definitive securing of the airways, with the 

aim of the best possible oxygenation and ventilation of the patient, is a central therapeutic 

measure in emergency medicine [80]. The basic vital functions directly linked to survival have to 

be secured. The “A” for airway and “B” for breathing are First Aid measures found in 

established standards on trauma care and therefore have a particular value in terms of weighting 

in both the prehospital and the early hospital management [3, 74, 107]. 

Variations in the emergency medical services (EMS) internationally pose a problem. Whereas 

paramedics are often used in the Anglo-American region, the emergency physician system is 

widely used in continental Europe. But even here there are differences. In Germany, (specialist) 

physicians in all disciplines can be involved in the emergency service after acquiring an 

appropriate additional qualification but in Scandinavian countries this is mainly the prerogative 

of anesthesiologists [9]. Consequently, the evaluation of international studies on the topic of 

securing the airway in the prehospital phase reveals that emergency services personnel have 

different levels of training. Depending on the personnel employed and how commonly they 

perform intubation, a high rate of esophageal intubations is found in up to 12% of cases in the 

literature [20]. In addition, there is a high rate of failed intubations (up to 15%) [99]. In 

paramedic systems, non-guideline-compliant airway management is more common [39]. Due to 

the different clinical routine of the users, negative outcomes in particular cannot be transferred 

directly from paramedic systems to the German emergency services and emergency physician 

system [60, 89]. In the Federal Republic of Germany, the agreed minimum qualification of 

“Additional qualification in emergency medicine” and the introduction of emergency anesthesia 

in the emergency physician system offers a different scenario compared to the Anglo-American 

paramedic system. 

The following features of the prehospital setting can and must influence the establishing of 

indications and planning of anesthesia, intubation and ventilation: 

� level of experience and routine training of emergency physician 

� circumstances of the medical emergency (e.g., patient is trapped, rescue time) 

� type of transport (land-based versus air support) 

� transport time 

� concomitant injuries around the airway and anything (assessable) that impedes intubation 

Depending on the individual case, the indication to carry out or not to carry out prehospital 

anesthesia, intubation/airway management and ventilation ranges between the extremes of 

“advanced training level, long transport time, simple airway” and “little experience, short 

transport time, predicted difficult airway management”. In any event, sufficient oxygenation 

must be secured by appropriate measures. 

Prehospital – Airway management, ventilation and emergency anesthesia 17


If no methodologically high-quality studies were available, a recommendation would still be 

issued by a consensus of experts if clinically relevant. The following recommendations cover 

emergency anesthesia, airway management and ventilation in the prehospital phase and 

emergency room management. 

Key recommendations 

Emergency anesthesia, endotracheal intubation, and ventilation must be 

carried out in the prehospital phase in multiply injured patients with apnea 

or gasping ( 29 

breaths per minute) 

GoR A 

GoR B 

The multiply injured patient must be preoxygenated before anesthesia. GoR A 

The in-hospital endotracheal intubation, emergency anesthesia and 

ventilation must be carried out by trained, experienced anesthesiologists. 

Explanation: 

GoR A 

Severe multiple injuries have a serious effect on the integrity of the human body in its entirety. 

In addition to the acute trauma consequences for the individual body sections, it causes a 

mediator-mediated whole-body reaction, i.e. Systemic Inflammatory Response Syndrome (SIRS) 

[26, 54]. Tissue oxygenation takes on special significance in this damage cascade. Tissue 

oxygenation can only be achieved if uptake, transport and release of oxygen are guaranteed. 

Oxygen uptake is only possible if the airway is secured, and endotracheal intubation is the gold 

standard according to the current European and non-European guidelines [32, 73, 74]. A severe 

impairment of consciousness due to a traumatic brain injury with a Glasgow Coma Score (GCS) 

< 9 is regarded as an intubation indication [8]. Endotracheal intubation for the consciousnessimpaired 

trauma patient with a GCS ≤ 8 is also recommended both prehospital and in-hospital 

according to the guideline of the Eastern Association for the Surgery of Trauma (EAST) [32] and 

other training programs (e.g., ATLS ® [3]). Hypoxia and hypotension are the “lethal duo” which 

induces secondary damage particularly in polytrauma with traumatic brain injury [18, 19, 52, 87, 

90]. It must be further pointed out that even patients with a GCS of 13 or 14, who were intubated 



endotracheally in the prehospital phase, displayed abnormal cerebral computed tomography 

(38%) and intracranial bleeding (28%) [36]. In a prehospital cohort study, it was shown that 

endotracheal intubation has a positive effect on survival following severe traumatic brain injury 

[56]. Another retrospective study showed a reduced case fatality rate for children with severe 

traumatic brain injury who were intubated by emergency physicians in the prehospital phase as 

compared to those receiving care on Basic Life Support (BLS) and delayed intubation in regional 

trauma centers [91]. If consideration is limited to a pediatric patient population, the prehospital 

endotracheal intubation in this study was carried out by emergency medical personnel with good 

transferability to the German emergency physician system. Using the Trauma and Injury 

Severity Score (TRISS) method, another study also confirms that prehospital endotracheal 

intubation leads to improved outcomes in survival and neurologic function [38]. Another paper 

further showed an improvement in measured systolic blood pressure, oxygen saturation and endtidal 

carbon dioxide (etCO2 compared to the baseline values prior to prehospital intubation in 

patients with severe traumatic brain injury [11]. 

Current review papers, however, refer to heterogeneous patient collectives, differing emergency 

services systems and differently trained users and therefore do not always come to a positive 

conclusion about intubation [9, 12, 25, 31, 60, 62, 69, 74, 98, 100]. The EAST guideline group 

also tackled this problem. In the “Guidelines for Emergency Intubation immediately following 

traumatic injury”, it was claimed that there are no randomized controlled trials on this research 

question. On the other hand, however, the authors of the EAST Guideline also found no studies 

that could present an alternative treatment strategy proven to be effective. In summary, 

endotracheal intubation was assessed overall as such an established procedure in hypoxia/apnea 

that, despite a lack of scientific evidence, a Grade A recommendation was formulated [73]. Other 

indications for endotracheal intubation (e.g., chest injury) are controversial issues in the literature 

[78]. There was evidence that hypoxia and respiratory insufficiency were a consequence of 

severe chest injury (multiple rib fractures, pulmonary contusion, unstable chest wall). 

Endotracheal intubation is recommended if the hypoxia cannot be remedied by oxygenation, by 

the exclusion of tension pneumothorax, and by basic airway management procedures [32]. 

Prehospital endotracheal intubation in patients with severe chest injury is suitable for preventing 

hypoxia and hypoventilation, which are associated with secondary neurologic damage and 

extremely severe consequences for the rest of the body. However, with difficult, prolonged 

intubation attempts and the associated hypoventilation and danger of hypoxia, endotracheal 

intubation itself can cause procedure-related secondary harms or even death. A database analysis 

of the Trauma Registry of the German Trauma Society showed no advantage in prehospital 

endotracheal intubation in patients with chest injury without respiratory insufficiency [78]. 

However, severe chest injury with respiratory insufficiency does present an indication for 

prehospital endotracheal intubation whereby the decision to intubate should be dependent on the 

respiratory insufficiency and not on the (suspected) diagnosis of severe chest injury, which is 

associated with a certain degree of uncertainty [7]. 

Endotracheal intubation is included as an “Advanced Life Support” procedure in the prehospital 

action algorithms of various training programs (e.g., PHTLS ® [71]. Using a scoring system to 

evaluate management problems plus the relevant autopsy reports, a series of fatal traffic 

accidents were retrospectively analyzed to characterize the effectiveness of prehospital care and 

potentially avoidable fatal incidents [76]. This flagged up an extended “prehospital and early in- 



hospital care period” and a “lack of airway securing using intubation” as factors which led to the 

incidence of avoidable fatal incidents [76]. 

A retrospective cohort study of 570 intubated patients compared to 8,137 non-intubated patients 

showed that the prehospital intubated patients had a prehospital phase which was between 5.2- 

10.7 minutes longer than the non-intubated patients [24]. The effect of early intubation within 2 

hours following trauma on the incidence of subsequent organ failure was evaluated in a 

prospective non-randomized study [97]. Despite a significantly higher degree of injury, there 

was a lowered incidence of organ failure and lower case fatality rate in the group of patients who 

were endotracheally intubated “early” within 2 hours following trauma, compared to the “later” 

intubated patients. The following factors must therefore be taken into account in selecting the 

best time to introduce anesthesia and endotracheal intubation: injury pattern, personal experience 

of the emergency physician/anesthesiologist, environmental conditions, transport distance, 

available equipment and complications associated with the procedure. Taking these points into 

consideration, the definitive care that the multiply injured patient should receive is emergency 

anesthesia with endotracheal intubation and ventilation. With the appropriate indication and 

appropriate training level, endotracheal intubation should be performed prehospital but, at the 

latest, during emergency room management. According to the analysis of data from the Trauma 

Registry of the German Trauma Society, out of 24,771 patients, 31% were unconscious at the 

accident scene (GCS < 9), 19% had severe hemodynamic instability (systolic blood pressure 

< 90 mmHg) and, overall, 55% of patients were endotracheally intubated by the emergency 

physician during the prehospital phase [77]. According to this analysis, in the case of 9% of 

multiply injured patients, it was necessary to discontinue the emergency room phase in hospital 

in favor of an emergency intervention/surgery; a total of 77% of multiply injured patients 

received surgery and 87% needed intensive care [77]. Due to a traumatic brain injury and/or 

chest injury, many multiply injured patients required intensive care ventilation and invasive 

ventilation therapy and all required adequate pain relief. In the study mentioned, the mean 

ventilation period for multiply injured patients was 9 days [77]. 

In order to prevent the harmful effects of hypoxia and hypoventilation, emergency anesthesia 

and endotracheal intubation and ventilation should be introduced prehospital or, at the latest, 

during emergency room care for the appropriate indication and with the appropriate training 

level. A large retrospective study using a trauma registry from a Level I trauma center studied 

6,088 patients who received endotracheal intubation within the first hour following hospital 

admission [88]. In addition, according to this trauma registry, a further 26,000 trauma patients 

were endotracheally intubated after the first hour of hospital care on the day of admission. In the 

hands of experienced anesthesiologists, the “rapid sequence induction” proved in these cases to 

be an effective, safe procedure in hospital care: no patient died as a result of endotracheal 

intubation. Of 6,088 patients, 6,008 were successfully intubated orotracheally (98.7%) and a 

further 59 nasotracheally (0.97%). Only 17 patients (0.28%) had to have a cricothyroidotomy 

and 4 patients (0.07%) received an emergency tracheotomy. Following the endotracheal 

intubation, 3 more patients received an emergency tracheotomy during the course [88]. In 

another retrospective study of a monocenter trauma registry, 1,000 trauma patients (9.9% out of 

10,137 patients) who had been endotracheally intubated within 2 hours of admission to the 

Trauma Center were studied [85]. At < 1%, the incidence of surgically securing the airway was 

uncommon in this study as well. Aspiration occurred in 1.1% of cases of endotracheal intubation. 



Early intubation was seen as safe and effective by the authors [85]. These data also confirm that 

endotracheal intubation of trauma patients is a safe procedure in the hands of trained personnel. 

Another retrospective study from a paramedic-supported system with 175 endotracheally 

intubated patients showed a success rate of 96.6% with a markedly higher cricothyroidotomy 

rate of 2.3% [37]. In 1.1% of cases, the patient was ventilated by bag-valve-mask during transfer 

to hospital. There were 5 instances found of right mainstem dislocation (2.9%) and 2 cases of 

tube dislocation (1.1%). No case of failed intubation was documented. 

In a retrospective study of a trauma registry, 3,571 prehospital endotracheal intubations in 

trauma patients were compared with 746 in the emergency room phase [6]. The endotracheal 

intubation first carried out during emergency admission was associated with a higher risk of a 

fatal course compared both to non-intubated patients (odds ratio [OR] 3.1; 95% confidence 

interval [-CI]; 2.1–4.5, p < 0.0001) and to patients who had already been endotracheally 

intubated in the prehospital phase (OR 3.0; 95% CI: 1.9–4.9, p < 0.0001) [6]. In addition, it was 

shown that patients who had been endotracheally intubated in the prehospital phase did not have 

a higher risk of dying than non-intubated patients in the emergency room phase (OR: 1.1; 95% 

CI: 0.7–1.9; p = 0.6). The authors concluded that the patients who were endotracheally intubated 

during emergency admission should have already been intubated in the prehospital phase [6]. 

In a prehospital cohort study with comparable injury severity (ISS 23 versus 24) and similar 

duration of care (27 versus 29 min, p = n.s.), 60 patients were treated by emergency services 

personnel (emergency medical technician [EMT], intubation rate 3%) and 64 patients in 

Advanced Life Support mode by emergency physicians (intubation rate 100%). Oxygen 

saturation was significantly improved upon arrival in hospital (SaO2: 86 versus 96; p = 0.04) and 

systolic blood pressure was significantly higher (105 versus 132 mmHg, p = 0.03). There was no 

difference in all-cause case fatality rate (42% versus 40%, p = 0.76). However, a sub-group 

analysis showed a significant survival advantage for those patients with a GCS between 6 and 8 

who had been treated by an emergency physician (case fatality rate: 78 versus 24%, p < 0.01; OR 

3.85, 95% CI: 1.84–6.38, p < 0.001). The authors concluded that the case fatality rate is reduced 

by a prehospital emergency physician system offering rapid sequence induction, sufficient 

oxygenation and circulation drug therapy particularly for patients with clouded consciousness 

[56]. 

In the German-speaking emergency physician system, pediatric and adult emergency patients 

can be endotracheally intubated with a very high success rate if this procedure is carried out by 

experienced and trained personnel. In a prospective study over a period of 8 years, 4% of all 

pediatric emergency patients (82 out of 2,040 children) were endotracheally intubated [35]. 

Pediatric emergency callouts made up 5.6% of all emergency calls (2,040 out of 36,677 

emergency physician callouts). Anesthesiologists carried out 58 of the pediatric endotracheal 

intubations with a success rate of 98.3%. Based on the incidence, the known number of 

emergency physicians employed each year, and their absolute number of callouts, it was 

calculated that each emergency physician in the emergency physician service has a gap of, on 

average, 3 years between pediatric endotracheal intubations and 13 years between infant 

endotracheal intubations. These results show that endotracheal intubation in childhood is rare 

outside the hospital setting and special attention must therefore be paid to maintaining specialist 



expertise and appropriate training outside the emergency services and emergency physician 

service. 

A prospective study of a cohort of 16,559 patients managed in the prehospital phase included 

2,850 trauma patients of which 259 (9.1%) were endotracheally intubated. More than 2 attempts 

were required in 3.9% of cases before endotracheal intubation was successful, and there was a 

failed intubation in 3.9% of cases. A difficult airway was described in 18.2% of cases. In 

comparison, patients with cardiac arrest had a difficult airway in only 16.7% of cases. This study 

also showed a success rate of 98.0% by anesthesia-trained emergency physicians [94]. Another 

prospective study of an emergency physician system showed a success rate of 98.5% in 598 

patients (of which 10% were trauma patients ) [92]. In another prospective study, endotracheal 

intubation by anesthesia-trained emergency physicians achieved a 100% success rate in a 

collective of 342 patients [n = 235 (68.7%) trauma patients]. In this case, endotracheal intubation 

was successful at the first attempt in 87.4% of cases, at the second attempt in 11.1% and at the 

third attempt in 1.5% [48]. Another study of the German emergency physician system showed a 

success rate of 97.9% in prehospital endotracheal intubation of trauma patients [1]. 

In a retrospective cohort study with 194 patients with traumatic brain injury, there was a 

significant difference in the case fatality rate between patients treated with basic life support 

(BLS) procedures in the land-based emergency services and patients who were treated with 

advanced life support (ALS) procedures by anesthesiologists in the air-borne emergency services 

(25 versus 21 %, p < 0.05). In this study, the survival rate of patients with traumatic brain injury 

who were treated highly significantly with more invasive measures in the air rescue group 

(intubation 92 versus 36%, chest drain 5 versus 0%) was better than the survival rate of patients 

treated in the land-based emergency services (54 versus 44%, p < 0.05) [10]. 

Procedural-related complications 

Regarding procedural-related complications, a retrospective study using data from a trauma 

registry showed that there was no higher risk of pneumonia developing in 271 prehospital and 

357 in-hospital endotracheally intubated trauma patients [96]. Regarding epidemiological data, 

prehospital intubated patients showed a lower GCS (4 versus 8, p < 0.001) and a higher injury 

severity according to the ISS (25 versus 22, p < 0.007) but otherwise no differences in the patient 

characteristics. Nevertheless, although it was to be expected, there was no difference in the 

length of hospital stay for both patient collectives (15.7 versus 15.8 d), in the length of intensive 

care stay (7.6 versus 7.3 d), in the number of days on a ventilator (7.8 versus 7.2 d), in the case 

fatality rate (31.7 versus 28.2%), and in the rate of resistant bacteria (46% in each case). On 

average, it took 3 days until the onset of pneumonia in both groups and the pneumonia rate was 

also not significantly different in both groups [96]. However, a significantly increased rate of 

pneumonia following prehospital intubation compared to in-hospital intubation was observed in 

another study [86]. However, this had no influence on the 30-day case fatality rate and the 

number of days in intensive care. Moreover, the group of prehospital intubated patients had an 

increased injury severity. In another study, frequency of pulmonary complications was found to 

be related to injury severity but not to intubation mishaps [84]. It cannot be definitely proven that 

prehospital endotracheal intubation is related to the incidence of pulmonary complications. In a 

retrospective study of 244 patients endotracheally intubated in the prehospital phase by an 



emergency physician, desaturation with an SpO2 < 90% was documented in 18% of cases and 

hypotension with systolic blood pressure < 90 mmHg in 13% of cases. The two complications 

did not occur in parallel in any of the cases [72]. Overall, a low complication rate can be 

accordingly assumed. 

Preoxygenation 

To avoid a fall in oxygen saturation during the introduction of anesthesia and endotracheal 

intubation, the multiply injured patient should, if practicable, be preoxygenated for up to 4 

minutes with an oxygen concentration of 100% via a face mask with reservoir [74]. In a nonrandomized 

controlled study of 34 intensive-care patients, the mean paO2 was (T0) 62 

± 15 mmHg at the start of preoxygenation, (T4) 84 ± 52 mmHg after 4 minutes, (T6) 88 

± 49 mmHg after 6 minutes and (T8) 93 ± 55 mmHg after 8 minutes. The differences in paO2 

were significantly different between T0 and T4–8 , but no statistical differences could be obtained 

between the paO2 between T4, T6 and T8. 24% of patients even showed a reduction in the paO2 

between T4 and T8. A longer period of preoxygenation for 4 to 8 minutes did not lead to any 

further marked improvement in arterial oxygen partial pressure and delayed securing the airway 

in critical patients [67, 68]. Accordingly, sufficient preoxygenation for 4 minutes has special 

importance in securing the airway in multiply injured patients. 

Training 

Key recommendation: 

Emergency medical personnel must be regularly trained in emergency 

anesthesia, endotracheal intubation, and alternative ways of securing an 

airway (bag-valve-mask, supraglottic airway devices, emergency 

cricothyroidotomy). 

Explanation: 

GoR A 

In a survey recently carried out among prehospital trained emergency physicians, they were 

questioned on their knowledge of and experience in endotracheal intubation and the alternative 

methods for securing an airway [93]. This survey included the responses from 340 

anesthesiologists (56.1%) and 266 non-anesthesiologists. It revealed that all anesthesia-trained 

emergency physicians could demonstrate more than 100 endotracheal intubations performed in 

hospital in contrast to only 35% of non-anesthesiologists performing more than 100 in-hospital 

intubations. A similar picture emerges for alternative methods for securing an airway as well. 

97.8% of anesthesia-trained emergency physicians had used alternative methods for securing an 

airway on more than 20 occasions while only 11.1% of non-anesthesia-trained emergency 

physicians had equivalent experience (p < 0.05). In addition, it emerges that only 27% of 

emergency equipment was equipped with CO2 monitors. From this study it can be concluded 

that there is an urgent training need for non-anesthesia-trained emergency physicians in 

endotracheal intubation, capnography and alternative methods for securing an airway [74]. 

Studies on first-year anesthesiology residents showed that more than 60 intubations were 



necessary in order to achieve a success rate of 90% within the first two endotracheal intubation 

attempts under standardized, optimum conditions in surgery [57]. However, as the success of 

alternative methods for securing an airway (e.g., supraglottic airways: laryngeal mask, laryngeal 

tube) can only be as good as the corresponding training level in this procedure and current 

evidence indicates that a corresponding training level is not available everywhere [93], 

endotracheal intubation continues to be the gold standard. This knowledge also illustrates that 

emergency medical personnel should be regularly trained in endotracheal intubation and 

alternative ways of securing an airway [74]. 



Alternative methods for securing an airway 


A difficult airway must be anticipated when endotracheally intubating a 

trauma patient. 

Alternative methods for securing an airway must be provided when 

anesthetizing and endotracheally intubating a multiply injured patient. 

Fiberoptic intubation must be available as an alternative when anesthetizing 

and endotracheally intubating in-hospital. 

If difficult anesthetization and/or endotracheal intubation are expected, an 

anesthesiologist must carry out or supervise this procedure in-hospital 

provided this does not cause a delay in an emergency life-saving measure. 

Suitable measures must be in place to ensure that an anesthesiologist is 

normally on site in time 

After more than 3 intubation attempts, alternative methods must be 

considered for ventilation and securing an airway. 

Explanation: 

GoR A 

GoR A 

GoR A 

GoR A 

GoR A 

Due to the framework conditions, the endotracheal intubation of an emergency patient is 

markedly more difficult in the prehospital environment than in-hospital. A difficult airway must 

therefore always be anticipated when endotracheally intubating a trauma patient [74]. In a large 

study of 6,088 trauma patients, risk factors and difficulties in endotracheal intubation consisted 

of foreign bodies in the pharynx or larynx, direct injuries to the head or neck with loss of normal 

anatomy in the upper airway, airway edema, pharyngeal tumors, laryngospasms and a difficult 

pre-existing anatomy[88]. In another study, trauma patients presented difficult airway securing 

markedly more frequently (18.2%) than, for example, patients with cardiac arrest (16.7%) and 

patients with other diseases (9.8%). Reasons described for difficult airway management were the 

position of the patient (48.8% of cases), difficult laryngoscopy (42.7% of cases), secretion or 

aspiration in the oropharynx (15.9% of cases) and traumatic injuries (including bleeding/burns) 

in 13.4% of cases [94]. Technical problems occurred in 4.3% and other causes in 7.3% of cases. 

Further studies show a similar frequency of causes of difficult intubation (blood 19.9%, vomit 

15.8%, hypersalivation 13.8%, anatomy 11.7%, changes in anatomy caused by trauma 4.4%, 

position of patient 9.4%, lighting conditions 9.1%, technical problems 2.9% [48]. In a 

prospective study with 598 patients, adverse events and complications occurred significantly 

more frequently in patients with severe injuries than non-traumatized patients (p = 0.001) [92]. 

At least one event was documented in 31.1% of traumatized patients. The number of attempts 

required for intubation was also significantly increased in traumatized patients (p = 0.007) [92]. 



An increased risk of difficult intubation exists particularly in patients with severe maxillofacial 

trauma (OR 1.9, 95% CI: 1.0–3.9, p = 0.05) [22]. Maxillofacial trauma even represents an 

independent factor for difficult airway management (OR 2.1, 95% CI: 1.1–4.4, p = 0.038). A 

retrospective analysis of a trauma registry over a period of 7 years identified 90 patients with 

severe maxillofacial injuries. Of these, 93% initially received definitive airway securing, in 80% 

of cases by means of endotracheal intubation and in 15% of cases through surgical airway 

securing [21]. On the basis of these available data, the trauma patient must definitely be assumed 

to be non-fasting. In addition, blood, vomit or other fluids associated with a more difficult 

intubation situation must be expected in the oropharynx to a greater extent. A high-performance 

suction unit must therefore be available as a matter of course. For structure- and process-related 

reasons, the possibility of a back-up procedure with an experienced anesthesiologist often does 

not exist in the prehospital setting but in-hospital the gold standard is generally to involve an 

anesthesiologist in the management when difficult intubations and anesthesia are expected. In a 

prospective cohort study, it was therefore shown that if an attending physician in anesthesiology 

was present at in-hospital emergency intubations, significantly fewer complications occurred 

(6.1 versus 21.7%, p < 0.0001) [81]. However, there was no difference in the ventilation-free 

days and the 30-day case fatality rate. 

If endotracheal airway securing fails, an appropriate algorithm must be followed, reverting back 

to bag-valve-mask ventilation and/or alternative methods of securing an airway [4, 15, 49, 73, 

74]. In a prospective study, intubation success was evaluated in 598 patients in an emergency 

physician system solely staffed by anesthesiologists. Endotracheal intubation was successful at 

the first attempt in 85.4% of all patients. Only 2.7% required more than two attempts, and 1.5% 

(n = 9) had supralaryngeal aids such as the Combitube (n = 7), laryngeal mask (n = 1) or an 

emergency cricothyroidotomy (n = 1) after the third unsuccessful intubation attempt [92]. The 

study illustrates that alternative methods must be provided even in highly professional systems 

[55]. 

In a retrospective study of 2,833 patients endotracheally intubated in-hospital at a Level I trauma 

center, it was shown that the risk of airway-associated complications was markedly increased 

with more than 2 intubation attempts: hypoxemia 11.8 versus 70%, regurgitation 1.9 versus 22%, 

aspiration 0.8 versus 13%, bradycardia 1.6 versus 21%, cardiac arrest 0.7 versus 11% [65]. 

Another study, which was prospective and multi-center, examined over an 18-month period how 

many intubation attempts (inserting the laryngoscope into the oral cavity) were necessary for 

successful endotracheal intubation in emergency patients [101]. In 94% of cases, endotracheal 

intubation was carried out by paramedics and in a further 6% by nurses or emergency physicians. 

Overall, 1,941 endotracheal intubations were carried out, of which 1,272 (65.5%) were in 

patients with cardiac arrest, 463 (23.9%) as intubation without drug administration in patients 

without cardiac arrest, 126 (6.5%) as intubations under sedation in patients without cardiac 

arrest, and 80 (4.1%) by means of rapid sequence induction using a hypnotic agent and a muscle 

relaxant. Over 30% of patients required more than one intubation attempt to achieve successful 

endotracheal intubation. More than 6 intubation attempts were not reported in any case. The 

cumulative success rate during the first, second and third intubation attempt was 70%, 85% and 

90% in patients with cardiac arrest. It was thus markedly higher than in the other 3 patient 

subgroups with intact circulatory function (intubation without drugs: 58%, 69% and 73%; 

intubation under sedation: 44%, 63% and 75%; intubation by means of rapid sequence induction: 



56%, 81% and 91%). The specific success rates of endotracheal intubation by paramedics, nurses 

and emergency physicians were not broken down further. The results of this study [101] show 

that the cumulative success rate of endotracheal intubation in a paramedic system is markedly 

below that of emergency physician systems staffed solely by anesthesiologists, whose rate is 97- 

100% [48, 92, 94]. However, the administration of drugs, as they are used during a rapid 

sequence induction (including muscle relaxants), helps to facilitate endotracheal intubation in 

patients without cardiac arrest and thus leads to a markedly higher intubation success. Both are 

frequently vital for survival in an emergency situation. According to the above-cited study 

results, alternative methods should be considered for securing an airway after more than 3 

intubation attempts [4, 65]. Although fiberoptic procedures are only available in isolated cases in 

the prehospital phase, fiberoptic intubation must be available in-hospital. In all common 

guidelines and recommendations on emergency airway securing, (awake) fiberoptic intubation is 

considered a possible procedure for securing an airway if there is appropriate experience and 

appropriate environmental conditions [33, 46, 49, 59]. 

In contrast, emergency cricothyroidotomy is simply the last resort in a “cannot ventilate - cannot 

intubate” situation to secure ventilation and oxygenation in an emergency. In national and 

international recommendations and guidelines, emergency cricothyroidotomy has a firm place in 

prehospital and hospital phases and is indicated if alternative methods for securing an airway and 

bag-valve-mask ventilation are not successful [9, 46, 49, 70]. 



Monitoring emergency anesthesia 


ECG, blood pressure measurement, pulse oxymetry and capnography must be 

used to monitor the patient for anesthesia induction, endotracheal intubation 

and emergency anesthesia. 

Explanation: 

GoR A 

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) lays down certain 

features for a “standard workplace” in its update to the directives on equipping the 

anesthesiology workplace [27]. Special attention must be paid to the often difficult prevailing 

circumstances (e.g., physical confines, unfavorable lighting conditions, limited resources) in 

prehospital emergency medicine and particularly in the care of trauma patients. 

The following items of equipment should be available in the prehospital phase for carrying out 

and monitoring emergency anesthetization [74]: electrocardiogram (ECG), non-invasive blood 

pressure measurement, pulse oxymetry, capnography/capnometry, defibrillator, emergency 

respirator, and suction unit. Appropriate equipment must be provided based on the guideline 

“Airway Management” of the German Society of Anesthesiology and Intensive Care Medicine 

[15] and the German DIN standards for emergency physician vehicle (NEF) [28], rescue 

helicopter (RTH) [29] and ambulance (RTW) [30]. 

In-hospital, the directives of the DGAI must be followed in the emergency room and in the other 

hospital wards [27]. 

Emergency ventilation and capnography 


During endotracheal intubation in the prehospital and in-hospital phases, 

capnometry/capnography must be used for monitoring tube placement and 

then for monitoring dislocation and ventilation. 

Normoventilation must be carried out in endotracheally intubated and 

anesthetized trauma patients. 

From emergency room treatment onwards, ventilation must be monitored 

and controlled by frequent arterial blood gas analyses. 

GoR A 

GoR A 

GoR A 



Explanation: 

In the prehospital and in-hospital phases, capnometry/capnography must always be used during 

endotracheal intubation for monitoring the placement of the tube and then to reduce incidence of 

dislocation and monitor ventilation. Capnography is an essential component here in monitoring 

the intubated and ventilated patient [74]. Normoventilation should be carried out in 

endotracheally intubated and anesthetized trauma patients. From emergency room treatment 

onwards, ventilation must be monitored and controlled by frequent arterial blood gas analyses. 

Capnography for monitoring tube placement and dislocation 

The most serious complication in endotracheal intubation is an unrecognized esophageal 

intubation, which can lead to the death of the patient. This is why, both prehospital and inhospital, 

all methods must be applied to recognize esophageal intubation and remedy it 

immediately. 

The percentage of esophageal intubations reported in the literature starts at less than 1% [100, 

106] spanning 2% [40], 6% [75], and reaching almost 17% [53]. Moreover, a high case fatality 

rate was shown as a result of tube misplacement in the hypopharynx (33%) or in the esophagus 

(56%) [53]. Esophageal intubation is thus not a rare event and, particularly in recent years, 

various studies have examined this catastrophic complication of endotracheal intubation in 

Germany as well. In a prospective observational study, helicopter emergency physicians trained 

in anesthesiology identified an esophageal tube placement in 6 out of 84 (7.1%) trauma patients, 

who had been intubated by land-based emergency physicians before arrival of the helicopter, and 

an endobronchial tube placement in 11 (13.1%) [95]. The case fatality rate of esophageally 

intubated patients was 80% in this study. In another prospective study with 598 patients in a 

German emergency physician system, the rate of esophageal intubations by non-medical 

personnel or physicians before arrival of the actual emergency physician system was 3.2% [92]. 

Another prospective observational study revealed esophageal intubation in 5.1% of 58 patients, 

who had been intubated by the land-based emergency service or emergency physician before 

arrival of the helicopter emergency physician trained in anesthesiology [43]. In a study focusing 

on the admitting emergency room team, esophageal intubation was found in 4 out of 375 

prehospital intubated and ventilated patients (1.1%) [41]. 

In a prospective observational study of 153 patients, evidence showed that none of the patients 

who had been monitored by capnography had an unrecognized misplaced intubation, but 14 out 

of the 60 patients (23.3%) not monitored by capnography had [83]. Capnography therefore 

belongs in the standard equipment of the anesthesiology workplace and has dramatically 

increased the safety of anesthesia. 

In a prospective observational study with 81 patients (n = 58 severe traumatic brain injury [TBI], 

n = 6 maxillofacial trauma, n = 17 multiple injuries), markedly greater sensitivity and specificity 

was demonstrated by monitoring tube placement by capnography compared to auscultation only 

(sensitivity: 100 versus 94%; specificity: 100 versus 66%, p < 0.01) [44]. These data prove that 

capnography must always be used for monitoring tube placement. 



A survey found that in Baden-Wurttemberg only 66% out of 116 emergency physician sites had 

capnography available in 2005 [42]. There is an urgent need here for optimization. In addition, it 

is unknown how often available capnography is actually used in prehospital endotracheal 

intubation, tube position verification, and emergency ventilation monitoring. The goal must be to 

reach a capnography rate of 100% in the prehospital and in-hospital phases. On the basis of the 

guideline “Airway Management” of the German Society of Anesthesiology and Intensive Care 

Medicine and the German DIN standards for emergency physician vehicles (NEF) [28], rescue 

helicopters (RTH) [29] and ambulances (RTW) [30] on the mandatory availability of 

capnography, the lack of appropriate equipment basically constitutes organizational negligence 

[42]. 

Capnography for normoventilation 

The introduction of emergency anesthetization is not only used to maintain adequate 

oxygenation but also effective ventilation and thus the elimination of carbon dioxide (CO2), 

which accumulates in the human metabolism. Both an accumulation of CO2 (hypercapnia and 

hyperventilation) and hyperventilation with consecutive hypocapnia can cause damage 

particularly in patients with traumatic brain injury and must be avoided in the first 24 hours [14, 

16]. This results in a vicious circle of elevated intracranial pressure, hypercapnia, hypoxemia, 

further cellular swelling/edema and subsequent further increase in intracranial pressure. 

In a retrospective analysis of prehospital care data from 100 prehospital intubated and ventilated 

patients, it was shown that an etCO2 > 30 mmHg was attained in 65 patients and an etCO2 ≤ 29 

mmHg in 35 patients. A lower case fatality rate was noticeably more likely in normoventilated 

patients (case fatality rate: 29 versus 46%; OR 0.49, 95% CI: 0.1–1.1, p = 0.10) [17]. 

In a prospective observational study, only 155 out of 492 patients intubated and ventilated in the 

prehospital phase showed a paCO2 between 30 and 35 mmHg in the initial arterial blood gas 

analysis (BGA) in the emergency room and were thus (according to the study protocol) 

normoventilated [102]. Eighty patients (16.3%) who were hypocapnic (paCO2 < 30 mmHg), 188 

patients (38.2%) who were mildly hypercapnic (paCO2 36–45 mmHg) and 69 patients (14.0 %) 

who were severely hypercapnic (paCO2 > 45 mmHg) were ventilated. The injury severity of the 

severely hypercapnic patients (paCO2 > 45 mmHg) was markedly higher and these patients also 

had hypoxia, acidosis or hypotension significantly more frequently compared to the other 3 

groups. The case fatality rate of prehospital intubated and ventilated trauma patients both with 

and without TBI was specifically lowered by normoventilation (OR: 0.57, 95% CI: 0.33–0.99), 

with patients with isolated TBI gaining more markedly from normoventilation (OR: 0.31, 95% 

CI: 0.31–0.96). According to the available results, hyperventilation with consecutive hypocapnia 

(paCO2 < 30 mmHg) in particular appears to be harmful in severely injured patients. These 

results make clear that, from emergency room treatment onwards, ventilation should be 

monitored and controlled by frequent arterial blood gas analyses. 

In a prospective study of 97 patients, it was shown that patients monitored by capnography had a 

significantly higher rate of normoventilations (63.2 versus 20%, p < 0.0001) and significantly 

fewer hypoventilations (5.3 versus 37.5%, p < 0.0001) compared to patients who were ventilated 

without capnography monitoring but by using the 10-10 rule [47]. Capnography is thus an 



orientating procedure in emergency ventilation. When capnography is used for controlling 

ventilation, it must be taken into account that the correlation between etCO2 and paCO2 is 

nevertheless weak (r = 0.277) [104]. As a result of a prospective observational study with 180 

patients, 80% of patients with an etCO2 of 35–40 mmHg were indeed hypoventilated (paCO2 

> 40 mmHg). In a prospective study of 66 intubated and ventilated trauma patients, those 

patients in particular with high injury severity according to the ISS, hypotension, severe chest 

injury, and metabolic acidosis revealed a larger difference between etCO2 and paCO2 [61]. Thus, 

the arterial CO2 (paCO2) cannot always be directly inferred from the CO2 (etCO2) obtained by 

capnography [74]. This is due to the fact that good correlation between etCO2 and paCO2 under 

physiologic conditions is negatively affected by pulmonary shunt fractions in pulmonary 

contusions, atelectasis, hypotension and metabolic acidosis. 

Thus, capnography primarily serves to evaluate tube placement and to monitor on-going 

ventilation, with ventilation control a secondary use. This was also briefly demonstrated in a 

retrospective cohort study with 547 trauma patients: all trauma patients and especially patients 

with severe TBI gained from paCO2-controlled ventilation (OR: 0.33, 95% CI: 0.16–0.75). There 

was a significant survival advantage if paCO2 was already between 30 and 39 mmHg on 

admission to the emergency room (OR 0.32, 95% CI: 0.14–0.75). In patients whose paCO2 could 

only be brought into the target range during their stay in the emergency room, there was only a 

non-significant trend towards a lower case fatality rate (OR 0.48, 95% CI: 0.21–1.09). A 

markedly worse survival rate was shown by those trauma patients who initially had a paCO2 of 

30–39 mmHg but were then hypoventilated (paCO2> 39 mmHg) or hyperventilated 

(paCO2 < 30 mmHg) or who never attained the target goal of a paCO2 of 30–39 mmHg during 

their stay in the emergency room. This study also illustrates that paCO2 must not be freely 

inferred from etCO2 [102]. 

Using capnography to check tube placement and to detect tube dislocations is advisable and 

essential. Capnography is the gold standard in standard anesthesia, and ventilation management 

is markedly better with capnography than without this procedure. There are limitations to 

ventilation management using capnography due to unpredictable shunt fractions. For this reason, 

ventilation must be managed by blood gas analysis as early as possible, in other words 

immediately upon admission to the emergency room. 

Lung protective ventilation 

In a prospective randomized study, ventilation with a small tidal volume (6 ml/kg BW) in 

patients with acute respiratory distress syndrome (ARDS) led to a significantly reduced case 

fatality rate and a lower incidence of barotrauma and improved oxygenation compared to 

ventilation with high tidal volume [2]. The multi-center randomized, controlled trial conducted 

by the ARDS network confirmed these results in a ventilation with low tidal volume and limiting 

plateau pressure to ≤ 30 cm H2O in patients with ARDS [5]. Chest injuries are observed in 

around 60% of multiply injured patients with the corresponding consequences (e.g., pulmonary 

contusions, ARDS), and the development of an acute lung injury (ALI) as an independent factor 

is associated with the case fatality rate (case fatality rate of trauma patients with ALI [n = 93]: 

23.7 versus without ALI [n = 190]: 8.4%, p < 0.01) [82]. Thus, lung protective ventilation with a 



tidal volume of 6 ml/kg BW and with the lowest possible peak pressures must be implemented as 

early as possible following endotracheal intubation [45]. 

Emergency anesthesia 


For endotracheal intubation in multiply injured patients, emergency 

anesthesia must be carried out as rapid sequence induction due to the usual 

lack of a fasting state and risk of aspiration. 

Etomidate should be avoided as an induction agent due to the associated side 

effects on adrenal function (ketamine is usually a good alternative here). 

Explanation: 

GoR A 

GoR B 

Emergency anesthesia is frequently an unavoidable component of the proper care of a multiply 

injured patient. Anesthesia induction must be carried out in a structured way; if carried out 

improperly, it is associated with an increased risk of morbidity and case fatality rate [74]. In a 

retrospective study, compared to non-emergency intubation (n = 2,136), emergency intubation (n 

= 241) was linked to a markedly higher risk of severe hypoxemia (SpO2 < 70%: 25 versus 4.4%, 

p < 0.001), regurgitation (25 versus 2.4%, p < 0.001), aspiration (12.8 versus 0.8%), bradycardia 

(21.3 versus 1.5%, p < 0.001), arrhythmia (23.4 versus 4.1%, p < 0.001) and cardiac arrest (10.2 

versus 0.7%, p < 0.001) [66]. 

In trauma patients, an airway is secured and anesthesia induction is normally carried out as rapid 

sequence induction (RSI) (ileus or crash induction) to secure an airway in the shortest possible 

time without aspiration if possible. In a prospective study, an evaluation was conducted over an 

18-month period on how many intubation attempts (inserting the laryngoscope into the oral 

cavity) were necessary for successful endotracheal intubation in 1,941 emergency patients. The 

cumulative intubation success in patients with intact circulatory function differed greatly in the 

first 3 intubation attempts between patients who received intubation entirely without drugs (58%, 

69% and 73%), intubation only under sedation (44%, 63% and 75%) or intubation by means of 

rapid sequence induction (56%, 81% and 91%) [101]. There was a high rate of failed intubations 

in other studies as well where no muscle relaxants were administered to optimize the intubation 

conditions during anesthesia induction for endotracheal intubation [34]. Drug-supported 

anesthesia induction in terms of rapid sequence induction is therefore vital for the success of 

endotracheal intubation. 

Depending on the hemodynamic state of the patient, the injury pattern, and the personal 

experience of the physician, various induction hypnotic agents can be used here (e.g., etomidate, 

ketamine, midazolam, propofol, thiopental). Each of these drugs has its own pharmacologic 

profile and associated side effects (e.g., etomidate: superficial anesthesia, affects the adrenal 

function, ketamine: arterial hypertension, midazolam: slower onset of effect, superficial 

anesthesia, propofol: arterial hypotension, thiopental: releases histamine and triggers asthma, 



necrosis due to extravasation). Ketamine in particular can be used, also in combination with 

midazolam or low-dose propofol, for rapid sequence induction in patients with marked 

hemodynamic instability [51, 64, 74]. For analgesics, fentanyl or sufentanil is suitable for 

patients with stable circulation and ketamine for patients with unstable circulation [51, 64, 74]. 

Etomidate 

Etomidate will be looked at in more detail below because important side effects have been 

discussed of late. In a retrospective analysis of the data from a trauma registry, the potentially 

negative effects from using etomidate in severe trauma were shown [105]. Etomidate was given 

to 35 out of 94 trauma patients (37%) during rapid sequence induction. There were no 

differences between the patients treated with and without etomidate in the demographic data 

(age: 36 versus 41 years), the cause of trauma, and the injury severity (injury severity score: 26 

versus 22). After adjustment of the data (according to physiology, injury severity and 

transfusion), etomidate was linked to an increased risk of ARDS and multiple organ failure 

(adjusted OR: 3.9, 95% CI: 1.24–12.0). The trauma patients anesthetized with a single dose of 

etomidate also had a longer hospital stay (19 versus 22 d, p < 0.02), more ventilation days (11 

versus 14 d, p < 0.04) and a longer intensive care stay (13 versus 16 d, p < 0.02). 

In another retrospective study of a US trauma registry, the results of the cosyntropin stimulation 

test (CST) on 137 trauma patients in intensive care units were examined [23]. 61% of the trauma 

patients were non-responders. Age (51 ± 19 versus 50 ± 19 years), sex (male: 38 versus 57%), 

trauma mechanism and injury severity (injury severity score: 27 ± 10 versus 31 ± 12, Revised 

Trauma Score: 6.5 ± 1.5 versus 5.2 ± 1.8) did not differ significantly between responders and 

non-responders. In addition, the rate of sepsis/septic shock (20 versus 34%, p = 0.12), the need 

for mechanical ventilation (98 versus 94%, p = 0.38) and the case fatality rate (10 versus 19%, 

p = 0.67) did not differ between the two groups. However, there were significant differences in 

the incidence of hemorrhagic shock (30 versus 54%, p < 0,005), the need for vasopressors (52 

versus 78%, p < 0.002), the incidence of coagulopathies (13 versus 41%, p < 0.001), the period 

in intensive care (13 ± 12 versus 19 ± 14, p < 0.007), the number of ventilation days (12 ± 13 

versus 17 ± 17, p < 0.006) and the use of etomidate as an induction hypnotic agent (52 versus 

71%, p < 0.03). The authors concluded that etomidate is one of the few modifiable risk factors 

for the development of adrenocortical insufficiency in critically ill trauma patients. 

In another prospective, randomized study, after arriving in a Level I trauma center, trauma 

patients received either etomidate and succinylcholine or fentanyl, midazolam and 

succinylcholine for rapid sequence induction [50]. The baseline serum cortisol concentration was 

recorded before anesthesia induction and an ACTH (adrenocorticotropic hormone) test was 

carried out. Altogether, 30 patients were examined. The 18 patients in the etomidate group 

showed no significant differences compared to the 12 patients treated with fentanyl/midazolam 

with regard to the following patient characteristics (age: 42 ± 25 versus 44 ± 20 years, p = 0.802; 

Injury Severity Score: 27 ± 10 versus 20 ± 11 years, p = 0.105; baseline serum cortisol 

concentration: 31 ± 12 versus 27 ± 10 µg/dl, p = 0.321). The patients treated with etomidate 

showed a slight rise in serum cortisol concentration after the ACTH test compared to the patients 

treated with fentanyl/midazolam (4.2 ± 4.9 µg/dl versus 11.2 ± 6.1 µg/dl, p < 0.001). The 

patients treated with etomidate had a longer stay in intensive care (8 versus 3 d, p = 0.011), a 



longer period of ventilation (6.3 versus 1.5 d, p = 0.007) and longer hospital treatment (14 versus 

6 d, p = 0.007). Two trauma patients in this study collective died, and both had been treated with 

etomidate. The authors concluded that other induction hypnotic agents instead of etomidate 

should be used for trauma patients. 

Overall, the current data status shows rather unfavorable results for the use of etomidate in 

trauma patients. Thus, etomidate should only be used with great care and deliberation in the 

induction of trauma patients. 



Procedure for endotracheal intubation with suspected cervical spine injury 


Manual in-line stabilization should be carried out for endotracheal 

intubation with the cervical spine immobilization device temporarily 

removed. 

Explanation: 

GoR B 

Normally, trauma patients, particularly multiply injured patients, are immobilized with a neck 

brace until a cervical spine fracture can be excluded by imaging technology. However, a 

correctly positioned cervical spine immobilization device restricts the mouth opening and thus 

the ability to insert a laryngoscope during an intubation maneuver. The cervical spine 

immobilization device prevents reclination of the head. Thus, it was possible in a prospective 

multi-center study to identify cervical spine immobilization as a cause of a more difficult 

endotracheal intubation [58]. For this reason, some users are replacing the cervical spine 

immobilization device in endotracheal intubation by manual in-line stabilization (MILS). In this 

case, the cervical spine is immobilized by another assistant using both hands to immobilize the 

cervical spine manually. The subsequent direct laryngoscopy under MILS was the standard of 

care in emergency situations for many years. However, there is controversy surrounding MILS 

and partially negative effects have been described [63, 79]. As an alternative to direct 

laryngoscopy, fiberoptic intubation as the gold standard can be performed on alert and 

spontaneously breathing patients in a stable cardiopulmonary condition by an experienced user 

in-hospital [13, 74]. 



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1.3 Volume replacement 

Key recommendations: 

Volume replacement should be introduced in severely injured patients, at a 

reduced level if there is uncontrollable bleeding, in order to keep the 

circulation at a low stable level and not exacerbate the bleeding. 

Volume replacement should be carried out with the aim of restoring 

normotension in hypotensive patients with traumatic brain injury. 

Normotensive patients do not require volume replacement but venous lines 

should be placed. 

Explanation: 

GoR B 

GoR B 

GoR B 

Due to underperfusion from hemorrhaging and consecutively occurring traumatic-hemorrhagic 

shock, there is an imbalance between oxygen supply and demand in the tissue [83]. This 

disturbed microcirculation is held responsible for the occurrence of secondary damage following 

hemorrhagic shock. The goal of volume replacement should be to improve microcirculation and 

thus organ perfusion. Expert opinion therefore holds that aggressive volume replacement has a 

favorable effect on the outcome for acutely bleeding patients [1, 28, 53, 56]. This rationale for 

the prehospital phase has not been confirmed in randomized controlled trials. In a randomized 

controlled trial [83], prehospital patients were randomized either to receive or not receive 

volume replacement. 1,309 patients were included. There was no difference between the groups 

in terms of mortality, morbidity and long-term outcome [83]. 

In a retrospective study by Balogh et al. [8], 156 patients in shock receiving supranormal 

resuscitation were compared to patients receiving less treatment which was terminated at the 

oxygen delivery index (DO2I) . Raised intraabdominal pressure, which is supposed to be 

associated with increased organ failure, was observed in the aggressive intervention group. 

Another study by Bickell et al. [11] found a negative survival effect from volume replacement 

after bleeding. However, this study only included patients with penetrating torso injuries. 1,069 

patients were included in the study. In this selected patient group, the introduction of volume 

replacement in the prehospital phase led to an increase in mortality from 30% to 38% and to an 

increase from 23% to 30% in post-operative complications in the group with prehospital volume 

replacement. The authors concluded from this that prehospital volume replacement should not be 

carried out and that surgical treatment should be started as quickly as possible. Many authors go 

along with this conclusion in reviews or experimental studies [9, 45, 48, 60, 67, 77, 82]. 

However, the authors always highlight there being uncontrollable intrathoracic or intraabdominal 

bleeding. In such a situation, surgery should be performed as rapidly as possible and not be 

delayed by prehospital interventions. The goal should be moderate volume replacement with 

“controlled hypotension” and a systolic blood pressure of about 90 mmHg should be aimed for 

Prehospital – Volume replacement 40


[10, 36, 51, 69]. However, even this is questioned in patients with cardiac damage or traumatic 

brain injury (TBI) [35, 51, 79]. On the other hand, other authors partly advocate aggressive 

volume replacement, often addressing a different set of patients with, for example, extremity 

injuries without uncontrollable bleeding [28, 52, 56, 61, 71]. More recent papers have been 

unable to confirm the results obtained by Bickell [44, 94]. 

The majority of papers recommend the introduction of intensive volume replacement upon 

arrival at the hospital and after surgery has begun or if there is controllable bleeding. Again, 

expert opinion indicates a target hematocrit value of 25-30% as the volume to be administered 

[12, 40, 55, 56]. Controlled studies on this topic do not exist. 

The use of catecholamines is viewed critically and only seen as a last resort [46, 56]. 

In one study, the extended prehospital treatment time due to carrying out volume replacement is 

given as 12-13 minutes [83]. The authors interpret this time loss partly as of little relevance [83] 

and partly as a major negative factor for mortality [73]. However, it is unclear whether this 

statement from North America can be transferred to the conditions of the German emergency 

physician-supported system. 

Table 3: Prehospital volume replacement - mortality 

Study LoE Patient collective 

Turner et al. 2000 

[83] 

Bickell et al. 1994 

[11] 

1b 

2a 

Multiply injured patients 

(n = 1,309) 

Patients with penetrating chest 

injury (n = 1,069) 

Mortality with 

volume 

replacement 

Mortality without 

volume 

replacement 

10.4% 9.8% 

38% 30% 



Crystalloids versus colloids 


Crystalloids should be used for volume replacement in trauma patients. GoR B 

Isotonic saline solution should not be used; preference should be given to 

Ringer’s malate, or alternatively Ringer’s acetate or lactated Ringer's 

solution. 

GoR B 

Human albumin must not be used in prehospital volume replacement. GoR A 

If colloidal solutions are used in hypotensive trauma patients, preference 

should be given to HES 130/0.4. 

Explanation: 

GoR B 

There is still controversy surrounding the choice of infusion solution to be used. The majority of 

data is taken from animal experiments or from operations and is limited in its evidential value. 

Different results are produced from the meta-analyses carried out. In 1989, Velanovich et al. 

showed a reduction of 12.3% in mortality of trauma patients when crystalloid volume 

replacement was given [85]. In 1999, Choi et al. confirmed this result and hypothesized a lower 

mortality after trauma when crystalloids were used [23]. A Cochrane analysis of 2008 yielded no 

difference between colloids and crystalloids after trauma [19, 20, 21]. The authors concluded 

from this that colloids could be dispensed with as a volume replacement drug as there was no 

evidence of an advantage from colloids, and crystalloids were cheaper. A proviso should be 

mentioned here that old, very large-molecule solutions were used in these reviews and the 

informative value of these reviews is limited. According to the available studies, the newer 

colloid hydroxy ethyl starch (HES) 1301/0.4 no longer seems to have the disadvantages of older 

starch solutions [39, 53]. However, a marked deterioration in coagulation was observed in one 

in-vitro study even for more modern volume solutions including hypertonic saline solution. This 

effect was not observed when using lactated Ringer's solution or 0.9% saline solution [14]. 

Lactated Ringer’s solution is the preferred choice of crystalloid over isotonic saline solution [30, 

41, 43, 78]. Experimental papers showed evidence of dilutional acidosis occurring after infusion 

of large amounts of isotonic saline solution [62, 63]. The addition of lactate to a Ringer’s 

balanced electrolyte solution prevents dilutional acidosis through the metabolization of the 

lactate to bicarbonate and water, thus buffering the bicarbonate pool. More recent experimental 

papers have found evidence of disadvantages in lactated Ringer's solution. According to these 

papers, lactated Ringer's solution triggers the activation of neutrophil granulocytes, thus causing 

more lung damage [4, 5, 6, 66]. The rate of granulocyte apoptosis is also apparently increased 

[32]. There is no evidence of this in clinical studies. 



Plasma lactate is used as a shock parameter in diagnosis. Lactated Ringer's solution leads to an 

iatrogenic increase in plasma lactate level and can thus interfere with the diagnosis [64, 65]. 

Ringer’s malate or Ringer’s acetate can be used instead. In animal experiments there was 

evidence of lower mortality with Ringer’s malate. In conclusion, the use of lactated Ringer's 

solution no longer appears to be worthy of recommendation. 

A Cochrane Review did not identify any evidence that one colloid is significantly superior to the 

other in the choice of colloid to be used [18]. The risk of an anaphylactic reaction to a colloid 

can be classified as minimal. In 1997, Ring [68] published his findings in The Lancet on the 

probability of an immune reaction to HES as 0.006%, to dextran as 0.0008% and to gelatine as 

0.038%. Individual research papers seem to want to see an advantage of HES over the other 

colloids [1, 54, 74]. In a large series in France, the tolerance of different colloids was studied in 

19,593 patients. 48.1% received gelatine solutions, 27.6% starch solutions, 15.7% albumin, and 

9.5% dextrans. Overall, 43 anaphylactic reactions were observed (0.219%). The distribution 

between the different volume solutions was as follows: 0.345% for gelatine, 0.273% for 

dextrans, 0.099% for albumin, and 0.058% for starch. 20% of all allergic reactions were serious 

to very serious (grade III and IV). In a multivariate analysis, independent risk factors were 

identified as the administration of gelatine (OR 4.81), dextran (OR 3.83), a medical history of 

allergy to drugs (OR 3.16), and male sex (OR 1.98). Thus, a 6-fold smaller risk of anaphylaxis 

was observed for starch solutions compared to gelatine and a 4.7 times lower risk for dextran 

[54]. 

In 1990, Hankeln et al. tested HES 200/0.6 compared to human albumin in a randomized study 

of 40 patients with vascular interventions and were able to establish an optimum volume effect 

for HES 200/0.6 [41]. According to other studies as well, human albumin as a colloid seems to 

be associated with increased mortality and is not to be recommended [41]. The influence of 

colloids on coagulation seems negligible [53]. Albumin does not appear to play a role in volume 

replacement [37]. 



Hypertonic solutions 


Hypertonic solutions can be used in multiply injured patients with hypotensive 

circulation after blunt trauma. 

Hypertonic solutions should be used in penetrating trauma if prehospital 

volume replacement is carried out. 

A hypertonic solution can be used in hypotensive patients with severe 

traumatic brain injury. 

Explanation: 

GoR 0 

GoR B 

GoR 0 

In recent years, the hypertonic 7.5% saline solution has increasingly gained in importance, 

especially in prehospital volume replacement. As already described above, the microcirculatory 

disturbance is the harmful factor in hemorrhagic-traumatic shock. 

The mechanism of action of the hypertonic solution is based on mobilizing intracellular and 

interstitial fluid into the intravasal space and thus on improving microcirculation and total 

rheology. 

The dosage of hypertonic solution is limited in order to counteract harmful hypernatremia. Based 

mainly on experimental papers, the optimum dosage has been established at 4 ml/kg body weight 

(BW). A single administration is prescribed. 

Microcirculatory disturbance during hemorrhaging is the main factor for late complications 

occurring. Hypertonic saline solution leads to interstitial and intracellular volume rapidly 

mobilizing into the intravasal space and thus to consecutively improving rheology and thereby 

the microcirculatory system [49]. No significant advantages of hypertonic solution have been 

found in controlled studies. Bunn et al. (2004) studied hypertonic versus isotonic solutions in a 

Cochrane Review [20]. The authors came to the conclusion that the available data was still 

insufficient to make a final judgment on hypertonic solution. In two controlled randomized trials, 

Mattox et al. (1991) and Vassar et al. (1991) argued an advantage of hypertonic solution for 

survival especially after traumatic brain injury [59, 84]. A paper by Alpar et al. (2004) follows 

the same line where an improvement in outcome is described in 180 patients especially after 

traumatic brain injury [2]. However, another controlled study from 2004 revealed that there was 

no significant difference to be observed in 229 patients in the long-term outcome after traumatic 

brain injury [29]. Moreover, Vassar et al. (1993) reported that the addition of dextrans did not 

bring any benefit for survival after trauma and bleeding [84]. This finding is contradicted by 

several papers which found a clear benefit from the addition of dextran [28, 49, 86, 87]. 

A positive effect on the clinical treatment of traumatic brain injury has been found in other 

studies. Wade (1997) and Vassar (1993) showed an effect on mortality after traumatic brain 



injury and initial treatment with hypertonic solution [84, 90]. Vassar found that the mortality rate 

dropped from 49 to 60% and Wade’s mortality rate from 26.9 to 37.0% with hypertonic solution. 

In the follow-up treatment for increased intracranial pressure, a lowering effect is described 

particularly for the combination of hypertonic solution/HES [42, 47, 75, 91, 92, 93]. However, 

this effect could not be confirmed in a controlled clinical trial [76]. Nor could any advantage 

from the hypertonic solution be detected in another current paper by Bulger et al. published in 

JAMA with the result that the study was discontinued after 1,313 patients [15]. Wade et al. 

conducted a comparative study in terms of a short meta-analysis of 14 papers on hypertonic 

saline solution with and without the addition of dextran and found no relevant advantage in 

hypertonic solutions [90]. In a paper from 2003, the same author describes a positive effect of 

hypertonic solutions in penetrating traumas. In a double-blind study with 230 patients, the 

patients initially received either hypertonic sodium chloride (NaCl) or isotonic solution. The 

mortality of the patients who were treated with hypertonic NaCl solution was 82.5% versus 

75.5%, which was a significant improvement. The surgery rate and bleeding rate were equal. The 

authors thus concluded that hypertonic solutions improve the survival rate in penetrating traumas 

without increasing bleeding [89]. 

In a current study by Bulger et al. [17], lactated Ringer's solution was compared to hypertonic 

NaCl solution with dextran in a group of 209 multiply injured patients with blunt trauma. The 

endpoint of this study was ARDS-free survival. As there were no differences, the study was 

discontinued after an intention-to-treat analysis. In a subgroup analysis, an advantage for 

hypertonic NaCl solution with dextran was only found after massive transfusion. Even the most 

recent publication from this working group did not show any advantages for hypertonic solutions 

after hemorrhagic shock [16]. In fact, a higher mortality rate was observed in patients not 

requiring transfusion after being given hypertonic solution [28-day mortality-- hypertonic 

solution with dextrans: 10%; hypertonic solution: 12.2% and 0.9% saline solution: 4.8%, 

p < 0.01) [16]. 

Immunologic effects are likewise ascribed to the hypertonic solution. Thus, experimental papers 

describe a reduction in neutrophil activation and in the pro-inflammatory cascade [4, 5, 6, 7, 26, 

27, 31, 33, 66, 81]. No evidence has yet been found on the clinical importance of these effects. 

Hypertonic solutions lead to a rapid rise in blood pressure and a reduction in volume requirement 

[3, 13, 22, 24, 38, 50, 57, 58, 93]. How far this influences the treatment outcome cannot be found 

in the literature. 

With regard to the dosage, Rocha and Silva (1990) showed in dogs that a 7.5% solution with 

4 ml/kg BW corresponds to the optimum dosage [70]; this was confirmed again by Wade et al. 

(2003) [88]. 

Anti-shock trousers 


Anti-shock trousers must not be used for circulatory support in multiply GoR A 



injured patients. 

Explanation: 

The anti-shock trousers (pneumatic anti-shock garment [PASG]) were promoted particularly in 

the 1980s and were often used in the military sector. Soft tissue damage and compartment 

syndromes brought their use into question. The current Cochrane Review from the year 2000 no 

longer recommends the use of anti-shock trousers. There are indications that the PASG increases 

mortality and extends the period of intensive treatment and hospital treatment [34]. Relevant 

complications after using anti-shock trousers have been described in several reviews and original 

papers [25, 80]. According to the literature available, the PASG should no longer be 

recommended. 



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1.4 Thorax 

Diagnostic tests 

The decision whether to carry out drainage or decompression of the pleural space is based on 

examination, assessment of findings (diagnosis), and benefit-risk evaluation (diagnosis certainty 

with limited diagnostic options, time factor, concomitant circumstances, and risks attached to the 

method itself). 

Examination 


A clinical examination of the thorax and respiratory function must be carried 

out. 

The examination should include as a minimum the measurement of the 

respiratory rate and auscultation of the lungs. The examination should be 

repeated. 

The following can be helpful: inspection (bilaterally unequal in respiratory 

excursion, unilateral bulging, paradoxical respiration), palpation (pain, 

crepitations, subcutaneous emphysema, instability) and percussion (hyperresonant 

percussion) of the thorax together with pulse oxymetry and, in 

ventilated patients, monitoring ventilation pressure. 

Explanation: 

Initial examination 

GoR A 

GoR B 

GoR 0 

The physical examination of the patient is required for establishing a diagnosis, which in turn is a 

prerequisite for treatment interventions. An acute life-threatening disorder can only be 

recognized by examination. Even without scientific proof, it appears to be absolutely essential 

[89]. 

Scientific studies on the type and scope of physical examination are mainly only on auscultation, 

measuring respiratory rate and on clarifying spontaneous pain and tenderness. Thus, only 

experience can define the required scope of the physical examination in the prehospital 

emergency examination. 

In the emergency situation at the accident scene, the initial examination of the thorax should 

include (after checking and securing the vital functions) checking the respiratory rate and 

auscultation (presence of breath sounds, bilaterally equal breath sounds) [14, 36, 39, 40]. All 

these signs are correlated to significant pathologies or have a direct influence on medical 

decisions. Other useful examinations can be inspection (for signs of injury, symmetry of the 



thorax, symmetry of respiratory excursion, paradoxical respiration, dyspnea, distended neck 

veins) and palpation (subcutaneous emphysema, pain points, crepitations, instabilities in the 

bony structure of the thorax). Monitoring ventilation pressure and pulse oxymetry can be added 

in the course of further management [55]. 

All the above-mentioned examinations are used to detect relevant, threatening or potentially 

threatening disorders and injuries, which altogether can make it necessary to administer 

immediate and specific treatment or make a logistical decision on the spot. All diagnostic 

procedures that can be introduced prehospital are without specific risk, the only disadvantage 

being the loss of time, which is usually minimal. 

The different findings are to some extent greatly dependent on the examiner, the patient and the 

environment. For instance, noise can make auscultation more difficult or impossible. Such 

circumstances must be taken into account when selecting and interpreting the primary diagnostic 

study [36, 40, 80, 135]. 

Several researchers showed that, under in-hospital conditions, ultrasound examination (lung 

sliding, lung point, comet tail, etc.) allows good and accurate detection of pneumothorax and 

hemothorax (review in [87]). However, there is no experience in prehospital application so a 

general recommendation cannot be made. 

Patient monitoring 

The respiratory rate and, if applicable, ventilation pressure should be checked and auscultation 

and pulse oxymetry performed during the course since a disorder in the respiratory system, a 

misplacement of the tube, tension pneumothorax or acute respiratory insufficiency can develop 

dynamically. The follow-up examination can serve as a performance check of the treatment 

administered. 



Diagnosing pneumothorax 


A suspected diagnosis of pneumothorax and/or hemothorax must be made if 

breath sounds are weaker or absent on one side (after checking correct 

placement of the tube). Absence of such auscultation findings largely rules 

out a larger pneumothorax, especially if the patient is normopneic and has no 

chest pain. 

The potential progression of a small pneumothorax which cannot initially be 

diagnosed in the prehospital phase should be taken into consideration. 

Explanation: 

GoR A 

GoR B 

There are currently no methods available for definite prehospital detection or exclusion of 

pneumothorax. This is only clinically possible by computed tomography (exclusion). 

Auscultation 

The studies on diagnostic accuracy of auscultation are summarized in 

Table 4. The specificity of a unilateral weakened or absent breath sound for the presence of 

pneumothorax is very high at 93-98%. The positive predictive value, i.e. the probability of there 

actually being a pneumothorax in the presence of a weakened breath sound, is also very high at 

86-97% [35, 135]. Pneumothoraces not detected by auscultation had a mean volume of 378 ml 

(max. 800 ml), non-detected hemothoraces had a mean volume of 277 ml (max. 600 ml). No 

large, acutely threatening lesions were missed [36, 80]. In another prospective series, 

auscultation was the most reliable method of detecting a pneumohemothorax compared to 

evidence of pain or tachypnea [24]. Conversely, a hemo-/pneumothorax was virtually excluded 

in the presence of normopnea and normal auscultation and palpation findings [24]. 

The prerequisite is the correct placement of the endotracheal tube (as available), which must be 

ensured beforehand if possible. A proviso must be given here that the cited studies were not 

conducted at the emergency site but on emergency admission in the hospital. However, they 

appear to be easily transferable as numerous confounders (e.g., high noise level, disturbance) can 

also predominate in a comparable manner in emergency admission. False positive findings can 

occasionally be present (4.5% of cases in [88]) in tube misplacements, diaphragmatic rupture [1, 

4] or ventilation disorders (large atelectases, shifting of deeper respiratory tracts). 

If there are severe bilateral chest injuries, the presence of a bilateral pneumothorax should be 

considered. Atypical examination findings may occur in this case. 

Data for differentiating between a pneumothorax and a hemothorax or mixed types are 

unavailable. Percussion can be helpful here but in the prehospital setting seems to be only of 



subordinate relevance as the differentiation between pneumo- and hemothorax has no provable 

effects on treatment requirements (see below). 

Table 4: Diagnostic valency of a pathologic auscultation finding with regard to a 

hemo/pneumothorax 

Study LoE Patient collective Sensitivity Specificity 

Hirshberg et al. 1988 [80] 1 Sharp trauma (n = 51) 96% 93% 

Wormland et al. 1989 

[143] 

3 Sharp trauma (n = 200) 73.3% 98.6% 

Thomson et al. 1990 [135] 1 Sharp trauma (n = 102) 96% 94% 

Chen et al. 1997 [36] 3 Sharp trauma (n = 118) 58% 98% 

Chen et al. 1998 [35] 1 

Mainly blunt trauma 

(n = 148) 

84% 97% 

Bokhari et al. 2002 [24] 2 Blunt trauma (n = 523) 100% 99.8% 

Bokhari et al. 2002 [24] 2 Sharp trauma (n = 153) 50% 100% 

Dyspnea 

Even if the symptoms of dyspnea and tachypnea are difficult to quantify in consciousnessclouded 

patients, evidence of normopnea (respiratory rate between 10-20/min) can be put to 

good use in clinical practice. Several studies revealed that normopnea is a very reliable sign that 

a larger hemo/pneumothorax can be excluded after blunt trauma (high specificity). In contrast, 

the presence of dyspnea in no way indicates the reverse, that pneumothorax is present (low 

sensitivity). 

Table 5: Diagnostic valency of dyspnea and tachypnea with regard to hemo/pneumothorax 


Wormland et al. 1989 [143] 3 Sharp trauma (n = 200 patients) 75.6% 84.1% 

Hing et al. 2001 [79] 4 Sharp trauma (n = 153 patients) 72.7% 95.5% 

Bokhari et al. 2002 [24] 2 Blunt trauma (n = 523 patients) 42.8% 99.6% 

Bokhari et al. 2002 [24] 2 Sharp trauma (n = 153 patients) 31.8% 99.2% 



Thoracic pain and pneumothorax 

Fully conscious patients can be asked if they have chest pains. In addition, the clinical 

examination provides indications of tenderness in the thoracic region. There is only one clinical 

study that ranks absence of pain, and it reveals good specificity particularly for sharp trauma 

[24]. On the other hand, this finding only has adequate diagnostic accuracy in the overall picture 

with other findings. 

Table 6: Diagnostic valency of thoracic pain with regard to hemo/pneumothorax 


Bokhari et al., 2002 [24] 2 Blunt trauma (n = 523 patients) 57.1% 78.6% 

Bokhari et al., 2002 [24] 2 Sharp trauma (n = 153 patients) 25.0% 91.5% 

Synopsis of thoracic pain, dyspnea, auscultation 

Table 7 presents the diagnostic accuracy for the presence of pneumothorax after blunt trauma in 

relation to the presence of thoracic pain, dyspnea, and unilateral weakened breath sounds 

detected by auscultation. 

Table 7: Statistical probabilities for the presence of a clinically relevant hemopneumothorax in 

various combinations of findings after blunt chest injury (basic assumption: 10% prevalence as 

pretest probability and independence of test) 

Thoracic pain 

(sensitivity 57%, 

specificity 79%) 

Dyspnea 



Auscultation 



Probability for hemo/ 

pneumothorax 

+ + + > 99% 

+ + - 40% 

+ - + 89% 

+ - - 2% 

- + + 98% 

- + - 12% 

- - + 61% 

- - - < 1% 

Chest injury and pneumothorax 

If a chest injury is present, it is not unusual to conclude an increased risk of pneumothorax being 

present and from this the indication for pleural drainage. Two issues must be considered here: 



the success rate of emergency physicians for diagnosing chest injury and the correlation between 

a chest injury and a concomitant pneumothorax. 

However, the diagnostic accuracy of the emergency physician is greatly limited. An analysis of 

data from the DGU Trauma Registry showed that the emergency physician had grossly 

overestimated the chest injury in 18% of cases, i.e. the emergency physician assumed a severe 

chest injury which was not actually there [7]. 

In 9-50% of patients with confirmed chest injury, there was also a pneumothorax. It should be 

noted with these figures that the diagnosis of chest injury in all these studies had been made after 

a full set of diagnostic tests including imaging. 

In the majority of studies, between 37 and 59% of patients with a relevant chest injury diagnosed 

in hospital had a pneumothorax [23, 55, 66, 137]. If occult pneumothoraces - in other words, 

those which can only be detected in CT but not clinically and not in standard radiography - are 

not included, then the proportion of patients with chest injury who have a relevant pneumothorax 

is actually only 17-25% [23, 137]. However, the incidence of pneumothorax secondary to chest 

injury was markedly lower at 8.9% in individual studies [52]. 

Table 8: Incidence of pneumothorax in the presence of chest injury 

Study Incidence of pneumothorax (radiologic diagnostic test without CT) 

Blostein et al. 1997 [23] 25% of chest injuries 

Demartines et al. 1990 [52] 8.9% of chest injuries 

Di Bartolomeo et al. 2001 [55] 21% of all critically injured 

Gaillard et al. 1990 [66] 41% of chest injuries 

Trupka et al. 1997 [137] 17% of chest injuries 

Other examinations and pneumothorax 

Evidence of subcutaneous emphysema is viewed as an indication of the presence of 

pneumothorax. However, there are no good diagnostic studies to support this. The specificity and 

positive predictive value are not known. However, the sensitivity is low and is between 12 and 

25% [47, 126]. In a 30-year old study, it was reported that subcutaneous emphysema in intensive 

care patients had 100% sensitivity for the presence of tension pneumothorax. However, these 

data are possibly not transferable to acutely ill trauma patients in the prehospital phase [130]. 

Taking into account the relatively high rate of false findings, the findings of an unstable thorax 

and of crepitations are indications of the presence of a chest injury but not of pneumothorax. 



Pneumothorax and progression 

The potential progression of an initially asymptomatic pneumothorax is important, particularly in 

air rescue as well. The progression of pneumothoraces can vary considerably among individuals, 

and basically the full range from in-hospital finding to rapid progression is possible. The 

observation of small pneumothoraces can provide certain clues. In a small retrospective series, 

13 patients with occult pneumothorax were conservatively treated, 6 of whom were being 

mechanically ventilated. It was subsequently necessary in 2 cases to insert a chest drain due to a 

progressive pneumothorax on the second and third day, respectively, after admission [38]. In a 

prospective randomized study, 8 out of 21 patients with an occult pneumothorax which was 

under observation developed progressive pneumothorax and, in 3 cases, tension pneumothorax. 

All these patients were ventilated [60]. The 3 tension pneumothoraces occurred in the operating 

room, post-operative after admission to the intensive care unit, and during a prolonged 

stabilization phase; exact times in hours after trauma are not available. A period of at least 30- 

60 minutes after hospital admission can at least be assumed. In another prospective randomized 

study of the treatment of occult pneumothoraces, the progression of pneumothorax in the group 

of conservatively treated patients (12.5%) was not greater than those on a pleural drain (21%) 

[25]. Details concerning the duration of pneumothorax progression were not recorded. In a series 

of 44 newborn, mostly intubated children, the time between the probable start of pneumothorax 

and the clinical diagnosis being made was on average 127 minutes with a scatter between 45 and 

660 minutes [99]. 

In 3 studies, the maximum size of pneumothorax was indicated as 5 x 80 ml (400 ml), beyond 

which pleural drainage was indicated [25, 60, 70]. However, as pneumothoraces of this size can 

usually already be clinically diagnosed by auscultation (see above), it can be assumed that the 

progression of pneumothoraces with normal auscultation finding meets the above-mentioned 

conditions. 

Most experts believe that the progression of pneumothorax to tension pneumothorax is greater in 

patients who are on positive pressure ventilation [13] but this cannot be quantified. 

To summarize, the data suggest that small, clinically non-diagnosable pneumothoraces generally 

progress relatively slowly and thus do not require any emergency decompression in the 

prehospital phase. 



Diagnosing tension pneumothorax 


A suspected diagnosis of tension pneumothorax should be made if 

auscultation of the lung reveals no breath sounds unilaterally (after checking 

correct placement of the tube) and, in addition, typical symptoms are 

present, particularly severe respiratory disorder or upper inflow congestion 

combined with arterial hypotension. 

Explanation: 

GoR B 

Good scientific data on diagnostic accuracy of examination findings for tension pneumothorax 

are few and far between. Practically all conclusions are based on case reports, animal 

experiments or expert opinion. There is no uniform definition on exactly what tension 

pneumothorax means. The definitions range from pneumothorax with threatening disorders to 

vital functions, hiss of escaping air during needle decompression, mediastinal shift on the chest 

X-ray, raised ipsilateral intrapleural pressure, and hemodynamic compromise [91]. For obvious 

reasons, the ad-hoc diagnosis in the prehospital phase can only be made on the basis of clinical 

examination findings. 

The vast majority of experts consider the diagnosis of tension pneumothorax as given if lifethreatening 

hemodynamic or respiratory disorders are present. Cyanosis, breathlessness, 

tachypnea, contralateral tracheal deviation, and a drop in oxygen saturation, elevated respiratory 

excursion and bulging hemithorax with hyper-resonant percussion on the diseased side are 

possible respiratory signs. Hemodynamic indicators can include distended neck veins, 

tachycardia, and ultimately a drop in blood pressure through to cardiac arrest (pulseless electrical 

activity). However, many of these signs can only be detected on closer examination and have not 

been systematically examined to date. There are few data on trauma patients; most information 

has been gained from observing tension pneumothoraces in intensive care medicine [90]. 

Experimental examinations show that, in the alert patient, respiratory impairment and paralysis 

of the respiratory center secondary to hypoxia precede cardiac arrest, and hypotension, the 

endpoint of which is cardiac arrest, is a late sign of tension pneumothorax [13, 124]. These 

experimental findings were recently confirmed by a patient with accidental tension 

pneumothorax, who became dyspneic, cyanotic and finally unconscious before respiratory arrest 

occurred. However, the carotid pulse could be felt throughout [131]. The patient’s condition 

normalized rapidly after decompressing the elevated intrapleural pressure. A tension 

pneumothorax in the radiograph (mediastinal shift to the contralateral side) without signs of 

impaired circulation has been described in another case report [101]. This patient’s circulation 

remained stable in the 30-minute period between making the diagnosis and inserting the chest 

drain. In another case report, the tension pneumothorax manifested itself clinically by cyanosis, 

an increase in respiratory and heart rate and impaired consciousness (GCS 10) while other signs 

were absent. However, a careful inspection revealed ipsilateral overextension and hypomobility 

in the chest wall. In a review article from 2005, the two symptoms, breathlessness and 



tachycardia, were presented as the typical and most frequent signs of tension pneumothorax in 

the alert patient [91]. 

However, the same authors also showed that in ventilated patients the cardio-circulatory 

symptoms of tension pneumothorax occurred earlier and the respiratory symptoms and fall in 

blood pressure often manifested themselves simultaneously. In the ventilated patient, very 

elevated or rising airway pressures are an important additional symptom that can be found in 

approximately 20% of patients with hemo/pneumothorax [14, 40]. However, systematically 

collected data concerning diagnostic accuracy are not available. According to expert opinion, the 

combination of (unilaterally) absent breath sound (with tube placement monitored) and lifethreatening 

respiratory and circulatory function disorders makes the presence of tension 

pneumothorax so probable that the diagnosis should be made and the necessary therapeutic 

consequences followed. The consequences of a false diagnosis of tension pneumothorax appear 

to be subordinate compared to failing to carry out necessary decompression. 

Indications for pleural decompression 


Clinically suspected tension pneumothorax must be decompressed 

immediately. 

Pneumothorax diagnosed on the basis of an auscultation finding in a patient 

on positive pressure ventilation should be decompressed. 

Pneumothorax diagnosed on the basis of an auscultation finding in patients 

not on ventilation should usually be managed by close clinical observation. 

Explanation: 

GoR A 

GoR B 

GoR B 

Comparative studies between conservative and interventional treatment are not available. The 

treatment recommendations are based on expert opinion and consideration of the probabilities. 

Tension pneumothorax 

Tension pneumothorax is an acute life-threatening situation and, if untreated, generally leads to 

death. Death can occur within a few minutes of the onset of signs of restricted pulmonary and 

circulatory function. There is no alternative to decompression. The experts are of the opinion that 

immediate emergency decompression should be carried out particularly on onset of circulatory 

or respiratory impairment and that the time lost through transferring the patient to a hospital, 

even one situated in the immediate vicinity, represents an unjustifiable delay. In a study of 3,500 

autopsies, there were 39 cases of tension pneumothorax (incidence 1.1%), half of whom had not 

been diagnosed while still alive. Among soldiers from the Vietnam war, 3.9% of all patients with 

chest injuries and 33% of all soldiers with fatal chest injury had tension pneumothorax [100]. An 

analysis of 20 patients who had been categorized as unexpected survivors based on the TRISS 



prognosis showed that tension pneumothorax had been treated by decompression in 7 of them in 

the prehospital phase [29]. 

Diagnosed pneumothorax 

A large pneumothorax, which can be assumed if a typical auscultation finding is collected, 

essentially presents an indication to evacuate the pleural cavity. Whether this has to take place in 

the prehospital phase or once admitted to hospital is difficult to decide in the individual case as 

the risk of progression from simple pneumothorax to tension pneumothorax and the amount of 

time that such a development can take are variable and difficult to estimate. The literature 

contains neither general data nor risk factors on this topic. There are indications that intubated 

patients with a chest injury when admitted to hospital are more likely to have tension 

pneumothorax than non-intubated patients. Overall, it still appears plausible to the experts that a 

pneumothorax diagnosed by auscultation in a ventilated patient has a markedly higher risk of 

developing into tension pneumothorax; thus, prehospital decompression is indicated. 

If a patient with pneumothorax diagnosed by auscultation is not ventilated, then the risk of 

progression to tension pneumothorax appears to be markedly lower. In a series of 54 

pneumothoraces after trauma, 29 were treated conservatively, i.e. without inserting a pleural 

drain. These were non-ventilated patients, mostly without concomitant injuries. A pleural drain 

was inserted in only 2 cases 6 hours after admission to hospital because of radiologic progressive 

pneumothorax [85]. Prehospital decompression does not appear to be necessary here and close 

clinical observation should be carried out. If appropriate clinical monitoring is an issue, e.g., 

during helicopter transfer, then there is a certain, unquantifiable risk that tension pneumothorax 

will develop which will not be recognized in time and/or which cannot be adequately treated due 

to space limitations. In such situations, if relevant clinical signs are present and after individual 

assessment, decompression of the pneumothorax can be carried out before transfer even in nonintubated 

patients. 

Chest injury without direct pneumothorax diagnosis 

If no pneumothorax is diagnosed (i.e. if the auscultation finding shows no lateral difference), 

then there is also essentially no indication for prehospital decompression or pleural evacuation. 

The presence of clear signs of severe chest injury means that between 10 and 50% of these 

patients may have a pneumothorax (see above) and thus pleural drainage could be indicated in 

every second to tenth patient. Conversely, this means that at least every second patient and up to 

9 out of every 10 patients would, under these conditions, receive unnecessary invasive treatment. 

This also coincides with the findings that air released from the pleural space was observed in 

only 32-50% of cases of prehospital decompression [14, 125], and decompression was not 

indicated in 9-25% of cases of pleural drains inserted in the prehospital phase as there was no 

pneumothorax or chest injury [7, 8, 125]. 

In addition, it should be considered that the radiologic findings have not been correlated to the 

clinical findings in the studies on pneumothorax incidence in chest injury. It can be assumed that 

numerous radiologically detectable pneumothoraces could also have been diagnosed by 

auscultation. The rate of pneumothoraces which cannot be diagnosed clinically but are present in 



chest injury can thus be assumed to be much lower [38]. As occult pneumothoraces were also 

included in a series of these studies, i.e. pneumothoraces which were first detectable at least 30 

minutes after hospital admission only by computed tomography but not by standard radiography 

[23, 137], the proportion of prehospital relevant pneumothoraces falls even further. The risk of a 

pneumothorax, which at the time of primary survey was small and yielded a normal auscultation 

finding, progressing to tension pneumothorax has already been discussed above and should be 

viewed as minor in the prehospital timeframe. 

Thus, in a justified individual case, decompression can be carried out in ventilated patients with 

clear signs of chest injury but normal auscultation finding prior to long road or helicopter 

transfer with limited clinical monitoring or treatment options. The high rate of false positive 

diagnoses of chest injury by the emergency physician must be taken into consideration. 

Under these conditions, decompression is not indicated in non-ventilated patients. 

Other indications 

Pneumothorax and hemothorax represent the only typical indications for pleural decompression 

or pleural drainage in prehospital acute medicine. The therapeutic management of pneumothorax 

has already been presented above. Although hemothorax is essentially an indication for 

evacuating the blood located in the pleural space, there is generally no direct danger of 

compression from the blood and there is no indication for evacuation of the blood to the outside 

in the prehospital phase. Emergency decompression can only be indicated in cases of massive 

bleeding, possibly with problems developing in terms of tension hemothorax. However, this 

situation is generally associated with a pathologic auscultation finding and will thus make it 

necessary to proceed as per the situation with a pneumothorax, especially as it is generally 

always difficult to differentiate between a hemothorax and a hemopneumothorax in the 


Treatment 

Methods 

The aim of the treatment is decompression of positive pressure in tension pneumothorax or 

tension hemothorax. The second treatment goal to be considered is the prevention of a simple 

pneumothorax developing into a tension pneumothorax. The permanent and, if possible, 

complete evacuation of air and blood is of no importance in the prehospital emergency. 


Tension pneumothorax should be decompressed by needle 

decompression, followed by surgery to open the pleural space with or without 

a chest drain. 

GoR B 



Pneumothorax should be treated with a chest drain provided the indication 

exists. 

Explanation: 

GoR B 

As there are no suitable comparative data on the 3 methods, no recommendation for a method of 

choice can be made based on the data. (Predominantly retrospective) data, case series and case 

histories are available for all 3 methods and they demonstrate that successful decompression of 

tension pneumothorax is possible by each of these methods. 

In view of the low evidence level on choice of method and benefit-risk profile in the direct 

comparison of methods, the individual ability of the treating emergency physician should be 

considered for reasons of practicability and risk potential. In one study, a significant difference 

in complication rate for insertion of a chest drain was observed between emergency admission 

physicians and surgeons [62]. In a more recent study, a lower complication rate associated with 

insertion by surgical compared to non-surgical residents was also observed in North America 

[11]. Due to a lack of reliable data, the extent to which these results are transferable to the 

German emergency physician system cannot be evaluated. 

Chest drain: Efficacy and complications 

Insertion of a chest drain is a highly effective, suitable but not complication-free procedure for 

decompressing a tension pneumothorax, which must be used particularly when the alternative 

interventions have failed or are insufficiently effective. Generally, it also represents the 

definitive treatment and has the highest success rate. In 79-95% of cases, pleural drains inserted 

in the prehospital phase were the successful, definitive treatment intervention [10, 52, 117, 125]. 

On the other hand, pleural drainage has a failure rate of 5.4-21% (mean of 11.2%) due to 

misplacements or insufficient efficacy. With this frequency, it was necessary to insert an 

additional pleural drain [10, 34, 45, 52, 62, 75, 117, 125]. This involved retained 

pneumothoraces and hemothoraces to more or less the same extent. Individual cases of persistent 

tension pneumothoraces were also observed with pleural drains inserted in the prehospital phase 

[10, 31, 98]. 

The pooled complication rates for pleural drainage are shown in 



Table 9 and in Table 10 (see appendix). There do not appear to be any relevant differences 

between pleural drains inserted in the prehospital and in-hospital phases. However, there are only 

2 studies in which the complication rates for prehospital and in-hospital treatment were directly 

compared within the same establishment [128, 144]. They revealed comparable infection rates 

(9.4 versus 11.7%) and misplacements (0 versus 1.2%). The number of days in situ was 

comparable in both groups in each study. 



Table 9: Complication rates for pleural drains inserted in the prehospital versus in-hospital phase 

Complication Only prehospital pleural drains * Only in-hospital pleural drains * 

Subcutaneous 

misplacements 

Intra-pulmonary 

misplacements 

Intraabdominal 

misplacements 

Infections (pleural 

empyema) 

2.53% (1.55–3.33%) 

n = 730, 9 studies 

[10, 14, 47, 52, 88, 117, 125, 126, 

144] 

1.37% (0.63–2.58%) 


[10, 14, 47, 52, 88, 125, 126] 

0.87% (0.32–1.88%) 


[10, 14, 47, 52, 88, 117, 125, 126] 

0.55% (0.11–1.59%) 


[10, 14, 52, 125, 144] 

0.39% (0.08–1.13%) 


[9, 19, 45, 46, 77, 144] 

0.63% (0.27-1.23%) 

n = 1,275, 7 studies 

[9, 19, 45, 46, 54, 77, 107] 

0.73% (0.29-1.50%) 


[9, 45, 46, 77, 107] 

1.74% (1.47-2.05%) 

n = 8,102, 13 studies 

* Mean values obtained from simply adding together the complications given in studies 

(confidence interval in brackets) 

[9, 19, 34, 46, 54, 62, 107, 144] [59, 

76, 77, 94, 129] 

The case histories for the puncture site of the anterior to midaxillary line also report on injury to 

the intercostal arteries [32], lung perforations [65], perforations of the right atrium [33, 104, 

127], the right ventricle [118] and the left ventricle [49], subclavian artery stenosis due to 

pressure from drain tip from inside [109], Horner syndrome due to pressure on the stellate 

ganglion from the drain lying in the apex [21, 31], an intraabdominal placement [64], a liver 

puncture [47], a perforation of the stomach [4] and of the colon [1] due to diaphragmatic hernia, 

a lesion in the subclavian vein, perforation of the inferior vena cava [61], and triggering of atrial 

fibrillation [12]. 

An arteriovenous fistula [43] as well as perforation of the cardiac wall [56] and perforation of the 

right atrium [104] were reported when the puncture was performed in the mid-clavicular line. 

In addition, other known complications are perforations of the esophagus, of the mediastinum 

triggering a contralateral pneumothorax, an injury to the phrenic nerve among others. 

Simple surgical opening: efficacy and complications 

The simple surgical opening of the pleural space is a suitable, effective and relatively simple 

intervention to decompress a tension pneumothorax. However, it is only suitable for patients on 

positive pressure ventilation as only they have constant positive intrapleural pressure. Negative 

intrapleural pressure develops in a spontaneously breathing patient and can cause air to be 

sucked in through the thoracotomy into the thorax. 

Clinical experience shows that air is released out when the pleural space is opened in a minithoracotomy 

to insert a pleural drain for a pneumothorax or tension pneumothorax. This release 

of air can be sufficient to critically improve the clinical symptoms in the case of a 



hemodynamically active tension pneumothorax. This technique was examined in a case series of 

45 patients in prehospital use and proved itself to be effective without any major complications 

[50]. In a prospective observational study of a helicopter emergency rescue service over a 2-year 

period, 55 patients with 59 suspected pneumothoraces underwent a simple surgical opening. As a 

result of the procedure, arterial oxygen saturation increased on average from 86.4% to 98.5%. A 

pneumothorax or a hemopneumothorax was found in 91.5% of the cases. No cases of recurrent 

pneumothorax were observed by the authors, likewise no serious complications (major bleeding, 

pulmonary laceration, pleural empyema) [97]. 

However, in another series, relevant complications were observed in 9% of patients involving 

non-decompressed tension pneumothoraces in just under half the cases [8]. 

The insertion of a pleural drain via the existing mini-thoracotomy is then indicated in hospital. 

Needle decompression: efficacy and complications 

Needle decompression is a drainage procedure which is frequently effective, suitable and simple 

but not complication-free. Surgical decompression and the insertion of a drain must be carried 

out immediately if efficacy is lacking or insufficient. 

In a prehospital study, 47% of needle decompressions discharged air. A clinical improvement 

was observed in 32% of patients who underwent needle decompression[14]. In a similar study 

[48] , a release of air was observed during needle decompression in 32% of 89 patients with no 

difference between pulseless patients and those with maintained circulation. However, the 

release of air in ventilated patients was more frequently documented than in non-ventilated 

patients (34.9 versus 25.0%). However, the total rate of 60% clinical improvements remains 

unexplained as it is unclear how needle decompression is supposed to lead to an improvement in 

vital functions if no tension pneumothorax has been decompressed (i.e. no release of air). In 

another prospective series of 114 needle decompressions [58], there was an improvement in vital 

parameters or in dyspnea in 12% of patients. 

In contrast, in a prospective series of 14 patients (a further 5 patients died in the emergency room 

and were not suitable for analysis) who underwent needle decompression, in 8 patients there was 

no indication of there having been a pneumothorax, in 2 patients there was an occult 

pneumothorax, in 2 patients a persistent pneumothorax, only in one case a successfully 

decompressed tension pneumothorax, and in one patient a persistent tension pneumothorax [44] 

with the result that only one out of 14 patients had unequivocally gained from needle 

decompression. 

In the study by Barton [14], needle decompression had to be supplemented by a drain in 40% of 

the cases (32 out of 123) due to insufficient efficacy. In other prehospital studies [37, 48], a chest 

drain was additionally inserted in the prehospital phase in 53–67% of all patients undergoing 

needle decompression. 

In 4.1% of cases of detected pneumothorax, needle decompression did not work at all as the 

needle could not be placed far enough in. In 2.4% of cases there was a secondary dislocation of 

the needle and in 4.1% of punctures the needle was difficult to position. No injuries to organs 



were observed [14]. In another study, needle decompression was unsuccessful in 2% of patients 

as the puncture was not deep enough. It was not indicated in a further 2% and an iatrogenic 

pneumothorax was the result. Infections and vessel injuries were not observed [58]. However, 

other researchers report on individual cases of lung injury [48] or cardiac tamponade [30]. In the 

latter case, breath sounds were absent in an unrecognized intubation of the right main bronchus. 

Another group reported on 3 patients with severe bleeding which necessitated a thoracotomy 

[119]. In addition, several case histories and case series reported a failure of needle 

decompression [28, 84, 110]. The most probable reason is that the needle was too short. In 

individual cases, a unilateral or bilateral tension pneumothorax was not identified in patients 

with chronic obstructive pulmonary disease (COPD) or asthma where the entire lung was not 

deflated [81, 108]. 

A known problem is the length of the needle used in relation to the chest wall thickness (for 

details, see II.2.2.1). A commonly used 4.5 cm long cannula is not sufficient in at least a quarter 

of patients for reaching the pleural fissure and is therefore unsuitable for decompressing a 

tension pneumothorax. It is not known by how much success rates could be increased if longer 

cannulas were used and to what extent the complication rate might increase through the longer 

cannula length. Thus, the use of longer needles cannot be recommended. 

Needle decompression versus pleural drain 

In 2 studies, needle decompression required a significantly shorter treatment time (about 5 

minutes less) at the scene compared to a pleural drain (20.3 versus 25.7 min) [14, 48]. 

Air evacuation was achieved with needle decompression in 47% of cases, but after insertion of a 

pleural drain it was achieved in 53.7% of patients [14]. 

However, in a randomized study of patients with spontaneous pneumothorax (traumatic 

pneumothoraces were excluded here), drainage by means of a pleural drain showed a 

significantly higher success rate with 93% compared to simple needle aspiration (68.5%) [5]. In 

another prospective randomized study [112] on the same research question, 59.3% of needle 

aspirations and 84.9% of pleural drains were immediately successful. In 33% of patients with 

needle aspiration, another puncture or insertion of a pleural drain was necessary. The 

transferability of these data to the traumatic pneumothorax is open. 

Some experts do not consider needle decompression an indication unless as a last resort [63]. 

If puncture by means of a needle is ineffective, surgical opening of the pleural space, if 

necessary with insertion of a drain, should be undertaken without delay or, in the case of obese 

patients, should be the first-line choice. 

Conduct 

Puncture site 

Some authors recommend needle decompression in the 2nd-3rd intercostal space in the 

midclavicular line [14, 40, 44, 58], whereas others recommend the anterior to midaxillary line at 

the level of the 5th intercostal space [22, 39, 119]. It is postulated that the thickness of the ventral 



chest wall is greater than at the axillary line but this could not be confirmed in a study of 

cadavers (chest wall thickness in the midclavicular line [MCL]: 3.0 cm, in the midaxillary line 

[MAL]: 3.2 cm) [26]. 

On the other hand, the danger of a lung injury due to adhesions is considered greater in lateral 

access, and air in the pleural space would more likely be found in the apex. However, there are 

no study results on the practical importance of the cited arguments. One study showed that there 

is a strong trend to puncture medial to the midclavicular line with the associated risk of injuring 

the heart or great vessels [110]. 

Both the 4th-6th intercostal space in the anterior to midaxillary line [40, 132, 136] and the 2nd- 

3rd intercostal space in the midclavicular line are recommended as puncture sites for inserting a 

pleural drain. The nipple can be used as a guide in male patients. Generally, punctures must not 

be made below this point because the risk of an abdominal misplacement and injury to 

abdominal organs increases when the puncture is made too low. It should be noted that the 

puncture site indicated refers to the opening between the ribs. The skin incision can also lie one 

intercostal space lower (see conduct of puncture). 

Deleterious complications for both puncture sites have been published as case histories. One 

prospective study found that the puncture level (2nd-8th intercostal space) or the lateral position 

(MCL or MAL) had no effect on the success rate of draining pneumothoraces or 

hemopneumothoraces following sharp trauma [57]. The complications from drain insertion in the 

2nd-3rd intercostal space in the midclavicular line (n = 21) and in the 4th-6th intercostal space in 

the anterior axillary line (n = 80) were analyzed in a cohort study [82]. Although the rate of 

interlobal misplacements when using lateral access was significantly higher, functional 

misplacement was comparably frequent at both puncture sites (6.3% versus 4.5%). 

Instruments (needle decompression) 

In a study of cadavers, the average chest wall thickness was approximately 3.2 cm with a wide 

scatter (standard deviation 1.5 cm) [26]. Britten confirmed these results using ultrasound 

measurements and observed that in 57% of cases the pleural depth exceeded 3 cm and in 4% of 

subjects exceeded 4.5 cm. He concluded that, for the pleural space to be reached at all, the 

minimum length of needle required in the vast majority of cases is 4.5 cm [27]. Even a 4.5 cm 

long needle can be too short to reach the pleural space [28]. In a more recent study [72], an 

average chest wall thickness at the midclavicular line of 4.16 cm in men and 4.9 cm in women 

was determined in trauma patients using computed tomography. A quarter of the patients had a 

chest wall thickness exceeding 5 cm. Marinaro et al. [95] found a chest wall thickness exceeding 

5 cm in 33% of their patients and even exceeding 6 cm in 10% of the injured. In a Netherlands 

study, the mean chest wall thickness at the midaxillary line was 3.9 cm in women and 3.4 cm in 

men. A needle with a length of 4.5 cm would not have reached the pleural space in 10-19% of 

men (under versus over 40 years) and 24-35% of women (under versus over 40 years) [145]. In a 

comparable study design, the average chest wall thickness in military personnel was 5.4 cm [74]. 

Some experts recommend the use of longer needles (exceeding 4.5 cm) to increase the chance of 

the pleural space being reached. Others fear that using longer cannulas carries a greater risk of 

injuring great vessels or the heart (see also [110]). There are no studies available on the actual 



benefit-risk evaluation of using longer versus normal length cannulas. Many experts therefore 

advise using the standard cannula (4.5 cm) and, if unsuccessful, surgically opening the pleural 

space (mini-thoracotomy). 

There are no data available on the cannula diameter or type of cannulas to be used. In general, 

the largest possible cannula diameter is recommended to allow the maximum amount of air to be 

released. 

Instruments (surgical decompression) 

A thin drain should also suffice for decompressing a pneumothorax. In the case of non-traumatic 

pneumothoraces, 75-87% of patients were successfully treated with size 8-14 French (Fr) pleural 

catheters [41, 96] A study of patients with pneumothorax secondary to isolated thoracic trauma 

showed a success rate of 75% with thin catheters (8 Fr). The remaining 25% required a chest 

drain [51]. One case history reports on the progression of a pneumothorax into a tension situation 

despite an indwelling 8-Fr drain. This was a ventilated patient with a ruptured air cyst [17]. 

However, as at least 30% of cases after trauma are combined pneumo-/hemothoraces, it is feared 

that the drain may block quickly if too narrow. For these reasons, the use of 24-32-Fr drains are 

recommended in adults [16, 83, 132, 136]. 

Discharge systems 

There are no reliable data on the question of whether and when a chest drain can be left open to 

the outside and, if so, which discharge system is to be used. A consensus expert recommendation 

also cannot be given. 

No closure 

Theoretically, the chest drain to the outside can be left open in a patient who is on positive 

pressure ventilation. There is a potentially increased risk of transferring infectious diseases to 

staff and there is contamination from the unprotected discharge of blood via the drain. On the 

other hand, there is only a minor risk of the discharge becoming obstructed and a recurrence of 

the (tension) pneumothorax. 

However, if the patient is spontaneously breathing, there is a danger during inspiration that air 

from outside can be sucked into the pleural space, leading to total collapse of the pulmonary 

lobe. In this situation it is necessary to insert a valve device. 

Heimlich valve 

One such commercially available valve device is the Heimlich valve. It was originally used for 

decompressing spontaneous pneumothoraces [20]. In one out of 18 cases, the valve stuck and 

there was a resulting loss of function. In a retrospective comparison, 19 patients with a Heimlich 

valve had a shorter drainage time and length of stay in hospital compared to 57 patients with a 

standard drainage system (1/3 of patients with traumatic pneumothorax). However, patients with 

hemothorax were excluded and 4 patients with a Heimlich valve had to change to the standard 

drainage group [111]. Thus, it is unclear whether these experiences can be transferred to the 



prehospital situation. Further case reports show that the valve can get stuck causing the outflow 

to be diverted and a recurrent tension pneumothorax occurred [78, 93]. Heimlich valves were 

routinely used during the Falklands war, where it was reported that they frequently got stuck due 

to blood coagulation and that the valve had to be repeatedly replaced; the problem was not 

quantified [142]. It was shown in experimental studies that 2 out of 8 valves had a loss of 

function and in 7 out of 8 cases where the Heimlich valve was past its expiry date it was 

defective [78]. In addition to material fatigue, coagulated blood can also cause a loss of function. 

This uncertainty regarding the functionality of the Heimlich valve creates an incalculable risk 

potential and close monitoring is necessary during use. These considerations essentially apply to 

all other valves with the exception of multi-bottle systems. The Heimlich valve also does not 

offer protection against contamination and dirt. 

Closed bag or chamber systems 

Although the attachment of a closed collection bag can reduce the danger of dirt and infection, it 

can rapidly fill up with air or blood if there is a relatively large air fistula and so may lead to 

positive pressure with tension developing again in the pleural space. 

Under in-patient conditions, a discharge via a 2- or 3-chamber system is generally used, these 

being predominantly closed commercial discharge systems. Advantages are their good 

functionality and protection against the surroundings being contaminated with blood. They 

would also be the definitive discharge system for ongoing treatment in hospital. In prehospital 

use, problems arise because they are awkward to handle when repositioning and during 

transportation and there is a resulting risk of tilting. If the chambers are overturned and there is 

uncontrollable displacement of the fill fluids between the chambers, their functional reliability is 

at risk [73]. 

In a prospective randomized study of patients following thoracotomy, a commercially available 

discharge system, consisting of a safety valve, a bag and an air outlet, was as successful as a 

multi-chamber system with underwater seal. Blockages were not observed here although the 

drains also conveyed blood and bloody secretion. There are no field reports on its use in the 

prehospital phase for traumatic hemothoraces or for pneumothoraces. 

The use of a simple bag without valve (e.g., colostomy bag) [138] is not an option for trauma 

patients and pneumothoraces. 

The Xpand Drain is a new development which has a collection reservoir attached via a valve to 

the pleural drain. A suction unit can be attached to the collection reservoir and larger amounts of 

fluid can be evacuated via a separate discharge. In a randomized but not blinded study, this 

collection reservoir (n = 34) was compared in a hospital setting with a conventional underwater 

seal (n = 33) in patients with pneumo- or hemopneumothorax after penetrating trauma [42]. The 

Xpand Drain was shown to be operationally comparable to the underwater seal. In principle, this 

system has potential advantages (small, easily transportable, transient overturning appears noncritical, 

clean) but to date there is no published experience on its use in the prehospital phase. A 

recommendation, therefore, should not be made until this is available. 



Conduct (needle decompression) 

The best technique has never been examined in controlled trials so these are expert opinions. 

Care must be taken to select the puncture site correctly as there is a tendency to puncture medial 

to the midclavicular line [110]. The puncture should follow a straight path using a permanent 

venous cannula attached to a syringe aspirating for air, continuing until air is aspirated [40]. 

After the pleural space has been punctured, the steel stylet should be left in situ to prevent the 

unprotected plastic cannula from kinking [44, 114]. Other authors hold the view that the steel 

stylet should be removed after puncture and only the plastic cannula left in situ[58, 110]. 

However, kinks have been documented (1 out of 18 punctures) [110]. 

Conduct (surgical decompression) 


The pleural space should be opened by mini-thoracotomy. The chest drain 

should be inserted without using a trocar. 

Explanation: 

GoR B 

The best technique has never been examined in controlled trials. Most experts recommend a 

standardized technique: a pleural drain must be inserted using a sterile technique. After the skin 

has been disinfected, a local anesthetic is administered to the not fully unconscious patient down 

to the pleural wall. A horizontal (transverse) skin incision approximately 4-5 cm in length is 

made with a scalpel along the upper border of the rib below the intercostal space to be punctured, 

or one rib lower (for cosmetic reasons this is done at the appropriate level in the sub-mammary 

fold in women). The subcutaneous layer and the intercostal musculature on the upper edge of the 

rib are opened up by blunt dissection or a clamp. The pleura can be separated by blunt dissection 

or by a small cut with the scissors. Then a finger (sterile glove) is inserted into the pleural space 

in order to verify correct access to the pleural space and ensure that there are no adhesions or, if 

applicable, to release them [16, 50, 107, 123, 132, 133, 136, 139]. If the ribcage is only to have a 

simple opening, the wound is covered with a sterile dressing, which is not taped on one side (for 

venting). 

If a chest drain is to be inserted, the intervention is continued: a subcutaneous tunnel is not 

considered necessary by all experts [133]. A trocar should never be used for blind preparation of 

the passage. Serious complications have occurred through its use such as the perforation to the 

right atrium in a patient with kyphoscoliosis [104] or perforations to the lung [65]. The 

complication rates in studies on the trocar technique are much higher than in the studies on the 

surgical technique (11.0% versus 1.6%) (Appendix). In a prospective cohort study (on intensive 

care patients), it was shown that the use of a trocar was associated with a significantly higher rate 

of misplacements [120]. At the moment of transsectioning the pleura and inserting the drain, 

some experts recommend ventilated patients have a short ventilation break to reduce the risk of 

injury to the lung parenchyma when the lung is expanded [65, 115, 116]. 



The chest drain is then inserted through the prepared passage. The finger inserted in parallel can 

be used as a guide. The tip of the drain can also be held in a clamp and guided using this more 

rigid guiding option. Alternatively, a trocar can be used to guide the drain (not for preparing or 

perforating the chest wall!). It must be ensured that the tip of the trocar never protrudes beyond 

the tip of the drain and that no force is applied in advancing the drain [136]. 

The drain must be prevented from dislocating by fixing steristrips or a suture. A self-locking 

plastic tie can also be used for fixation [105]. 

Alternative techniques for insertion 

A series of alternative techniques and modifications to the mini-thoracotomy for evacuating the 

pleural space have been published. They have usually been published simply as a description of 

the technique or examined in small case series or studies. There is usually no description of 

prehospital use or use in trauma patients. For these reasons, there are no perspectives that appear 

to justify use of these techniques as an equivalent alternative to the standard mini-thoracotomy 

described for trauma patients in the prehospital phase. Although there are no scientific proofs of 

the superiority of the standard technique either, it is the unanimous opinion of the experts that 

empirical experiences justify the recommendation of the standard technique as long as the 

alternative procedures have not supplied evidence of equivalence or superiority under the abovementioned 

conditions. 

Altman [3] modified the standard technique using mini-thoracotomy such that a Tiemann 

catheter consistent with the Seldinger technique is first inserted with a clamp into the pleural 

space and then serves as a guide bar for the actual drain. This enables a smaller skin incision 

compared to the standard technique. 

The use of a laparoscopic trocar catheter is a technique that has been well-studied compared to 

numerous other alternative guide techniques but not in direct comparison with the standard 

technique [18, 67, 86, 92, 140]. Technique and complications were described in a prospective 

cohort study in which 112 patients were included, 39 of them after trauma [140]. The only 

complication (0.89%) described was an injury to the lung. 

In 1988 Thal and Quick described a technique involving the insertion of a guidewire after direct 

puncture and expansion of the puncture passage using increasingly larger dilators and insertion 

of the drain (up to 32 Fr) over the guidewire [113, 134]. The technique led to an initial success in 

24 pediatric patients (14 pneumothoraces, 3 hemothoraces, 7 others). In 5 cases (approx. 20%) 

there were complications due to kinking in the 10-20 Fr catheters [2]. In a systematic review, no 

advantages in the Seldinger technique could be confirmed compared to other techniques [6]. 

A frequent alternative, used particularly in pediatrics, is pigtail catheters with narrow lumen (7-8 

Fr) inserted by direct puncture (with or without the Seldinger technique). Gammie et al. [68, 69] 

used an 8.3 Fr pigtail catheter in 109 partially-ventilated patients (10 trauma patients). The 

success rate was 86% for pleural effusions (no hemothorax) and 81% for pneumothoraces 

(predominantly not traumatic). Roberts reports a complication rate of 11% insufficient drainage, 

2% each hemo- and pneumothoraces, 1% liver perforation and 2% kinking or compression 

through the chest wall. The drainage success was insufficient particularly in pneumothoraces 



(25%) and hemothoraces (15%) [121]. There was a failure rate of 25% with 8-Fr catheters which 

were inserted using guidewire in 16 adult patients with traumatic pneumothorax [51]. 

Transferability to acute trauma patients remains unclear. 

Other techniques have been suggested such as inserting a guidewire, subsequent dilation using a 

Howard Kelly clamp and then inserting the drain via the dilated passage [106]. 

In a small prospective randomized study, Röggla et al. [122] compared the standard pleural drain 

(14 Fr trocar, 13 patients) with the Tru-Close® Thoracic Vent catheter with valve and integrated 

collection chamber (17 patients) in spontaneous or iatrogenic pneumothorax. With a comparable 

success rate for re-expansion, the patients with the Thoracic Vent had less need of analgesics and 

could be treated more frequently as outpatients. As hemothoraces and ventilated patients were 

excluded, it is not possible to transfer these results to prehospital trauma patients. 

At the end of the 1970s, McSwain developed a system for a prehospital chest drain (15 Fr), 

called the McSwain Dart ® [102, 103], which most closely resembles a basket catheter, which is 

inserted via a puncture using a cannula. In a case series of 40 patients [141], the McSwain Dart 

revealed good effectiveness with 2 (5%) complications (diaphragm injury and intercostal artery 

lesion). The authors explained that some of the catheters were later blocked by blood and had to 

be replaced. The device was not considered suitable for draining a hemothorax. In a study of 

dogs, the McSwain Dart frequently caused injuries to the lung parenchyma if no pneumothorax 

was present [15]. 

Gill et al. [71] developed a 5 cm long, conical, expandable, puncture cannula with a 10 mm 

diameter, which was pushed through the pleural drain and studied in 22 patients. 



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119. Rawlins R, Brown Km, Carr Cs et al. (2003) Life 

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a prospective computed tomography study. 

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121. Roberts J, Bratton S, Brogan T (1998) Efficacy and 

complications of percutaneous pigtail catheters for 

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124. Rutherford Rb, Hurt Hh, Jr., Brickman Rd et al. 

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Appendix 

Table 10: Complications when inserting a pleural drain 

Author N SC IP IA PE MF PS Technique Site QF Comments 

Baldt et al. [10] 77 2.6% 6.4% 0 3.9 21% * no data 

trocar and 

blunt 

Barton et al. [14] 207 1.2% 0 1.2% § 0 14.2% MAL no data PRE 

Bailey et al. [9] 57 0 0 0 1.8% no data MAL blunt 

Bergaminelli et 

al. [19] 

Prehospital – Volume replacement 83 

PRE EP 

Flight 

nurse 

191 1.0% 0.6% no data 2.6% no data no data no data no data no data 

Chan et al. [34] 373 no data no data no data 1.1% 15% * no data no data 

Curtin [45] 66 0 1.5% 4.5% 

no 

data 

ED 

ICU 

ED, 

OR, 

ward 

EDP 

SURG 

EDP 

18% * no data no data ED SURG 

Daly et al. [46] 164 0.6% 0.6% 0.6% 1.2% no data MAL blunt 

David et al. [47] 52 4% 2% 2% 

no 

data 

ED, 

ICU, 

OR 

SURG 

no data MAL trocar PRE EP 

Misplacements: 

trocar technique 29%; 

blunt technique: 19% 

Complications: ED: 14% 

OP: 9% 

Ward: 25% 

(continued)


Table 10: Complications when inserting a pleural drain - contd. 


Demartines et al. 

[53] 

90 5.4% 0 0 0 18.9% * no data no data PRE EP 

Eddy et al. [59] 117 no data no data no data 5% no data no data no data ED SURG 

Etoch et al. [62] 599 no data no data no data 1.8% 9.8% * no data no data 

Heim et al. [75] 40 0 5% 0 

Helling et al. [76] 


no 

data 

45% * no data no data 

216 no data no data no data 3% no data MAL blunt 

Lechleutner et al. 

[88] 44 4.5% 4.5% 2.3% § 

no 

data 

ED, 

ICU 

etc. 

PRE, 

ED 

ER, 

OP, 

ICU 

SURG 

EDP 

NA, SURG 

no data 


Mandal et al. 

[94] 5.474 no data no data no data 1.6% no data no data no data hospital no data 

Millikan et al. 

[107] 447 no data 0.25% 0.75% 2.4% no data MAL blunt ED 

Peters et al. [117] 

33 9% 21% # 3% 

no 

data 

SURG, 

EDP 

12% * no data no data PRE EP 

Complications: 

Surgeons: 6% 

ED physicians 13% 

Complications: ED: 37% 

OP/ICU: 34% 

(continued)


Table 10: Complications when inserting a pleural drain - contd. 


Schmidt et al. 

[125] 

Schöchl et al. 

[126] 

Sriussadaporn et 

al. [129] 

76 1.3% 0 0 0 5.2% * MAL blunt PRE 

111 2.7% 1% 1% 


no 

data 

NA 

(SURG) 


42 no data no data no data 3% no data no data no data hospital no data 

* Additional pleural drain necessary; # possibly false CT interpretation; § in diaphragmatic rupture 

SC, subcutaneous misplacement; IP, intrapulmonary misplacement; IA, intraabdominal misplacement; PE, pleural empyema; MF, malfunction; PS, puncture site; QF, 

qualification of medical staff; PTX, pneumothorax; HTX, hemothorax; PRE, prehospital; ED, emergency department; ICU, intensive care unit; OP, operating room; EP, 

emergency physician; SURG, surgeon; EDP, emergency department physicians; MAL, mid to anterior axillary line; MCL, midclavicular line


1.5 Traumatic brain injury 

Interventions at the accident scene 

Vital functions 


The goal in adults should be arterial normotension with a systolic blood 

pressure not below 90 mmHg. 

GoR B 

A fall in arterial oxygen saturation below 90% should be avoided. GoR B 

Explanation: 

Prospective randomized controlled trials, which examine the effect of hypertension and/or 

hypoxia on the treatment outcome, are certainly indefensible on ethical grounds. However, there 

are many retrospective studies [8, 25] which provide evidence of a markedly worse treatment 

outcome if hypotension or hypoxia is present. The absolute priority of diagnostic and treatment 

interventions at the accident scene is therefore to recognize and if possible immediately eliminate 

all conditions associated with a fall in blood pressure or reduction of oxygen saturation in the 

blood. Due to side effects, however, aggressive treatment to raise blood pressure and oxygen 

saturation has not always proved successful. The goals are normoxia, normocapnia, and 

normotension. 

Intubation is always considered for insufficient spontaneous breathing. However, it can also be 

considered in cases of unconsciousness with adequate spontaneous breathing. Unfortunately, the 

literature does not contain any high quality evidence on this to prove a clear benefit for the 

intervention. The main argument in favor of intubation is the efficient prevention of hypoxia. 

This is a threat in unconscious persons even with sufficient spontaneous breathing as the 

impaired protective reflexes can cause aspiration. The main argument against intubation is the 

hypoxic damage that can occur through misplaced intubation. During the development of the 

DGNC Guideline “Traumatic brain injury in adulthood” [6], which served as a model, there was 

consensus that there was overall benefit, and an A recommendation was thus given in this 

guideline. It was not possible to reach this consensus for the current polytrauma guideline. 

Interventions to ensure cardiovascular functions in multiply injured patients are described 

elsewhere in this guideline (see Chapter 1.3). Specific recommendations cannot be made for the 

infusion solution to be used in volume replacement in multiple injuries with concomitant 

traumatic brain injury [8]. 

Prehospital – Traumatic brain injury 86


Neurologic examination 


Full consciousness, clouded consciousness or unconsciousness with pupil 

function and Glasgow Coma Scale must be recorded and documented at 

repeated intervals. 

Explanation: 

GoR A 

In the literature, the only clinical findings with a prognostic informative value are the presence of 

wide, fixed pupils [8, 23, 26] and a deterioration in the GCS score [8, 17, 23], both of which 

correlate with a poor treatment outcome. There are no prospective randomized controlled trials 

on using the clinical findings to guide the treatment. As such studies are definitely not ethically 

justifiable, the importance of the clinical examination was upgraded to a Grade of 

Recommendation A during the development of the guideline on the assumption, which cannot be 

confirmed at present, that the outcome can be improved by the earliest possible detection of lifethreatening 

conditions with corresponding therapeutic consequences. 

Despite various difficulties [2], the Glasgow coma scale (GCS) has established itself 

internationally as the assessment of the recorded severity at a given point in time of a brain 

function impairment. It enables the standardized assessment of the following aspects: eye 

opening, verbal response and motor response. The neurologic findings documented with time of 

day in the file are vital for the sequence of future treatment. Frequent checks of the neurologic 

finding must be carried out to detect any deterioration [8, 10]. 

However, the use of the GCS on its own carries the risk of a diagnostic gap, particularly if only 

cumulative values are considered. This applies to the initial onset of apallic syndrome, which can 

become noticeable through spontaneous decerebrate rigidity which is not recorded on the GCS, 

and to concomitant injuries to the spinal cord. Motor functions of the extremities must therefore 

be recorded with separate lateral differentiation in arm and leg as to whether there is incomplete, 

complete or no paralysis. Attention should be paid here to the presence of decorticate or 

decerebrate rigidity. Providing no voluntary movements are possible, reaction to painful stimulus 

must be recorded on all extremities. 

If the patient is not unconscious, then orientation, cranial nerve function, coordination, and 

speech function must also be recorded. 



Cerebral protection treatment 


Glucocorticoids must not be administered. GoR A 

Explanation: 

According to the latest scientific knowledge, the goal of interventions to be taken at the accident 

scene is to achieve homeostasis (normoxia, normotension, prevention of hyperthermia) and 

prevention of threatening complications. The intention is to limit the extent of secondary brain 

damage and to provide those brain cells with functional impairment but which have not been 

destroyed with the best conditions for functional regeneration. This applies equally if multiple 

injuries are present. 

Up till now, there is no evidence from the data in the scientific literature of benefit being derived 

from more extensive treatment regimens viewed as specifically cerebral-protective. At present, 

no recommendation can be given on the prehospital administration of 21-aminosteroids, calcium 

antagonists, glutamate receptor antagonists or tris-(tris[hydroxy methyl]aminomethane) buffer 

[8, 11, 18, 29]. 

Antiepileptic treatment prevents the incidence of epileptic seizures in the first week after trauma. 

However, the incidence of a seizure in the early phase does not lead to a worse clinical outcome 

[20, 25]. 

The administration of glucocorticoids is no longer indicated due to a significantly increased 14day 

case fatality rate [1, 4] with no improvement in clinical outcome [5]. 

Treatment for suspected severely elevated intracranial pressure 


If severely elevated intracranial pressure is suspected, particularly with signs 

of transtentorial herniation (pupil widening, decerebrate rigidity, extensor 

reaction to painful stimulus, progressive clouded consciousness), the following 

treatments can be given: 

� Hyperventilation 

� Mannitol 

� Hypertonic saline solution 

GoR 0 



Explanation: 

In cases of suspected transtentorial herniation and signs of apallic syndrome syndrome (pupil 

widening, decerebrate rigidity, extensor reaction to painful stimulus, progressive clouded 

consciousness), hyperventilation can be introduced as a treatment option in the early phase after 

trauma [8, 25]. The guide values are 20 breaths/min in adults. However, hyperventilation, which 

used to be used because of its often impressive effect in reducing intracranial pressure, also 

causes reduced cerebral perfusion because of the induced vasoconstriction. With aggressive 

hyperventilation, this involves the risk of cerebral ischemia and thus deterioration in clinical 

outcome [25]. 

The administration of mannitol can lower intracranial pressure [ICP] for a short time (up to 1 

hour) [25]. It can also be given without measuring ICP if transtentorial herniation is suspected. 

Up till now, there has been only scant evidence of the cerebral-protective effect of hypertonic 

saline solutions. Mortality appears to be somewhat less compared to mannitol. However, this 

conclusion is based on a small number of cases and is statistically not significant [28]. 

There is insufficient evidence [19] for the administration of barbiturates, which was 

recommended in previous guidelines for intracranial pressure crises not controllable by other 

means [23]. When administering barbiturates, attention must be paid to the negative inotropic 

effect, possible fall in blood pressure, and impaired neurologic assessment. 

Transport 


In the case of penetrating injuries, the penetrating object should be left in situ; 

in certain circumstances it must be detached. 

Explanation: 

GoR B 

It is essential that multiply injured persons with symptoms of concomitant traumatic brain injury 

are admitted to a hospital with adequate treatment facilities. In the case of a traumatic brain 

injury with sustained unconsciousness (GCS ≤ 8), increasing cloudiness (deterioration in 

individual GCS scores), pupillary disorder, paralysis or seizures, the hospital should definitely 

have provision for neurosurgical management of intracranial injuries [8]. 

No clear recommendation can be given on analgesic sedation and relaxants for transportation as 

there is a lack of studies with evidence of a positive effect on traumatic brain injury. With these 

interventions, cardiopulmonary management is definitely easier to guarantee so that the decision 

on this must be left to the judgment of the treating emergency physician. The disadvantage of 

these interventions is a more or less severe limitation on the ability to make a neurologic 

assessment [23]. 



In the case of penetrating injuries, the penetrating object should be left in situ; in certain 

circumstances it must be detached. Injured intracranial vessels are often compressed by the 

foreign body so that removing it encourages the development of intracranial bleeding. Removal 

must therefore be carried out under surgical conditions with the possibility of hemostasis in the 

injured brain tissue. Even if there are no prospective randomized controlled trials on the 

optimum procedure for penetrating injuries, this procedure makes sense from a pathophysiologic 

viewpoint. 

The possibility of a concomitant unstable spine fracture should be considered during 

transportation, and the patient should be appropriately positioned (see Chapter 1.6). 



References 

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Systematic Reviews 2005, Issue 1. 

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Predictive value of Glasgow Coma Scale after brain 

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with clinically significant head injury (MRC CRASH 

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6. Firsching R, Messing-Jünger M, Rickels E, Gräber S 

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34: 5-10, 1976 

8. Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, 

Walters BC; Brain Trauma Foundation. Guidelines for 

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Lindgren S, Luyendijk W, Norlen G, Ommaya AK, 

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asmuth druck + crossmedia. 2004. 

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Issue 1, 2004. Chichester, UK: John Wiley & Sons, 

Ltd. 

12. Lorenz, R. Neurotraumatologie. Standartisierte 

Nomenklatur. Berlin, Springer 1990 

13. Kraus JF, Black MA, Hessol N, Ley P, Rokaw W, 

Sullivan C, Bowers S, Knowlton S, Marshall L. The 

incidence of acute brain injury and serious impairment 

in a defined population. Am J Epidemiol. 1984 

Feb;119(2):186-201. 

14. Kraus JF, Fife D and Conroy C. Incidence, Severity, 

and Outcomes of Brain Injuries Involving Bicycles 

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15. Maas, A. et al.: EBIC-Guidelines for mangement of 

severe head injury in adults. Acta Neurchir. (Wien) 

139, 286-294, 1997 [Evidenzbasierte Leitlinie] 

16. Marion DW and Carlier PM. Problems with initial 

Glasgow Coma Scale assessment caused by 

prehospital treatment of patients with head injuries: 

results of a national survey. J Trauma. 1994, 36(1):89- 

95. 

17. Marmarou A, Lu J, Butcher I, McHugh GS, Murray 

GD, Steyerberg EW, Mushkudiani NA, Choi S, Maas 

AI. Prognostic value of the Glasgow Coma Scale and 

pupil reactivity in traumatic brain injury assessed 

pre‐hospital and on enrollment: an IMPACT analysis. 

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2004 

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(Cochrane Review). In: The Cochrane Library, Issue 1, 

2004. Chichester, UK: John Wiley & Sons, Ltd. 

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Ltd. 

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22. Teasdale G, Jennett B: Assessment and prognosis of 

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Hirnschädigungen. Ärztliche Praxis 5: 13-14, 1953 

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Chichester, UK: John Wiley & Sons, Ltd. 



1.6 Spine 

When should a spinal injury be assumed? 

What diagnostic procedures are required? 


A thorough physical examination including the spine and the functions 

associated with it must be carried out. 

Explanation: 

GoR A 

A physical examination of the patient is the basic requirement for making a diagnosis which, in 

turn, is the prerequisite for subsequent treatment interventions. 

After the vital functions have been monitored and secured, the initial examination of a 

responsive patient’s spine in the emergency situation at the accident scene involves the 

exploratory neurologic assessment of sensitivity and motor functions. A segmental neurologic 

deficit indicates the presence of a spinal cord injury. The level and complete/incomplete lesions 

can be measured to a limited extent. An absence of back pain is not a definite sign that there can 

be no relevant injury to the thoracic or lumbar spine [28]. 

To complete the initial examination, the cervical spine and the entire back are inspected (for 

signs of injury, deformities) and felt (tenderness, percussion tenderness, steps, displacements, 

palpable gaps between spinous processes). 

Assessing the mechanism of injury can provide clues on the probability of a spinal injury [20]. 

Even if there are no scientific studies on the importance and the necessary scope of the physical 

examination in the prehospital emergency examination, it is still an indispensable requirement 

for detecting symptoms and making (suspected) diagnoses. All the above-mentioned 

examinations are used to detect relevant, threatening or potentially threatening disorders and 

injuries, which altogether can make it necessary to administer immediate and specific treatment 

or make a logistic decision on the spot [2, 17]. 

The circulation parameters, blood pressure and pulse, should be measured more than once at 

least during the course (depending on finding, overall situation and timeframe). These are 

dynamic values, which are indicators for the occurrence of neurogenic shock. 

Various scoring systems do not permit a clear statement but combining several scores increases 

the probability of success [63]. 

Which concomitant injuries make the presence of spinal injury likely? 


Prehospital – Spine 93


The presence of a spinal injury must be assumed in unconscious patients until 

evidence to the contrary is found. 

Explanation: 

GoR A 

The coincidence of spinal injuries and certain other injury patterns is increased. These are purely 

statistical probabilities. 

How is the diagnosis for unstable spinal injury made and how definite is it? 


If the following 5 criteria are absent, it can be assumed that no unstable spinal 

injury is present: 

� impaired consciousness 

� neurologic deficit 

� spinal pain or myogelosis 

� intoxication 

� trauma in the extremities 

Explanation: 

GoR A 

Several groups have developed clinical decision rules to simplify prehospital patient 

transportation and to set sensible limits to the radiologic primary diagnostic study after blunt 

trauma to the spine. Some of these decision rules relate to the prehospital situation [23, 24, 45] 

whereas others relate to the emergency department [9, 33, 35, 36, 56]. Whereas some studies 

examine the whole spine, others limit themselves to the cervical (C) or thoracic/lumbar spine 

(T/L). 

The results of these studies correspond [9] to the maximum extent so that we can primarily rely 

hereinafter on the prospectively validated criteria of Domeier et al. and Muhr et al. [24, 25]. 

Smaller studies have concentrated solely on multiply injured patients [53] but find similar 

predictors so that it appears justified to generalize the results. On other hand, Muhr et al. and 

Holmes et al. regarded the presence of other relevant injuries as a criterion that made the definite 

exclusion of a spinal injury more difficult or impossible. A retrospective study of patients with 

thoracolumbar spinal injuries found that the presence of concomitant injuries lowered the 

frequency of (pressure) pain in the back from over 90% to 64% [43]. However, one can assume 

from this that multiply injured patients have either an extremity fracture or impaired 

consciousness so that, depending on the decision rules, a suspected spinal injury cannot be ruled 

out. 



Taking into consideration the 5 criteria of impaired consciousness, neurologic deficit, spinal pain 

or myogelosis, intoxication, and trauma in the extremities, Domeier et al. missed only 2 relevant 

spinal injuries [24]. In addition, there were 13 stable spinal injuries that did not require 

osteosynthesis thus yielding a sensitivity of 95% with a negative predictor value of 99.5%. The 

study related to the whole spine and found approximately 100 fractures each in the cervical, 

thoracic, and lumbar spine. 

Rotation injuries (type C according to AO) are relatively unstable and have an increased risk of 

further neurologic deterioration [32]. If a rotation injury is suspected on the basis of the 

mechanism of injury, immobilization should be carried out carefully and without delay on 

account of the instability. 

How is the diagnosis for spinal injury without spinal cord involvement made and how 

definite is it? 


Acute pain in the spinal region after trauma should be assessed as an 

indication of a spinal injury. 

Explanation: 

GoR B 

The cited injury signs may be present both in a bony spinal injury and in a solely soft tissue 

injury surrounding the bone. There are no prehospital findings that can be collected which can 

prove or exclude a spinal injury with certainty. External injury signs - deformations, tenderness, 

percussion tenderness, steps, lateral displacements, palpable gaps between spinous processes - 

are indirect clues to the presence of an injury to the spine. An evaluation of the (positioning) 

stability of the injury cannot be made in the prehospital phase. 

How is the diagnosis for spinal injury with spinal cord involvement made and how definite 

is it? 

Explanation: 

The neurologic deficit in sensitivity and/or motor functions is definitive in the diagnosis of 

damage to the spinal cord. It is highly probable that a bony injury to the spine is also present in 

adults. Neurologic deficits without bony involvement can occur more frequently in children 

(SCIWORA [Spinal Cord Injury Without Radiographic Abnormality] syndrome) [7]. 

The level and complete/incomplete lesions can only be measured to a limited extent. It is 

therefore not possible to make a conclusive statement on the prognosis of the injury at the 

accident scene. 

On the other hand, a normal neurology finding does not exclude a spinal injury with spinal cord 

involvement. 



How is a spinal injury treated in the prehospital phase? 

What is the technical rescue procedure for a person with a spinal injury? 


In the event of acute threat to life (e.g., fire/danger of explosion), which can 

only be eliminated by immediate rescue from the danger zone, immediate, 

direct rescue from the danger zone must be effected even if a spinal injury is 

suspected, if necessary even disregarding precautionary measures for the 

injured person. 

GoR A 

The cervical spine must be immobilized before technical rescue. GoR A 

Explanation: 

The first prehospital procedure for a casualty is to immobilize the cervical spine using a cervical 

collar. To date, however, we are not aware of any literature that confirms this procedure in 

preventing secondary damage during the technical rescue. No differences in the use of different 

immobilization collars have been found [18, 51]. 

During the rescue of an injured person, all non-physiologic spine movements, particularly 

flexion, segmental rotation and lateral inclination, must be avoided. The spine must be moved 

into its neutral position, i.e. flat supine position, in a coordinated way with enough assistants [6]. 

With due consideration of the time required, a more extended technical rescue - e.g., involving 

removal of a car roof - should be considered. Aids such as the scoop stretcher or spine boards 

make it easier to rescue a person with a spinal injury in the above-mentioned neutral position 

from a difficult accident scene. 

How is a person with a spinal injury positioned/immobilized? 

Explanation: 

Up till now, the first prehospital procedure for a casualty is the immobilization of the cervical 

spine using a cervical collar, even if the evidence level for this is not high. The cervical spine is 

thereby put into the neutral position. If this causes pain or an increase in neurologic deficit, do 

not reposition in the neutral position. 

In a prospective study, Bandiera and Stiell found evidence that clinically significant injuries 

could be detected with a sensitivity of 100% using the Canadian C-spine rule [56]. However, a 

proviso should be added here that this study was conducted in hospital on fully conscious 

patients [5]. Thus, a relatively long period of time has already elapsed since the accident and, at 

this later point in time, the symptoms of milder acceleration injuries to the cervical spine also 

manifest themselves for the first time; these may not occur at the accident scene due to the 

psychologic impairment. 



When there is a traumatic brain injury and a suspected cervical spine injury, it should be weighed 

up whether to fit a rigid cervical collar or whether another type of immobilization (e.g., only a 

vacuum mattress) is possible in order to prevent a potential increase in ICP [21, 22, 37, 38, 39, 

50]. In another clinical study, there was no evidence of an increase in ICP if the rigid cervical 

collar was fitted correctly [39]. So, when a rigid cervical collar is being fitted on a patient with a 

TBI, care should be taken that it is the correct size and not too tightly fastened so that the 

possibility of any venous outflow obstruction is excluded. In addition, the upper part of the body 

should be elevated if possible in this situation. 

The above-mentioned position can also be immobilized on the vacuum mattress. This achieves 

the currently most effective immobilization of the whole spine as well. If the head is also 

enclosed with high cushions or belts, this further restricts possible residual movement of the 

cervical spine. To date, there is no randomized study that provides evidence of a positive effect 

from immobilizing the spine [40]. 

A patient carry sheet on the vacuum mattress makes subsequent re-positioning in hospital easier 

[8]. Other aids such as the scoop stretcher or spine boards can only immobilize the spine to a 

limited extent. 



How is a person with a spinal injury transported? 


Transport should be as gentle as possible and free of pain. GoR B 

Explanation: 

A patient with a spinal injury should be transported as gently as possible, i.e. without further 

external force to avoid pain and possible secondary damage. After positioning and strapping in, 

analgesics are administered during transportation. A helicopter offers the smoothest form of 

transport. In addition, it might offer a time advantage when a patient with a spinal injury and 

neurologic deficits has to be transported to a center. 

Is there a specific treatment for spinal injury in the prehospital phase? 

Explanation: 

The benefit of a high dose of cortisone treatment being administered prehospital (or 

subsequently) for spinal injuries with neurologic deficit is controversial [65]. Following the 

successful administration of corticosteroids for spinal trauma in many animal experiments [1, 25, 

26, 58, 59, 66], it has not been possible to confirm the results in all clinical studies. Criticism has 

been leveled at the NASCIS (National Acute Spinal Cord Injury Studies) several times [19], for 

instance, the lack of effect in the NASCIS I study (there was no control group here but low-dose 

cortisone was compared with too little high-dose cortisone) and the lack of placebo group in the 

NASCIS III study as well [19]. The positive effects in the NASCIS II study were only minor, of 

limited clinical relevance, and less marked after 1 year than after 6 months. 

Here is a summary of the advantages and disadvantages of giving methylprednisolone according 

to current literature: 

Reasons for cortisone treatment: 

1. The NASCIS II study showed an improvement in motor outcome providing methyl 

prednisolone treatment was started within 8 hours [11, 12]. However, this outcome was 

only unilaterally verified and dependent on the researcher. 

2. Other studies of worse methodological quality have also found a benefit from cortisone 

treatment but in this case the start of treatment was predominantly evaluated after 

admission to hospital. 

3. The NASCIS III study showed a greater effect in treatment duration of 48 hours 

providing treatment commenced between 3 and 8 hours after trauma [14, 15]. 

4. Relevant side effects such as abdominal bleeding are not increased [27] and there has 

been no evidence of accumulation of femoral head necroses following high-dose 

cortisone treatment [64]. 



5. There is no other definitive pharmacologic treatment for spinal cord injury. 

Reasons against cortisone treatment: 

1. No relevant benefit could be found in the NASCIS I study [13]. 

2. The proven benefit was only found in patients who had received treatment within 8 

hours. 

3. The proven benefit was small, of unconfirmed clinical significance, and even smaller 

after 1 year than after 6 months [10, 12]. 

4. There was no placebo control group in the NASCIS III study [14, 15]. 

5. Further studies showed a higher complication rate in the patients treated with cortisone 

(increase in lung complications [29, 31], particularly in elderly patients [42], and 

gastrointestinal bleeding [48]). 

6. Lack of neurologic benefit in other studies with frequently unclear injury pattern [30, 42, 

48, 49]. 

Infusion treatment to stabilize the circulation is necessary in neurogenic shock with due 

consideration being paid to other possible sources of bleeding caused by injury. The infusion 

volume to be administered and the target mean arterial pressure is also disputed by expert 

opinion. Adequate analgesic treatment is necessary to prevent shock. 

Extreme pulling forces on the cervical spine, e.g., when removing a motorbike helmet, and 

segmental torsions on unstable C injuries (cervical vertebrae) of the spine can lead to 

deterioriation in the neurologic deficit by directly affecting the spinal cord. It should be noted 

here that there are no references to secondary damage in the literature on this either. 



Are there advantages for the patient with spinal injury in being transported primarily to a 

trauma center with a spine surgery facility? 


Patients with neurologic deficits and suspected spinal injury should be 

transported primarily and as a minimum to a regional trauma center with a 

spine surgery facility. 

Explanation: 

GoR B 

Early surgery on spinal injuries with spinal cord involvement can improve the neurologic 

outcome [44, 52]. 

Early surgery (within 72 hours) on cervical spine injuries with neurologic deficits does not 

conceal an increased risk of additional complications [44]. 

For this reason, particularly in the case of isolated spinal trauma and a non-acute threat to life, 

management should, if possible, be in a spinal center [60]. Patients with a spinal canal 

constriction, particularly in the cervical region, appear to gain from early surgery [4]. Even if 

there is only little evidence, it should still be assumed that patients with incomplete neurology 

and partial displacement of the spinal canal could gain from early reduction and, if necessary, 

surgical debridement. 

Summary: 

The vast majority of the screened literature relates mainly to the hospital situation, in other 

words, to studies which were conducted after admission to hospital. Provided they are relevant, 

these data must be extrapolated to the prehospital situation. There is a relatively large number of 

studies which were conducted in the USA and thus in the paramedic system. This initial 

management at the accident scene is only partially comparable with the German rescue and 

emergency physician system. 

These two points must be taken into account as this means that conclusions (in terms of a 

guideline) have only restricted validity on applicability to the prehospital emergency physician 

situation in Germany. 



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1.7 Extremities 

Priority 


Heavily bleeding extremity injuries, which can impair the vital function, must 

be given first priority. 

The management of extremity injuries must avoid further damage and not 

delay the total rescue time if there are additional threatening injuries present. 

Explanation: 

GoR A 

GoR A 

Securing the vital functions and examining the head and trunk should precede the examination of 

the extremities. Specifics can occur in extremity injuries with severe blood loss [21, 27]. 

Severe and immediate life-threatening bleeding must be treated immediately even ignoring the 

ABCDE protocol (see page 133). 

Confirmation of more major, external bleeding which is not directly life-threatening is important 

and is usually carried out under “C” (circulation) whereas more minor bleeding comes under the 

“secondary survey” [21]. 

The first rule is to avoid further damage, restore and maintain vital functions and transport to a 

suitable hospital [11, 25]. 

The management of extremity injuries (irrigation/wound management/splinting) should not delay 

the rescue time if there are additional threatening injuries present [23]. 

Diagnostic study 

Medical history 

A very detailed medical history (firsthand/third party) of the circumstances of the accident can 

be gathered to obtain sufficient information on the impacting force and, if applicable, the degree 

of contamination of open wounds [2, 27]. 

If possible, information (allergies, medication, previous diseases and fasting state) should be 

collected in addition to the accident history and the time of the accident. In addition, details of 

tetanus immunization status should be obtained [21, 34]. 

Prehospital – Extremities 104


Examination 


All extremities of a casualty should undergo an exploratory assessment in the 


Explanation: 

GoR B 

Alert patients should be asked first whether they have any pain and where it is. If there is pain, 

adequate analgesics can be administered early on [21]. A prehospital examination should be 

carried out [11]. The examination at the accident scene should assess to an appropriate extent the 

severity of the injury without delaying the total rescue time too much [2]. The examination 

should be an exploratory survey from head to toe and not last longer than 5 minutes [34]. 

The examination should be carried in the following order: inspection 

(malposition/wounds/swelling/circulation), stability test (crepitation, abnormal mobility, stable 

and unstable fracture signs), assessment of circulation, motor functions and sensitivity. Soft 

tissue findings should also be assessed (closed versus open fracture, compartment syndrome) 

[11, 21, 27]. 

Leather clothing such as motorbike apparel, for example, should be left on if possible as this 

serves as a splint with compression effect particularly for the pelvis and the lower extremity [14, 

21]. 

Capillary reperfusion can be tested by comparing with the uninjured limb [21]. 

Treatment 

General 


Even if an extremity injury is only suspected, it should be immobilized against 

rough movement and before transporting the patient. 

Explanation: 

GoR B 

Immobilizing an injured extremity is an important procedure in prehospital management. An 

extremity injury should be immobilized against rough movement and before transporting the 

patient. Reasons for this are to alleviate pain, prevent further soft tissue damage/bleeding and 

reduce the risk of a fat embolism and neurologic damage [21, 34]. 

Even a suspected injury should be immobilized [10, 34]. 



The joints proximal and distal to the injury should be included in the immobilization [10, 11, 24, 

34]. The injured extremity should be supported flat [4]. Particularly in shortened femoral 

fractures, traction/immobilization under traction should be carried out to minimize bleeding [2, 

21]. Vacuum splints are suitable for immobilizing an abnormal position. Vacuum splints are 

rigid and can adapt to the shape of the extremity [21]. Air chamber splints are suitable for 

splinting upper extremity injuries with the exclusion of injuries in the proximity of the shoulder 

joint. In the lower extremity, they are suitable for immobilizing knee, lower leg, and foot 

injuries. On their attachment, the pressure in the air chamber splints and the peripheral blood 

supply must be regularly checked [4]. The advantage of the air chamber splint is its low weight; 

the disadvantage is the compression of soft tissue which can cause secondary damage. Vacuum 

splints are therefore preferred. Air chamber and vacuum splints are unsuitable for immobilizing 

femoral fractures and those in the proximity of the shoulder joint [5]. Cooling can reduce 

swellings and help to alleviate pain [10]. Femur injuries can be adequately immobilized without 

complications with a spine board or rigid splinting. It is not absolutely necessary for traction 

splints to be carried in the emergency medical service. 

In a retrospective study with 4,513 callouts made by emergency paramedics in an American 

emergency medical system (EMS), 16 patients (0.35%) with injuries to the mid-femur were 

singled out. While 11 of these patients had only minor injuries, 5 of these patients (0.11% of all 

patients) were treated under a femoral fracture diagnosis. Three of these 5 patients received a 

traction splint. In one of the cases, the traction splint had to be removed again due to severe pain 

and a rigid immobilization device was attached. One patient could not have a traction splint 

because of simultaneous hip trauma. Another patient who was free of pain was transported in a 

comfortable position. The authors conclude that femur injuries and/or a suspected fracture are 

rare and can be well managed with a backboard or rigid immobilization. For this reason, it is not 

absolutely necessary for traction splints to be carried in the emergency medical service [1]. 

Traction splints should not be used particularly on multiply injured patients as there are many 

contraindications for their use in these patients (pelvic fracture/knee/lower leg/ankle joint injury) 

[33]. They are only rarely used due to the existing contraindications on the use of a traction 

splint, particularly in critically injured patients. Dislocated proximal femoral fractures are also 

contraindications for the use of a traction splint [7]. 

Traction splints are useful and, depending on the model, easy to use for immobilizing femoral 

fractures, even dislocated proximal femoral fractures. Further studies are necessary [8]. Traction 

splints reduce muscle spasms and thus alleviate pain. Traction helps to restore the femur shape 

and by reducing volume leads to a decrease in bleeding [8, 30, 31]. Oxygen can be given via a 

non-rebreather mask (15 l/min) [2, 21]. Jewelry (rings/chains) must be removed from the injured 

extremity [2, 10]. 

Photos of wounds/open fractures can be taken for documentation (polaroid/digital). Photographic 

documentation of wounds, open fractures or discovered malpositions appears expedient as it can, 

under circumstances, avoid immobilized extremities or wounds already dressed in the 

prehospital phase from being exposed again in the hospital until they are definitively treated. 

Photographic documentation can assist the subsequent treating physician in assessing the injury. 

Photographic documentation must not extend the management/rescue time [2, 21]. 



The severity and extent of the injuries must be documented in the emergency physician logbook 

and the local finding must be described to the subsequent treating surgeon, if possible in person 

[3]. 

Fractures 


If possible, and particularly with concomitant ischemia in the extremity 

concerned/with a long rescue time, grossly dislocated fractures and 

dislocations should be approximately reduced in the prehospital phase. 

Explanation: 

GoR B 

The primary goal is to secure the local and peripheral blood supply. The primary goal is not an 

exact anatomic reduction. What is more important is correct axial positioning and the restoration 

of an adequate local and peripheral blood supply [3, 5]. If the neurovascular supply to the 

extremity distal to the injury is not compromised, reduction can be ignored in principle [2]. If 

possible, and particularly with concomitant ischemia in the extremity concerned/with a long 

rescue time, grossly dislocated fractures and dislocations should be reduced in the prehospital 

phase by axial traction and manual correction into the neutral position or into a position that is 

nearest to the neutral position. It is important to check the peripheral blood supply and motor 

functions and sensitivity (where possible) before and after reduction [3, 4, 5, 11, 21, 25]. Too 

much longitudinal traction must be avoided as this increases compartmental pressure and 

worsens the blood supply in the soft tissue [3, 5]. 

A neurologic or vascular deficit distal to the fracture requires an immediate reduction attempt. 

The same applies if the soft tissue sheath/skin is compromised [21]. After successful 

immobilization, circulation, sensitivity, and peripheral motor functions should be checked again 

[2, 21]. If neurovascular circulation deteriorates after a reduction attempt, the extremity must be 

immediately placed back in the initial position and stabilized as well as possible [21]. 

Reduction of ankle fractures/ankle dislocation fractures should only be carried out by those 

experienced in this procedure. Otherwise, the goal is immobilization in the position found [21]. 

In the case of commonly dislocated ankle joint fractures with obvious malposition, reduction can 

be carried out at the accident scene. With adequate analgesia, an approximately correct axial 

position can be achieved by controlled, continuous longitudinal traction with both hands on the 

calcaneus and heel of the foot; this position can then be immobilized. After this, the blood supply 

and neurologic situation should be recorded again. 

Obvious long bone fractures in the shaft area should also be treated in this way. Fractures in 

proximity to joints are difficult to assess in their extent and, after being immobilized in the painfree 

position found, can be transferred as rapidly as possible for further hospital diagnosis [2, 

34]. 



Stronger longitudinal traction should be avoided in distal femoral fractures as this can 

compromise the popliteal vessels. The knee joint can be supported in a slightly bent position (30- 

50 degrees) [4]. 

Open fractures 


Each open fracture should be cleaned of coarse contamination and covered 

with a sterile dressing. 

Explanation: 

GoR B 

Each open fracture should be identified and coarse contamination immediately removed [21]. 

Open fractures should be irrigated with physiologic saline solution [2, 21, 23, 26]. All open 

wounds should be covered with a sterile dressing [3, 4, 11, 21, 26, 34]. Without further cleansing 

or disinfection measures, open wounds must be covered with a large sterile dressing. Coarse 

contamination is removed [3, 4, 5]. Thereafter, they should be immobilized as for closed injuries 

[26, 34]. It is best if the dressings are not removed until in the operating room [21, 26]. 

Antibiosis should be carried out at the earliest possible time. The risk of infection increases 

dramatically after 5 hours [26]. If available, intravenous antibiosis can be administered in the 

prehospital phase, usually with a 2nd generation cephalosporin which is easily distributed in the 

bone [4]. Prehospital antibiosis should be carried out if the rescue time is extended [23]. 




Active bleeding should be treated according to the following stepwise 

approach: 

� manual pressure/pressure dressing 

� (elevation) 

� tourniquet 

Indications for immediate use of a tourniquet/arrest of blood supply can be: 

� life-threatening bleeding/multiple sources of bleeding in an extremity 

� inability to reach the actual injury 

� several injured persons with bleeding 

Explanation: 

GoR B 

GoR 0 

The measures for arresting bleeding should follow a stepwise approach. A primary attempt 

should be made to arrest active bleeding by manual pressure and elevation of the extremity. Then 

a pressure dressing should be applied. If this is not adequate, a second pressure dressing should 

be applied over the first one. A sterile pad can be used to help to focus pressure. If bleeding 

persists, pressure should be applied to an artery proximal to the injury. In addition, if possible, a 

tourniquet should be applied. As an exception, the vessel can be clamped (amputation, longer 

transportation time, neck vessel, anatomic position makes the use of a tourniquet impossible) [3, 

4, 11, 21, 32]. 

In regions where tourniquets cannot be applied (proximal extremities), hemostatic dressings can 

be used [13]. Applying a tourniquet requires appropriate analgesia [21]. A blood pressure cuff 

with 250 mmHg can be applied to the upper arm and one with 400 mmHg to the femur [3, 5]. 

The time at which the tourniquet was applied should be noted [21, 22, 28]. The tourniquet must 

interrupt the arterial blood flow completely. An incorrectly applied tourniquet can intensify 

bleeding (only compromises low pressure system) [22]. Effectiveness is monitored by an arrest 

in bleeding rather than the disappearance of the distal pulse. In the case of a fracture, bleeding 

can also come from the bone marrow [22]. 



Indications for immediate use of a tourniquet can be [22]: 

� Extreme bleeding/multiple sources of bleeding in an extremity necessitating parallel 

securing of vital functions 

� Inability to reach the actual injury (e.g., trapped person) 

� Mass casualty incident 

The following points should be borne in mind when applying a tourniquet: 

� Apply as far distally as possible, approx. 5 cm proximal to the injury 

� Apply directly on the skin to prevent it slipping [22, 28]. 

If ineffective, re-apply with more pressure and only after that consider applying a second 

tourniquet directly proximal to the first [22]. Cooling an extremity that has a tourniquet applied 

can increase ischemic tolerance during long rescue times [15]. 

There is only insufficient data on the safe application time for a tourniquet. The general 

recommendation is 2 hours but this has emerged from data obtained from normovolemic patients 

with a pneumatic tourniquet [22]. If the transportation time until surgery is less than 1 hour, the 

tourniquet can remain in situ. For longer rescue times (> 1 hour), attempts should be made to 

release the tourniquet in a stabilized patient. If bleeding should start again, the newly applied 

tourniquet should then remain in situ until it is managed in the operating room [22]. After 30 

minutes, the tourniquet should be checked to see if it is still necessary. This is not indicated if the 

patient is in shock or the attendant circumstances (personnel) are adverse [12]. 

In a retrospective case series on war injured from the database of the British military, tourniquets 

were applied to 70 patients out of 1,375 patients who had been treated during the period in 

English field hospitals (5.1%). A total of 107 tourniquets were applied (17 of the treated [24%] 

had 2 or more tourniquets applied). Of this number, 5 had a double tourniquet applied for the 

same injury and 12 of the injured had bilateral tourniquets (maximum number per injured 4 - 2 

each on both lower extremities). A hundred and six tourniquets were applied prior to arrival at 

the field hospital. Sixty-one of these 70 patients (87.1%) survived. Mean value of the survivors: 

ISS = 16, mean value of fatalities (only 6 could be autopsied): ISS = 50. 

Whereas prior to the introduction of tourniquets as standard (February 2003 to April 2006) only 

9% (6 injured persons) were treated with a tourniquet, following introduction (April 2006 

through February 2007) it was 64 (91%). Without details of the total number of injured persons 

during this period, the authors indicate a 20-fold increase in the use of tourniquets. Three 

complications directly caused by the tourniquets were observed. There were 2 cases of 

compartment syndromes (one each in the femur and lower leg, one of which was due to incorrect 

application of the tourniquet) and one case of damage to the ulnar nerve (with no further details 

on the course). The use of tourniquets was assessed as life-saving in 4 cases of patients with 

isolated extremity injuries, hypovolemic shock and massive transfusion (and factor VIIa 

administration) [9]. 



In a retrospective study of 165 patients (inclusion criteria: traumatic amputation or severe vessel 

injury in extremities), Beekley et al. showed that the prehospital use of tourniquets led to 

improved control of bleeding; this relates particularly to multiply injured patients (ISS > 15). 

Forty percent of soldiers (n = 67) had a tourniquet. Reduced mortality could not be observed. 

The average tourniquet time was 70 minutes (min.: 5 minutes; max.: 210 minutes); damage due 

to use was not observed [6]. 

In a prospective cohort study of 232 patients who had 428 tourniquets applied, Kragh et al. 

showed that there was no link between tourniquet time (average 1.3 hours) and morbidity 

(thromboses, number of fasciotomies, pareses, amputations). With tourniquet times over 2 hours, 

there is a trend towards increased morbidity with respect to amputations and fasciotomies. 

The tourniquet should be applied as early as possible. If a tourniquet does not lead to the 

disappearance of the distal pulse, a second should be applied directly proximal to the first one to 

increase effectiveness. There should be no materials underneath the tourniquet as they can lead 

to the tourniquet loosening. Tourniquets should be applied directly proximal to the wound. The 

effectiveness of tourniquets should be re-evaluated during the course [17]. The use of tourniquets 

is linked to a higher survival probability. The use of tourniquets before the occurrence of shock 

is linked to a higher survival probability, likewise when it is applied in the prehospital phase. No 

amputation has been require as a result of the use of a tourniquet. 

In a study of the US army in Baghdad with 2,838 injured persons with severe extremity injury, 

232 (8.2%) of those treated had 428 tourniquets applied (to 309 injured extremities). Of these, 

13% died. In a matched pair analysis (Abbreviated Injury Scale [AIS], Injury Severity Score 

[ISS], all male, age) of 13 injured persons with tourniquet applied (survival rate 77% [10 out of 

13]) and 5 (more were not identified in the time span) without tourniquet (but where there was an 

indication for tourniquet use and who all died in the prehospital phase [usually only 10-15 

minutes!]), it was shown that early use of tourniquets significantly increased the survival 

probability in severe extremity injuries (p < 0007). Ten of the injured only received the 

tourniquet in a manifest state of shock, and 9 (90%) died. Two hundred and twenty-two received 

the tourniquet before the onset of shock and only 22 died (10%, p < 0001). Twenty-two of the 

194 patients who already received the tourniquet in the prehospital phase (11%) and 9 of the 38 

(24%) who only received the tourniquet in the hospital’s emergency department died (p = 0.05). 

Ten cases of transient nerve paralysis occurred without any correlation to the length of time the 

tourniquet was applied [18]. 

The use of tourniquets is an effective, simple (for medical and non-medical personnel) method to 

prevent exsanguination in the military prehospital setting [20]. The use of tourniquets is a safe, 

rapid and effective method to control bleeding from an open extremity injury and should be used 

routinely and not only as a last resort (civil study) [16]. Tourniquets can contribute towards a 

reduction in mortality of those injured in battle and show only low complication rates (nerve 

paralysis, compartment syndrome). The loss of an extremity due to the use of a tourniquet is a 

rarity [13]. 

Amputations 




The amputated part should be cleaned of coarse contamination and wrapped 

in sterile, damp compresses. It should be indirectly chilled while being 

transported. 

Explanation: 

GoR B 

In addition to arresting bleeding, the amputation stump should be splinted and a sterile dressing 

applied. Only coarse contamination should be removed [3, 4]. The amputated part must be 

preserved. Bony parts or amputated digits should be taken from the accident scene or, if 

necessary, brought on afterwards. 

Wrap the amputated part in sterile, damp compresses and transport chilled, if possible packed 

using the “double bag method”. Here, the amputated part is packed in an inner plastic bag with 

sterile, damp compresses. This bag is placed in a bag with iced water (1/3 ice cubes, 2/3 water) 

and sealed. This avoids secondary cold damage (no direct contact between ice or cool pack and 

the tissue) [2–4, 19]. 

Amputations influence the choice of designated hospital and advance warning should be given 

[2, 3]. 



References 

1. Abarbanell Nr (2001) Prehospital midthigh trauma 

and traction splint use: recommendations for treatment 

protocols. Am J Emerg Med 19:137-140 

2. Anonymous (2006) Limb trauma. In: School WM (ed) 

Clinical Practice Guidelines. For use in U.K. 

Ambulance Services. Guidelines of the Joint Royal 

Colleges Ambulance Liaison Committee and The 

Ambulance Service Association. Warwick Medical 

School, London, p 

http://www2.warwick.ac.uk/fac/med/research/hsri/em 

ergencycare/guidelines/limb_trauma_2006.pdf 

[Evidenzbasierte Leitlinie] 

3. Beck A (2002) Notärztliche Versorgung des 

Traumapatienten. Notfall- und Rettungsmedizin 1:57- 

61 

4. Beck A (2002) Wunde- Fraktur- Luxation. Notfall- 

und Rettungsmedizin 8:613-624 

5. Beck A, Gebhard F, Kinzl L et al. (2001) [Principles 

and techniques of primary trauma surgery 

management at the site]]. Unfallchirurg 104:1082- 

1096; quiz 1097, 1099 

6. Beekley Ac, Sebesta Ja, Blackbourne Lh et al. (2008) 

Prehospital tourniquet use in Operation Iraqi 

Freedom: effect on hemorrhage control and outcomes. 

J Trauma 64:S28-37; discussion S37 

7. Bledsoe B, Barnes D (2004) Traction splint. An EMS 

relic? Jems 29:64-69 

8. Borschneck Ag (2004) Traction splint: proper splint 

design & application are the keys. Jems 29:70, 72-75 

9. Brodie S, Hodgetts Tj, Ollerton J et al. (2007) 

Tourniquet use in combat trauma: UK military 

experience. J R Army Med Corps 153:310-313 

10. Cuske J (2008) The lost art of splinting. How to 

properly immobilize extremities & manage pain. 

JEMS 33:50-64; quiz 66 

11. Dgu (2007) Leitlinie Polytrauma. In: Unfallchirurgie 

DGf (ed), p http://www.dguonline.de/de/leitlinien/polytrauma.jsp 

12. Doyle Gs, Taillac Pp (2008) Tourniquets: a review of 

current use with proposals for expanded prehospital 

use. Prehosp Emerg Care 12:241-256 

13. Ficke Jr, Pollak An (2007) Extremity War Injuries: 

Development of Clinical Treatment Principles. J Am 

Acad Orthop Surg 15:590-595 

14. Hinds Jd, Allen G, Morris Cg (2007) Trauma and 

motorcyclists: born to be wild, bound to be injured? 

Injury 38:1131-1138 

15. Irving Ga, Noakes Td (1985) The protective role of 

local hypothermia in tourniquet-induced ischaemia of 

muscle. J Bone Joint Surg Br 67:297-301 

16. Kalish J, Burke P, Feldman J et al. (2008) The return 

of tourniquets. Original research evaluates the 

effectiveness of prehospital tourniquets for civilian 

penetrating extremity injuries. JEMS 33:44-46, 49-50, 

52, 54 

17. Kragh Jf, Jr., Walters Tj, Baer Dg et al. (2008) 

Practical use of emergency tourniquets to stop 

bleeding in major limb trauma. J Trauma 64:S38-49; 

discussion S49-50 

18. Kragh Jf, Jr., Walters Tj, Baer Dg et al. (2009) 

Survival with emergency tourniquet use to stop 

bleeding in major limb trauma. Ann Surg 249:1-7 

19. Lackner Ck, Lewan U, Deiler S et al. (1999) 

Präklinische Akutversorgung von 

Amputationsverletzungen. Notfall- und 

Rettungsmedizin 2:188-192 

20. Lakstein D, Blumenfeld A, Sokolov T et al. (2003) 

Tourniquets for hemorrhage control on the battlefield: 

a 4-year accumulated experience. J Trauma 54:S221- 

225 

21. Lee C, Porter Km (2005) Prehospital management of 

lower limb fractures. Emerg Med J 22:660-663 [LoE 

4] 

22. Lee C, Porter Km, Hodgetts Tj (2007) Tourniquet use 

in the civilian prehospital setting. Emerg Med J 

24:584-587 

23. Melamed E, Blumenfeld A, Kalmovich B et al. (2007) 

Prehospital care of orthopedic injuries. Prehosp 

Disaster Med 22:22-25 

24. Perkins Tj (2007) Fracture management. Effective 

prehospital splinting techniques. Emerg Med Serv 

36:35-37, 39 

25. Probst C, Hildebrand F, Frink M et al. (2007) 

[Prehospital treatment of severely injured patients in 

the field: an update]. Chirurg 78:875-884 [LoE 5] 

26. Quinn Rh, Macias Dj (2006) The management of 

open fractures. Wilderness Environ Med 17:41-48 

27. Regel G, Bayeff-Filloff M (2004) [Diagnosis and 

immediate therapeutic management of limb injuries. 

A systematic review of the literature]. Unfallchirurg 

107:919-926 [LoE 3a] 

28. Richey Sl (2007) Tourniquets for the control of 

traumatic hemorrhage: a review of the literature. 

World J Emerg Surg 2:28 


(1997) Evidence-based medicine: How to practice and 

teach EBM. Churchill Livingstone, London 

30. Scheinberg S (2004) Traction splint: questioning 

commended. Jems 29:78 

31. Slishman S (2004) Traction splint: sins of commission 

vs. sins of omission. Jems 29:77-78 

32. Strohm Pc, Bannasch H, Goos M et al. (2006) 

[Prehospital care of surgical emergencies]. MMW 

Fortschr Med 148:34, 36-38 

33. Wood Sp, Vrahas M, Wedel Sk (2003) Femur fracture 

immobilization with traction splints in multisystem 

trauma patients. Prehosp Emerg Care 7:241-243 

34. Worsing Ra, Jr. (1984) Principles of prehospital care 

of musculoskeletal injuries. Emerg Med Clin North 

Am 2:205-217 



1.8 Genitourinary tract 


In the case of a suspected urethral injury, prehospital bladder catheterization 

should not be carried out. 

Explanation: 

GoR B 

Genitourinary tract injuries can occur in approximately 5-10% of cases of multiply injured 

persons and are thus relatively frequent. In numbers, kidney injuries are at the forefront, 

followed by bladder and urethra. In contrast, about half of all urologic trauma are associated with 

further injuries consistent with multiple injuries [1, 7]. Relatively severe and combined 

genitourinary injuries typically occur only with multiple injuries [4, 7]. Due to their relative 

frequency and clinical importance, recommendations shall be given below for injuries to the 

kidney, ureters, bladder, and urethra. In contrast, injuries to the external genital organs are not 

discussed as they are relatively rare and are usually treated in a similar way in polytrauma as in 

monotrauma. 

In contrast to other injuries, injuries to the ureter, bladder, and urethra do not represent a direct 

threat to life (evidence level [EL] 4 [2]). Although kidney ruptures are potentially lifethreatening, 

they cannot be treated in the prehospital phase. Accordingly, there are scarcely any 

specific prehospital procedures for diagnosis and treatment of urological injuries. A diagnosis 

time advantage is assumed only for the transurethral catheterization of the bladder because the 

presence and severity grade of hematuria can be important both in the choice of designated 

hospital and for its management upon arrival in hospital. As time losses represent a relevant risk 

quoad vitam to multiply injured patients particularly in prehospital care, prehospital 

catheterization may be advantageous if longer rescue/transport times are predicted providing it in 

turn does not lead to delays. Internationally, the transurethral bladder catheter is a quite common 

procedure in the prehospital treatment of multiply injured patients. 

There is a slight risk that an additional injury is caused through bladder catheterization (EL 4 [3]) 

by turning an incomplete urethral rupture into a complete rupture. In addition, the transurethral 

catheter can cause a via falsa in a complete urethral rupture (EL 5 [5, 6]). Based on these 

considerations, it seems advisable to dispense with transurethral catheterization in patients with 

clinical signs of a urethral injury until the diagnostic study has been completed. Hematuria 

and/or blood leakage from the meatus urethra are the main clinical criteria for a urethral injury. 

In addition, dysuria, suspected pelvic fracture, local hematoma development, and the general 

mechanism of injury can provide diagnostic clues. 

Prehospital – Genitourinary tract 114


References 

1 Cass AS, Cass BP. Immediate surgical management 

of severe renal injuries in multiple-injured patients. 

Urology 1983: 21(2):140-145. 

2 Corriere JN, Jr., Sandler CM. Management of the 

ruptured bladder: seven years of experience with 111 

cases. J Trauma 1986: 26(9):830-833 [LoE 4] 

3 Glass RE, Flynn JT, King JB, Blandy JP. Urethral 

injury and fractured pelvis. Br J Urol 1978: 

50(7):578-582 [LoE 4] 

4 Monstrey SJ, vander WC, Debruyne FM, Goris RJ. 

Urological trauma and severe associated injuries. Br J 

Urol 1987: 60(5):393-398. 

5 Morehouse DD, Mackinnon KJ. Posterior urethral 

injury: etiology, diagnosis, initial management. 

UrolClin North Am 1977: 4(1):69-73 [LoE 5] 

6 Nagel R, Leistenschneider W. [Urologic injuries in 

patients with multiple injuries]. Chirurg 1978: 

49(12):731-736 [LoE 5] 

7 Zink RA, Muller-Mattheis V, Oberneder R. [Results 

of the West German multicenter study "Urological 

traumatology"]. Urologe A 1990: 29(5):243-250. 

Prehospital – Genitourinary tract 115


1.9 Transport and designated hospital 


Primary air rescue can be used for the prehospital management of severely 

injured persons as it can result in a survival advantage particularly for 

medium to high injury severity. 

Explanation: 

GoR 0 

For years, air rescue has been a permanent component in the care provided by the emergency 

services not only in Germany but also internationally. In most European countries, a 

comprehensive network of air rescue bases has been built up over recent decades covering the 

primary and secondary management sectors. Numerous studies to date have tried to prove the 

effectiveness of air rescue. Thus, a possibly shorter prehospital period (time of accident until 

hospital admission) and more aggressive prehospital treatment have been referred to as potential 

grounds for an improved outcome in multiply injured patients. For a long time, however, it 

remained controversial whether the use of air rescue actually led to a reduction in mortality. A 

lack of medical effectiveness together with high contingency costs has thus put a question mark 

over air rescue for primary use. 

The necessity of the partly enormous logistic contingency costs in trauma centers has also come 

under question. In addition to expensive technology, staff resources in particular have been held 

in readiness, necessary for the optimum logistic management of multiply injured patients. Up till 

now, there has also been a lack of justifiable study conclusions on the rationale of high 

contingency costs. 

The results of the prehospital management of multiply injured patients by air rescue were 

compared in 19 studies (evidence Level 2b [2–6, 8, 11, 14, 16, 17, 18, 20, 21, 28, 29, 32] with 

those of land-based rescue. The case fatality rate was the primary endpoint here in all cases. Nine 

studies were designed as prospective, 8 studies as retrospective, and 6 studies were multicenter. 

In 16 studies, the primary designated hospital was exclusively a Level 1 trauma center [1], and in 

one study [20] Level 2/3 hospitals were also involved. 

Case fatality rate 

In 11 studies there was evidence of a statistically significant reduction in case fatality rate 

(between -8.2 and -52%) through the use of air rescue. Six studies show no advantage in 

outcome for patients transported by air rescue but reveal the following abnormalities: 

Phillips et al. 1999 [21]: With identical case fatality rates in both patient groups, the injury 

severity of the rescue helicopter (RTH) group was increased highly significantly (p < 0001); an 

adjusted case fatality rate comparison was not carried out. Schiller et al. 1988 [28]: The patients 

in the rescue helicopter group had both a significantly increased case fatality rate and a 

significantly higher injury severity; an adjusted case fatality rate comparison was not carried out. 

Nicholl et al. 1995 [20]: The patients in both treatment groups were also treated in Level 2 and 3 

Prehospital – Transport and designated hospital 116


hospitals as well as trauma centers. Cunningham et al. 1997 [11]: Patients in the rescue 

helicopter group with mean injury severity (ISS = 21–30) had a significantly reduced case 

fatality rate; but this result was not confirmed in the logistic regression. Bartolomeo et al. 2001 

[12]: Only patients with severe head injuries (AIS ≥ 4) were studied. The land-based emergency 

physician team also carried out invasive prehospital treatment interventions comparatively 

frequently so that the “gap” between their treatment level and that of the rescue helicopter group 

was only very slight. In Biewener et al. (2004) [5]: In their own paper it is also noticeable that a 

comparatively high level of invasive prehospital treatment is carried out by the land-based 

emergency physician team. 

Comparability and transferability of study results 

As a result of very different country-specific emergency service structures, the comparability of 

the studies must be questioned. For instance, a rescue system based on paramedics is found 

particularly in the North American region, whose structure cannot be compared with the German 

rescue service. The studies also differ noticeably in the injury pattern. For instance, blunt injuries 

in particular are predominant in European countries whereas penetrating trauma are predominant 

in North America. The studies also differ enormously in the transport distances to be covered 

and the aggressiveness of the prehospital management. The majority of the studies (11/17) show 

a statistically significant reduction in case fatality rate of multiply injured patients - particularly 

with average injury severity - through the use of air rescue. The 6 studies without evidence of a 

direct treatment advantage nevertheless reveal a trend towards better results with helicopter 

patients through increased injury severity with identical case fatality rate. 

Furthermore, all studies show a marked extension to the prehospital period. This is firstly 

because of a partly markedly longer transport distance, and secondly because of a markedly more 

aggressive prehospital management strategy. However, further evidence on the effectiveness of 

aggressive prehospital treatment is incomplete. 

In summary, these papers show a trend towards a fall in the case fatality rate of multiply injured 

patients through the use of air rescue compared with the land-based emergency service. This is 

particularly relevant to patients with average injury severity whose survival is particularly 

strongly dependent on treatment effects. The reasons are considered to be a better clinical 

diagnostic study and treatment due to the rescue helicopter team’s training and experience 

advantages. This conclusion is limited in its general validity and transferability by the listed 

systematic error sources of the cited papers and by the heterogeneity of the regional emergency 

service and hospital structures and of the types of injury. 

Comparison of trauma center versus hospital level II and III 

The importance of the duration of prehospital management of multiply injured patients has been 

proven in numerous studies and the term “golden hour” has been coined. The goal must be to 

transport the patient to a hospital which has at its disposal a 24-hour acute diagnostic and acute 

treatment unit in terms of prompt availability of all medical and surgical disciplines and the 

provision of corresponding capacities for acute treatment. Furthermore, it was shown that 

hospitals with a high footfall of critically injured patients had a clearly better outcome than 

facilities with markedly less annual revenue. 




Severely injured patients should be primarily transferred to a trauma center. GoR B 

Explanation: 

Hospital level: 

In the analysis of the studies, the term hospital levels 1-3 and partly also 1-4 are used. In this 

context, a Level 1 hospital equates to a maximum care hospital, which normally represents a 

trauma center, a term which does not have an internationally consistent definition. 

A care Level 2 hospital equates to a specialist hospital, and a care level 3 hospital equates to a 

basic, general hospital. 

Through the development of DGU trauma networks, 3 new categories of trauma care have been 

defined [24, 31]: “transboundary trauma center”, “regional trauma center”, and “basic care 

facilities”. 

Each care level is clearly defined using a certification procedure and is obliged to maintain the 

required performance. In addition to the previous structures, these facilities are linked to each 

other via “network development”. This enables shared resources and integrated patient care. 

Based on those trauma networks which are being developed and the corresponding lack of 

studies, the existing hospital grades (Level 1-3) have to be used to define the designated hospital 

recommendations. However, it might be possible to assume from an interlinking of various care 

centers that even the care quality of regional trauma centers legitimizes polytrauma care. 

The German Trauma Society (DGU) has developed the White Paper in association with the 

development of the trauma network [31]. It summarizes inter alia data of relevant international 

and national care studies, prospective data in the trauma registry of the German Trauma Society, 

and data and literature analyses of the interdisciplinary working group “S3 Guideline of the 

DGU on the treatment of seriously and multiply injured patients” in order to give 

recommendations on the structure, organization, and equipment for the care of the severely 

injured. 

The authors of the White Paper recommend that a severely injured patient is transferred to the 

nearest regional or transboundary trauma center if there is an indication for emergency room 

management based on mechanism of injury, injury pattern, and vital parameters and if the 

trauma center can be reached within 30 minutes’ drive time. If it cannot be reached in that time, 

the patient must be transported to an adequately equipped smaller hospital (currently called a 

basic care facility). If a criterion exists for onward transfer, secondary transfer to a regional or 

transboundary trauma center is carried out from there after the vital parameters have been 

stabilized. 



Comparison of Level 1-trauma center versus Level 2/3 hospitals 

The research yielded 7 studies from the USA (n = 3), Canada (n = 2), Australia (n = 1), and 

Germany (n = 1), which directly compare the results of trauma centers (maximum care hospital) 

with Level 2/3 hospitals (specialist/basic and general care) [5, 9, 10, 15, 23, 26, 27]. 

All papers come to the conclusion that the case fatality rate is lowered if the primary treatment of 

patients with serious blunt and penetrating injuries is carried out in the trauma center. This result 

is statistically significant in 5 studies. The significance level falls just short (p = 0.055) in one 

study [27]. Differences in prehospital management (prehospital interval, amount of treatment) 

which could have contributed to the difference in the case fatality rate were documented only in 

their own paper. The interpretation of the study results is simplified in that all papers come to a 

comparable, statistically confirmed result: the case fatality rate of multiply injured patients is 

lowered through direct admission to a trauma center or a hospital with a comparable quality of 

care. 

However, due to the considerable, not fully controlled sources of bias and the heterogeneity of 

the care systems studied, this conclusion cannot equate to definitive scientific evidence. Some 

authors pointed out that stabilization in a regional hospital followed by transfer to a trauma 

center, did not negatively influence the case fatality rate compared to patients directly admitted 

to the trauma center [7, 13, 19, 22, 30, 31, 33]. Patients who died before a possible transfer are 

not included in these papers. The “transfer” patient cohort is thus positively selected. This should 

be taken into consideration in the final analysis. It is thus not possible to conclude whether this 

care pathway actually does represent an equivalent alternative to direct admission to a trauma 

center or a hospital of comparable quality of care. 

Furthermore, a fresh analysis of the treatment results at all care levels must be conducted after 

the trauma networks are implemented to provide scientific proof of potential positive effects on 

the outcome from networking. 

Conclusion 

The analyzed papers on comparing air rescue with the land-based emergency service reveal a 

trend towards a fall in the case fatality rate through the use of air rescue. If available, primary air 

rescue can be used for the prehospital care of severely injured persons as it can result in a 

survival advantage particularly for medium to high injury severity. Severely injured patients 

should undergo primary transfer to a trauma center as this procedure leads to a lowering of the 

case fatality rate. If a regional or transboundary trauma center cannot be reached within a 

reasonable time (White Paper recommendation: 30 minutes), then the patient should be taken to 

a closer hospital which is able to carry out primary stabilization and life-saving first aid 

measures. During the further course, if circulation is stable and specific criteria are present, 

secondary transfer to a regional or transboundary trauma center can be carried out if necessary. 



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1.10 Mass casualty incident (MCI) 

The mass casualty incident represents a big challenge for the medical team management. 

Screening and triage of emergency patients must utilize the available personnel and material 

resources as efficiently as possible in the prehospital individual management of the injured. 

Following the attacks inter alia in Madrid and London and the Football World Cup in Germany 

in 2006, for example, the extreme topicality of this problem should not be in dispute. 

The major catastrophic event must be differentiated from a disaster. A strategy for controlling a 

major catastrophic event with a mass casualty incident was drawn up here according to 

methodological criteria; its transferability and application in a disaster scenario is only possible 

to a limited extent at this juncture. 

Results 

The literature screening revealed that there is no literature of Evidence Level 1 according to the 

current state of knowledge. The major literature citations for Level 2 and 3 are: [4, 6, 10, 11, 12, 

15, 16, 20, 22, 23, 27, 37, 41, 43, 44, 50, 56, 57, 63, 64, 74]. Case histories are difficult to extract 

from literature citations for Evidence Level 3 as they are generally the only authentic and 

practically utilizable experience reports of major catastrophic events. For this reason, these 

publications are also classified in our guideline under Evidence Levels 4 and 5: [1, 3, 5, 8, 9, 13, 

14, 17, 18, 21, 23, 30–33, 36, 38–40, 42, 45, 47, 49, 51–53, 55, 58–62, 67, 69–71, 73, 75, 76]. 

Computer simulations were also applied; their quality is also up for discussion [29, 65]. 

Status of discussion 

Due to the present data status, the evidence-based development of a strategy for the mass 

casualty incident is currently not possible. As no evidence could be found for individual steps 

and individual research questions, the authors initially developed a proposal from the synopsis of 

literature and their own experiences to illustrate the process management in a mass casualty 

incident. While assessing available study results, the appointed experts group therefore carried 

out a formal consensus process to draw up the treatment strategy. Within the framework of the 

nominal group process, the individual opinions could be modified, thus enabling the 

requirements for a democratic consensus to be fulfilled with appropriate legitimization [35, 54]. 

The relevant decision criteria and intervention options were defined accordingly and assessed in 

order of priority with regard to presenting them using an algorithm. To present the results, a 

modified flow diagram was selected which gives sufficient clarity despite the complexity of the 

task [34]. The final approval was obtained in a Delphi conference [24]: the anonymized opinions 

of the experts were gathered by interview and listed. Several survey rounds followed and after 

each round the responses received were summarized and submitted again for appraisal by those 

surveyed. This led to systematic modification and criticism of the summarized responses. A 

group response was achieved by summarizing the individual opinions in a final round, after 

which it was possible to produce a convergence of opinions. 

The algorithm developed for the prehospital processing of a major catastrophic event with a 

mass casualty incident defines as a treatment strategy both the entire process and the major 

Prehospital – Mass casualty incident (MCI) 122


decision points and management steps. It consists of 2 parts: action instructions for the 

ambulance team management (SanEL, consisting of the lead emergency physician, LEP, and the 

organizational leader of the emergency service (OrgL) and part 2, the triage of the injured. The 

essential prerequisite for processing it is to ensure the accident scene is safe so that the personnel 

involved are not exposed to any unnecessary hazard. 

Discussion 

At a mass casualty incident, it is generally not possible for time reasons for the lead emergency 

physician to carry out prehospital individual triage of all patients. Although there is a good half 

dozen published triage instructions in the literature, these are neither applicable to the individual 

medical care systems in equal measure nor do they reveal any type of relatively high evidence 

[19]. Thus, our own triage algorithm, which can be well and easily applied to the German 

emergency services conditions, had to be developed from the data in the literature and from the 

experiences of the members of the consensus conference. The START (Simple Triage and Rapid 

Treatment) algorithm commonly used in North America, which enables a targeted sorting of the 

injured by the emergency services personnel first on the scene, serves as an important basis for 

the algorithm developed for prehospital triage. The START strategy was initially developed for 

the Californian fire department [10] and is superior to other triage algorithms in the recognition 

of critical injuries [28]. Besides the priorities according to the ATLS ® specifications [2], the 

algorithm developed for prehospital triage also takes account of the specific requirements of the 

German emergency system [68], both with regard to the tasks and activity of the lead emergency 

physician or of the ambulance team management and to the appropriate screening categories. 

Triage is generally made more difficult in that the severely injured must be rapidly and definitely 

identified from among a large number of casualties with minor injuries. Usually, the problem is 

less one of undertriage, in other words, of not recognizing critically at-risk patients, and far more 

one of overtriage, of the incorrect assessment of the non-critically injured. The rate of overtriage 

correlates linearly with the mortality of the critically injured [25] as prehospital and hospital 

resources are used up in the initially non-urgent treatment of those with minor injuries when 

these resources are urgently required for the treatment of the critically injured. 

After triage has commenced, all the walking wounded are first of all sent to a collection point for 

those with minor injuries. Patients whose vital functions are acutely threatened are identified 

according to the ABCD priorities (Airway, Breathing, Circulation, Disability) and dispatched for 

treatment as rapidly as possible. If there is an acute surgical indication such as 

thoracotomy/laparotomy to arrest bleeding or decompression in the case of traumatic brain 

injury, the patient is transported without delay to the nearest suitable hospital after a second 

screening and approval given by the lead emergency physician (or the SanEL). 

The algorithm particularly takes account of the problem that among the large number of injured 

only a small proportion of the patients have acutely threatened vital functions and require 

immediate treatment. Besides the life-saving interventions that can be carried out at the scene, it 

also includes the rapid, resource-dependent transportation to acute surgical care. 

An additional fifth screening category for dead persons accommodates the requirement of the 

European Consensus Conference [68] to assign dead persons and still alive patients who 



nevertheless have no hope of survival due to their injuries to their own group instead of the 

hitherto usual 4 groups. 

The strategy introduced for the mass casualty incident is essentially based on the results of the 

consensus conference where there is insufficient data available. Studies of Evidence Level 2 use 

simulation models for the major catastrophic situation using analysis of carefully documented 

populations of trauma patients [28] or of events such as the Munich Oktoberfest with a pile-up of 

many casualties [63]. Although the partial issue of screening and triage can be researched in this 

way, the operational logistics cannot be recorded with such studies. 

The following problems relating to process quality are identified both in the literature [6, 32, 46] 

and by the members of the working group: 

� Lack of communication at the scene and with the competent superordinate locations 

(hospitals, emergency control center, etc.) 

� Persons in charge at the scene are not clearly identified 

� Lack of documentation of the incident 

� Lack of identification of the injured 

Summary: 

Finally, the following conclusion should be drawn: contingencies cannot be predicted or 

practiced in advance in the context of a major catastrophic event and definitely not in a disaster. 

In such situations, it has been proven of more advantage to build up available structures as 

required (regular emergency services, fire department, ambulance service, disaster protection, 

etc.) rather than create new structures for major catastrophic events. But one thing still stands: 

good preparation and good training [26] are the best basic prerequisites for dealing with such a 

situation despite all contingencies [33, 48]. This means the sensible overhaul and improvement 

in process quality by all local committees involved. Simulation games are a suitable means for 

evaluation. The algorithm specified by us for processing a major catastrophic event must be 

included in the local considerations which relate (according to Stratmann) to the medical care 

principles and to coordinating the cooperation of the emergency services with other 

organizations (e.g., fire department, police, ambulance service, disaster protection, German 

army) [72]. The algorithm should be adapted as required to local circumstances, and existing 

disaster protection plans or similar should also be adapted to it. 



Figure 1: Operational algorithm for mass casualty incident (MCI) [7] 

Alert according to 

RTLS Notification & 

Mobilization 

Logistic operations 

checklist 

• casualty collection point for 

severely injured 

• access/departure/helicopter 

landing pad 

• ambulance rendezvous point 

• zone coordination 

• bed list 

• casualty collection point for 

those with minor injuries 

• patient registration 

Checklist of 

operational personnel 

• emergency 

physicians/physicians 

• emergency medical 

technicians/EMT 

• means of transport 

• incident command post on site 

• technical rescue services (fire 

dept.) 

• water rescue 

• technical relief 

• church info service/pastoral 

care 

Resources checklist 

• casualty kits 

• medications (BTM) 

• protection against the weather 

• drinks & food for 

uninjured/helpers 

• roll-off containers (fire dept.) 

• Federal army/federal border 

guard containers 

Prehospital – Mass casualty incident (MCI) 

yes 

Approach in consultation 

with RTLS 

Arrange traffic barriers 

Are there sufficient 

emergency services 

personnel? 

X 

no 

Call via RTLS 

for back-up 

while en route 

Pass on 1st back-up call 

Set up Incident Command 

Set up local Incident 

Command 

(with fire dept.& police) 

Classify size of accident 

incident 

Has accident scene been 

made safe? 

Do zones have to be 

demarcated? 

X 

no 

Establish logistic operations 

Triage injured 

Establish treatment priority 

Registration by 

Incident Command 

Are operational 

personnel/resources 

adequate? 

no 

Request supplies 

Reorganization 

yes 

yes 

Checklist orientation 

accident scene approach 

• expected no. of patients? 

• hazardous substances? 

• size of accident scene? 

• emergency services alerted? 

• location of incident command 

post, police, fire department? 

Assign 

zone leader & 

communication path 

Checklist for triaging injured: 

Triage Categories I-V 

I: Acute life-threatening injuries 

1st priority (red) 

II: Severely injured/hospitalization 

(yellow) 

III: Minor injured/later (outpatient) 

treatment 

(green) 

IV: No prospect of survival 

(blue) 

V: Dead persons (black) 

See Algorithm: triage of injured 

persons in mass casualty 

incident 

125


Missing persons? 

Inform police incident 

command 


Sort patients according to 

available beds/suitable 

hospital 

by Incident Command, if 

nec. discuss with zone 

leader 

Patients with acute 

surgery indication from 

Triage Group I ? 

no 

Complete triage 

Allocate suitable 

means of transport 

Release transport: Incident 

Command 

Final registration 

Pass on to local police 

incident command 

Media, tel. no., for relatives 

Include feedback of 

accompanying emergency 

physician/hospital 

in evaluation of available 

beds 

Final search of 

accident site with technical 

incident command 

(police, fire dept.) 

Operational documentation 

Quality control 

Scoring 

End of operation 

Operational debriefing 

(at earliest opportunity) 

yes 

Immediate transport with emergency 

physician/rescue physician 

or form convoy 

126


Figure 2: Triage of injured persons at mass casualty incident [7] 

yes 

A 

B 

C 

D 

Triage of injured persons 

at mass casualty incident 

Does the accident scene 

present a hazard? 

Commence triage 

Able to walk? 

no 

Fatal injury 

no 

Central pulse absent? 

no 

Spontaneous respiration 

absent? 

no 

Respiratory rate above 

30/min? 

no 

Palpable radial pulse? 

yes 

Spurting haemorrhage? 

no 

no 

Unable to follow simple 

commands? 

no 

Urgent treatment 

Casualty collection point 

for minor injured 


II 

no 

yes 

yes 

yes 

yes 

yes 

yes 

Do NOT approach 

yes 

no 

Possible to release 

airways? 

Arrest bleeding (compression 

bandage) 

Casualty collection point 

for severely injured 

Re-evaluation – 

deterioration? 

yes 

no 

No treatment V 

Delayed treatment IV 

Treat as quickly as possible 

Emergency 

physician/emergency medical 

personnel to treat - 

NOT triage physician/local 

ES/Incident Command 

Acute surgical 

indication? 

yes 

Incident Command to approve 

transport 

Immediate transportation, if 

necessary form convoy 

Re-evaluation/re-triage 

Transport acc. to urgency I/II 

Delayed treatment III 

I 

no 

127


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2 Emergency room 


How would you treat? 

You are called to the emergency room one winter’s night. As this is your first shift in trauma 

surgery, you’re feeling quite nervous when you enter the casualty department. You reach the 

preheated emergency room and shortly afterwards receive a handover from the emergency 

physician. He reports that a 42-year-old patient has had a motorbike accident. The initial GCS at 

the accident scene was 13, the right chest wall has marked crepitations, peripheral saturation is 

85% during spontaneous breathing and, in addition, the patient is complaining of an intense 

tenderness in the right upper abdomen. The pelvis is stable and he has not noticed any extremity 

injuries. After prehospital anesthesia induction and oral intubation, peripheral saturation has 

risen to over 95%. Due to adequate oxygenation and normal capnometry, the insertion of a chest 

drain was dispensed with for the short transport journey. The patient is now intubated and 

ventilated and has stable circulation (110/80 mmHg, pulse 85). However, measurement of 

peripheral saturation yields a value of 90%. The patient is not fully undressed. A cervical collar 

has been applied. You look up at the wall in your emergency room and recognize an algorithm 

there which you are familiar with, which you recently learnt on a polytrauma course: 

A Airway with immobilization of the cervical spine 

B Breathing/Ventilation 

C Circulation 

D Disability/Neurology 

E Expose – Environment/Undress - Keep Warm 

Your confidence grows and you immediately start with the “primary survey and treatment” in 

the emergency room. You note that the cervical collar is sitting in the correct place. Under “B”, 

the on-duty anesthesiologist notices a weakened breath sound in the right chest, and peripheral 

saturation is now 83%. You have a brief discussion with him and decide to insert a chest drain 

via a mini-thoracotomy. Air is released and approximately 400 ml of blood. You check the 

success of your intervention and notice an increase in saturation to 99%. You are still nervous 

but know what you have to do next under “C”. Meanwhile, a central venous catheter and arterial 

access have been placed. Blood pressure is 110/80 mmHg, heart rate 85/min. Ultrasonography of 

the abdomen (FAST) detects free fluid in the Douglas cavity and around the liver, the on-duty 

radiologist estimates the volume to be approximately 500 ml. You do not detect any relevant 

bleeding to the outside. After alerting the visceral surgeon, the neurosurgeon has meanwhile 

checked the pupils under point “D”. After he has established that they are narrow but lightreactive, 

you start “E” and examine the now fully-undressed patient. A full-body CT scan is 

conducted because of the mechanism of injury. The laboratory values show a hemoglobin value 

of 11.5 g/dl, INR of 90%, and a base excess of -1.5 mmol/l. The patient has received a total of 

1,500 ml fluid. 

Emergency room - Introduction 131


The visceral surgeon who has meanwhile arrived confirms the ultrasonography finding. The fullbody 

CT scan shows a severe pulmonary contusion on the right and a liver laceration without 

active bleeding. You come to a consensual decision to proceed as follows: conservative 

treatment of the abdominal injury and direct transfer of the patient to an intensive care unit. 

The aim of this “emergency room” guideline section 

The case presented at the start shows the importance of a logical and clear algorithm in an 

extreme situation. The sequence of actions in the emergency room must be checked against the 

evidence from as complete a literature base as possible. An expert committee examines the 

evidence levels, resulting in the grades of recommendation, which can strongly influence the 

sequence of actions. Thus, the aim of this guideline section is, on the one hand, to create clear, 

sustainable process sequences which, on the other hand, must contribute towards further 

improving care of the critically injured. For it is precisely the scientific reproducibility of the 

clinician’s actions in the emergency room that form the basis of reproducible, valid treatment 

and, in collaboration with the various medical disciplines, effectuate the parallelizing of 

processes and thus an improvement in the treatment. 

Special notes: 

A guideline does not claim to be able to treat every situation conclusively; this also applies to the 

emergency room. Not infrequently, the generation of clear recommendations is hampered by the 

lack of studies with a high evidence level. Clear views are expressed on this issue in the 

corresponding background texts to each chapter. In addition, various statements are subject to a 

time dynamic. This is accommodated by conducting a re-evaluation after 2 years. Nevertheless, 

there is a need to describe important correlations in detail. 

Managing a multiply injured patient in the emergency room places a great demand on the 

treatment process because of the acuteness of the events and the large number of treating 

physicians from different specialties. As with all complex sequences of actions, errors do occur. 

But not every error need have a negative influence on the quality of treatment [1]. However, an 

accumulation of errors can occasionally have fatal consequences for the patient. For this reason, 

the basis of rational quality management lies in calmly working through the complications, and 

this approach should be firmly established within a quality circle in hospitals which are involved 

in the care of the critically injured [5]. Care in the emergency room should be quite rigorously 

characterized here by prescribed sequences and a common language with prehospital and 

emergency room care merging together seamlessly. Course strategies, such as depicted by 

Prehospital Trauma Life Support ® (PHTLS ® ) for prehospital care and Advanced Trauma Life 

Support® (ATLS®) or European Trauma Course® (ETC®) for clinical care, can automate and 

thus improve this process through a clear hierarchy of treatment sequences and a common 

language [3, 4]. It is important that every hospital has an emergency room algorithm and that all 

those potentially involved are familiar with it. 

Working groups and quality circles have been successfully introduced in many hospitals and 

they regularly evaluate and improve their own emergency room strategy based on actual cases. 

Both the leadership of such quality circles and the question of responsibility in the emergency 

room are issues that are the subject of heated debate in professional associations. Because severe 



injury is part of the core competence in trauma surgery, it may be legitimate for physicians 

qualified in this discipline to be in charge of both the quality circles and treatment in the 

emergency room [5]. However, it must not be forgotten that there are also other operational 

strategies in emergency room care [6, 7, 9]. For this reason, during the development of the 

guideline, this sensitive topic has been accommodated in various places in the background text as 

even strategies without a team leader are feasible involving just a multidisciplinary team working 

together. However, it should be discussed upfront who takes over responsibility in which 

situation in order to be prepared especially for medico-legal questions [8]. 



References 

1. Ruchholtz S, Nast-Kolb D, Waydhas C, Betz P, 

Schweiberer L (1994) Frühletalität beim Polytrauma – 

eine kritische Analyse vermeidbarer Fehler. 

Unfallchirurg 97: 285–291 

2. Ertel W, Trentz O (1997) Neue diagnostische Strategien 

beim Polytrauma. Chirurg 68: 1071–1075 

3. Sturm JA, Lackner CK, Bouillon B, Seekamp A, 

Mutschler WE (2002) Advanced Trauma Life Support 

(ATLS ® ) und Systematic Prehospital Life Support 

(SPLS). Unfallchirurg 105: 1027–1032 

4. Advanced Trauma Life Support, 8th Edition, The 

Evidence for Change John B. Kortbeek, MD, FRCSC, 

FACS, Saud A. Al Turki, MD, FRCS, ODTS, FACA, 

FACS, Jameel Ali, MD, MMedEd, FRCS, FACS et. 

al. J Trauma. 2008;64:1638 –1650 

5. Frink M, Probst C, Krettek C, Pape HC (2007) 

Klinisches Polytrauma-Management im Schockraum 

– Was muss und kann der Unfallchirurg leisten? 

Zentralbl Chir 132:49–53 

6. Bergs EA, Rutten FL, Tadros T et al. (2005) 

Communication during trauma resuscitation: do we 

know what is happening? Injury 36:905–911 

7. Cummings GE, Mayes DC (2007) A comparative study 

of designated Trauma Team Leaders on trauma 

patient survival and emergency department length-ofstay. 

CJEM 9:105–110 

8. Bouillon B (2009) Brauchen wir wirklich keinen 

„trauma leader” im Schockraum? 112:400–401 

9. Wurmb T, Balling H, Frühwald P, et al. 

Polytraumamanagement im Wandel. Zeitanalyse 

neuer Strategien für die Schockraumversorgung. 

Unfallchirurg 2009; 112: 390-399 



2.2 The emergency room - personnel and equipment resources 

The annual number of multiply injured patients in Germany is approximately 32,000-38,000 [13, 

30, 39, 53]. In the Federal Republic of Germany, there are currently approximately 700-800 

hospitals available for the initial treatment of these patients (emergency room treatment). 

Although this figure would seem to indicate demand is adequately covered, it should be 

emphasized that a) not all hospitals have sufficient personnel or structural requirements or the 

specialist competence to care for these patients, b) there are still regions in Germany without 

sufficient provision of hospitals for polytrauma treatment, and c) fully equipped hospitals cannot 

always be reached within acceptable time periods, particularly at night if rescue helicopters are 

not allowed to take off due to the existing nighttime flying ban or because of capacity problems. 

The introduction of regionalized trauma centers with defined standards in the management of 

trauma patients resulted in a reduction in the rate of avoidable deaths in the United States [8, 54]. 

To further improve polytrauma management in Germany, and make it more consistent across the 

whole country, it seems logical to define the requirements for the care of severely injured 

patients in terms of structure and personnel, and to standardize them to the maximum possible 

extent. 

The DGU Trauma Network Project D has been initiated to implement this requirement. In the 

participating hospitals, which already number approximately 800 (as at April 2010), the DGU 

Trauma Network D is coordinating the implementation of the written contents of the DGU’s 

White Paper on the management of the severely injured [8, 54]. 

Emergency room team 


In polytrauma management, fixed teams (known as emergency room teams) 

must work according to pre-structured plans and/or have completed special 

training. 

Explanation: 

GoR A 

To achieve coordinated, balanced cooperation among various staff in polytrauma management, it 

is internationally commonplace to put together fixed teams for emergency room care, which 

work according to pre-structured plans and/or have completed special training (particularly 

ATLS ® , ETC, Definitive Surgical Trauma Care [DSTC]) [14a] [4, 47, 49, 51, 56]. Various 

studies have found that this emergency room strategy has clinical advantages [13, 30, 39, 53]. 

Ruchholtz et al. showed, for example, that an interdisciplinary team, integrated into a quality 

management (QM) system and acting on the basis of internal hospital guidelines and discussions, 

works very efficiently under joint surgical and anesthesiologic management [8, 54]. 


Emergency room – Personnel and equipment resources 135


The basic emergency room team must consist of at least 3 physicians (2 

surgeons, 1 anesthesiologist), with at least 1 anesthesiologist and 1 surgeon 

having attained specialist grade. 

Explanation: 

GoR A 

There are no validated studies on the composition of the emergency room team so that 

statements on team composition can only relate to how these are predominantly formed 

internationally. So, the question as to which specialties should be primarily represented in the 

emergency room team often depends on local conditions [6, 9, 11, 12, 14, 20–25, 27, 31–33, 38, 

41, 45, 50]. On the other hand, individual studies from other countries show that a large 

proportion of multiply injured patients can be effectively managed even with only 2 physicians 

[3, 7, 12]. Depending on the injury pattern/severity, however, the team initially comprising at 

least 2-3 persons will then have to be supplemented with more colleagues [29, 40, 46]. In 

screening the international literature, it emerged that almost all teams worldwide had either 

special trauma surgeons of different training levels or general surgeons with (many years’) 

trauma experience, also with different training levels. 

Accordingly, the cited team composition of at least 3 physicians can only serve as a minimum 

number and the team should be enlarged by one or two other 1-2 physicians (e.g., radiologist, 

neurosurgeon) depending on the size and care level of the hospital and the severely injured 

workload. In any event, the management of the severely injured must be undertaken by a 

qualified surgeon whose minimum qualification must be at the level of a specialist in 

general/visceral surgery or a specialist in orthopedics and trauma surgery (regional medical 

association (Landesärztekammer) [LÄK], Rules for Specialist Training for Physicians, as at 

07/2009). The treating anesthesiologist must have the minimum qualification of specialist. 

The function of and necessity for a “trauma leader” in the emergency room is a matter of much 

controversy in the literature. Even in the consensus conferences during the development of the 

S3 guideline, there was intense, heated debate about the necessity for a “team leader” and about 

what his duties should be and to which specific specialist area he should be assigned. A 

structured literature search was conducted on these issues during the guideline development. In 

terms of patient survival, no credible evidence was identified for the superiority of one particular 

management structure in the emergency room (“trauma leader” versus “interdisciplinary 

management group”) or for the assignment of a “trauma leader” to one particular specialist area 

(trauma surgery, surgery versus anesthesia). 

Hoff et al. [21] showed that bringing in a team leader (known as a command physician) 

improved the care and treatment pathway [21]. Alberts et al. also found evidence of improved 

treatment pathways and treatment results after the strategy of “trauma leader” had been 

introduced [1]. Depending on the tasks - including patient handover, examining the patient, 

carrying out and monitoring therapeutic and diagnostic measures, consulting with other specialist 

disciplines, coordinating all medical and technical team members, preparing examinations 

following on from emergency room care, contacting relatives after completion - that the “trauma 

leader” needs to be able to take on in principle, this task must either be carried out on an 



interdisciplinary basis or by a “team leader” experienced in the management of multiply injured 

patients. In an interdisciplinary process even closer attention should be paid that the treatment 

pathways are agreed and consensual to avoid any time delays [18, 21, 37, 50]. 

According to the recommendations of the American College of Surgeons Committee on Trauma 

(ACS COT), a qualified surgeon must take over the team leadership [8, 54]. In a large 

comparative study of over 1,000 patients, there were almost identical case fatality rates and 

length-of-hospital-stays irrespective of whether 1 out of 4 trauma surgeons or 1 out of 12 general 

surgeons, albeit with trauma surgery knowledge, were responsible for the emergency room [41]. 

In a comparison between “trauma surgeons” and “emergency physicians”, Khetarpal showed that 

under traumatologic leadership the management times and the start of surgery were shorter, but 

without this apparently having had an effect on the treatment outcome [8, 54]. In a study by 

Sugrue et al. it is confirmed that no serious implications arise from who leads the ER team so 

long as he has adequate experience, expertise, and training [8, 54]. In many places, trauma teams 

have also been led very effectively, cooperatively, and successfully by anesthesiologists for 

many years. 

High specialization in the individual specialist disciplines is particularly taken into account in 

interdisciplinary leadership models. Here, each specialist discipline has predefined tasks and is in 

charge of the devolved tasks at defined points in time within emergency room management. The 

leadership group, comprising anesthesiology, radiology, surgery, and trauma surgery (in 

alphabetical order), confers at fixed times and in addition to these if the situations in question 

demand it [57]. 

Notwithstanding, the experts argue for clear rules on responsibilities aligned to local conditions, 

agreements, and competences. Team leadership should be encouraged, irrespective of which 

specialist discipline it originates from or whether consisting of one person or a leadership group. 

The task of the team leadership is to collect and inquire about the findings of the individual 

specialized team members and to effectuate decision-making. The team leadership heads 

communication and establishes further diagnostic and treatment steps in agreement with the 

team. Within the quality circles of the establishment, the functions and qualifications of the 

“team leader” and of the “interdisciplinary leadership group” should be established in the 

emergency room. Ideally, after agreement, the “best” (one or more persons) must take on the 

task of “trauma leader” and “interdisciplinary leadership group”. In particular, rules must be 

made for the following points, which must stand up to a “best practice jurisdiction” inspection. 

� Responsibility 

� Leadership structure for coordination, communication and decision-making within 

the context of emergency room management 



� Monitoring and ensuring quality (implementing quality circles; identifying quality 

and patient safety indicators; continuous monitoring of structures, processes, and 

results) 


Trauma centers must have provision for enlarging emergency room teams GoR A 

Explanation: 

The size and composition of the enlarged emergency room team is determined by the care level 

of the hospital concerned and the corresponding injury severity to be expected there as well as by 

the maximum number of surgical interventions that can be performed there if necessary (White 

Paper). Accordingly, transboundary trauma centers, being the highest care level, should contain 

all specialist disciplines which perform emergency care. Table 11 gives an overview. A qualified 

specialist (specialist physician) from the department concerned must be able to get there within 

20-30 minutes (see below). 




Attending physicians necessary for subsequent care must be present within 

20-30 minutes of being alerted. 

Explanation: 

GoR A 

A comparative study of hospitals found that it was not absolutely necessary for the trauma 

surgeon to be available in the hospital all hours provided the distance to the hospital was not 

greater than 15 minutes and a resident was already in the hospital [11]. Allen et al. and Helling et 

al. give 20 minutes as the limit here [3, 19]. In contrast, Luchette et al. and also Cornwell et al. 

found “in-house” readiness to be an advantage [9, 33] although Luchette showed that only the 

diagnosis and start of surgery was speeded up if an attending physician was initially present, 

both the period of intensive care and mortality of patients with severe thoraco-abdominal or head 

injuries remaining unaffected [13, 30, 39, 53]. 

In a comparison over several years, figures from the Trauma Audit and Research Network 

(TARN) (England & Wales) confirm that the increased presence of a qualified 

specialist/attending physician (60% versus 32%) contributes to significant reductions in 

mortality [28]. Wyatt et al. also found evidence that severely injured patients in Scotland 

(n = 1,427; ISS > 15) were treated faster and were more likely to survive if they were treated by 

an experienced attending physician/consultant instead of a resident [58]. In the ACS COT 

recommendations, the presence of an attending surgeon is not mandatory, provided a senior 

surgical resident is directly involved in the management of the severely injured [8, 54]. In a 

retrospective analysis over a period of 10 years, Helling et al. showed that no relevant 

improvement in treatment outcomes are achieved by the initial presence of an attending 

physician [35, 39, 52]. For patients with penetrating injuries, in shock, with a GCS < 9 or ISS 

≥ 26, there was no difference in the care quality with regard to mortality, start of surgery, 

complications or length of treatment in the intensive care unit if the on-duty physician 

participated in the subsequent care within 20 minutes (“on call”). Only the initial care period and 

the total length of stay in hospital were less for blunt trauma if the attending physician could be 

in the emergency room (“in-house”) immediately. These results are confirmed to a large extent 

by Porter et al., Demarest et al., and Fulda et al. [11, 16, 43]. 

Overall, it can be concluded from these results that an attending physician does not have to be 

present immediately at the start of emergency room care if a surgeon qualified in the care of the 

severely injured (specialist grade and if applicable ATLS ® and ETC certified) initially carries out 

the care of the injured. However, it should be ensured that an attending physician can be reached 

quickly. 

A thoracic surgeon, ophthalmologist, maxillofacial surgeon and otolaryngologist (ENT) should 

be reachable within 20 minutes [18, 27, 34, 42]. According to Albrink et al. [2], the thoracic 

surgeon should be brought in as early as possible particularly in the case of aortic lesions. 



It seems that a pediatric surgeon is also not necessary in the basic ER team. The studies of 

Knudson et al. [26], Fortune et al. [15], Nakayama et al. [36], Rhodes et al. [44], Bensard et al. 

[5], D’Amelio et al. [10], Stauffer [48] and Hall et al. [17] were unable to find evidence of any 

improvement in treatment outcome through the involvement of special pediatric surgeons. 

An anesthesiologist necessary for the subsequent care of the multiply injured patient must also 

be present within 20–30 minutes of being alerted. 


The size of the emergency room should be 25-50 m 2 (per patient to be treated). GoR B 

Explanation: 

The information given is based on a) the recommendations for initial management of the patient 

with traumatic brain injury and multiple injuries of the individual working group and circles of 

the German Society of Anesthesiology and Intensive Care Medicine (DGAI), the German 

Society for Neurosurgery (DGNC), and the German Interdisciplinary Association of Intensive 

Care and Emergency Medicine (DIVI). They recommend a minimum size per treatment unit of 

25 m 2 [55]. 

In addition, the room size can also be calculated b) using the specifications of the Technical 

Rules for Workplaces (Arbeitsstätten-Richtlinie) (ASR), the Workplaces Ordinance 

(Arbeitsstättenverordnung) (ArbStättV, 2nd section; room dimensions, air space), the German Xray 

Ordinance (Röntgenverordnung) (RöV), and the Technical Rules for Hazardous Substances 

(Technische Regeln für Gefahrenstoffe) (TRGS). It specifies that 18 m 3 of breathable air per 

person carrying out heavy physical activity and 15 m 3 for average physical activity must be 

ensured in rooms with natural ventilation or air conditioning; 10 m 3 is estimated for every 

additional person who is only temporarily there. Thus, a room volume of about 75-135 m 3 would 

be required if there were 5-9 persons present (3-5 physicians, 1 medical radiologic technologist, 

1-2 trauma surgery nurses, anesthesiology nurses) and the assumption of average physical work 

(lead aprons worn during care). With a ceiling height of 3.2 m, this corresponds to a room size of 

approximately 23-42 m 2 . Not included in the calculation is the loss of space through anesthesia 

and ultrasonography equipment, work surfaces, patient stretcher, cupboards and similar so that a 

total of 25-50 m 2 per unit should be the starting point. If it is possible to treat a maximum of 2 

severely injured patients simultaneously, the area is enlarged accordingly. Section 38 (2) of the 

German Workplaces Ordinance of 1986 specifies a clear door width of at least 1.2 m with a door 

height of 2 m for paramedic and first aid rooms. 




The emergency room, ambulance entrance, radiology department, and 

surgery department should be in the same building. The helicopter landing 

pad should be located in the hospital grounds. 

Explanation: 

GoR B 

All screening tests necessary for emergency surgery (laparotomy, thoracotomy, external 

fixator/pelvic C-clamp) must be kept in readiness. 

Table 11: Composition and presence of specialist grade physicians in the enlarged emergency 

room team in relation to the care level 

Specialist Department 

Transboundary 

TC 

Regional TC Local TC 

Trauma surgery X X X 

General or visceral surgery X X X 

Anesthesia X X X 

Radiology X X X 

Vascular surgery X * – 

Neurosurgery X * – 

Cardiac or thoracic surgery * * – 

Plastic surgery * * – 

Ophthalmology * * – 

ENT * * – 

OMFS * * – 

Pediatrics or pediatric surgery * * – 

Gynecology * * – 

Urology * * – 

X: required –: not required *: optional 



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Arch Surg 127:333-338 

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a logical solution to the pediatric trauma manpower 

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not improve management or outcome of critically 

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20. Highley Da (1994) Review of the composition and use 

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21. Hoff Ws, Reilly Pm, Rotondo Mf et al. (1997) The 

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22. Jacobs Ia, Kelly K, Valenziano C et al. (2000) Cost 

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23. Kaplan Lj, Santora Ta, Blank-Reid Ca et al. (1997) 

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25. Khetarpal S, Steinbrunn Bs, Mcgonigal Md et al. 

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28. Lecky F, Woodford M, Yates Dw et al. (2000) Trends 

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2.3 Criteria for emergency room activation 

Efficiently working trauma score systems or parameters should select and identify patients so 

precisely that the necessary treatment is allotted to each casualty according to his injury severity. 

The difficulty lies in being able to assess injury severity adequately. Ideally, trauma/emergency 

room activation criteria should minimize as much as possible the rate of undertriage as well as 

that of overtriage of severely injured patients. Undertriage describes the proportion of patients 

who, despite a relevant severe injury requiring emergency room treatment, for example, are not 

identified as such. In contrast, overtriage describes the proportion of patients with a minor injury 

or none at all who nevertheless are classified as severely injured and, for example, are delivered 

to an emergency room. An advantage of overtriage - besides the optimum treatment of each 

patient - can be team training as the interplay and sequences can be practiced in “quasi-serious 

situations” even with non-severely injured persons. However, overtriage is associated with 

considerable costs and an often considerable disruption to routine sequences. The effectiveness 

of individual, different trauma score systems/trauma criteria can be described by parameters such 

as sensitivity, specificity, positive predictive value, and the calculation of overtriage and 

undertriage. The American College of Surgeons Committee on Trauma [25] gives an undertriage 

rate of 5-10% with simultaneous 30-50% overtriage as necessary in order to carry out efficient 

emergency room care. In a paper by Kane et al., the authors describe how, in order to attain a 

sensitivity of more than 80%, the rate of overtriage could not be brought below 70%. 

The primary goal of trauma/emergency room activation criteria is therefore to keep undertriage 

low and at the same time not increase overtriage to an unacceptable level. 

Emergency room – Criteria for emergency room activation 

144


Activation criteria 


The trauma/emergency room team should be activated for the following 

injuries: 

� Systolic blood pressure below 90 mmHg after trauma 

� Penetrating injuries to the neck and torso regions 

� Gunshot wounds to the neck and torso regions 

� GCS below 9 after trauma 

� Respiratory impairment/requirement for intubation after trauma 

� Fracture of more than 2 proximal bones 

� Unstable chest 

� Pelvic fractures 

� Amputation injury proximal to hands/feet 

� Spinal cord injury 

� Open head wounds 

� Burns > 20% and degree ≥2b 

Explanation: 

Blood pressure/respiratory rate 


GoR A 

Individual studies have shown that hypotension following trauma with a systolic blood pressure 

below 90 mmHg is a good predictor/good criterion for activating the emergency room team. 

Thus, Franklin et al. [1] showed that 50% of trauma patients with prehospital hypotension or 

hypotension at admission were sent for immediate surgery or transferred to an intensive care 

unit. A total of 75% of patients with hypotension were operated on during the course of the 

hospital stay. 

Tinkoff et al. [2] found a 24-fold increased mortality, a 7-fold increased admission to the 

intensive care unit, and a 1.6-fold increased emergency surgery rate where hypotension was 

present after trauma as an expression of existing shock. In the recommendations of the American 

College of Surgeons Committee of Trauma [25], hypotension is found to be an important 

criterion for admission to a trauma center. Smith et al. [3] cite hypotension as a consistently used 

criterion for trauma team activation in all hospitals in the state of New South Wales in Australia. 

In a review by Henry et al. [4] of the New York State Trauma Registry, there were mortality 

145


rates of 32.9% in trauma patients with an SBP (systolic blood pressure) of < 90 mmHg and 

28.8% for trauma patients with a respiratory rate of < 10 or > 29/min. 

Gunshot wounds 

In a study by Sava et al. [5], the authors ascertained that gunshot wounds to the torso as a single 

activation criterion had a high informative value similar to the TTAC (Trauma Team Activation 

Criteria) used up till then. In a subgroup with gunshot wounds to the abdominal/pelvic region, 

the frequency of severe injuries was equal in the group with and without TTAC (74.1% and 

70.8%, p = 0.61). A proviso must be made here that the overwhelming proportion of patients 

(94.4%) with gunshot wounds had already been identified using the TTAC. Tinkoff et al. [2] also 

found a significant correlation between gunshot wounds to the neck or torso and the need to 

admit to an intensive care unit (see below). Furthermore, this criterion was predictive for the 

existence of severe or fatal injuries and for emergency surgery. In a retrospective analysis, 

Velmahos et al. [6] report an overall survival rate following penetrating gunshot and stab wounds 

of over 5.1% in patients without vital signs in the emergency room. In a literature review (25 

years, 24 studies), Rhee et al. [7] found a survival rate of 8.8% following emergency 

thoracotomy due to penetrating trauma. 

The American College of Surgeons Committee on Trauma [25] listed various, differentlyweighted 

triage criteria in its last edition (2006). The Step One and Step Two criteria, which 

necessitate admission to a Level 1 or Level 2 trauma center include: a) GCS below 15 or b) 

systolic blood pressure (BP) below 90 mmHg or c) respiratory rate below 10/min or above 

29/min (Step One). Step Two criteria are a) penetrating injuries to the head, neck, torso, and 

proximal long bones, b) unstable thorax, c) fracture of 2 or more proximal long bones, d) 

amputation(s) proximal to the hands/feet, e) unstable pelvic fractures, f) open head fractures, and 

g) spinal cord injuries. Overall, there is currently rather a lack of evidence for the cited criteria. 

In a study by Knopp [8] on 1,473 trauma patients, the authors found a positive predictive value 

(PPV) of 100% for an ISS > 15 for spinal cord injuries and amputation injuries; however, 

fractures of the long bones only had a PPV of 19.5%. 

In their study, Tinkoff et al. [2] examined several of these criteria for their accuracy in 

identifying severely injured and high-risk patients. Trauma patients who fulfilled the criteria of 

the ACS COT had more severe injuries, higher mortality, and longer stay in intensive care than 

patients in the control group. Systolic blood pressure below 90 mmHg, endotracheal intubation, 

and a gunshot wound to the neck/torso were predictive in the study for the necessity of 

emergency surgery or admission to intensive care. Mortality was markedly increased with 

systolic blood pressure below 90 mmHg, endotracheal intubation or GCS of less than 9. In their 

study, Kohn et al. [9] analyzed various trauma team activation criteria (see Table 1a), which are 

similar to those of the ACS COT. Kohn et al. found the parameter “respiratory rate below 10 or 

above 29/min” as the most predictive in terms of informative value for the presence of a severe 

injury. Additional parameters with high prediction were: a) burns with more than 20% body 

surface (BS), b) spinal cord injury, c) systolic blood pressure below 90 mmHg, d) tachycardia, 

and e) gunshot wounds to the head, neck or torso. 


146


Open head injuries 

With a lack of studies on the relevance of open head injuries, this criterion is regarded by the 

ACS COT rather as a significant indicator of severe injuries which require a high level of 

specialist medical competence and should thus be assigned to the Step One criteria. 

GCS 

Kohn et al. [9] regard a GCS of less than 10 as an important predictor of severe trauma. 44.2% of 

patients, for whom the ER team was activated because they had a low GCS, had confirmed 

severe injuries. The value of the GCS as a predictor of a severe injury and as an activation 

criterion for the emergency room team was also confirmed in studies by Tinkoff et al., Norwood 

et al., and Kühne et al. [2, 10, 11]. In these patients, Norwood as well as Kühne found that even 

GCS scores of less than 14 indicated pathologic intracerebral findings and the necessity for 

inpatient admission. However, according to this, the activation of the trauma/emergency room 

team does not appear to be absolutely necessary with these patients (GCS ≤ 14 and ≥ 11). For a 

GCS of less than 10, Engum [12] found a sensitivity of 70% for the endpoint OP, intensive care 

unit (ICU) or death. The odds ratio (OR) was 3.5 (95% CI: 1.6–7.5). The authors found a PPV of 

78% for the presence of a severe injury in children with a GCS < 12. 


147



The trauma/emergency room team should be activated for the following 

additional criteria: 

� fall from more than 3 meters height 

� road traffic accident (RTA) with 

- frontal collision with intrusion by more than 50-75 cm 

- a change in speed of delta >30 km/h 

- collision involving a pedestrian or two-wheeler 

- death of a driver or passenger 

- ejection of a driver or passenger 

Explanation: 

Accident-related/-dependent criteria 


GoR B 

Accident-related/-dependent criteria are evaluated very differently in the literature with regard to 

their informative value for the presence of severe trauma. 

Norcross et al., Bond et al., and Santaniello et al. [13, 14, 15] report on rates of overtriage of up 

to 92%, sensitivities of 70-50%, and PPV of 16.1% if accident-related mechanisms have been 

included as the sole criterion for describing the injury severity. If physiologic criteria were also 

used, a sensitivity of 80% was attained with a specificity of 90% [14]. 

Knopp et al. found only poor positive predictive values for the parameters road traffic accident 

(RTA) with ejection or death of a driver or passenger and road traffic accident involving a 

pedestrian [8]. Engum et al. also found the lowest predictive power for the road traffic accident 

involving a pedestrian at 20 mph (miles per hour) and the road traffic accident with death of a 

driver or passenger and trauma from being run over [12]. In the ACS COT recommendations, the 

trauma from being run over was removed from the criteria in the current version. Frontal 

collision with intrusion by more than 20-30 inches, death of a driver or passenger, road traffic 

accident involving pedestrian/two-wheeler collision at ≥ 20 mph, and ejection of a driver or 

passenger are cited as Step Three criteria, i.e. there is no necessity to transport these patients to 

centers of the maximum care level. Kohn et al. [9] also regard the rollover trauma as lacking in 

suitability. According to Kohn et al., the same also applies to the criteria/parameters road traffic 

accident (RTA) with ejection or death of a driver or passenger and road traffic accident involving 

a pedestrian [9]. 

Champion et al. [16] regard a vehicle rollover as an important indication of severe injury. The 

average probability of suffering a fatal injury is markedly greater after a rollover than not after 

one. 

148


Nevertheless, the ACS COT removed the rollover mechanism from its triage criteria because 

relevant injuries after such an accident incident would already be included in Step One or Step 

Two. 

Deformation to vehicle bodywork 

In a multivariate analysis of 621 patients, Palanca et al. [17] found no significant relationship 

between vehicle deformation (intrusion of > 30 cm or > 11.8 inches) and the presence of a 

relevant severe injury (OR: 1.5; 95% CI: 1.0–2.3; p = 0.05). Henry came to comparable results in 

the multivariate analysis in his study [4]. Using the data of the National Automotive Sampling 

System Crashworthiness Data System (NASS CDS), Wang found a PPV of 20% for an ISS > 15 

[18]. 

Death of a driver or passenger 

Knopp et al. found an increased risk of surgery or death if a driver or passenger was fatally 

injured (OR: 39.0; 95% CI: 2.7–569; PPV 21.4%) [8]. Palanca et al. [17] could not confirm any 

statistically significant relationship between the death of a driver or passenger and the existence 

of a severe injury even if the simultaneous frequency of a severe injury was 7%. 

Fall from a great height 

In a prospective study by Kohn et al. [9], 9.4% of patients who had suffered a fall from more 

than 6 meters height had severe injuries - defined as intensive care admission or immediate 

surgery. Yagmur et al. [19] found 9 meters to be the average height for patients who died from 

the consequences of a fall. 

Burns 

It is essential to distinguish whether a thermal injury is present without additional injuries. In the 

case of a combination injury where the non-thermal component is predominant, the patient 

should be brought to a trauma center [25]. 

Age 

Kohn et al. [9] analyzed various trauma team activation criteria which are similar to those of the 

ACS COT. Of the criteria examined, “age over 65” had the least informative value. The authors 

therefore recommended that this criterion be removed from the “first-tier activations”. 

Demetriades et al. [20] found a markedly higher mortality (16%), increased admission to 

intensive care, and an increased necessity for surgical intervention (19%) in patients over 70 

years of age compared to younger patients. However, all patients who could remain outpatients 

were excluded from the study beforehand so that the cited percentages are probably an 

overestimation. Kühne et al. [21] found an increase in mortality - irrespective of ISS - with 

increasing age in a retrospective study of over 5,000 trauma patients in the DGU Trauma 

Registry. The cut-off value of mortality increase was 56 years. MacKenzie et al. [22] also found 

a marked increase in (fatal) injuries from > 55 years of age upwards. In a 13-year review, 

Grossmann et al. [23] found that mortality increased by 6.8% per additional year over 65 years 


149


of age. In a study by Morris et al. [24], patients who died from the consequences of an accident 

had a lower ISS than younger patients in the control group. 

Overall, there is variation and controversy over the assessment of the influence of age on the 

outcome of trauma. The American College of Surgeons COT has classified age as a criterion for 

triage in a Level 1 or Level 2 trauma center as rather low (Step Four criterion). 


150


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EH, Richardson JD. Prehospital hypotension as a 

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5 Sava J, Alo K, Velmahos GC, Demetriades D. All 

patients with truncal gunshot wounds deserve trauma 

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triage criteria revisited. Surgery. 2003; 134: 698-703; 


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for mechanism criteria for field triage. Presented at 

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from flat-roofed houses: a surgical experience of 1643 

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151


2.4 Thorax 

What importance does the previous medical history have? 


A detailed previous medical history (from third party if necessary) should be 

taken. 

High energy trauma and road traffic accidents with lateral collision should be 

interpreted as indications of a chest injury/aortic rupture. 

Explanation: 

GoR B 

GoR B 

Even if there are only a few studies on taking the medical history with regard to chest injury, it is 

still an essential requirement for assessing the injury severity and the injury pattern and is used to 

establish whether an accident has in fact occurred. Collecting exact details of the circumstances 

of the accident is important in taking the medical history. The speed of the vehicle at the moment 

of impact and the direction of the impacting force are particularly important questions in road 

traffic accidents involving passenger vehicles. For instance, there are marked differences in the 

occurrence and severity of the chest injury and the overall injury severity depending on whether 

the impact is lateral or frontal. 

Horton et al. [1] demonstrated a sensitivity of 100% and a specificity of 34% for aortic rupture in 

a lateral collision of the vehicle and/or with a change in velocity (delta V) ≥ 30 km/h. In another 

study [2], high velocity injuries at speeds of > 100 km/h were graded as suspicious for aortic 

rupture. Richter et al [3] also found an increased risk of chest injury in lateral collisions. In this 

study, delta V correlated with the AIS (thorax), ISS, and clinical course. In the study by 

Ruchholtz et al. [4], chest injury was diagnosed in 8 out of 10 cases of passenger vehicle 

accidents involving lateral collision. In this study, 72% of patients who had an accidental fall 

also sustained a chest injury. 

In a study of 286 passenger vehicle occupants with an ISS ≥ 16, the probability of an aortic 

injury after a lateral collision was twice as high as after a frontal collision [5]. An impact in the 

region of the superior thoracic aperture appears to be particularly important and there appears to 

be increased incidence of fractures to ribs 1-4 [6]. 

Children also have a 5-fold higher risk of a severe chest injury (AIS ≥ 3) and a significantly 

higher overall injury severity when they are passenger vehicle occupants in a lateral collision 

compared to a frontal collision [7]. 

The effect of a seatbelt on the presence of a chest injury appears uncertain. Thus, in a 

retrospective study of 1,124 patients with relatively minor overall injury severity (ISS 11.6), 

Porter and Zaho [8] did find cumulative incidence of sternum fractures (4% versus 0.7%) in 

Emergency room – Abdomen 152


belted patients but the proportion of patients with chest injury was identical in both groups 

(21.8% versus 19.1%). 

What importance do physical examination findings have? 


A clinical examination of the thorax must be carried out. GoR A 

The physical examination should include auscultation. GoR B 

Explanation: 

Even if there are hardly any scientific studies except for auscultation on the importance and the 

required scope of the physical examination, it is still an indispensable requirement in identifying 

symptoms and in making (suspected) diagnoses. The above-mentioned examinations are used to 

identify relevant, life-threatening or potentially fatal disorders or injuries which require 

immediate, specific treatment. Even if a physical examination has already been carried out in the 

prehospital phase and a chest drain has already been inserted, the physical examination must be 

carried out in the emergency room as a change could have occurred in the constellation of 

findings. 

The initial physical examination should include: 

� auscultation (presence of breath sounds and lateral uniformity) 

� details of pain 

� respiratory rate 

� inspection (skin and soft tissue injuries, symmetry of the thorax, symmetry of respiratory 

excursion, paradoxical respiration, inflow congestion, belt marks) 

� palpation (subcutaneous emphysema, crepitation, tenderness points) 

� dyspnea 

Monitoring ventilation pressure, blood oxygen saturation (pulse oxymetry), and expiratory 

CO2concentration can be added during the course. 

The auscultation finding is the lead finding for making a diagnosis of chest injury. In addition, 

subcutaneous emphysema, palpable instabilities, crepitations, pain, dyspnea, and elevated 

ventilation pressures can be indications of a chest injury. 

In a prospective study, Bokhari et al. [9] examined 676 patients with blunt or penetrating chest 

injury for clinical signs and symptoms of hemopneumothorax. But out of 523 patients with blunt 

trauma, only 7 had a hemopneumothorax. In this group, auscultation has a sensitivity and 



negative predictive value of 100%. The specificity was 99.8% and positive predictive value was 

87.5%. In penetration injuries, the sensitivity of auscultation is 50%, specificity and positive 

predictive value 100%, and negative predictive value 91.4%. In both mechanisms of injury, pain 

and tachypnea are inadequate indications of the presence of a hemopneumothorax. 

In a retrospective study of 118 patients with penetrating trauma, Chen et al. [10] also found for 

auscultation only a sensitivity of 58%, specificity and positive predictive value of 98%, and 

negative predictive value of 61%. In a prospective study of 51 patients with penetrating trauma, 

the combination of percussion and auscultation exhibited a sensitivity of 96%, specificity of 

93%, and positive predictive value of 83% [11]. 

These studies show that in penetrating trauma a weakened breath sound generally has an 

underlying pneumothorax and a chest drain can then be inserted before a radiograph is taken. 

In their search for a clinical decision aid to identify children with chest injury, Holmes et al. [12] 

studied 986 patients, 80 of whom had a chest injury. This yielded an odds ratio of 8.6 for a 

positive auscultation finding, an odds ratio of 3.6 for an abnormal physical examination 

(reddening, skin lesions, crepitation, tenderness), and an odds ratio of 2.9 for an elevated 

respiratory rate. 

What importance is attached to the diagnostic equipment (chest radiograph, ultrasound, 

CT, angiography, ECG, laboratory tests) and when is it indicated? 


If a chest injury cannot be clinically excluded, a radiologic diagnostic study 

must be carried out in the emergency room. 

Every patient with clinical and anamnestic indications of a severe chest injury 

should undergo a helical CT scan of the thorax with contrast agent. 

Explanation: 

GoR A 

GoR B 

As given under points 1 and 2, both the mechanism of injury and the findings from the physical 

examination provide important information on the presence or absence of a chest injury. For this 

reason, a chest radiograph can be dispensed with if, with respect to the circumstances of the 

accident, a chest injury can be excluded and at the same time there are no findings from the 

physical examination that make an intrathoracic injury probable. 

On the other hand, a chest radiograph should be taken of all patients with confirmed chest injury. 

This serves to confirm diagnoses already made and to confirm or exclude further possible 

diagnoses. The initially taken radiograph is used to diagnose a pneumothorax and/or 

hemothorax, rib fractures, tracheobronchial injuries, pneumomediastinum, mediastinal 

hematoma, and pulmonary contusion [13]. The chest radiograph is widely used as the primary 

diagnostic tool due to its low costs and availability. Nevertheless, there is little evidence on 



sensitivity and specificity in the diagnosis of pulmonary or thoracic injuries. There are only a 

few studies that report on a series of major injuries missed in the radiographs. 

In a prospective study of 100 patients, there was evidence that the most important chest injuries 

can be detected by a chest radiograph examination. The sensitivity of images taken upright was 

78.7% and that of supine images 58.3% [14]. On the other hand, McLellan et al. [15] found 

autopsy evidence in a series of 37 patients who died within 24 hours of admission that the chest 

radiograph did not detect important injuries in 11 cases. Among these were 11 cases of multiple 

rib fractures, 3 sternum fractures, 2 diaphragmatic ruptures, and 1 aortic intimal tear. 

The chest radiograph offers sufficient accuracy for indicating a chest drain, for example. In a 

prospective study of 400 multiply injured patients, Peytel et al. [16] thus showed that insertion of 

chest drains (n = 77) based on the radiographic findings was correct in all cases. 

Yet, numerous studies have shown that intrathoracic injuries can be revealed with significantly 

higher frequency by CT scan than by chest radiograph alone. In particular, there is a marked 

superiority in the detection of pneumothoraces and hemothoraces, pulmonary contusion, and 

aortic injuries. Here, preference should be given to the helical CT with administration of 

intravenous (i.v.) contrast agent [17]. By using multi-slice helical CTs, the examination time for 

a full-body scan can be reduced from an average of 28 to 16 minutes compared to the single-slice 

helical CT, and initial diagnostic information can even be taken from the realtime images on the 

monitor [18]. 

In a series of 103 severely injured patients, Trupka et al. [19] obtained additional information 

from 65% of patients on the underlying chest injury (pulmonary contusion n = 33, pneumothorax 

n = 34, hemothorax n = 21) compared to the radiographic examination. In 63% of these patients, 

direct therapeutic consequences resulted from the additional information, which in the majority 

of cases consisted of the chest drain being re-inserted or corrected. 

In patients with relevant trauma (road traffic accidents with crash speed > 15 km/h, fall from a 

height of > 1.5 m), Exadaktylos et al. [20] were unable to detect chest injuries in 25 out of 93 

patients using the conventional radiograph. In 13 of these 25 patients, however, the CT showed 

in part substantial chest injuries, including 2 aortic lacerations. In a prospective study of 112 

patients with deceleration trauma, Demetriades et al. [21] performed a helical CT scan of the 

chest, which produced the diagnosis of aortic rupture in 9 patients. Four of these patients 

exhibited a normal chest radiograph. The aortic rupture was confirmed by CT in 8 patients. In 

one patient with an injury to the brachiocephalic artery, the CT revealed a local hematoma but 

the vessel was not visible in the CT slices. Even in patients without clinical signs of chest injury 

and with a negative radiographic finding, chest injuries showed up in the CT in 39% of patients, 

and in 5% of cases led to a change in treatment [22]. 

Blostein et al. [23] come to the conclusion that a routine CT is not to be recommended generally 

in blunt chest injury as, out of 40 prospectively studied patients with defined chest injuries, 6 

patients had a change in treatment (5x chest drains, 1x aortography with negative result). 

However, the authors also state that, in patients who require intubation and ventilation, the CT 

produces findings that are not visible on the conventional radiograph. In patients with an 

oxygenation index (PaO2/FiO2) < 300, the CT can help to estimate the extent of the pulmonary 



contusion and to identify patients at risk of pulmonary failure. Moreover, patients can be 

identified in whom an incompletely decompressed hemo- and/or pneumothorax could lead to 

further decompensation. In a retrospective study with 45 children [24] with 1) pathologic 

radiographic finding (n = 27), 2) abnormal physical examination finding (n = 8), and 3) 

substantial impact on the chest wall (n = 33), additional injuries were found in the CT in 40%, of 

which 18% of cases led to a change in treatment. 

Although for blunt chest trauma the supplementary diagnostic information from the chest CT is 

generally accepted in more recent literature [25], there is controversy surrounding the benefit of 

the effect on the clinical outcome and it is not yet confirmed. In a prospective study by Guerrero- 

Lopez et al. [26], the chest CT proved to be more sensitive in detecting hemo/pneumothorax, 

pulmonary contusion, spinal fractures, and chest drain misplacements and led to treatment 

changes in 29% of cases. In the multivariate analysis, no therapeutic relationship could be 

ascertained between the CT and ventilation time, intensive care stay or mortality. The authors 

therefore conclude that a chest CT should only be performed if there are suspected severe 

injuries that can be confirmed or excluded by the CT. 

Current studies showed a clear benefit from multi-slice CTs of the chest if there was a defined 

indication. Brink et al. [122] studied its routine, selective use in 464 and 164 patients. The 

indications for a routine CT were: high-energy trauma, vital parameters under threat, and severe 

injuries such as pelvic or spinal fractures, for example. The indications for a selective CT were: 

abnormal mediastinum, more than 3 rib fractures, pulmonary shadowing, emphysema, and 

fractures in the thoracolumbar spine. Injuries which were not visible in the conventional 

radiograph were found in 43% of patients who underwent routine CT. This led to changes in 

treatment for 17% of patients. Among the 7.9% of patients with a normal chest radiograph, 

Salim et al. [121] found pneumothoraces in 3.3%, a suspected aortic rupture in 0.2%, pulmonary 

contusions in 3.3%, and rib fractures in 3.7%. 

If the literature results are summarized, this produces an indication for chest CT in the presence 

of the following indication criteria: 

Indication criteria for chest CT (summarized according to [121, 122]): 

� road traffic accident Vmax > 50 km/h 

� fall from > 3 m height 

� patient ejected from vehicle 

� rollover trauma 

� substantial vehicle deformation 

� pedestrian knocked down at > 10 km/h 

� biker knocked down at > 30 km/h 

� crush 



� pedestrian hit by vehicle and flung > 3 m 

� GCS < 12 

� Cardio-circulatory abnormalities (respiratory rate > 30/min, pulse > 120/min, systolic blood 

pressure < 100 mmHg, blood loss > 500 ml; capillary refill > 4 seconds) 

� Severe concomitant injuries (pelvic ring fracture, unstable spinal fracture or spinal cord 

compression) 

A retrospective multicenter analysis using the database of the DGU Trauma Registry found 

evidence of an improvement in survival probability for patients who had initially undergone a 

full-body CT scan [128]. The use of full-body CT leads to a relative reduction in mortality of 

25% in TRISS and of 13% in the RISC score. The CT proved to be an independent predictor for 

survival in the multivariate analysis. 




Every patient with clinical signs of chest injury should undergo an initial 

ultrasound examination (as part of the ultrasound examination of the torso) 

unless an initial chest helical CT with contrast agent has been carried out. 

Explanation: 

GoR B 

In a prospective study of 27 patients, chest X-rays, ultrasound examinations and CT were 

compared for accuracy in diagnosing a pneumothorax. The ultrasound examination of the thorax 

showed a sensitivity and a negative predictive value of 100% and a specificity of 94% [27]. In 

another study, the ultrasound examination compared with the X-ray examination showed a 

sensitivity and a positive predictive value of 95% and a negative predictive value of 100% for 

diagnosing a pneumothorax [28]. However, emphysema bullae, pleural adhesions or extensive 

subcutaneous emphysema can falsify the results of ultrasonography. 

As a retrospective study of 240 patients showed, the ultrasound examination ranks equally with 

the X-ray in diagnosing hemothorax. In 26 of these patients, the hemothorax was confirmed 

either by a chest drain or by chest CT. Ultrasound and chest X-ray each showed a sensitivity of 

96%, a specificity and a negative predictive value of 100%, and a positive predictive value of 

99.5% [29]. 

In a prospective study of 261 patients with penetrating injuries, chest ultrasound had a sensitivity 

of 100% and specificity of 96.9% for detecting pericardial tamponade [30]. However, falsenegative 

ultrasound results can occur especially in patients with larger hemothoraces which can 

conceal smaller hematomas in the pericardium [31]. For this reason, sensitivity of the ultrasound 

was only 56% in this study. 

In a retrospective study of 37 patients with a pulmonary contusion confirmed in a CT, 

ultrasonography revealed a sensitivity of 94.6%, specificity of 96.1%, and a positive and 

negative predictive value of 94.6% and 96.1%, respectively [127]. 

A chest helical CT scan with contrast agent excluded aortic injuries in patients without detected 

mediastinal hematoma, resulting in angiography not being necessary. Due to inadequate 

sensitivity, conventional CT examinations are less suited for the exclusion of an aortic injury 

[32, 33, 34]. 

In the prospective study by Gavant et al. [35], 1,518 patients with blunt trauma underwent helical 

CT scans with contrast agent. Of this group, 127 patients with abnormalities in the mediastinum 

or aorta received aortography. An aortic injury was detected in 21 of these patients. Sensitivity 

for the CT and the aortography was 100 and 94.4%, respectively, whereas specificity was 81.7 

and 96.3%, respectively. It was concluded from this that in the absence of a mediastinal 

hematoma or if the aorta presented normally despite mediastinal hematoma, CT was sufficient 

for diagnosis and aortography was not necessary. 



In a prospective study, Dyer et al. [2] studied 1,346 patients after blunt chest trauma using 

contrast CT and 19 of the patients exhibited an aortic injury in the CT. All patients with positive 

CT findings had additional angiography. On the assumption of a periaortal hematoma as 

indication of an aortic injury, the CT has a sensitivity and a negative predictive value of 100%, a 

specificity of 95%, and a positive predictive value of 22%. The authors conclude that 

aortography should only be carried out in patients who have undergone a CT scan that cannot be 

interpreted or have a periaortal hematoma without direct signs of an aortic injury. Aortography 

can also prove necessary if the proximal extent of the aortic injury cannot be reliably assessed 

from the CT scan. 

In another prospective study of 494 patients with blunt chest trauma and mediastinal hematoma, 

the sensitivity for helical CT with contrast agent was 100% compared to 92% for aortography 

[36]. The specificity for the CT was 83% compared to 99% for aortography. The positive 

predictive value for the CT was 50% compared to 97% for aortography and the negative 

predictive value was 100% compared to 97%. In contrast to the above-mentioned study by Dyer 

et al. [2], Fabian et al. [36] conclude that patients with a mediastinal hematoma but no direct 

indication of an aortic injury also require no further diagnostic workup. 

The prospective study by Parker et al. [37] of 142 patients with radiographically abnormal 

mediastinum showed that both the helical CT and the aortography produced a sensitivity and a 

negative predictive value of 100% for aortic injury. In a retrospective study of 74 patients, Tello 

et al. [38] found normal CT findings in 39 patients. Of these 39 patients, 5 received an 

angiography which showed all findings normal and 34 patients were asymptomatic at a clinical 

follow-up examination 12 months later. 

There is general consensus now that helical CT with contrast agent is suitable for the exclusion 

of an aortic rupture [123, 124, 126]. There is a high probability that patients without detectable 

mediastinal hematoma have no aortic injury. Through the use of computed tomography, a large 

number of unnecessary aortographs can thus be avoided. However, if a brain CT scan is 

required, it should be carried out before the chest CT scan as the administration of contrast agent 

hampers the traumatic brain injury diagnosis. 

As comparative studies on angiography have shown, a CT without evidence of a mediastinal 

hematoma has a negative predictive value of 100% for the injury of large intrathoracic vessels 

[39]. However, the specificity in the study by Parker et al. [37] is only 89% due to 14 falsepositive 

findings. It is therefore recommended that angiography is performed on patients with a 

para-aortic hematoma detected by CT or with peribranch vessel hematomas and abnormal aortic 

contours. A negative contrast agent CT scan definitively excludes an aortic rupture [34, 40, 41]. 

In an analysis of 54 patients with surgically detected aortic ruptures, Downing et al. [42] showed 

a sensitivity of 100% and specificity of 96% for helical CT. In a prospective study of 1,104 

patients with blunt chest trauma, Mirvis et al. [43] found mediastinal bleeding in 118 cases, of 

which 25 patients had an aortic rupture. For the aortic rupture, the helical CT showed a 

sensitivity and a negative predictive value of 100%, a specificity of 99.7%, and a positive 

predictive value of 89%. In a retrospective study on chest CT, Bruckner et al. found a negative 



predictive value of 99%, a positive predictive value of 15%, a sensitivity of 95%, and a 

specificity of 40%. 

In another prospective study of 1,009 patients, 10 patients had an aortic injury [44]. For the 

detection of direct signs of an aortic injury, the helical CT showed a sensitivity and a negative 

predictive value of 100%, a specificity of 96%, and a positive predictive value of 40%. 

In contrast to the above-mentioned prospective studies, Collier et al. [45] found only a sensitivity 

of 90% and a negative predictive value of 99% in a retrospective study of 242 patients; an aortic 

injury was found during the autopsy of one patient with a normal CT finding who had 

subsequently died from the consequences of a traumatic brain injury. In another retrospective 

study, angiography did not detect any aortic injury in 72 patients with an intrathoracic hematoma 

detected in a CT scan but no evidence of a direct aortic or other intrathoracic vessel injury [125]. 

Transesophageal echocardiography (TEE) is a sensitive screening test [46, 47, 48] but 

angiography was often additionally carried out afterwards [49, 50]. TEE requires an experienced 

examiner [51] and is generally not so rapidly available as CT or angiography. The benefit of 

TEE may lie in imaging small intimal tears [47] which might not be visible in angiography or 

helical CT. However, TEE cannot provide good images of the ascending aorta and the branches 

of the aorta, which thereby elude diagnosis [52]. To date, there is only one prospective study in 

which helical CT has been compared to TEE in the diagnosis of aortic injury. CT and TEE 

showed a sensitivity of 73 and 93%, respectively, and a negative predictive value of 95%. 




A 3-lead ECG must be carried out to monitor vital functions. GoR A 

A 12-lead ECG should be carried out if there is a suspected blunt myocardial 

injury. 

Explanation: 

GoR B 

The initial ECG is essential for every severely injured patient. The ECG is necessary particularly 

in the absence of palpable pulses in order to differentiate in cardiac arrest between rhythms that 

can be defibrillated and those that cannot be defibrillated. The ECG can also be used as a 

screening test for potential cardiac complications from a blunt cardiac injury. 

Patients with a normal ECG, normal hemodynamics and no other additional relevant injuries do 

not require any further diagnostic tests or treatment. Cardiac enzymes are irrelevant in predicting 

complications from a blunt cardiac injury although raised troponin I levels can predict 

abnormalities in echocardiography. The echocardiogram should not be used in the emergency 

room for the diagnosis of blunt cardiac injury as it does not correlate with the occurrence of 

clinical complications. Echocardiography should be carried out on hemodynamically unstable 

patients in order to diagnose pericardial tamponade or pericardial rupture. Transthoracic 

echocardiography should be the method of choice here as to date there have been no clear 

evidence that transesophageal echocardiography is superior in diagnosing blunt cardiac injury. 

The ECG is a rapid, cost-effective, non-invasive examination which is always available in the 

emergency room. In a meta-analysis of 41 studies, it was shown that the ECG and the creatine 

kinase MB (CK-MB) levels have a higher importance than radionuclide examinations and the 

echocardiogram in diagnosing clinically relevant blunt cardiac injury (defined as a complication 

requiring treatment) [53]. 

Fides et al. [54] report prospectively on 74 hemodynamically stable patients with normal initial 

ECG with no existing heart disease or other injuries. None of these patients developed cardiac 

complications. Another retrospective study of 184 children with blunt cardiac injury showed that 

patients with a normal ECG in the emergency room did not develop complications [55]. In a 

meta-analysis of 41 studies, an abnormal admission ECG correlated with the development of 

complications requiring treatment [53]. In contrast, in a prospective study by Biffl et al. [56], 17 

out of 107 patients with a contusion developed complications. Only 2 out of 17 patients initially 

had an abnormal ECG and 3 had sinus tachycardia. In another retrospective study of 133 patients 

in 2 establishments with clinical suspicion of a blunt cardiac injury, 13 patients (9.7%) 

developed complications but no patient with a normal initial ECG showed other abnormalities 

[57]. In the study by Miller et al. [58], 4 out of 172 patients developed arrhythmias requiring 

treatment with all 4 patients having an abnormal initial ECG. Wisner et al. [59] studied 95 

patients with suspected blunt cardiac injury and discovered that 4 patients developed clinically 

significant arrhythmias, only 1 of which had a normal admission ECG. In summary, the majority 



of authors recommend that asymptomatic, patients with stable circulation with a normal ECG do 

not require any further diagnostic tests or treatment. 


The measurement of troponin I levels can be undertaken as an additional 

laboratory test in the diagnosis of blunt myocardial injuries. 

Explanation: 

GoR 0 

The studies on creatine kinase MB (CK-MB) in the diagnosis of blunt cardiac injury reveal a 

major limitation in the lack of a clear definition of blunt cardiac injury and the lack of a gold 

standard. In a retrospective study of 359 patients, 217 of whom were included to exclude blunt 

cardiac injury, 107 were diagnosed either because of an abnormal ECG finding or elevated CK- 

MB level. 16% of patients developed complications requiring treatment (arrhythmias or 

cardiogenic shock). All of these patients had an abnormal ECG but only 41% of them had 

elevated CK-MB levels. The course was without complication in patients with normal ECG and 

elevated CK-MB [56]. In a prospective study of 92 patients who all received an ECG, a CK-MB 

analysis, and continuous monitoring, 23 patients developed arrhythmias which, however, did not 

require any specific treatment. This shows that the number of arrhythmias requiring clinical 

treatment is small. 52% of patients with arrhythmias revealed elevated CK-MB levels whereas 

19% of patients without arrhythmias also had elevated CK-MK levels [60]. In addition, other 

studies showed no correlation between elevated CK-MB levels and cardiac complications [58, 

59, 61-65]. 

Troponin I and T are sensitive markers in the diagnosis of myocardial infarction and 

considerably more specific than CK-MB as they are not present in skeletal muscle. In a study of 

44 patients, the 6 patients with blunt cardiac injury confirmed by echocardiography showed 

simultaneously elevated CK-MB and troponin I. Of the 37 patients without cardiac injury, 26 

had elevated CK-MB levels but no patient had elevated troponin I [66]. In another study of 28 

patients, 5 of whom had a blunt cardiac injury detected by echocardiography, troponin I had a 

specificity and sensitivity of 100% for the contusion. In a study of 29 patients, troponin T 

showed higher sensitivity (31%) than CK-MB (9%) in diagnosing blunt cardiac injury. Troponin 

T showed a sensitivity of 27% and a specificity of 91% in 71 patients for predicting clinically 

significant ECG changes [67]. 

In a more current prospective study of 94 patients, 26 patients were diagnosed with blunt cardiac 

injury either by ECG or echocardiography. Troponin I and T showed a sensitivity of 23 and 

12%, respectively, sensitivity of 97 and 100%, respectively, and a negative predictive value of 

76.5 and 74%, respectively. The authors describe an unsatisfactory correlation between the two 

enzymes and the occurrence of complications [68]. In another prospective study, sensitivity, 

specificity, and the positive and negative predictive values of troponin I are given as 63, 98, 40, 

and 98%, respectively, for detecting blunt cardiac injury [69]. Velmahos et al. carried out ECG 

tests and troponin I measurements prospectively in 333 patients with blunt chest trauma [70]. In 

44 diagnosed cardiac injuries, the ECG and troponin I showed a sensitivity of 89 and 73%, 



respectively, and a negative predictive value of 98% and 94%, respectively. The combination of 

ECG and troponin I produced a sensitivity and a negative predictive value of 100% each. Rajan 

et al. [71] showed that a cTnI level below 1.05 µg/l at admission and after 6 hours excludes 

myocardial injury. 

The results available to date show that troponin I in particular is a more specific indicator than 

CK-MB for the presence of a blunt cardiac injury. However, the importance of troponin in 

predicting complications is still the subject of current discussion. 

A transthoracic echocardiography (TTE) is often carried out in the diagnosis of blunt cardiac 

injury but has hardly any importance in patients with stable circulation. In a prospective study, 

Beggs et al. carried out TTE in 40 patients with suspected blunt chest injury. Half of the patients 

had at least one pathologic finding either in the ECG, in the cardiac enzymes or in TTE. There 

was no correlation between TTE, the enzyme or ECG findings, and TTE could not predict the 

development of complications [72]. In another prospective study of 73 patients who all 

underwent TTE, CK-MB measurements, and cardiac monitoring, 14 patients presented 

abnormalities in the echocardiography. However, only 1 patient who initially had a pathologic 

ECG developed a complication in the form of a ventricular arrhythmia [73]. A prospective study 

of 172 patients came to the conclusion that only an abnormal ECG or shock has a predictive 

value with reference to monitoring or to a specific treatment. Patients with abnormalities in TTE 

or elevated CK-MB levels without a simultaneous pathologic ECG developed no complications 

requiring treatment [58]. Although there are a number of studies which show the benefit of TTE 

in the diagnosis of pericardial effusion or of pericardial tamponade in penetrating trauma, the 

benefit of this study on blunt trauma is debatable [30, 58, 74]. 

There are a number of studies which show that the accuracy of transesophageal 

echocardiography (TEE) is greater than that of TTE in the diagnosis of cardiac injuries [75-79]. 

In addition, other cardiovascular changes such as aortic injuries, for example, can be diagnosed 

by TEE. Vignon et al. [80] prospectively carried out helical CT and, in the intensive care unit, 

TEE on 95 patients with risk factors for an aortic injury. The sensitivity of TEE and CT was 93 

and 73%, respectively, the negative predictive value was 99% and 95%, respectively, and the 

specificity and the positive predictive value were 100% for both examination methods. TEE 

proved to be superior in identifying intimal tears whereas an aortic branch lesion was missed. 

In summary, echocardiography should be carried out if a pericardial tamponade or pericardial 

rupture is suspected. 

What additional diagnostic tests exist for emergency room patients? 

Fabian et al. [36] state that patients with a mediastinal hematoma and no direct evidence of an 

aortic injury require no further assessment. This also applies to intimal tears and pseudoaneurysms. 

However, patients with changes that cannot be classified in more detail should 

undergo angiography for further assessment. Gavant et al. [35] also stated that, in the absence of 

a mediastinal hematoma or if the aorta presented normally despite mediastinal hematoma, helical 

CT with contrast agent was sufficient for diagnosis and aortography was not necessary. 



Mirvis et al. [43] and Dyer et al [44] suggest that an aortic injury detected in a CT or an injury to 

the main lateral branches and a mediastinal hematoma require either an angiography or direct 

thoracotomy depending on the experience of the establishment concerned. Angiography is also 

necessary for a mediastinal hematoma in direct contact with the aorta or with the proximal great 

vessels without direct evidence of a vessel injury or for abnormal aortic contours [37]. 

Downing et al. [42] conclude from the results of their study that surgical treatment can be carried 

out without further diagnostic tests if a helical CT clearly detects an aortic rupture. In contrast to 

the above-mentioned study by Dyer et al. [2], Fabian et al. [36] conclude that patients with a 

mediastinal hematoma but no direct evidence of an aortic injury require no further work-up. 

To date, there are no comparative studies which investigate the necessity of additional 

angiography prior to a planned intervention for an aortic injury detected in a CT scan. For this 

reason, the recommendations are based, on the one hand, on conclusions from studies which 

evaluated angiography and CT in the diagnosis of aortic injury and, on the other hand, on data 

from diagnostic tests carried out prior to endovascular treatment. 

Thus, Gavant et al. [35], recommend that aortography is carried out prior to surgical or 

endovascular treatment in order to confirm the injury and define the extent of the damage. Parker 

et al. [37] also consider angiography necessary for confirming positive CT findings. 

In patients with direct indication of an aortic injury and a mediastinal hematoma, Mirvis et al. 

[43] and Dyer et al [44] suggest either angiography or direct thoracotomy depending on the 

experience of the establishment concerned. 

Downing et al. [42] and Fabian et al. [36] hold the view that a thoracotomy can also be carried 

out without additional angiography if the CT finding is clear. 

In a series of 5 patients with acute traumatic rupture of the thoracic aorta, a CT scan and 

angiography were carried out on all patients prior to stent implantation [81]. 

What importance is attached to emergency procedures (chest drain, intubation, 

pericardiocentesis, thoracotomy)? 


A clinically relevant or progressive pneumothorax must first be decompressed 

in the ventilated patient. 

A progressive pneumothorax should be decompressed in the non-ventilated 

patient. 

GoR A 

GoR B 

A chest drain must be inserted for this purpose. GoR A 

Preference should be given to wide lumen chest drains. GoR B 



Explanation: 

A pneumothorax detected in the radiographic image represents an indication to insert a chest 

drain particularly if mechanical ventilation is necessary. This represents general clinical practice 

although there are no comparative studies on this in the literature [12, 82-85]. Due to the 

underlying pathophysiology, it is upgraded to Grade of Recommendation A. Westaby and 

Brayley [86] recommend that a chest drain should always be inserted for a pneumothorax which 

exceeds 1.5 cm in size and is at the level of the 3rd intercostal space. If the size is less than 1.5 

cm, a chest drain should only be inserted if ventilation is necessary or if there is bilateral 

occurrence. The insertion of a chest drain can be omitted only in small ventral pneumothoraces 

detected by CT although close clinical monitoring is required. 

The insertion of a chest drain should be carried out in the emergency room as the risk of a 

progressive pneumothorax can lead to a tension pneumothorax and the timespan of such a 

development cannot be estimated. The risk of a tension pneumothorax occurring should be rated 

markedly higher in ventilated patients than in non-ventilated patients. In non-ventilated patients, 

small pneumothoraces less than 1-1.5 cm in width can initially be treated conservatively by close 

clinical monitoring. If this is not possible for logistic reasons, the pneumothorax should also be 

decompressed in this situation. 

The increasing use of abdominal and chest CT in the diagnosis of blunt trauma has led to 

pneumothoraces being detected in a CT scan which had not been detected previously by 

conventional supine radiographic images. These so-called occult pneumothoraces, usually lying 

ventrally, are found in 2-25% of patients after severe multiple injuries [19, 22, 23, 87-89]. Based 

on the available literature, the initial insertion of a Bülau drain should be omitted in an occult 

pneumothorax diagnosed by CT if: 

� the patients are hemodynamically stable and have a largely normal lung function, 

� there are frequent clinical checks with the possibility of radiography in between 

and 

� a chest drain can be inserted at any time by a qualified physician. 

Also in a prospective randomized study, Brasel et al. [91] studied the necessity of inserting a 

chest drain for an occult traumatic pneumothorax. Chest drains were inserted in 18 patients while 

21 patients were clinically observed only. Ventilation was necessary in 9 patients in each group. 

In the group with chest drains, the pneumothorax increased in 4 patients; in the group without 

chest drain, a Bülau drain was inserted in 3 patients, of whom 2 patients were then also 

ventilated. 

In a prospective study of 36 patients with 44 occult pneumothoraces, the subdivision was made 

into minimal (< 1 cm visible on a maximum of 4 CT slices), anterior (> 1 cm but not extending 

laterally into the dorsal half of the chest), and anterolateral pneumothoraces [92]. Fifteen 

minimal pneumothoraces were closely clinically monitored irrespective of the necessity for 

ventilation. The secondary insertion of a chest drain was then required in 2 cases. A drain was 



always inserted for anterior and anterolateral pneumothoraces if ventilation was required. In a 

prospective study of children, Holmes et al. identified 11 patients with occult pneumothoraces 

which were also subdivided according to the above-mentioned plan [93]. In the case of minimal 

pneumothoraces, the patients were also conservatively treated irrespective of the necessity for 

ventilation. 

In a retrospective study, patients with pneumothorax were treated with (13) and without (13) a 

chest drain [94]. Out of 10 patients who required mechanical ventilation, 2 patients had to have a 

secondary chest drain inserted. However, there are no data on the size of the initial 

pneumothorax. In another retrospective study, the size of the occult pneumothorax was 

compared against the requirement to insert a chest drain and it was suggested that 

pneumothoraces less than 5 x 80 mm could be observed irrespective of the necessity for 

mechanical ventilation [95]. Weißberg et al. [96] stated in their retrospective study of 1,199 

patients (of whom 403 patients had traumatic pneumothorax) that management by clinical 

observation is possible for a pneumothorax volume less than 20% of the pleural space. However, 

there are no details on the effect of possible mechanical ventilation. 

A score was proposed by De Moya for the improved definition of the “small” pneumothorax, 

which is composed of 2 parts: 1) the largest diameter of the pneumothorax and 2) its relationship 

to the pulmonary hilus. If the pneumothorax does not exceed the pulmonary hilus, 10 is added to 

the millimeter figure of the pneumothorax; if the hilus is exceeded, 20 is added. The sum of the 

individual values for each side gives the score value. The positive predictive value for a chest 

drain was 78% for a score > 30 and the negative predictive value was 70% for a score < 20 

[136]. In a randomized study of 21 ventilated patients, observation of the occult pneumothorax 

proved to be reliable. In 13 patients initially treated without a chest drain, there was no need for 

emergency decompression in any case even though pleural effusion had to be decompressed 

during the course in 2 patients and an increasing pneumothorax had to be decompressed after 

insertion of a central venous catheter in one patient. It seems justifiable to take a “wait and see” 

attitude towards inserting a chest drain for an occult pneumothorax both in spontaneously 

breathing and ventilated patients [129, 130]. 


Pericardial decompression should be carried out if there is evidence of 

pericardial tamponade and acute deterioration in vital parameters. 

Explanation: 

GoR B 

Irrespective of the patient’s condition, the diagnosis of pericardial tamponade should be made 

rapidly and reliably so that surgery can be performed quickly if required. Although the diagnosis 

of tamponade can be confirmed by the insertion of a pericardial window, this is an invasive 

procedure, particularly if there is only slight suspicion of a cardiac injury. Ultrasound 

examination has been proven to be a sensitive procedure in the diagnosis of pericardial effusion 

and thus represents the current method of choice. In a prospective multicenter study of 261 

patients with penetrating pericardial chest injuries, there was a sensitivity of 100%, a specificity 



of 96.7%, and an accuracy of 97% [30]. There were no false-negative study results. In another 

study, fluid was detected by ultrasound scan in the pericardium in 3 cases out of 34 patients. One 

patient, who was hemodynamically unstable, underwent a thoracotomy and the other two 

patients had a negative pericardial window [105]. 

Pericardiocentesis is now of lesser importance in the diagnosis of pericardial tamponade, having 

been replaced by ultrasound examination [30, 106]. 




A thoracotomy can be performed if there is an initial blood loss of > 1,500 ml 

from the chest drain or if there is persistent blood loss of > 250 ml/h over more 

than 4 hours. 

Explanation: 

GoR 0 

The indication for thoracotomy depending on the volume of initial or continuous blood loss from 

the chest drain has been intensely discussed by the guideline group, not least because of the 

inconsistent volumes described in the literature. These are almost exclusively cohort studies on 

penetrating trauma; randomized studies are not available on this research question. The available 

data is considerably less clear for blunt trauma; a thoracotomy is indicated rather less frequently 

and usually later than for penetrating trauma. Under certain circumstances, with a certain volume 

of blood loss, the thoracotomy can also be useful in hemodynamically stable patients. There are 

no data on coagulation status as a decision criterion but body temperature can be taken into 

account. 

In the 1970s, based on the experiences of penetrating injuries in the Vietnam War, McNamara et 

al. [107] described a reduction in mortality after early thoracotomy. Indication criteria for 

thoracotomy were given as an initial blood loss after chest drainage of 1,000-1,500 ml and a 

blood loss of 500 ml during the first hour after insertion of the drain. 

Kish et al. [108] analyzed 59 patients in whom one thoracotomy was necessary. A thoracotomy 

was performed in 4 out of 44 patients with penetrating injuries and in 2 out of 15 patients with 

blunt trauma 6-36 hours after the accident where there was continuous bleeding of 150 ml/hour 

over more than 10 hours or 1,500 ml over a shorter time span. The strategy of performing a 

thoracotomy where there is an initial blood loss of > 1,500 ml after insertion of a chest drain or a 

continuous hourly blood loss of > 250 ml over 4 hours is accepted for penetrating injuries [109]. 

In a multicenter study of 157 patients who had a thoracotomy because of chest bleeding, there 

was a correlation between mortality and the level of thoracic blood loss [110]. With a blood loss 

of 1,500 ml compared to 500 ml, the mortality risk was increased by the factor 3.2. The authors 

thus conclude that a thoracotomy should be considered in patients with penetrating and blunt 

trauma with a thoracic blood loss of 1,500 ml in the first 24 hours after admission even if there 

are no signs of hemorrhagic shock. 

In the current version of the NATO Handbook [111], an initial blood loss of 1,500 ml and 

drainage of 250 ml over more than 4 hours are given as indication for a thoracotomy. The 

different volumes given as threshold values for indicating a thoracotomy were checked by the 

guideline group. Agreement was reached on the volume laid down in the recommendation of 

> 1,500 ml initially or > 250 ml/h over more than 4 hours. 




An emergency thoracotomy should not be performed in the emergency room 

on patients with blunt trauma and absence of vital signs at the accident scene. 

Explanation: 

GoR B 

If vital signs are absent at the accident scene, an emergency thoracotomy is not indicated in the 

emergency room for patients with blunt trauma. Vital signs include pupillary reaction to light, 

any type of spontaneous breathing, movement caused by painful stimulus or supraventricular 

activity in the ECG [112]. However, if cardiac arrest only develops on admission to hospital, an 

immediate thoracotomy should be performed particularly in the case of penetrating trauma. 

Boyd et al. carried out a retrospective study of 28 patients who underwent a thoracotomy in the 

emergency room for the purpose of resuscitation. A meta-analysis was also carried out [112]. 

The survival rate was 2 out of 11 patients with penetrating trauma and 0 out of 17 patients with 

blunt trauma, with the survival rate (2 out of 3 patients) being highest if vital signs were present 

both at the accident scene and in the emergency room. A meta-analysis of 2,294 patients yielded 

a survival rate of 11% with the survival rate being significantly better after penetrating trauma 

compared to blunt trauma (14% versus 2%). There were no survivors in the patient group with 

absent vital signs at the accident scene and there were no survivors of blunt trauma without 

neurologic deficit among the patients with absent vital signs in the emergency room. 

Velhamos et al. [113] retrospectively analyzed 846 patients, who underwent an emergency 

thoracotomy in the emergency room. All patients presented a loss of vital signs at the time of 

admission or cardiac arrest in the emergency room. Out of 162 patients who were successfully 

resuscitated, it was possible to discharge 43 (5.1%) from hospital with 38 of these patients 

having no neurologic deficit. Out of 176 patients with blunt trauma, only 1 patient (0.2%) 

survived with serious neurologic deficits. 

Branney et al. [114] found an overall survival rate of 4.4% in 868 patients who underwent 

emergency thoracotomy. Eight out of 385 patients with blunt trauma survived (2%). Of these, 4 

patients had no neurologic deficit. Out of patients with blunt trauma and absent vital signs at the 

accident scene, 2 patients survived with serious neurologic deficit. In contrast, the outcome for 

absent vital signs at the accident scene and penetrating trauma was markedly better with 12 

neurologically-intact surviving patients out of 355. This result differs markedly from the abovementioned 

meta-analysis by Boyd et al. [112] and later studies by Esposito et al. [115], 

Mazzorana et al. [116], Brown et al. [117], and Lorenz et al. [118], which described no surviving 

patients among those with penetrating trauma and absent vital signs. 

Another retrospective study of 273 thoracotomies performed in the emergency room yielded 10 

surviving patients without neurologic deficit [119]. These all had penetrating injuries and 

presented vital signs either at the accident scene or in the emergency room. Out of 21 patients 

with blunt trauma, no patient survived. The authors thus conclude that an emergency room 

thoracotomy should only be performed on patients with penetrating trauma who show vital signs 

either at the accident scene or in the emergency room. Out of 19 patients with blunt trauma, 

Grove et al. [120] were also unable to list any surviving patients after an emergency 



thoracotomy. On admission, 5 of these patients showed no vital signs and 14 patients showed 

vital signs. All patients died within 4 days. The survival rate for penetrating trauma was 3 out of 

10 patients. 

Based on a meta-analysis of 42 outcome studies with a total of 7,035 documented “Emergency 

Department Thoracotomies”, the American College of Surgeons has published a guideline on the 

indication and performance of an emergency room thoracotomy [131]. The resulting statements 

are based chiefly on the finding that, with an overall survival rate of 7.8%, only 1.6% of patients 

survived after blunt trauma but 11.2% after penetrating trauma. More recent studies have also 

confirmed that an emergency thoracotomy during cardiopulmonary resuscitation (CPR) can 

improve the prognosis particularly in the case of penetrating trauma and appears to be 

particularly expedient if vital signs are initially present [132, 133, 134, 135]. 



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2.5 Abdomen 


The abdomen must be examined although a normal finding does not exclude a 

relevant intraabdominal injury even in the alert patient. 

Explanation: 

GoR A 

In a prospective study of hemodynamically stable patients after blunt abdominal trauma, Miller 

et al. describe how, out of 372 patients examined, an intraabdominal injury could be detected by 

CT in only 25.5% of 157 with a painful abdomen or pelvis. The CT detected an injury in only 

20% of patients with “seatbelt sign” [24]. 

Livingston et al. [18] report in a multicenter prospective study of 2,299 patients with blunt 

abdominal trauma (exclusion criteria: GCS ≤ 14, children ≤ 16, patients having undergone 

emergency laparotomy) that 1,406 (61%) of patients had a positive clinical examination with 

regard to external signs of injury or stomach pain. Of these, an abdominal injury could only be 

detected by CT in 26 % whilst the clinical examination was recorded as normal in 11% of 

patients with an injury detected in the CT. Out of 265 patients with free intraabdominal fluid 

detected in the CT, 212 (80%) had an abnormal finding in the clinical examination. In the study, 

the sensitivity of the clinical examination for free fluid detected in CT is 85%, specificity 28%, 

the positive predictive value 63%, and the negative predictive value 57%. 

In a prospective study of 350 patients, Ferrara et al. studied the informative value of abdominal 

painfulness for the presence of an intraabdominal injury which had been verified either by CT or 

diagnostic peritoneal lavage (DPL) [6]. They calculated a sensitivity of 82%, a specificity of 

45%, and a positive predictive value of 21% with a negative predictive value of 93%. 

In a prospective study of 162 patients (2001-2003, Level 1 trauma center) after blunt trauma with 

a state of clear consciousness (GCS ≥ 14) and normal clinical examination of the abdomen (but 

with the necessity of an emergency extraabdominal surgical intervention [88% trauma surgery] 

and a CT scan of the abdomen), Gonzalez et al. [7] showed that these patients do not need to 

receive any CT diagnostic test prior to the emergency intervention being carried out as the 

clinical examination offers sufficient reliability in this patient population. The CT diagnostic 

study produced pathologic intraperitoneal findings in only 2 cases (1.2%), which did not require 

further intervention (spleen injury, mesenteric hematoma). 

Concomitant injuries 

In a study of 1,096 patients with blunt abdominal trauma, Grieshop et al. [9] attempted to 

discriminate clinical options by which patients who do not require a further diagnostic test such 

as CT or DPL could be filtered out. Patients in a state of shock with a GCS value < 11 or who 

had suffered spinal trauma were analyzed but due to the limited possibility of clinical 

examination were not included in the statistics (n = 140). The authors came to the conclusion that 



besides an abnormal clinical examination (abdominal tenderness, guarding or other signs of 

peritonism) the presence of gross hematuria or chest trauma (fractures in ribs 1 or 2, multiple rib 

fractures, sternum fracture, scapula fracture, mediastinal widening, hemo- or pneumothorax) 

must also be viewed as risk factors. According to them, the risk of an intraabdominal injury with 

concomitant chest trauma increases by a factor of 7.6 and in the case of a concomitant gross 

hematuria by a factor of 16.4. All patients with relevant intraabdominal injuries (n = 44) 

belonged to the group with either an abnormal clinical examination or the presence of either or 

both cited risk factors (n = 253) corresponding to a sensitivity of 100%. To exclude an injury to 

an organ, the authors further claim that additional diagnostic tests, e.g., performing a computed 

tomography scan of the abdomen, must be carried out in such cases. No intraabdominal injuries 

were found in the remaining 703 patients who had neither an abnormal clinical examination nor 

a risk factor. The calculated negative predictive value was 100% so that further diagnostic tests 

could be dispensed with in these cases. A concomitant bony pelvic injury, a closed traumatic 

brain injury, spinal injuries, and fractures of the long bones in the lower extremity are not 

significant independent risk factors according to this study. 

In contrast, Ballard et al. and Mackersie et al. found in prospective studies that pelvic fractures 

are also linked to an increased risk of intraabdominal organ injury so that a computed 

tomography diagnostic test is thus required for several reasons [2, 20]. 

Schurink et al. [39] studied the importance of the clinical examination in a retrospective study of 

204 patients with further subdivision of the collective into 4 groups: patients with isolated 

abdominal trauma (n = 23), patients with lower rib fractures (ribs 7-12) (n = 30), patients with 

isolated head injury (n = 56), and multiply injured patients (ISS ≥ 18) (n = 95). All patients 

received an abdominal ultrasound examination. With reference to the group with isolated 

abdominal trauma, the researchers found in the clinical examination of 20 patients a sensitivity 

of 95%, and a negative predictive value of 71% with a positive predictive value of 84% for the 

presence of an intraabdominal injury. In the patients with rib fractures, there was a sensitivity 

and a negative predictive value of 100% in 4 abnormal clinical findings. 



Ultrasonography 


Initial focused abdominal ultrasonography should be performed to screen for 

free fluid, “focused assessment with ultrasonography for trauma” (FAST). 

Ultrasound examinations should be repeated at intervals if a computed 

tomography scan cannot be performed promptly. 

If computed tomography cannot be performed, a focused ultrasonographic 

search for parenchymal injuries can represent an alternative to FAST. 

Explanation: 

GoR B 

GoR B 

GoR 0 

In a systematic review of 4 randomized controlled trials on the value of ultrasound-based 

algorithms in diagnosing patients after blunt abdominal trauma, Stengel et al. showed that there 

is no evidence at present to recommend ultrasound-based algorithms [45]. The same author 

carried out an earlier meta-analysis/systematic review on the topic of the diagnostic value of 

ultrasonography as the primary test tool for detecting free intraabdominal fluid (FAST) (19 

studies) or an intraabdominal organ injury (11 studies) after blunt abdominal trauma. The 30 

analyzed studies included studies up to July 2000 with a total of 9,047 patients and evidence 

levels from IIb-IIIb [44]. One reported result of the analysis is that abdominal ultrasonography 

has only low sensitivity in diagnosing free fluid and intraabdominal organ injuries. It is stated, 

for example, that 1 in 10 organ lesions are not identified in primary ultrasonography. For this 

reason, ultrasonography is considered inadequate in the primary diagnostic study after abdominal 

trauma, and additional diagnostic tests (e.g., helical CT) are recommended both in the case of a 

negative and a positive finding [44, 45]. 

FAST 

In a prospective study of 359 hemodynamically stable patients, Miller et al. studied the 

importance of FAST under the hypothesis that confidence in the reliability of a FAST 

examination leads to intraabdominal injuries after abdominal trauma being missed [24]. As the 

gold standard, an abdominal CT scan was performed on all patients within 1 hour of the 

ultrasound examination. FAST was carried out in 4 views and positively assessed if there was 

evidence of free fluid. The FAST examination yielded 313 true-negative, 16 true-positive, 22 

false-negative, and 8 false-positive findings. This led to a sensitivity of 42%, a specificity of 

98%, a positive predictive value of 67%, and a negative predictive value of 93%. Of the 22 

patients with a false-negative diagnosis, 16 had parenchymal damage of the liver or spleen, one 

each had a mesenteric injury and a gallbladder rupture, 2 had a retroperitoneal injury, and 2 

further patients had free fluid without any injury detectable by CT. Six patients in this group 

required surgery and one underwent vascular embolization by means of angiography. Among the 

313 patients with a true-negative FAST finding, a further 19 hepatic and splenic injuries, and 11 

retroperitoneal injuries (inter alia hematoma in the aortic wall, bleeding from pancreas head, 



renal contusion) were diagnosed by the CT scan. None of these patients had to undergo surgery. 

Consequently, irrespective of the FAST examination finding, the authors call for further 

assessment of the adequately hemodynamically stable patient by a CT scan of the abdomen and 

pelvis [24]. 

In a systematic review of studies by McGahan et al. on the importance of FAST in the diagnostic 

study after abdominal trauma, the sensitivity of the examination for detecting free fluid ranged 

widely from 63 to 100%. McGahan et al. are critical of the fact that, in the studies which gave 

high sensitivities and which cited FAST as a suitable initial screening method, significant 

weaknesses can be found in the study design (no standard reference, no consecutive inclusion) 

[22]. 

Various other authors also report on organ injuries which could not be diagnosed by FAST and 

led to subsequent surgical intervention. In a retrospective study of 2,576 patients, Dolich et al. 

found that there were false-negative FAST findings in 1.7% (43 patients) [5]. Ten of these 

patients had to undergo a laparotomy as a result. The lack of hemoperitoneum in detected 

intraabdominal injuries is described as a limitation of the FAST examination, which is intended 

to be used for the primary rapid screening of free fluid. In a retrospective study, it was 

demonstrated that 34% of patients (157 out of 467 patients) with an intraabdominal injury had no 

hemoperitoneum and thus eluded diagnosis. Twenty-six of these patients had to undergo surgery 

[40]. 

Soyuncu et al. describe a prospective case series with 442 included patients who sustained a 

blunt abdominal trauma. They were able to show that a FAST examination carried out by an 

operator experienced in abdominal ultrasonography (minimum 1 year’s experience) has a 

sensitivity of 86% and a specificity of 99% with 0.95% false-positive and 1.1% false-negative 

results (verified by laparotomy, CT, autopsy) [43]. 

Ultrasonography with organ diagnosis 

In a prospective study, Liu et al. [17] compared among 55 hemodynamically stable patients the 

diagnostic evidential value of ultrasound (with screening for free fluid and organ lesion), 

computed tomography, and DPL each on the same patients. The DPL was carried out after the 

imaging procedures so that they did not falsify the diagnosis of free fluid. In the diagnosis of an 

intraabdominal injury (without differentiating between the detection of free fluid and the direct 

detection of an organ lesion), the authors found a sensitivity of 91.7% and a specificity of 94.7% 

for ultrasound, which lay below the results of DPL and CT. The disadvantages of ultrasound are: 

(1) the technical difficulty of ultrasound in subcutaneous emphysema, (2) in pre-operated 

patients free fluid possibly may not flow into the Douglas space and thus elude diagnosis, (3) 

pancreas and hollow organ injuries might not be well assessed and (4) the poor assessability of 

the retroperitoneal space. In conclusion, the authors recommended ultrasound because of its 

practicability as a primary diagnostic tool in the examination of hemodynamically unstable 

patients. However, due to the limitations cited, they warned against overestimating its 

informative value. 

In a study of 3,264 patients, Richards et al. [34] examined the quality of the abdominal 

ultrasound examination in the diagnosis of free fluid and parenchymal organ lesions after 



abdominal trauma. Diverging from the FAST examination, ultrasound was thus used explicitly in 

this study to detect parenchymal organ lesions in the liver and spleen or kidneys. The results 

were verified by CT, laparotomy, DPL or clinical observation. Free fluid was detected by 

ultrasonography in 288 patients and checked by CT and laparotomy. This yielded a sensitivity of 

60%, a specificity of 98%, a negative predictive value of 95%, and a positive predictive value of 

82% for the diagnosis of free fluid alone. Specific organ lesions were found in 76 cases, 45 with 

simultaneously occurring free fluid. The simultaneous focused ultrasound for a parenchymal 

organ lesion increased the sensitivity of the diagnosis of an intraabdominal injury to 67%. 

Like Richards and Liu et al., Brown et al. [4] examined 2,693 patients after abdominal trauma 

for free fluid and also focused for parenchymal injuries. Of these, 172 had an intraabdominal 

injury which had been verified by laparotomy, DPL, CT, clinical course or autopsy. In 44 

patients (26%) no hemoperitoneum could be detected in the ultrasound but in 19 of these patients 

(43%) an organ lesion could be diagnosed in the ultrasound. The authors conclude that organ 

injuries are missed by limiting to short ultrasonography focused (FAST) on the diagnosis of free 

fluid. As part of the emergency diagnostic study, therefore, an ultrasound examination must be 

carried out to look for free fluid and injuries to parenchymal organs. 

In a prospective study of 800 patients, higher sensitivities (88%) for the detection of an 

intraabdominal injury were found by Healey et al. [10]. This study also included screening for 

free fluid and organ lesions, which were compared to CT, DPL, laparotomy, repeated 

ultrasonography or clinical course. 

In a comparative study design, Poletti et al. [33] also reported higher sensitivities. They 

examined 439 patients after abdominal trauma. Of these patients, 222 were not further examined 

after the primary normal finding and were discharged with the proviso that they should return if 

they thought there was deterioration. Only the remaining 217 patients were analyzed: For the 

ultrasonography, a sensitivity of 93% (77 out of 83 patients) was demonstrated for detecting free 

fluid and a sensitivity of 41% (39 out of 99 patients) for the direct detection of a parenchymal 

organ injury, injuries to the liver being well diagnosed compared to other organ lesions. In a 

repeat examination in the case of a primary negative finding, these values could be increased 

further but a pathologic finding had previously been found in a CT examination and was also 

known to the examiner. A total of 205 patients underwent a follow-up CT examination. 

Likewise, in these two studies and in another by Yoshii et al. [52], the high sensitivities for 

detecting free fluid are debatable as not all patients received a baseline examination and/or 

different baseline examinations (DPL, CT, laparotomy, repeat ultrasonography, clinical 

observation) had been used. In addition, patients with primary normal findings were discharged 

and did not receive a follow-up examination either [31]. 

McElveen et al. [21] studied 82 consecutive patients (for free fluid and organ lesion) and verified 

all these patients with a baseline examination (71 by CT, 6 by repeat examination, 3 by DPL, and 

2 by laparotomy) and a follow-up for a period of 1 week after trauma, either as an inpatient or an 

outpatient. With a sensitivity of 88% and a specificity of 98%, accompanied by a negative 

predictive value of 97% for the diagnosis of an intraabdominal injury, they recommended the 

ultrasound examination as the initial examination method after abdominal trauma. 



In a prospective examination of 210 consecutively included, hemodynamically stable patients 

after blunt abdominal trauma, Poletti et al. compared the diagnostic quality of ultrasonography 

(with and without intravenous contrast agent) with CT. The patients first received conventional 

ultrasonography (including organ diagnostic workup) and then a CT scan. Patients with falsenegative 

findings in the primary ultrasonography then received conventional repeat 

ultrasonography and, if that yielded a negative finding as well, contrast agent enhanced 

ultrasound examination. Poletti et al. [32] showed that neither conventional repeat 

ultrasonography nor contrast agent enhanced ultrasonography achieved the quality of computed 

tomography in detecting organ injuries. In the computed tomography, 88 organ injuries (solid 

organs) were detected in 71 patients. Out of 142 patients in whom no free fluid (intra- or 

retroperitoneal) could be detected in the CT, 33 (23%) organ lesions (all organs) were found. 

Four of these patients (12%) required an intervention (laparotomy/interventional angiography). 

Primary ultrasonography identified 40% (35 out of 88), monitoring ultrasonography 57% (50 out 

of 88), and contrast agent enhanced ultrasonography 80% (70 out of 88) of injuries to solid 

organs. They concluded that even contrast agent enhanced ultrasonography cannot replace 

computed tomography in hemodynamically stable patients. 

Repeat examinations 

With regard to the importance of repeat sonographic monitoring of the patient after abdominal 

trauma, Hoffmann et al. [13] showed that in 19 (18%) of 105 patients with a primary unclear 

finding it was only possible to definitely detect free fluid intraabdominally with a repeat 

ultrasound examination in the emergency room (after circulation-stabilizing procedures). The 

authors pointed out that, if possible, the examination should be carried out by the same examiner 

to achieve optimum monitoring. The monitoring examination should be carried out about 10-15 

minutes after the primary examination in patients with initially minimal evidence of fluid (1- 

2 mm border) or unclear findings. Compared to a DPL, a possible increase in free fluid can by 

documented by repeat ultrasonography and the ultrasonography can also be used to diagnose 

retroperitoneal and intrathoracic injuries. 

In the above-mentioned study, Richards et al. [34] also report an increase in sensitivity of the 

ultrasound examination through a repeat examination. 

In a prospective study of 156 patients after blunt or penetrating abdominal trauma, Numes et al. 

[29] showed that, through repeat ultrasound examinations during the course, false-negative 

results for the detection of free intraabdominal fluid could be reduced by 50% and thus the 

sensitivity of 69% (with a single scan) was increased to 85%. 

Practitioners 

With regard to the question as to who must carry out the examination, Hoffmann et al. [13] are 

of the opinion that stand-alone screening for free fluid by ultrasound is easily learnt and can then 

be reliably carried out by a member of the emergency room team. However, the extent to which 

specific questions can be reliably answered depending on the type and length of training remains 

unclear. 



A prospective study by Ma et al. [19] showed that a 10-hour theory introduction coupled with 

carrying out 10-15 examinations on healthy subjects is sufficient to achieve diagnostic certainty 

in emergency ultrasonography of the abdomen provided this is restricted to detection/exclusion 

of free fluid. 

McElveen et al. [21] make the same recommendation although it is not based on a study. They 

stipulate 15 examinations on normal patients and 50 monitored examinations on trauma patients. 

A retrospective study by Smith et al. [42] on the quality of the ultrasound by trained, experienced 

surgeons showed that previous extensive ultrasound experience is not required and there is no 

learning curve. 

Although also without a comparator study, Brown et al. [4] call for screening for specific organ 

lesions to be also included in terms of increasing the sensitivity of the ultrasound examination, 

and recommend that this is carried out by an experienced practitioner. 



Diagnostic peritoneal lavage (DPL) 


Diagnostic peritoneal lavage (DPL) must only be used in exceptional cases. GoR A 

Explanation: 

With a sensitivity of 100% and a specificity of 84.2%, DPL was the most sensitive method for 

detecting an intraabdominal injury in the comparative study with CT and ultrasonography by Liu 

et al. [17]. As the authors argue, however, the high sensitivity (e.g., by detection of blood from 

catheter insertion) leads to a relevant number of non-therapeutic laparotomies. Lui et al. are 

critical of DPL also when a retroperitoneal hematoma is present as even small tears in the 

peritoneum were reported to yield a positive result, which led to an unnecessary laparotomy in 

half of the 6 patients with a retroperitoneal hematoma. 

DPL is rapid and, like ultrasonography, can be carried out in parallel with stabilization of the 

patient. Its interpretation is not as practitioner-dependent as ultrasonography, it is easy to learn 

and can also be repeated. The complication rate is generally given as approximately 1% [8, 23, 

47]. Limitations of DPL are its invasiveness and lack of ability to confirm precisely the 

underlying injury type and location of the injury and thus the assessment of its clinical relevance. 

Using a study of 167 patients with stable circulation with suspected intraabdominal lesion, Mele 

et al. showed that, firstly, the number of missed injuries could be reduced by combining a 

positive DPL with a subsequent specific examination such as CT compared to a single diagnostic 

test by CT and, secondly, as with stand-alone DPL, the number of unnecessary laparotomies 

could be reduced [23]. 

Gonzalez et al. [8] came to the same results in a study of 252 hemodynamically stable patients. 

Due to the lower complication rate, with identical diagnostic accuracy, preference should be 

given to the open technique over the closed technique for carrying out DPL [12]. 

Hoffmann [13] sees the indication for DPL only in exceptional cases where patients cannot be 

examined with ultrasound (e.g., extreme obesity or abdominal wall emphysema) as DPL permits 

no conclusion on retroperitoneal injuries compared to ultrasound and to CT. Waydas cites prior 

laparotomies in the lower abdomen in particular as a contraindication of DPL. However, in a 

prospective study of 106 multiply injured patients, the authors found a marked lower sensitivity 

for ultrasonography (88%) compared to DPL (95%). Despite the lower sensitivity, they 

recommended ultrasound as the initial screening method because it is non-invasive, never 

contraindicated, and as a diagnostic tool is also able to detect specific organ lesions. In the case 

of hemodynamic instability with unclear or negative ultrasound finding, this method can be 

supplemented by DPL to increase sensitivity [47]. 

Indications for primary use of DPL theoretically exist for hemodynamically unstable patients and 

if other diagnostic tools (ultrasonography) have failed. 



Computed tomography 


Multi-slice helical CT (MSCT) has a high sensitivity and the highest specificity 

for identifying intraabdominal injuries and must therefore be carried out 

after abdominal trauma. 

Explanation: 

GoR A 

In the prospective study by Liu et al. [17], the authors compared among 55 hemodynamically 

stable patients the diagnostic evidential value of ultrasound (with screening for free fluid and 

organ lesion), computed tomography, and DPL each on the same patients. They found a 

sensitivity of 97.2% with a specificity of 94.7% for CT. Correspondingly good results are also 

separately described in more recent studies [15, 30] for the detection of a hollow organ injury by 

computed tomography (after administration of an oral, intravenous contrast agent) but in other 

studies this was identified as a diagnostic weak point of CT [41]. In addition, Liu et al. describe 

the advantages of computed tomography of the abdomen compared to ultrasonography and DPL 

because of the option of reliably imaging the retroperitoneum as well. CT can differentiate well 

between hemoperitoneum and fluid retention and can localize fresh bleeding by means of 

contrast agent. In addition, computed tomography of the abdomen (through the bone window) 

could simultaneously provide a diagnostic study of the spine and the pelvis (or a full-body 

helical scan depending on the injury pattern) [28]. Due to the results likewise already reported, 

Miller et al. and other authors recommend computed tomography of the abdomen in patients 

with stable circulation irrespective of the ultrasound result from a FAST examination as CT 

appears, in comparison, to be more sensitive in diagnosing an intraabdominal lesion [24]. 

With regard to the technicalities of the examination, Linsenmaier recommends a multi-slice 

helical CT (MSCT) with regular venous administration of contrast agent for abdominal trauma. 

At a pitch of 1.5, the layer thickness should be a minimum of 5-8 mm in the craniocaudal 

scanning direction. If there is a suspected injury to the genitourinary system, a delayed scan (3-5 

minutes after bolus dose) should be carried out [16]. If it is feasible, an oral contrast agent can 

also be administered in principle to improve the diagnosis of intestinal injuries [16, 28]. 

Novelline describes the administration of Gastrografin via nasogastric tube first in the 

emergency room directly after insertion, then shortly before transfer, and lastly in the gantry. 

Normally, the stomach, duodenum, and jejunum could be visualized in this way. It is also 

possible to contrast the rectum/sigmoid via administration of a contrast agent through a rectal 

drain [28]. 

In a retrospective case-control study of 96 patients (54 consecutively included with 

intestinal/mesenteric injury and 42 matched pairs without injury) with laparotomy after 

abdominal trauma and with pre-operative CT (standardized with administration of an oral 

contrast agent via the nasogastric tube while still in the emergency room), Atri et al. [1] showed 

that the multi-slice CT reliably detects relevant injuries in the intestine/mesentery and has a high 

negative predictive value. Three radiologists at different stages of training evaluated the CTs 



without knowing the outcome. Thirty-eight (40%) of those examined had surgically relevant 

injuries, 58 (60%) had either no or negligible injuries in the intestine or mesentery. Sensitivity 

was between 87-95% for the 3 examiners. Only 10 CTs were carried out without oral contrast 

agent as the patients were transferred immediately to CT. 

In contrast, Stuhlfaut et al. came to the conclusion in a retrospective study of 1,082 patients 

(2001-2003) who underwent a multi-slice CT of the abdomen and pelvis without oral contrast 

agent that this procedure is sufficient to detect intestinal and mesenteric injuries that require 

surgical treatment. Fourteen patients had a suspected intestinal or mesenteric injury after the CT. 

Four CTs of these patients showed a pneumoperitoneum, 2 a mesenteric hematoma and intestinal 

wall changes, and 4 each showed only a mesenteric hematoma or intestinal wall thickening. In 

11 of these patients, an intestinal/mesenteric injury was surgically confirmed. There were 1,066 

true-negative, 9 true-positive, 2 false-negative, and 5 false-positive results. Sensitivity was 82% 

and specificity 99%. The negative predictive value of the multi-slice helical CT (MSCT) 

examination without contrast agent was 99% [46]. 

In cases of unclarity (only unspecific radiologic findings), Brofman et al. [3] recommend a 

clinical re-evaluation and a repeat examination for the possible presence of intestinal/mesenteric 

injuries. 

The introduction of multi-slice helical CTs is evaluated unanimously by expert opinion as 

progress in helical CT technology because, in addition to better resolution, the scanning period 

can be considerably shortened and motion artifacts have less effect [16, 28, 33, 35]. The same 

authors point out the importance of using pre-programmed protocols for CT diagnosis of recently 

injured persons (positioning, layer thickness, table advance, time and type of administration of 

contrast agent, bone/soft tissue window, reconstructions) as the examination can thereby be 

considerably shortened. In considering the concomitant injuries, some authors recommend the 

use of a full-body MSCT after stabilization, if necessary (during which ultrasonography of the 

abdomen must be carried out to detect free fluid). Besides the examination of the abdomen, the 

full-body MSCT also allows the diagnostic study of head, thorax, skeletal trunk, and the 

extremities in one examination round [35]. 

Computed tomography is the only diagnostic method for which injury scores [25] exist, on the 

basis of which treatment decisions can be derived [38]. 

Carrying out an MSCT can be restricted by the hemodynamic status of the patient (see section 

“Influence of the hemodynamic status of the patient on diagnostic study”). 

Influence of the hemodynamic status of the patient on the diagnostic study 


An emergency laparotomy should be introduced without delay in patients who 

cannot be hemodynamically stabilized because of an intraabdominal lesion 

(free fluid). The possibility of shock of non-abdominal origin should be 

considered here. 

GoR B 



Explanation: 

The diagnostic algorithm of a patient with blunt abdominal trauma is fundamentally influenced 

by his vital parameters. 

The immediate evaluation and stabilization of the vital parameters thus have top priority in the 

early phase of treatment. In this section of the early hospital treatment phase, a systolic blood 

pressure of > 90 mmHg after infusion of 2,000 ml of crystalloid solution (or > 100 mmHg in 

elderly patients) is considered hemodynamically stable with regard to circulatory stability. If, 

despite immediate volume replacement and massive transfusion, adequate circulatory function 

cannot be restored, Nast-Kolb et al. call for an immediate emergency laparotomy to be 

performed in the event of a positive accident anamnesis and existing suspicion of an 

intraabdominal injury [27]. It is imperative that, even with unstable vital parameters, the 

indication for emergency laparotomy should be supported by ultrasonography of the abdomen in 

parallel with polytrauma management. This basic diagnostic work-up is possible without an 

additional delay in time [17, 33]. Nast-Kolb’s working group calls for early laparotomy when a 

state of shock exists and in multiply injured patients (ISS ≥ 29) even if the detection of fluid is 

only small. The authors justify this with the fact that a retrospective, non-therapeutic laparotomy, 

compared to the necessary secondary operation in the case of primary missed organ injury, 

represents considerably less traumatization and danger [27]. 

A CT examination of the abdomen should not be carried out until there is adequate circulatory 

stability [26, 27, 35, 36, 48] as therapeutic interventions which can sometimes be necessary for 

stabilizing the patient are only possible to a limited extent in the CT gantry [27, 35, 36, 48]. 

According to some authors, this recommendation maintains its validity despite the integration of 

the CT in the emergency room (in terms of a priority-oriented use of the emergency room CT 

after ABC with basic diagnostic work-up) [14, 49, 50], while Hilbert et al. [11] already discuss 

the primary use of CT even in unstable patients. 



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Acute management in the emergency room 

Once the clinical finding has been checked and the vital functions secured, an imaging diagnostic 

study that includes the brain is generally required for multiply injured patients with traumatic 

brain injury. As the immediate elimination of intracranial bleeding can be life-saving, there is no 

reason for delay if both respiratory and circulatory functions are stable. This requirement also 

applies to the responsive injured person at the accident scene who is sedated for intubation and 

transport because only a CT examination can differentiate between intracranial bleeding that is 

developing and a drug cause for unconsciousness. 

Monitoring the clinical finding 


State of consciousness with pupil function and Glasgow Coma Scale (bilateral 

motor function) must be recorded and documented at repeated intervals. 

Explanation: 

GoR A 

In the literature, the only clinical findings with a prognostic informative value are the presence of 

wide, fixed pupils [11, 23, 26] and a deterioration in the GCS score [11, 15, 23], both of which 

correlate with a poor outcome. There are no prospective randomized controlled trials on using 

the clinical findings to guide the treatment. As such studies are definitely not ethically justifiable, 

the importance of the clinical examination was upgraded to a Grade of Recommendation A 

during the development of the guideline on the assumption, which cannot be confirmed at 

present, that the outcome can be improved by the earliest possible detection of life-threatening 

conditions with corresponding therapeutic consequences (see the following recommendations). 

Despite various difficulties [3], the Glasgow coma scale (GCS) has established itself 

internationally as the assessment of the recorded severity at a given point in time of a brain 

function impairment. It enables the standardized assessment of the following aspects: eye 

opening, verbal response and motor response. The neurologic findings documented with time of 

day in the file are vital for the sequence of future treatment. Frequent checks of the neurologic 

finding must be carried out to detect any deterioration [11, 13]. 

However, the use of the GCS on its own carries the risk of a diagnostic gap, particularly if only 

cumulative values are considered. This applies to the initial onset of apallic syndrome, which can 

become noticeable through spontaneous decerebrate rigidity which is not recorded on the GCS, 

and to concomitant injuries to the spinal cord. Motor functions of the extremities must therefore 

be recorded with separate lateral differentiation in arm and leg as to whether there is incomplete, 

complete or no paralysis. Attention should be paid here to the presence of decorticate or 

decerebrate rigidity. Providing no voluntary movements are possible, reaction to painful stimulus 

must be recorded on all extremities. 

Emergency room – Traumatic brain injury 189


If the patient is not unconscious, then orientation, cranial nerve function, coordination, and 

speech function must also be recorded. 

2.7.3.2 Vital functions 


The goals are normoxia, normocapnia, and normotension. A fall in arterial 

oxygen saturation below 90% must be avoided. 

Intubation with adequate ventilation (with capnometry and blood gas 

analysis) must be carried out in unconscious patients (reference value GCS 

≤ 8). 

The goal in adults should be arterial normotension with a systolic blood 

pressure not below 90 mmHg. 

Explanation: 

GoR A 

GoR A 

GoR B 

Prospective randomized controlled trials which study the effect of hypotension and/or hypoxia 

on the outcome are certainly indefensible on ethical grounds. However, there are many 

retrospective studies [11, 25] which provide evidence of a markedly worse outcome if 

hypotension or hypoxia is present. The first priority is to avoid all conditions associated with a 

fall in blood pressure or reduction of oxygen saturation in the blood. Due to side effects, 

however, aggressive treatment to raise blood pressure and oxygen saturation has not always 

proved successful. The goals are normoxia, normocapnia, and normotension. 

Intubation is necessary in the case of inadequate spontaneous breathing but definitely also in the 

case of unconscious persons with adequate spontaneous breathing. Unfortunately, the literature 

does not contain any high quality evidence on this to prove a clear benefit for the intervention. 

The main argument in favor of intubation is the efficient prevention of hypoxia. This is a threat 

in unconscious persons even with adequate spontaneous breathing as the impaired protective 

reflexes can cause aspiration. The main argument against intubation is the hypoxic damage that 

can occur through misplaced intubation. In the conditions of the emergency room, however, it 

can be assumed that misplaced intubation can be recognized and corrected immediately. After 

intubating, it is frequently necessary to ventilate, the effectiveness of which must be monitored 

by capnometry and blood gas analyses. 

Procedures to secure cardiac circulatory functions are arresting obvious bleeding (provided this 

has not already been done), monitoring blood pressure and pulse, and replacing fluid losses, as 

described in this guideline. Specific recommendations cannot be made for the infusion solution 

to be used in the case of concomitant traumatic brain injury [11]. 



Imaging diagnostic tests 


A CCT scan must be performed in the case of polytrauma with suspected 

traumatic brain injury. 

A (monitoring) CT scan must be performed in the case of neurologic 

deterioration. 

A monitoring CCT should be performed within 8 hours on unconscious 

patients and/or if there are signs of injury in the initial CCT. 

Explanation: 

GoR A 

GoR A 

GoR B 

The literature does not disclose any high quality evidence on which situations require cranial 

imaging when there is suspected traumatic brain injury. In TBI on its own, the following findings 

are associated with an increased risk of intracranial bleeding (absolute indication [16]). 

� coma 

� clouded consciousness 

� amnesia 

� other neurologic disorders 

� vomiting if there is a close time relationship to the impact of force 

� cramp seizure 

� clinical signs or roentgenologic evidence of a brain fracture 

� suspected impression fracture and/or penetrating injuries 

� suspected cerebrospinal fluid fistula 

� evidence of a coagulation disorder (third party medical history, “marcumar pass”, nonarresting 

bleeding from superficial injuries, etc.) 



Optional indications that require close monitoring as an alternative to imaging comprise: 

� unclear information about the accident history 

� severe headache 

� intoxication through alcohol or drugs 

� evidence of high-energy trauma. These are [1] a vehicle speed > 60 km/h, a large 

deformation of the vehicle, penetration of > 30 cm into the passenger cabin, time required to 

rescue from vehicle > 20 min, a fall > 6 m, a rollover trauma, a pedestrian or motorbike 

collision at > 30 km/h or the rider being thrown from his motorbike. 

As a bigger impact force can always be assumed in a multiply injured patient, there was 

consensus in the development of the guideline that cranial imaging must be performed in the 

event of symptoms of brain damage. If symptoms first occur during the course of treatment or 

increase in severity during the course, the imaging must be monitored as intracranial bleeding 

can have a delayed onset or can increase in size. The finding of compressive intracranial 

bleeding (see Chapter 3.5) requires surgical intervention without delay. 

This recommendation is based on the clinical observation that in patients with initially 

apparently normal cranial computed tomogram (CCT), intracranial bleeding causing 

compression can develop or smaller findings not requiring surgery increase markedly in size and 

thus represent a surgery indication. The occurrence of neurologic symptoms can take several 

hours and is concealed by the intensive care treatment of unconscious patients. For this reason, 

there was agreement that monitoring of CCT should be carried out regularly in these cases. 

Computed tomography is the gold standard of cranial imaging because of its generally rapid 

availability and easier examination procedure compared to magnetic resonance imaging [28]. 

Magnetic resonance imaging has a higher sensitivity for localized tissue injuries [10]. For this 

reason, it is recommended particularly in patients with neurologic disorders without pathologic 

CT finding. 



Cerebral protection treatment 


Glucocorticoids must not be administered in the treatment of TBI. GoR A 

Explanation: 

Replacement of failed functions (respiration, nutrient intake [17, 25] etc.) is necessary in braininjured 

patients. In the current state of scientific knowledge, the most important goal is to 

achieve homeostasis (normoxia, normotension, prevention of hyperthermia) and avert 

threatening (e.g., infectious) complications. Sepsis, pneumonia, and blood coagulation disorders 

are independent predictors of a poor clinical outcome [18]. The goal of these measures is to limit 

the extent of secondary brain damage and to provide those brain cells which have functional 

impairment but which have not been destroyed with the best conditions for functional 

regeneration. This applies equally if a traumatic brain injury is present in multiple injuries. 

Controversy has surrounded the necessity of antibiotic prophylaxis in frontobasal fractures with 

liquorrhea. However, there is no evidence for administering antibiotics [5, 27]. 

Thrombosis prophylaxis by means of physical measures (e.g., compression stockings) is an 

undisputed measure for preventing secondary complications. When administering heparin or 

heparin derivatives, the benefit must be weighed up against the risk of an increase in the scale of 

intracranial bleeding as these drugs are not approved for brain injuries and thus their off-label 

use must be approved by the patient or his legal representative. 

Antiepileptic treatment prevents the incidence of epileptic seizures in the first week after trauma. 

However, the incidence of a seizure in the early phase does not lead to a worse clinical outcome 

[22, 25]. Administration of antiepileptics extending over 1-2 weeks is not associated with a 

reduction in late traumatic seizures [6, 22, 25]. 

Up till now, the available data in the scientific literature has been unable to prove the benefit of 

other treatment regimens regarded as specifically cerebral-protective. At present, no 

recommendation can be given on hyperbaric oxygen treatment [4], therapeutic hypothermia [12, 

21], administration of 21-aminosteroids, calcium antagonists, glutamate receptor antagonists or 

TRIS buffer [11, 14, 20, 30]. 

Administering glucocorticoids is no longer indicated due to a significantly increased 14-day case 

fatality rate [2, 7] with no improvement in clinical outcome [8]. 



Treatment of increased intracranial pressure 


If severely elevated intracranial pressure is suspected, particularly with signs 

of transtentorial herniation (pupil widening, decerebrate rigidity, extensor 

reaction to painful stimulus, progressive clouded consciousness), the following 

treatments can be given: 

� Hyperventilation 

� Mannitol 

� Hypertonic saline solution 

Explanation: 

GoR 0 

In cases of suspected transtentorial herniation and signs of apallic syndrome (pupil widening, 

decerebrate rigidity, extensor reaction to painful stimulus, progressive clouded consciousness), 

hyperventilation can be introduced as a treatment option in the early phase after trauma [11, 25]. 

The guide values are 20 breaths/min in adults. However, hyperventilation, which used to be used 

because of its often impressive effect in reducing intracranial pressure, also causes reduced 

cerebral perfusion because of the induced vasoconstriction. With aggressive hyperventilation, 

this involves the risk of cerebral ischemia and thus deterioration in clinical outcome [25]. 

The administration of mannitol can lower intracranial pressure [ICP] for a short time (up to 1 

hour) [25]. Preference should be given to managing treatment through ICP measurement [29]. 

Mannitol can also be given without measuring ICP if transtentorial herniation is suspected. 

Attention must be paid to serum osmolarity and renal function. 

Up till now, there has been a paucity of evidence on the cerebral-protective effect of hypertonic 

saline solutions. Mortality appears to be somewhat less compared to mannitol. However, this 

conclusion is based on a small number of cases and is statistically not significant [29]. 

The raised position of the upper body to 30 ° is often recommended although CPP is not affected 

by this. However, extremely high ICP values are reduced. 

(Analgesic) sedation per se has no ICP reducing effect. However, restless states with abnormal 

independent breathing can lead to an increase in ICP but can be favorably influenced. In 

addition, improved oxygenation can be achieved through improved breathing. There is 

insufficient evidence [19] for the administration of barbiturates, which was recommended in 

previous guidelines for intracranial pressure crises not controllable by other means [23]. When 

administering barbiturates, attention must be paid to the negative inotropic effect, possible fall in 

blood pressure, and impaired neurologic assessment. 



References 

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American College of Surgeons Committee on 

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2.7 Pelvis 

What importance does the initial clinical evaluation of the pelvis have? 


An acute life-threatening pelvic injury must be excluded when the patient is 

admitted to the hospital. 

GoR A 

The stability of the patient’s pelvis must be clinically examined. GoR A 

Explanation: 

Circulatory unstable polytrauma with external pelvic massive bleeding represents an acute lifethreatening 

situation. There is no alternative to immediate surgery to arrest bleeding and to 

accelerated blood replacement (expert opinion with strong evidence from medical experience in 

general). A life-threatening pelvic injury must therefore be excluded at the earliest opportunity 

within the first minutes after arrival in the emergency room [1]. 

Prerequisites for making the diagnosis are the pelvic examination for stability and external injury 

signs and inspection of the abdomen by ultrasonography. 

As a rollover trauma is associated with a pelvic fracture in approximately 80% of cases, the 

detailed circumstances of the accident event should be ascertained. 

The following definitions are commonly used for the most serious type of pelvic fracture with 

threatened vitals: 

“in extremis” pelvic injury: external pelvic massive bleeding such as, for example, in traumatic 

hemipelvectomy or crush injuries after a severe rollover trauma 

complex trauma of the pelvis and acetabulum: pelvic and acetabular fractures/ 

dislocations with additional peripelvic injuries to the cutaneous muscle sheath, the genitourinary 

system, the intestine, the great vessels and/or the major neural pathways 

complex pelvic trauma, modified according to Pohlemann [43, 45]: similar see above including 

pelvic bleeding from torn pelvic veins and venous plexus 

traumatic hemipelvectomy: unilateral or bilateral tearing of the bony hemipelvis combined with 

the tearing of the major intrapelvic neural and vessel pathways 

pelvic-induced circulatory instability (importance of initial blood loss, e.g., > 2,000 ml according 

to Bone [6] and > 150 ml/min according to Trunkey [62]) 

If, based on the clinical assessment, a complex pelvic trauma in terms of an “in extremis” 

situation is probable (complex trauma with circulatory instability), the pelvic ring must be closed 

immediately, if possible while the patient is still in the emergency room. 

Emergency room – Pelvis 197


The priorities of individual injuries should be weighed up against each other if several injuries 

are present. If one or several injuries per se are also life-threatening, only emergency pelvic 

stabilization is initially undertaken. 

What procedures should be performed during the primary diagnostic study if pelvic 

injuries are suspected? 


During the diagnostic study a pelvic survey radiograph should be taken 

and/or computed tomography (CT) be performed. 

Explanation: 

Clinical examination 

GoR A 

If the patient does not have acute life-threatening injuries, the physical examination can be 

carried out in more detail. It consists of an external inspection and palpation of the pelvic region 

ventrally and dorsally. The examination comprises the external search for bruising or 

hematomas, checking pelvic stability, and inspection of body orifices with vaginal and rectal 

examination. Shlamovitz et al. attest only a low sensitivity of the clinical examination of the 

pelvis for detecting a, by definition, mechanically unstable pelvic ring fracture [52]. In a study 

from Essen, the sensitivity and specificity of the clinical examination of the pelvis for instability 

was 44% and 99%, respectively. However, approximately 1/5 of the unstable pelvic injuries 

were first diagnosed using the survey radiograph of the pelvis [38]. In contrast to Kessel et al. 

[33] and Their et al. [57], who questioned the necessity of an emergency pelvic survey 

radiograph if there is provision for an emergency CT, the pelvic survey should continue to 

remain part of the emergency room diagnostic study of polytrauma, according to Pehle [38]. This 

also corresponds to the current recommendation of the ATLS ® algorithm. The circulatory 

situation must be given priority in decision-making: according to the data from Miller et al. [35], 

if blood pressure does not respond to volume replacement, a 30% specificity can be concluded 

for relevant intrapelvic bleeding. Conversely, relevant bleeding can be excluded with a high 

degree of certainty if blood pressure exceeds 90 mmHg (negative predictive value 100%). 

Imaging diagnostic tests: 

The radiograph diagnosis should consist of a minimum of an a.p. (anteroposterior) view, which 

is then supplemented if necessary by inlet/outlet or oblique views according to Judet. Young et 

al. [66] describe that 94% of all pelvic fractures are correctly classified with only an a.p. view of 

the pelvis. Edeiken-Monroe [19] found a success rate of 88% for the a.p. view of the pelvis. 

Petrisor [41] found that the Judet views usually provide no relevant information. 

There are several studies available on the comparison of CT and radiography diagnostic tests 

with respect to pelvic fractures: In a retrospective study by Berg [4], 66% of all pelvic fractures 

were detected in the a.p. radiograph whereas this rate was 86% in the CT scan with 10-mm axial 

slices. The inlet/outlet views also only achieved a success rate of 56%. The study by Harley [30] 



also found a higher sensitivity in the CT scan especially for identifying fractures in the sacrum 

and acetabulum. Resnik [46] also described how the plain radiograph misses 9% of fractures but 

noted that these missed fractures were not clinically relevant. In contrast, Stewart [55] 

recommends that plain radiography should be omitted if computed tomography is already 

planned. Kessel et al. [33], Their et al. [57], and Duane et al [18] also question the necessity of 

an emergency pelvic survey radiograph if there is provision for an emergency CT. 

There is also a series of studies on the different modalities of CT diagnostic tests, which suggest 

the conclusion that a 3D reconstruction and particularly the multi-plane reconstruction provide 

clear information and simplify the presentation of the extent of the injury. 

Naturally, the plain radiograph is of little help in diagnosing bleeding from the pelvic vessels. 

Such bleeding can be excluded with high probability only in cases in which no fracture can be 

detected in the radiograph. Individual studies have examined to what extent a classification of 

fractures can be deduced using conventional diagnostic radiology of vessel lesions. Thus, Dalal 

et al [15] found a significantly higher volume requirement particularly in critical anteroposterior 

pelvic fractures but which can also be explained by the intraabdominal injuries. 

In addition, there are figures on the comparison of CT and angiography in the diagnostic study of 

relevant pelvic bleeding: In the study by Pereira [39], an accuracy exceeding 90% was 

demonstrated for the dynamic helical CT in identifying pelvic bleeding which required 

embolization. Similarly, Miller [35] also reports a sensitivity and specificity of 60% and 92%, 

respectively. For Kamaoui, the CT scan of the pelvis with or without contrast agent extravasation 

also assists in selecting patients who should undergo angiography [32]. 

In a study by Brown et al [9], 73% of patients with pelvic fracture and contrast blush in the CT 

showed relevant bleeding in the subsequent angiography. Conversely, a source of bleeding was 

found in the angiography in almost 70% of patients with a negative CT so that the relevance of 

the bleeding must be questioned here. Brasel et al. also describe contrast agent extravasation in 

the CT as a marker for the injury severity of pelvic injuries which, however, do not make 

angiography compulsory. Similarly to Brown, even though the CT was negative, they found 

bleeding in the pelvic region in 33% of cases, which benefit from angiography and embolization 

[8]. 

Blackmore [5] suggested inferring intrapelvic bleeding from contrast agent extravasation in the 

CT of 500 ml or more. The analysis of 759 patients produced a highly significant association for 

this correlation with a relative risk of 4.8 (95% CI, 3.0-7.8). With an extravasate exceeding 

500 ml, bleeding is thus present in almost half of cases. However, provided that less than 200 ml 

extravasate is visible, it can be assumed with 95% certainty that there is no bleeding. Sheridan 

[51] reports that the bleeding can also be estimated in the plain CT as a correlation exists in the 

CT between hematoma formation and bleeding area exceeding 10 cm 3 . 

A current study from 2007 [24] studied as an alternative to CT the sensitivity and specificity of 

FAST in patients with pelvic fracture as a decision aid between emergency laparotomy and 

emergency angiography. The sensitivity and specificity for FAST yielded 26% and 96% but the 

emergency ultrasonography with negative result did not assist in deciding between the need for a 

laparotomy and angiography in patients with pelvic fracture [24]. A CT scan of the abdomen is 



stipulated for this decision and an ultrasound examination in terms of FAST is not classified as 

adequate [8]. 

Classification of injuries 

The injuries of the bony pelvis should be classified using imaging diagnostic tests. A precise 

classification of the pelvic fracture forms the basis of prioritized treatment [19]. This 

classification should also be undertaken as soon as possible in patients with life-threatening 

vitals. 

Generally, the classification of the Working Group on Osteosynthesis is used here, which 

distinguishes according to Tile between 3 groups: 

� stable A injuries with osteoligamentous integrity in the posterior pelvis ring, intact pelvic 

floor; the pelvis can resist physiologic forces without dislocation 

� rotationally unstable B injuries with partially retained stability in the posterior pelvic ring 

� translationally unstable C injuries with disruption in all posterior osteoligamentous 

structures and also in the pelvic floor. The dislocation direction (vertical, posterior, 

distraction, excess rotation) plays a subordinate role. Thus, the pelvic ring is disrupted 

anterior and posterior and the pelvic halves are unstable. 

The concept of a complex pelvic fracture applies to all bony injuries of the pelvis with an injury 

to the hollow visceral pelvic organs being simultaneously present or injuries to nerves and 

vessels or to the efferent urinary tract. 

In addition, it is helpful to differentiate between open and closed pelvic injuries. A pelvic injury 

is described as open in the following situations: 

� primary open pelvic fractures: according to the definition, direct link between bone fracture 

and skin or membrane of vagina or of anorectum 

� closed pelvic fracture with enclosed tamponades for hemostasis 

� closed pelvic lesion with documented contamination of the retroperitoneum due to an 

intraabdominal injury [31] 

� In contrast, pelvic fractures only with an injury to the bladder or urethra should not be 

described as open but instead as complex. Due to the concomitant intraabdominal injuries 

with the risk of acute exsanguination and late onset sepsis, open pelvic injuries also have a 

high mortality rate of approximately 45% [17]. 

How is an unstable pelvic fracture detected? 

Instability, particularly in the posterior pelvic ring, is accompanied by a strong bleeding tendency 

from the presacral venous plexus. Detection of instability should lead to increased attention 

being paid to the circulatory situation. Instabilities are described, depending on the rotational 

ability of the iliac wing, inwards or outwards, as internal and external rotational instability. In the 



case of translatory instability, this can be present in the horizontal plane as craniocaudal 

instability or in the sagittal direction as anteroposterior instability. Besides increased risk of 

bleeding, the instability can lead to further complications such as thrombosis and secondary 

nerve, vessel and organ injuries. The last-cited injuries can also be primary and have to be 

excluded during the primary diagnostic study of unstable pelvic injuries. The pelvic instability 

should be managed by early surgery which, depending on the condition of the patient, can only 

be done as an emergency procedure initially or can be definitive straightaway, which often takes 

more time. 

Signs of pelvic instability can be identified in imaging diagnostic tests. These include, for 

example, a widening in the symphysis or in the SI joints. A displacement of the iliac wings in a 

horizontal or vertical direction should likewise be interpreted as instability. It must always be 

borne in mind that the dislocation at the time of the accident is often more drastic than at the time 

of the diagnostic study. Thus, the fracture in the transverse process of the 5th lumbar vertebra 

should also be classed as a sign of instability if there is simultaneously a pelvic injury but no 

displacement of the iliac wing can be detected in the imaging diagnostic study. 

The direction of the pelvic instability is important for classification. If there is only rotational 

instability of the pelvis around the vertical axis of the posterior pelvic ring, this is a group B 

injury. If there is translational instability in the vertical or horizontal direction, this is a group C 

injury. 



How is emergency stabilization of the pelvis carried out? 


Emergency mechanical stabilization should be carried out if the pelvic ring is 

unstable and there is hemodynamic instability. 

Explanation: 

GoR B 

Only simple and rapidly applicable procedures are suitable for emergency stabilization of the 

pelvis. With regard to the mechanical stability achieved, wrapping a sheet round the pelvis or 

using a pneumatic or other type of industrial pelvic girdle is clearly inferior to the ventral 

external fixator and the pelvic C-clamp. Nevertheless, both procedures represent an effective 

emergency procedure at least temporarily in the emergency situation [16]. On the other hand, the 

Ganz pelvic C-clamp or an external fixator differs in the achievable mechanical stability 

depending on the fracture type. 

Controversy remains around the question of whether to use the ventral external fixator 

(supraacetabular) or the pelvic C-clamp. In unstable pelvic injuries of type C according to Tile et 

al., preference should be given to the pelvic C-clamp over the external fixator as evidenced by 

biomechanical studies [44]. In unstable pelvic injuries of type B, no notable differences could be 

found between the external fixator and pelvic C-clamp. There have also been no studies to date 

on the question of which method of emergency stabilization has the best effect on arresting 

bleeding [10, 14]. 

Overall, the pelvic C-clamp is used less often than the fixator as it is of a preliminary nature with 

regard to pelvic stabilization and is not without risk in its use compared to the external fixator. 

Trans-iliac pelvic fractures represent a contraindication because, in the event of dislocation, the 

pins can lead to an organ injury in the lesser pelvis. On the other hand, reliable stabilization with 

an external fixator is not always possible in dorsal instabilities. Siegmeth et al. [53] hypothesize 

that an external fixator is sufficient for instabilities in the anterior pelvic ring but that an injury to 

the posterior pelvic ring also requires additional compression in an emergency. As early as the 

1980s, Trafton et al. [61] also stipulated the same. The most recent studies on a commercial 

emergency pelvic girdle produce contradictory results regarding the reduction in mortality and 

the reduction in transfusion of packed red blood cells and the length of hospital stay due to the 

accident. While Croce [13] found advantages in applying the pelvic girdle studied by him, this 

assumption was not confirmed in the results by Ghaemmaghami et al. [25]. 



What procedures should be applied in pelvic fractures with regard to concomitant 

hemodynamic instability? 


In the case of persistent bleeding, surgical hemostasis or selective angiography 

with subsequent angioembolization should be performed. 

Explanation: 

GoR B 

Depending on the degree of dislocation of the posterior pelvic ring, an unstable pelvis fracture 

often leads to a strong bleeding tendency. If an unstable pelvic fracture is diagnosed in 

combination with circulatory instability, the pelvic fracture should be considered as the possible 

cause of the circulatory instability. Except in the case of severe pelvic rollover trauma, 

emergency stabilization of the pelvis can effectuate sustained circulatory stabilization with the 

methods already illustrated in combination with the infusion treatment so that the indication for 

surgical hemostasis should be re-considered. 

If circulatory instability continues despite the previous procedures, further measures should be 

taken. There are principally 2 options available: surgical packing and embolization. In selecting 

the procedure, it should be considered that only arterial bleeding can be embolized and that it is 

estimated that it is the cause of bleeding in severe pelvic injuries in only 10-20% of cases. The 

remaining 80% of bleeding is of venous origin [36]. 

In view of these circumstances, arrest of bleeding through surgically undertaken packing of the 

lesser pelvis appears expedient and, at least in the German-speaking world, is considered to be 

the first line choice in such a case ([20], prospective study with 20 patients). Likewise in a 

prospective study with 150 patients, Cook [11] showed the advantage of rapid mechanical 

stabilization and subsequent surgical arrest of bleeding or packing. Pohlemann [43] also came to 

similar recommendations based on a prospective study with 19 patients, as did Bosch [7] after a 

retrospective analysis of 132 patients. 

But embolization can also be considered. Miller [35] values angiography and embolization over 

mechanical stabilization. He considers surgical stabilization as simply constituting a delay in 

effective hemostasis and moreover as an avoidable surgical trauma for the patient. According to 

Hagiwara as well, patients with hypotension and partial responders after 2 l fluid with blunt 

abdominal trauma and injuries to the pelvis and/or liver and/or spleen, etc. benefit from 

angiography and subsequent embolization. Volume requirement fell significantly after 

embolization and the shock index normalized [28, 29]. 

Agolini [2]states that only a small percentage of patients with pelvic fractures require 

embolization. However, if applied, it can then be almost 100% effective. The age of the patient, 

the time of embolization, and the extent of the initial circulatory instability influence the survival 

rate; e.g., angiography performed 3 hours after the accident showed a mortality of 75% 

compared to 14% at less than 3 hours after the accident. In their article from 2004, Pieri et al. 

also report 100% effectiveness in emergency angiography with embolization in pelvic-induced 



circulatory instability and bleeding from the obturator artery and the gluteal arteries [42]. In a 

more recent study by Tottermann, 2.5% of patients with pelvic injury showed significant arterial 

bleeding from the internal iliac artery. With an all-cause mortality of 16% in the patient 

population, he found an inverse proportionality between age and survival probability [59]. 

Panetta [37] postulated early embolization with his own time of 1-5.5 hours (mean: 2.5 hours) 

but sees no correlation between the time of the procedure and mortality. No advantages from 

embolization were found in outcome reports with a success rate of approximately 50% with a 

time of procedure of less than 6 hours after the accident [39]. The group from Kimbrell [34] und 

Velmahos [63] confirms the liberal use of embolization in abdominal and pelvic injuries with 

detected arterial bleeding even in patients without initial signs of hemodynamic instability. 

Gourlay et al. [26] describe angiography as the gold standard in arterial bleeding with pelvic 

fractures. A special subpopulation of approximately 7-8% even needed follow-up angiography 

due to persistent circulatory instability. In a study by Shapiro [50], indicators for re-angiography 

were persistent shock symptoms (BP < 90 mmHg), absence of any other intraabdominal injury, 

and persistent base excess of < -10 for more than 6 hours after admission. In the subsequent reangiography, 

there was pelvic-induced bleeding in 97% of cases. 

In a study by Fangio, approximately 10% of patients with pelvic injury were circulatory 

unstable. Subsequent angiography was successful in 96% of cases. Angiography enabled pelvicindependent 

bleeding to be diagnosed and treated in 15% of cases. This led to the rate of falsepositive 

emergency laparotomies falling in the stated patient population [23]. Sadri et al [47] also 

discovered that a specific subgroup of pelvic injuries (approximately 9%) with persistent volume 

requirement benefited from emergency mechanical stabilization of the pelvic ring with the pelvic 

C-clamp and subsequent angiography/embolization. 

On the other hand, Perez [40] basically considers embolization a reliable procedure as well but 

sees a need for clarification of the parameters that define the indication and the effectiveness. In 

a study by Salim et al., the following parameters were found to have significant predictive values 

in identifying the patient population which benefits from angioembolization: SI joint disruption, 

female gender, and persistent hypotension [48]. 

According to Euler [21], interventional-radiologic procedures such as embolization or balloon 

catheter occlusion only have importance in the later, post-primary treatment phase and not 

during the management of polytrauma. Only 3-5% of patients with unstable circulation with 

pelvic injury require or benefit from embolization [3, 22, 36]. 

As illustrated, there are differing opinions in the literature. To some extent, these differences can 

be explained through considerable differences in the patient collectives and their injury severity. 

Ultimately, no exclusive recommendation can be given due to the lack of high quality evidence 

both for packing and for embolization. Which procedure is given preference in each case 

certainly also depends on the local conditions. Besides the availability of embolization, it should 

be particularly taken into account that no other procedures can be carried out in parallel on the 

patient during this procedure. Finally, reference is made to strict time management, which should 

be adhered to in each case. 



It is an interesting fact that 2 studies with favored pelvic packing turn up for the first time in the 

North American studies of 2007 which originally emphasized angiography: this corresponds to a 

paradigm shift. In his study, Tottermann found a significant BP increase after surgical packing 

was carried out. In the subsequent angiography, evidence of arterial bleeding was still 

demonstrated in 80% of cases in the patient population studied so that a graduated scheme with 

surgical packing and subsequent embolization has been proposed by him [60]. In the study by 

Cothren, a significant reduction in packed red blood cells requirement within 24 hours after 

hospital admission (approximately 6 versus 12 packed red blood cells (ECs);[12]) was 

demonstrated in the pelvic packing-only group compared to the angiography group. 

In contrast to this, the latest but not yet published data of the Working Group Pelvis III of the 

DGU indicate an increase in emergency angiographies carried out in Germany from 

approximately 2% to 4%. In 2008, Westhoff recommended the early clinical integration of 

interventional emergency embolization for pelvic fractures if the appropriate infrastructure was 

available [65]. 

Verbeek also discussed the necessity of adapting current treatment protocols in the management 

of seriously injured patients with pelvic fractures. The goal is to arrest the pelvic-induced 

bleeding, and non-therapeutic and false-positive laparotomies in particular must be avoided in 

the future [64]. 

Are there abnormalities present in children and elderly persons with pelvic fractures which 

must be noted? 

A severe pelvic injury is much more life-threatening to a child and also to the elderly than to a 

middle-aged adult, thus requiring even more rapid action. The physiologic compensation options 

for circulatory regulation and homeostasis are markedly fewer. The time pressure for decisionmaking 

is increased. The challenge with regard to the child is firstly to identify the threat to vital 

function. Circulatory decompensation does not emerge but appears suddenly as the physiology of 

the child scarcely offers compensation options. Emergency stabilization of the pelvis can be 

carried out through simple, lateral compression on both sides, if necessary using the hands. There 

are no large series of pediatric pelvic fractures in the literature. The papers of Torode [58], Silber 

[54], and Tarman [56] can be cited, which all report that the treatment guidelines essentially do 

not differ from those for adults. There are no reports of the use of a pelvic C-clamp in a child. 

The requirements of infusion treatment and surgical arrest of bleeding apply as for adults. 

Regarding the imaging diagnostic tests, magnetic resonance imaging has the advantage over 

computed tomography in the young growing skeleton in representing structures that are not yet 

ossified, thus enabling a multi-planar presentation of a pelvic injury as well. Compared to 

computed tomography, plain radiographs have a markedly weaker informative value in 

diagnosing bony pelvic structures and, according to Guillamondegui et al. [27], can be 

subordinate to CT or completely omitted. As part of screening for injury, the conventional pelvic 

survey radiograph is only definitely indicated in patients with unstable circulation, according to 

the authors. The elasticity of the pediatric pelvis should be particularly taken into account; it can 

lead to a complete restoration of the pelvic skeleton despite severe rollover trauma. In 20% of 

pediatric complex pelvic injuries, a normal pelvic skeleton is visualized in the plain radiograph 

and in the computed tomography. 



Figure 3: Treatment algorithm for complex pelvic trauma [49] 

1st decision (3-5 min) 

2nd decision (10-15 min) 

3rd decision (15-30 min) 

Treatment algorithm for complex pelvic trauma: 

Initial assessment, 

accident history 

2 

Complex trauma with 

unstable circulation? yes 

Emergency room – Pelvis 206 

no 

X-ray or CT of pelvis, 

general treatment, if 

necessary primary 

diagnostic study of other 

regions 

yes 

Evidence of unstable 

pelvic fracture? 

yes 

Unstable circulation? 

yes 

Massive transfusion, 

pelvic C-clamp 


yes 

Surgery: open reduction, 

packing, 

pelvic stabilization 

Angiography and 

embolization 

1 

4 

5 

7 

10 

6 

8 

12 

no 

no 

no 

Surgery: 

surgical hemostasis, 

packing, pelvic stabilization 

Primary diagnostic 

study/treatment of other 

regions acc. to 

polytrauma protocol 

no 


yes 

3 

9 

11


Despite the varying and in part quite weak level of evidence, a treatment algorithm can be 

derived from the current state of knowledge which can, however, be modified depending on 

local logistic conditions. 



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Pelvic trauma in rapidly fatal motor vehicle accidents. 

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controlling pelvic fracture hemorrhage. J Trauma 

43:395-399 [LoE 4] 

3. Ben-Menachem Y, Coldwell Dm, Young Jw et al. 

(1991) Hemorrhage associated with pelvic fractures: 

causes, diagnosis, and emergent management. AJR 

Am J Roentgenol 157:1005-1014 [LoE 5] 

4. Berg Ee, Chebuhar C, Bell Rm (1996) Pelvic trauma 

imaging: a blinded comparison of computed 

tomography and roentgenograms. J Trauma 41:994- 

998 [LoE 2] 

5. Blackmore Cc, Jurkovich Gj, Linnau Kf et al. (2003) 

Assessment of volume of hemorrhage and outcome 

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6. Bone L (1992) Emergency treatment of the injured 

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Primary clinical diagnostic study 


During the initial exploratory survey, the external urethral meatus and the 

transurethral bladder catheter (if the latter is already inserted) should be 

examined for blood. 

Explanation: 

GoR B 

Gross hematuria is the cardinal symptom for injuries to the kidney, bladder and/or urethra 

whereas in this primary survey ureter injuries are clinically normal in about half of cases [15]. 

For this reason, the urinary catheter or the meatus should be inspected for blood during the 

primary survey of the undressed patient. Blood at the urethral meatus and hematuria must be 

differentiated in the clinical examination because they have different diagnostic meanings. 


The region of flank, abdomen, perineum, and external genitals should be 

inspected for hematomas, ecchymoses, and external injuries. 

Explanation: 

GoR B 

As the external physical examination can be carried out rapidly and easily, it should be carried 

out in full on all multiply injured patients even if it has only low diagnostic informative value 

[16]. The examination includes the search for external injury signs (hematomas, abrasions, 

swellings, etc.) in the region of the flanks, perineum, groins, and external genitals. Cotton et al. 

and Allen et al. showed that ecchymoses and abrasions in the abdominal region have a close 

correlation with the risk of an intraabdominal injury [17, 18]. However, a hematoma on the 

penile shaft or a perineal butterfly hematoma indicates an anterior urethral injury. 

The value of the digital rectal examination is very critically evaluated in the current literature 

[19, 20] as abnormalities are generally found only rarely. In addition to assessing sphincter tone 

in the patient with spinal cord injury, the rectal examination should also be carried out if blood 

on the meatus or the presence of a relatively severe pelvic fracture indicates a urethral injury. 

The finding of a non-palpable, dislocated or hematoma-surrounded prostate represents additional 

clinically valuable information which in turn indicates a prostato-membranous tear. 

The responsive patient can be questioned about possible details of the accident and pain from an 

injury to the genitourinary organs. Abdominal pain can give nonspecific clues to the presence of 

intraabdominal lesions [17, 21, 22]. In addition, a bladder rupture is specifically indicated if a 

patient experiences the urge to urinate before the trauma but no longer experiences this urge after 

Emergency room – Genitourinary tract 211


the trauma (without evidence of neurologic lesions) [23] or if the patient tries to urinate without 

success [24]. 

Further information is provided by the circumstances of the accident, the mechanism of injury 

[25, 26], and the general condition of the patient [27]. In the injury pattern, particular attention 

should be paid to the close relationship between a pelvic fracture and efferent urinary tract 

lesions; this will be differentiated below according to organ. From a general view, injuries to the 

bladder and/or urethra are present in 6% of all pelvic fractures but on an Abbreviated Injury 

Scale (AIS) ≥ 4 injuries are markedly more frequent at 15% than on an AIS ≤ 3 injuries at 5% 

[25]. With the same severity of pelvic injury, men have almost double the risk for urologic 

injuries due to their anatomy, in particular the urethra [25, 28]. Rib fractures and injuries to 

intraabdominal organs increase the probability of injuries being present in the kidneys, ureters, 

and bladder [29]. If hypotension cannot be explained by blood losses of other origin, this can 

indicate a relatively severe injury to the kidney. 

If there is complete urethral rupture, this can cause the transurethral catheter to go off-course [13, 

14]. Likewise, an already existing urinary tract injury can be aggravated by the insertion of a 

transurethral catheter [30]. Based on these considerations, the patient with clinical signs of a 

urethral injury can have a transurethral catheter inserted during the diagnostic examination in the 

emergency room in order to better monitor the patient’s urination. Contraindications for 

catheterization only exist in very unstable patients for whom catheter insertion would represent 

an unnecessary time delay and in unclear conditions even during the diagnostic test (e.g., 

retrograde urethrogram). This also applies to the possibility that transurethral catheterization is 

impossible, e.g., due to a complete urethral tear. A more detailed diagnostic work-up follows 

below. 




In the case of circulatory instability that does not permit initial continuing 

diagnostic tests and if it is impossible to insert a transurethral bladder 

catheter, a suprapubic urinary diversion should be performed percutaneously 

or by laparotomy (with simultaneous exploration). 

Explanation: 

GoR B 

If circulatory instability is present and if the patient cannot be diagnosed further due to the time 

delay and for these reasons a laparotomy should be performed, a suprapubic catheter should be 

inserted during this intervention [31] as this can then also be used subsequently for diagnostic 

purposes [30]. A rapid urine test and measurement of serum creatinine should be carried out for 

laboratory tests. 

A rapid urine test (e.g., strip test) of the urine should be carried out to detect hematuria. 

Compared to the microscopic examination, the rapid urine test (e.g., strip test) has over 95% 

sensitivity and specificity [32-36]. The advantage of the rapid test lies in the results being 

available in less than 10 minutes. It is also helpful for the further course of action to have 

verification of bacteriuria; this occurs more frequently in elderly patients and can then be 

particularly problematic when combined with a urinary tract injury. 

Measurement of serum creatinine can assist the ongoing course assessment and the detection of 

pre-existing kidney diseases. Hematologic parameters which permit the detection of bleeding, 

e.g., from the kidney, are also measured. 

Calling on a qualified urologist is considered advisable for all patients with evidence of 

genitourinary injuries [37-39], even if this naturally depends on the qualifications of the 

physicians involved and the physical and organizational conditions. 



The necessity of imaging diagnostic tests 


All patients with hematuria, blood discharge from the urethral meatus, 

dysuria, impossibility of catheterization or any other medical history 

information (local hematoma, concomitant injuries, mechanism of injury) 

have an increased risk of genitourinary injuries and should be given a focused 

diagnostic work-up of the kidney and/or the efferent urinary tract. 

Explanation: 

GoR B 

Even if lesions in the upper and lower urinary tract occur simultaneously in only approximately 

0.6% of patients with urologic injuries [40], a complete urological diagnostic study is still 

usually carried out in all patients with corresponding indications as this normally records the 

complete urinary system in the form of computed tomography with confirmed microscopic or 

gross hematuria [41, 42]. 

Whereas gross hematuria is pathognomonic for genitourinary injuries, microscopic hematuria 

represents a borderline situation. In general, however, it is accepted nowadays that microscopic 

hematuria should only entail further diagnostic study if other diagnostic injury evidence is 

simultaneously present [43-47]. 

In a large series of 1,588 patients with microscopic hematuria after sharp trauma, only 3 patients 

were found with relevant kidney injury [48]. In a similar study of 605 patients with blunt trauma, 

none of the patients with only microscopic hematuria had an injury requiring surgery [49]. This 

rate was 1 out of 77 in Fallon et al. [50]. Prospective series have confirmed these results [51]. In 

a pseudo-randomized study [52], in which the patients received different care depending on the 

admission team, Fuhrmann et al. compared 2 different indications for a cystogram: They were 

either examined for pelvic fracture, gross or microscopic hematuria (n = 134 patients) or the 

examination was limited to patients with gross hematuria only (> 200 erythrocytes per field of 

view). All urological injuries in the two groups were correctly identified. Thus, further acute 

diagnostic study of the kidneys can be dispensed with in patients who only have microscopic 

hematuria without additional injury signs. There are similar results for pediatric trauma and 

multiple injuries [53-56]. 

An important exception is the fact that vertical deceleration trauma in particular contains an 

increased risk for kidney injuries [57], which show up as normal in the primary clinical 

examination. Biomechanical studies support this argument so that further diagnostic study is 

recommended in strong deceleration trauma even without other criteria being present. 




Further imaging diagnostic tests should be carried out on the efferent urinary 

tract if one or more of the following criteria apply: hematuria, bleeding from 

the urethral meatus or vagina, dysuria, and local hematoma. 

Explanation: 

GoR B 

Numerous studies have shown that bladder ruptures are associated with a pelvic fracture in 80- 

90% of cases [24, 25, 58, 59]. This correlation varies slightly depending on what severity grade 

the injuries have [11]. Hochberg and Stone [60] found a direct correlation between the number of 

fractured pubic rami (1, 2 or 3, 4) and the frequency of bladder ruptures (4%, 12%, 40%). Aihara 

et al. [61] also found that the symphysis or the sacroiliac joint had separated in 75% of bladder 

ruptures after blunt trauma. Nevertheless, a bladder rupture cannot be deduced from the presence 

of a complex pelvic fracture because only 20% (positive predictive value) of patients with 

symphysis and sacroiliac joint separation had a bladder rupture. 

The close correlation between pelvic fracture and urethral injury is also well documented. 

However, the severity grade of injuries again plays a major role [25, 62, 63]. Koraitim et al, 

Morgan et al. and Aihara et al. showed consistently that fractures to the pubic rami increase the 

risk of a urethral injury, but that this risk rises hugely particularly in more complex pelvic 

fractures (type C) [61, 64, 65]. Aihara et al. emphasize that fractures of the lower pubic rami in 

particular indicate a urethral injury [61]. Palmer et al. noticed in a series of 200 patients with 

pelvic fracture that 26 out of the 27 patients with urologic lesions had a fracture in the anterior 

and posterior pelvic ring [66]. This association is less marked in women due to the shorter length 

and less connective tissue fusing in the female urethra [67]. Urethra injuries in women are 

usually accompanied by bleeding vaginal injuries [68-70]. 

The classic combination of pelvic fracture and gross hematuria allows the conclusion of a 

bladder and/or urethral injury to be made with great certainty [71]. Rehm et al. found that of 719 

patients with blunt pelvic/abdominal injury all 21 cases with bladder injury were indicated by the 

presence of hematuria, which showed up in 17 cases also as gross hematuria [72]. Morey et al. 

[71] also reported that all their 85 patients with pelvic fracture had gross hematuria with 

simultaneous bladder rupture. In Palmer et al. this rate was in 10 out of 11 patients [66], in Hsieh 

et al. in 48 out of 51 [73]. A gap in the symphysis and separation in the sacroiliac joint doubled 

the risk for a bladder injury in the study by Aihara et al [61]. But even without a pelvic fracture 

being detectable, patients with gross hematuria or blood discharge from the urethral meatus must 

be assumed to have an injury to the efferent urinary tract [74]. 

The difference between hematuria and blood at the urethral meatus can be helpful in 

differentiating between bladder and urethral injuries. Thus, Morey et al. describe how all 53 

patients with bladder rupture had a hematuria but that the simultaneous presence of blood at the 

urethral meatus correctly indicated in all 6 cases a concomitant urethral injury [71]. 



Studies available internationally show clearly that the absence of hematuria and the simultaneous 

exclusion of a pelvic fracture definitely exclude a relevant injury to the bladder or urethra. This 

assessment is somewhat more difficult if there is positive evidence of a pelvic fracture. Hochberg 

and Stone found that a urologic injury is very unlikely here as well provided the pelvic fracture 

does not affect the pubic rami [60]. 

Imaging diagnostic test of kidneys and ureters 


Computed tomography with contrast agent should be performed in the case of 

suspected kidney injury. 

Explanation: 

GoR B 

The importance of computed tomography (CT) in the primary assessment of blunt abdominal 

trauma is not the subject of this text as the diagnostic test focuses on all intraabdominal trauma. 

Thus, only the degree of accuracy with which injuries to the kidney and efferent urinary tract can 

be detected in the CT will be discussed below. In the literature review, the CT diagnostic test 

appears to be the most reliable, comfortable method in assessing blunt abdominal trauma [9, 41, 

47, 75-82]. 

Intravenous pyelography is inferior to CT with respect to diagnostic accuracy [44, 76] yet 

represents an important option if CT cannot be performed. This may be the case if the admitting 

hospital does not have the necessary equipment available or, more usually, if the patient is 

hemodynamically unstable and requires immediate emergency surgery [83]. In such cases, i.v. 

pyelography makes it possible to carry out the urologic diagnostic study directly during surgery 

[9, 41, 44]. The images are available approximately 10 minutes after administration of the 

contrast agent (2 ml/kg). For 284 patients with blunt kidney trauma, Nicolaisen et al. report 

perfect sensitivity of i.v. pyelography for identifying blunt injuries and state that in 87% of cases 

it was also possible to classify the injury severity grade correctly [29]. Although in 5 cases of 60 

patients with normal excretory urography Halsell et al. found smaller renal lesions in the 

computed tomography [84], these lesions were clinically less important and could be 

conservatively treated. 

Various studies report a sensitivity of over 90% in detecting renal injuries by ultrasonography 

[85, 86] but the sensitivity is obviously less if the injury has not resulted in free fluid in the 

abdomen [85]. This can occur in about 10-20% of cases [87]. Overall, however, ultrasonography 

is not sufficiently reliable. On average, intraabdominal lesions will be present in 10-20% of cases 

despite negative ultrasonography [87, 88]. Ultrasonography is therefore only suitable as an 

additional diagnostic test. However, a randomized study showed that primary ultrasonography 

could reduce the necessity of a CT diagnostic test [89] as negative ultrasonography was assessed 

as adequately reliable in individual patients without evidence of abdominal injuries. 

Angiographic techniques have much more of a therapeutic role than a diagnostic one as 

angiography does not really provide any additional diagnostic information compared to CT [77, 



90]. In cases where an injury to the renal artery or its lateral branches can be assumed or active 

bleeding is detected by computed tomography, it is expedient to use angiography as preparation 

for an embolization [91-95]. In vascular injuries to the renal pedicle (e.g., intimal tear), this 

enables the patency of the renal artery to be restored using an endovascular stent. Moreover, in 

relatively severe renal injuries with massive bleeding, selective embolization of the bleeding 

vessel should be carried out [9, 41, 42] provided the patient has stable circulation. The number of 

primary operated patients can be minimized through this radiologic intervention option, which 

leads to a reduction in the nephrectomy rate. The success rate of radiologic intervention is about 

70-80% [42]. Angiography can also be necessary if CT equipment is not locally available and 

the i.v. pyelography does not show the kidney. 

In addition to the methods cited, magnetic resonance imaging has been tested by Leppaniemi et 

al. [96-98] and it can image some details better than CT [96, 99]. Due to the increased time 

involved, however, it is seldom advisable to use this procedure in multiply injured patients 

during the acute phase. Magnetic resonance imaging could be beneficial in rare cases if CT is 

unavailable or cannot be used because of an allergy to the contrast agent or the CT finding is 

unclear. 

Detecting a ureter lesion is much more difficult [100-102]. Medina et al. described a sensitivity 

of 20% although a very wide range of diagnostic modalities (CT, intravenous pyelography [IVP], 

and retrograde pyelogram) was used [15]. In 81 patients with non-iatrogenic blunt ureter injury, 

Dobrowolski et al. [103] found i.v. and retrograde pyelography helpful. Ghali et al. [102] 

considered only pyelography to be diagnostically reliable even when compared to intraoperative 

inspection. 



Imaging diagnostic tests of the lower urinary tract 


If prioritizing permits, retrograde urethrography and a cystogram should be 

performed in patients with clinical reference points for a urethral lesion. 

If prioritizing permits, a retrograde cystogram should be performed in 

patients with clinical reference points for a bladder injury. 

Explanation: 

GoR B 

GoR B 

If there is a suspected urethral and/or bladder lesion, retrograde urethrography and a cystogram 

should be performed [30]. Retrograde urethrography consists of the transurethral administration 

of approximately 400 ml of contrast agent. Provided the urethra is uninjured, urethrography 

enables the bladder to be adequately filled with contrast agent. Thereafter, a radiograph is taken, 

ideally on 2 planes but often limited for practical reasons to the anteroposterior plane in multiply 

injured patients [72]. However, both planes should be represented so that retrovesicular 

extravasates are not missed [23]. The cystogram consists of an image after drainage in addition 

to the voided image and the filling image as otherwise there will be approximately 10% falsenegative 

results [104]. In cases where no retrograde bladder filling can be achieved, the bladder 

must be filled via a suprapubic catheter as combined injuries to the bladder and urethra make up 

10-20% of all bladder or urethral injuries [61]. 

In multiply injured patients, due to concomitant injuries, it is not possible in about 20% of cases 

to carry out the cystogram within the initial emergency room phase [73]. This may be 

unavoidable in individual cases but the diagnostic test must be carried out as soon as possible 

thereafter so that no injuries are missed. On the other hand, Hsieh et al. [73] saw no serious 

disadvantages in the cases where the diagnosis of a bladder rupture had been delayed until later. 

Ultrasound does not play a big role in assessing bladder or urethral injuries but is very helpful in 

localizing the bladder for inserting the suprapubic bladder catheter. I.v. pyelography is also 

unreliable in assessing uncertain bladder injuries as the bladder resting pressure is too low and 

dilutes the contrast agent too much. Several clinical studies have shown that i.v. pyelography 

does not detect 64%-84% of bladder injuries [105-108]. 

Although computed tomography cannot make definite statements on urethral injuries, it is still 

very valuable in diagnosing bladder ruptures [109]. However, without separate filling of the 

bladder with contrast agent, the CT diagnostic test can only supply indirect evidence. Although 

the absence of pelvic fluid collections makes bladder ruptures less likely [110], it can never 

definitely exclude a relevant injury. Only the CT cystogram is suitable for this, and it can also be 

performed as an alternative to the normal cystogram. In a series of 316 patients, Deck et al. 

found evidence of a sensitivity and specificity of 95% and 100%, respectively, for the CT 

cystogram in identifying bladder ruptures [111, 112]. Even if these values were somewhat worse 

for intraperitoneal ruptures (78% and 99%), the authors still consider that the CT cystogram 



ranks at least equally with the conventional cystogram. Other groups have reported similar 

results [113, 114]. For this reason, the CT cystogram can offer time and organizational 

advantages particularly in multiply injured patients as the CT diagnostic test is often indicated 

here because of other injuries. However, the prerequisite for a definite diagnosis is the sufficient 

administration of contrast agent (> 350 ml) to be able to produce and detect an extravasate at all 

in the presence of a rupture through sufficient fill pressure [104, 109, 115]. 



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2.9 Spine 

A suspected spinal injury exists in principle in patients who are transferred to hospital with 

suspected multiple injuries. In our own hospital population between the years 2000-2002, 34% of 

the multiply injured patients (245 out of 720) had a spinal injury. Other studies have found a rate 

of 20% [29]. Conversely, about 1/3 of all spinal injuries are associated with concomitant injuries 

[34, 91]. Overall, the figure for Germany is approximately 10,000 serious spinal injuries per 

year, of which 1/5 involve the cervical spine and 4/5 the thoracic/lumbar spine [31]. 

Approximately 10% of multiply injured patients will have a cervical spine injury [33]. At 1-27 

injuries/million children/year in Western Europe/North America, pediatric spinal injury is 

relatively rare [9]. 

The presence of a spinal injury as part of multiple injuries has considerable consequences for the 

diagnostic study and therapeutic course of action. Typical concomitant injuries, e.g., thoracic or 

abdominal, must first be excluded. If surgical stabilization is necessary, a comprehensive preoperative 

CT diagnostic work-up is required of the injured region. Intensive care positioning 

options depend on the stability of a detected spinal injury. For this reason, it is desirable to assess 

the stability of a spinal injury if the general condition of the patient permits this (circulation, 

temperature, coagulation, intracranial pressure, etc.) and before the trauma patient is transferred 

from the emergency room or from the operating room to the intensive care unit. 

Medical history 


The medical history has high importance and should be taken. GoR B 

Explanation: 

In the case of multiply injured patients, the medical history is usually taken from a third party. 

The mechanism of injury is an important piece of information here and should be passed on from 

the prehospital to the hospital care. Multiple injuries as such [4, 39, 49], high energy road traffic 

accidents [4, 16, 34, 101, 115, 149], road traffic accidents involving persons not restrained by 

belt or airbag [81, 101], pedestrians who have been run over [16], falls from a great height [14, 

39, 49, 128, 132], alcohol or drug influence [138], and advanced age [16, 100, 134] represent 

predispositions for a spinal injury. In the unconscious patient, the medical history should also 

include active movement of the extremities and information about pain before loss of 

consciousness or intubation. 

Traumatic brain injury and facial injuries are considered risk factors for the presence of a 

cervical spine injury. According to the multivariate analysis by Blackmore et al. [16], patients 

with a head fracture or continued unconsciousness have a markedly higher risk of having a 

cervical spine injury (odds ratio 8.5) whereas with milder injuries such as facial/jaw fracture or 

temporary unconsciousness, for example, this is less common (OR 2.6). Similarly, Hills and 

Deane [73] found that the risk of a cervical injury in patients with TBI is about 4 times higher 

than in patients without TBI. With a GCS below 8, the risk is actually 7 times higher. Other 

Emergency room – Spine 226


studies on the importance of traumatic brain injury [73, 83], loss of consciousness [46, 77, 79, 

131, 149], and craniofacial fractures [63, 73, 103, 122] confirm the association with spinal 

injuries. Only one study with a large number of patients described a tendentially reduced risk of 

cervical injuries in patients with facial or head injuries [165] but where the GCS was significant 

as a predictor. It is debatable whether clavicular fractures can also be considered as a predictor 

[165]. 

Clinical examination 


The clinical examination for spinal injuries has a high importance in the 

emergency room and should be carried out. 

Explanation: 

GoR B 

Due to its simplicity and speed, the clinical examination of the spine is a valuable diagnostic aid 

in the emergency room [49]. It comprises the inspection and palpation of the spine where 

contusions and hematomas are seen and displacement or malposition of the spinal process and 

indentations in the segments concerned can be felt. Information about pain in the head and torso 

can indicate a spinal injury. Tenderness, distraction or movement and involuntary malpositions 

are additional features of spinal injury [25, 128]. Provided the patient is conscious, motor 

functions and sensitivity should be tested. If there are existing deficits, the neurologic 

examination should document a precise, standardized finding, if possible according to the ASIA- 

IMSOP (American Spinal Injury Association - International Medical Society of Paraplegia) 

classification sheet [32, 33]. 

Although there are well-validated clinical decision rules for monotrauma [11, 74, 150, 151] that 

enable a spinal injury to be definitely excluded, in turn saving on unnecessary diagnostic 

radiology, these decision rules cannot be transferred to polytrauma because prehospital 

interventions (particularly intubation) and concomitant injuries (particularly to the head) 

generally make it impossible to obtain a reliable medical history and carry out an examination 

[36, 159]. Thus, Cooper et al. [39] found that pain from a spinal fracture could only be found in 

63% of severely injured patients compared to 91% of the minor injured, patients with a TBI not 

being included. Meldon and Moettus reported quite similar figures (58% versus 93%) [105] so 

that a clinical examination was only considered reliable if there was a GCS of 15. Mirvis et al. 

and Barba et al. observed that about 10-20% of all apparently severely injured patients were 

actually less severely injured and thus adequately evaluable to be able to exclude a spinal injury 

clinically [12, 108]. This shows that the clinical examination of multiply injured patients is 

heavily dependent on the overall injury severity. The radiologic work-up of the spine can 

perhaps only be dispensed with in those cases where a patient is admitted with suspected 

multiple injuries but the injury severity then turns out to be less (ISS < 16). This is, however, 

outside the focus of this guideline. The clinical diagnostic study is not sufficiently reliable in 

polytrauma for clearing with adequate certainty a suspected spinal injury. 



On the other hand, if specific signs of a spinal injury are present, the clinical examination can 

affirm a suspected diagnosis [16, 59, 149]. Despite low sensitivity but due to its high positive 

predictive value (> 66%), the following signs permit the suspected diagnosis of spinal injury in 

polytrauma [80]: palpable step formation in the median-sagittal plane, pain on palpation, 

peripheral neurologic deficits or blood effusion around the spine. The papers by Holmes et al. 

[79], Gonzalez et al. [59], and Ross et al. 1992 [131] support the valency of the clinical finding. 

For the clinical examination, Gonzalez et al. and Holmes et al. report overall a sensitivity 

exceeding 90% in the cervical spine and up to 100% in the thoracic/lumbar spine but patients 

with a medical history of risk factors (painful or concomitant injuries affecting level of 

consciousness) were separately distinguished as a clinical risk group. These studies are thus not 

transferable to polytrauma. 

In unconscious trauma patients, slack muscle tone, particularly also the anal sphincter, lack of 

pain resistance, solely abdominal breathing, and priapism indicate a transverse lesion. Thus, the 

overall data status is somewhat better than the medical history for rating the clinical examination 

even if some of the studies have been conducted on monotrauma or mixed patient populations. In 

essence, a spinal injury can be predicted by the presence of clinical symptoms. Their absence, 

however, does not definitely exclude a spinal injury. 

Imaging diagnostic tests 


After circulatory stabilization and before transfer to the intensive care unit, a 

spinal injury should be cleared by imaging diagnostic tests. 

Explanation: 

GoR B 

In principle, the diagnostic study of the spine should be concluded as early as possible because 

otherwise the continuing immobilization makes medical and nursing procedures more difficult 

(e.g., positioning, central venous access, intubation) and immobilization itself can lead to side 

effects (e.g., pressure sores, infection) [110, 161]. 

The diagnostic work-up of the multiply injured patient with unstable circulation presents a 

challenge. Prioritization is applied here, giving priority to treatment and also surgery of lifethreatening 

injuries (e.g., epidural hematoma, pneumothorax). If this goal is achieved and there 

are no other contraindications (e.g., hypothermia), the spine is cleared by imaging technology as 

described above before transfer to the intensive care unit. If this is not advisable because of the 

situation, e.g., there is no current consequence, then the spine is usually cleared by imaging 

technology the next day, after stabilization of the overall condition [160]. 

In individual cases, other injuries can make it necessary to dispense with the primary imaging 

diagnostic study of the spine [160]. If such be the case, the usual safety precautions must be 

applied until further notice: cervical collar, positioning and turning en bloc, re-positioning using 

a rollboard, vacuum mattress, etc. [56, 136]. “Excluded by imaging” means no dislocation or 

unstable spinal fracture in evaluable X-ray images or in a CT scan of the spine. The 



immobilization of the spine can only be terminated when the imaging diagnostic study has been 

completed or the patient has recovered sufficiently that a spinal injury can be excluded by the 

clinical finding. However, a few authors deliberately dispense with the primary diagnostic 

radiology in patients with minor injuries if it is foreseeable that the patient can be clinically 

evaluated again within 24 hours so that diagnostic radiology can definitely be circumvented [25]. 

However, this is rarely the case in polytrauma so that this course of action is not recommended 

here. 


Depending on the facilities of the admitting hospital, the spine should be 

cleared if circulation is stable during the emergency room diagnosis: 

preferably by multi-slice helical CT from head to pelvis or alternatively by 

conventional diagnostic radiology of the entire spine (a.p. and lateral, 

odontoid view). 

Explanation: 

GoR B 

Plain diagnostic radiology with focused CT work-up is clinically common in many cases [50, 

109]. The radiologic cervical work-up has the highest priority over the rest of the spine. This 

work-up is possible by means of CT and conventional diagnostic radiology (a.p., lateral, and 

odontoid view). A lateral-only view of the cervical spine has proved to be inadequate to enable 

bony injuries to be adequately excluded [37, 143, 152, 162, 169]. The following requirements 

must be met: all 7 cervical vertebrae should be viewed in the lateral plane [55, 111]. An a.p. 

projection should be taken of the C2-T1 spinous process; the C1 and C2 lateral masses should be 

easy to evaluate in the odontoid view [48]. The 45 ° oblique views for the C7/T1 alignment, 

swimmer’s and similar projections are of subordinate priority as they provide less informative 

value, waste time, and have a higher radiation dose [52, 102, 125]. If necessary, oblique views 

should take priority over swimmer’s views [84]. On the other hand, other authors have found that 

patients with inadequate visualization of the C7-T1 junction in the primary imaging were then 

better cleared using oblique views than using computed tomography [88] because the CT 

diagnostic study could be avoided in over 10% of all cases. 

Functional views of the cervical spine of unconscious patients should be held under image 

converters by the physician to exclude ligamentous injuries if there is justified suspicion [3, 45, 

97, 142]. Their sensitivity is 92%, their specificity 99% in patients with maintained 

consciousness [25]. However, as morbid findings are overall only seldom revealed in the 

functional views, the routine and also selective use of functional views in the primary diagnostic 

study is of questionable effectiveness [6, 62, 97, 121]. Computed tomography or particularly 

magnetic resonance imaging provides an alternative (see below). 

Missed musculo-skeletal injuries comprise approximately 12% in polytrauma [51]. The cervical 

spine is the first priority [5, 30, 133, 155]. The causes are radiology examinations that are 

inappropriate or not carried out, or a required diagnostic test not followed consistently [55, 104, 

106, 133], which is why CT should be used for clearance in unconscious patients with lack of 



visualization in the C0-C3 and C6/7 regions [25, 157]. Twenty per cent of spinal injuries are 

missed because the diagnostic study is incomplete [19, 42]. This is confirmed by data on 39 

multiply injured patients, 9 of whom had a cervical spine injury which could be diagnosed using 

conventional radiography in only 6 of these patients. In contrast, supplementary examinations 

(1x functional views and 2x CT) were necessary in the remaining 3 patients [141]. 

The diagnosis of polytrauma contains per se a considerable risk that important injuries will be 

missed in the primary survey [129]. Fifty percent of missed injuries in polytrauma affect the 

whole spine. The result is an extended length of hospital stay and additional follow-up operations 

[133]. It is therefore recommended in polytrauma to clear the whole spine as a matter of routine 

[44, 116]. Particularly in the case of blunt, high energy traumas and falls from a great height, 

injuries with second fractures at other levels are seen with a frequency of 10%. For this reason, 

thoracic and lumbar spine must also be X-rayed in 2 planes [32, 166]. 

Computed tomography 


Pathologic, suspect and non-evaluable regions in conventional radiography 

should be further cleared with CT. 

Explanation: 

GoR B 

Due to greater diagnostic accuracy in detecting spinal injuries, preference should be given to the 

CT diagnostic test, if available [7]. Another practical advantage of the CT diagnostic test is the 

markedly faster clearing of the spine compared to conventional diagnostic radiology [68, 71, 72] 

because non-evaluable views virtually no longer occur. The CT diagnostic test is usually 

performed with administration of i.v. contrast agent. The CT diagnostic test is also considered to 

be advantageous in children even though the radiation dose at approximately 400 mrem 

(millirem) is higher than in conventional diagnostic radiology (150-300 mrem), as shown by a 

pseudo-randomized study [2]. Despite the above-mentioned problems, it is recommended that 

the options for clinical findings are exhausted fully in children [65]. Essentially, the procedure 

for children in the emergency room is no different from that for adults. 

Detected spinal injuries should not be operated on without CT [75] as fracture evaluation and 

classification is often changed decisively through CT compared to the plain radiograph [68, 70]. 

The preceding CT visualization and analysis is necessary particularly for rotationally unstable 

fractures [144]. The helical CT examination from head to pelvis without conventional diagnostic 

radiology is particularly suitable for clearing the spine in polytrauma because it saves time, has 

greater reliability compared to conventional diagnostic radiology, is associated with less 

discomfort, and costs less [112]. If the spine is visualized normally in the CT, additional 

conventional radiology is superfluous [26, 28, 35, 123, 135] as the negative predictive value 

reaches almost 100%. With today’s permanent availability, the CT diagnostic study appears at 

present to be the tool of choice for detecting spinal injuries in polytrauma in the emergency room 

phase [86]. 



Cervical spine (C) 

Harris et al. (2000) [66] describe the conventional diagnostic radiology in cervical spine injuries 

as not satisfactory so that CT or, if applicable, magnetic resonance imaging (MRI) is 

recommended particularly in polytrauma. CT is markedly more accurate than conventional 

diagnostic radiology for cervical spine injuries: The cervical spine injury was detected in 38 out 

of 70 patients using the conventional X-ray image and 67 out of the same 70 patients using CT 

[139]. Similar results are provided by a current meta-analysis [78] and the reviews by Crim et al. 

(2001) [41] and Link et al. (1994) [99]: using conventional lateral radiographs, 60-80% of 

cervical spine injuries were identified, and 97-100% with CT [119] (Table 2). Further studies 

show that the layer thickness in computed tomography affects the diagnostic accuracy [70], 

which must also be taken into account when assessing older studies with CT equipment which is 

obsolete by today’s standards. 

Based on the figures in the literature, Blackmore et al. also come to the conclusion that the 

primary CT diagnostic study has better clinical and economic results compared to conventional 

radiography in patients with average and high risk of a spinal injury [17]. 

Thoracic/lumbar spine (T/L) 

Table 3 gives a summary of important studies on the CT diagnostic test in the emergency room 

for thoracic/lumbar spine injuries as part of polytrauma. This also shows a clearly greater 

sensitivity of the CT diagnostic test compared to the conventional diagnostic test. It must be 

noted that not all additional findings such as transverse process avulsions were clinically relevant 

in the CT but could easily refer to other relevant injuries (abdominal injuries). In addition, there 

are advantages with regard to time and planning of surgery. According to Hauser et al. (2003) 

[68], the time for sufficient clearing of the spine was 3 hours for conventional diagnostic 

radiology, and one hour for CT. Moreover, the rate of false fracture classifications in CT was 

1.4% and in radiography 12.6%. 

Concomitant injuries in head/thorax/abdomen 

To clear the spine and concomitant injuries in polytrauma, a standard CT from head to pelvis is 

recommended initially in polytrauma, which takes approximately 20 minutes [96]. Computed 

tomography is indicated on the day of admission particularly for cervical spine injuries combined 

with TBI [141]. For thoracic spine fractures, the emergency CT examination of the thorax is 

indicated because of the high risk of complex thoracic-pulmonary injuries [58]. The constellation 

of lumbar spine injuries and abdominal trauma in the form of bleeding into the abdominal wall 

after a belt injury also supports the clearing of the spinal injury by CT in order to enable a 

simultaneous evaluation of the abdomen [13]. Miller et al. (2000) [107] and Patten et al. (2000) 

[117] also refer to the importance of transverse process fractures in the lumbar spine as important 

indications of a concomitant abdominal injury, which is why CT is recommended. Moreover, 

clearing the thoracic-lumbar spine by CT is also recommended for acetabular and pelvic 

fractures [8, 70]. In conventional diagnostic radiology, significant spinal fractures are missed in 

11% of cases of transverse process fractures. These are only picked up by CT, which is why it is 

stated that CT is necessary for clearing these fractures [92]. 



Magnetic resonance imaging (MRI) 

Magnetic resonance imaging examinations play a quantitatively subordinate role overall in 

polytrauma during the emergency room phase [148]. For logistic reasons (access, metal objects, 

time, availability), an MRI examination in the acute phase is usually not expedient for 

polytrauma. The main indication for MRI is in clearing unclear neurologic deficits. In particular, 

lesions on the spinal cord, the invertebral disc, and ligaments can be visualized [41, 57, 89]. 

However, in view of the rarity of this injury, Patton et al. [118] considered a search for 

ligamentous injuries using MRI to be superfluous. There are no studies on the direct comparison 

between conventional functional views and MRI imaging so that both options appear to be 

worthy of recommendation. With a sensitivity of only 12% and a specificity of 97%, MRI is 

little suited to the detection of fractures [90]. 

MRI examinations are indicated for neurologic symptoms during the further course and have 

partially replaced the functional views for defined research questions such as in the case of the 

hangman fracture, for example [87]. In general, there is no need to worry about false-negative 

results but specificity is low [25]. If a neurologic deficit without morphologic correlation is 

present in the CT, the corresponding spinal segment must be examined by MRI as a matter of 

urgency. Additional indications arise occasionally in the early post-operative or post-traumatic 

course to be able to evaluate, e.g., intraspinal epidural hematomas, prevertebral bleeding or 

invertebral disc injuries [43, 147, 163]. 

Emergency procedures such as reduction and cortisone treatment 


In the exceptional case of a closed emergency reduction of the spine, this 

should only be carried out after sufficient CT diagnostic study of the injury. 

Administration of methyl prednisolone (“NASCIS scheme”) is no longer 

standard practice but can be introduced within 8 hours after the accident if 

there is neurologic deficit and evidence of injury. 

Explanation: 

GoR B 

GoR 0 

A precise analysis of the spinal injury must be made before each reduction, i.e. preceded by a 

careful analysis of the imaging (CT). Despite the poor quality of evidence, the recommendation 

has been upgraded because of the risk of complication. Generally, reduction is directly carried 

out preoperatively in the operating room or open during surgery, followed by surgical 

stabilization of the reduced injury. Care must be taken in closed reduction without surgical 

stabilization or invertebral disc removal as it can herniate dorsally during reduction and have a 

detrimental effect on the neurology [60]. 

A Cochrane Review [21] found on the basis of 3 randomized studies [22, 114, 120] that, 

compared to a placebo, methyl prednisolone improves the neurologic outcome one year after the 



accident if it is given within 8 hours after the accident. The recommended dose (“NASCIS 

scheme”) is methyl prednisolone 30 mg/kg body weight i.v. over 15 minutes in the first 8 hours 

after the accident, thereafter 5.4 mg/kg BW each hour for 23 hours. In the NASCIS-3 study, 

administration of methyl prednisolone over 48 hours proved at best to have a trend towards 

improvement [23] and was recommended only for patients who could be started on the treatment 

after 3 or more hours. 

If there is evidence of neurologic symptoms or they can be assumed, with corresponding CT 

morphologic evidence of narrowing of the spinal canal, a NASCIS (National Acute Spinal Cord 

Injury Study) scheme can be started early [10]. The rehabilitation time can thus be shortened. 

However, other analyses show no effect from cortisone treatment [145, 146] or do not 

recommend cortisone treatment because the positive effect was not seen [82]. In addition, the 

validity of the NASCIS-2 study has been questioned [38]. The more recent results on 

administering corticosteroids for TBI [40] also cast a shadow on the efficacy of steroids for 

spinal cord trauma. 

Although, overall, the high-dose steroid administration to surgical/traumatologic patients can be 

seen as safe and to some extent even as advantageous [130, 137, 154], the possible side effects 

are an important argument against administration of steroids according to the NASCIS protocol 

[94, 153]. Known complications of steroid treatment in patients with spinal cord injury are: 

infections [53, 54], pancreatitis [69], myopathies [124], psychologic problems [158], and severe 

lactic acidosis when combined with the high dose of methyl prednisolone with i.v. adrenaline 

supply [67]. 



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2.10 Extremities 

The importance of evaluation and examination 

Even if there are no scientific studies on the importance and the necessary scope of the physical 

examination in the emergency room examination, it is still an indispensable requirement in 

identifying symptoms and in making (suspected) diagnoses. The systematic examination of the 

extremities of the undressed patient “in craniocaudal sequence” serves primarily to detect 

relevant, partially threatening injuries which can lead to a radiologic diagnostic study, immediate 

specific treatment and, in many cases, also a logistic decision taken while still in the emergency 

room [2, 14]. Its intended use is to estimate the overall injury severity. 

The examination in the region of the extremities consists of the detailed inspection and manual 

examination of the extremities for any type of external injury signs such as swelling, hematoma 

or wounds. Any closed or open soft tissue damage present is also classified. Definite fracture 

signs should be noted down. The systematic examination of the extremities allows fractures, 

dislocations, and dislocation fractures to be clinically detected or at least delimited. The stability 

test should be carried out on the large and small joints. 

The purport of the primary survey is also to distinguish a disorder in circulation, motor functions, 

and sensitivity. The possibility of compartment syndrome should be excluded. The neurologic 

finding for all extremities can only be collected from alert patients; otherwise, the reflex status 

must be checked as a minimum. It is essential for the treatment of extremity injuries to 

distinguish again between neurologic disorders in the central nervous system and those from 

peripheral causes. 

Missed injuries are also found retrospectively in the extremities region, particularly in 

unconscious and multiply injured patients. These injuries often require surgical management [3]. 

The incidence of missed injuries is independent from any interruption in emergency room 

diagnosis due to emergency surgery. 

The examination of the extremities is sometimes neglected in an unstable patient and injuries are 

missed [4, 5]. Another source of error is the examiner-dependent evaluation of radiographs, 

which can be subject to a false interpretation [6, 7, 8]. 

In this context, process optimization and monitored training [9], and the introduction of 

guidelines lead to an improvement in patient care [10]. However, missed injuries to the 

extremities are rarely life-threatening and, after the multiply injured have been stabilized, can 

often be diagnosed in the secondary survey and surgically managed [32]. 

Emergency room – Extremities 240


Diagnostic equipment 


If there are confirmed or unconfirmed fracture signs, extremity findings 

should be assessed depending on the patient’s condition using a suitable 

radiologic procedure (plain radiograph in 2 planes or CT). 

The radiologic diagnostic study should be performed at the earliest possible 

opportunity. 

Explanation: 

GoR B 

GoR B 

The length of stay in the emergency room affects the treatment results and the morbidity/case 

fatality rate of a severely injured patient [10]. There is no absolute value to adhere to such as the 

“golden hour”, for example [11]. 

In certain regions, the scope of diagnostic radiology can be limited by the confirmed clinical 

examination. For example, without weight-bearing pain, effusion or hematoma, a fracture has 

been excluded in knee injuries (as monotrauma) [12]. 

A lateral radiograph is sufficient for specific screening of a knee fracture. It is 100% sensitive 

[13]. 

If a bony extremity injury is clinically suspected in stable patients, a radiograph should be taken 

in at least 2 planes. Deliberately dispensing with the radiologic visualization is only justifiable if 

the emergency room diagnostic tests are interrupted due to emergency surgery [14]. 

Studies on length of stay in the emergency room and on treatment results specifically on 

extremity injuries are not known. There are also no studies on the issue of whether a deliberate 

postponement of diagnostic radiology on extremity injuries to shorten the emergency room phase 

affects the treatment results of the injured. 

There are several scientific studies with a poor outcome on the delayed management of injuries 

to the extremities. However, they are not considered in conjunction with a postponement in the 

emergency room diagnostic tests. 



Diagnostic study/Treatment 

Should obvious malpositions in the extremities be reduced? 


Malpositions and dislocations in the extremities should be reduced and 

stabilized. 

GoR B 

The reduction outcome should not be altered through other interventions. GoR B 

Explanation: 

An injured extremity that has been correctly immobilized by the emergency services should be 

left alone in the emergency room until definitive care. Any alteration in immobilization in the 

actual injury area can potentially lead to a worsening in soft tissue damage and pain reactions, 

particularly in bony unstable conditions [15]. A reliable interface with the emergency services 

avoids unnecessary repositioning. To date, there have been no scientific studies on whether 

repositioning measures in the emergency room affect the extremity injury. 

With the prehospital care of the injured by an emergency services system, it can be assumed that 

extremity injuries are immobilized in the neutral position. If this immobilization is correctly 

performed, repositioning measures of the whole patient have virtually no effect on the individual 

injury to the extremities. If immobilization is correctly performed, removing/altering the 

immobilization of an extremity is unnecessary until in the operating room. 

Lack of pulse after a prehospital fracture reduction has not been described in the literature up till 

now. 

Open fractures 


If sufficiently reliable information has been provided by the emergency 

services, a sterile emergency dressing should be left in place until entry to the 

operating room. 

Explanation: 

GoR B 

In the emergency room, open fractures should be managed according to the basic principles of 

aseptic wound management. In principle, open fractures are a surgical emergency, requiring 

immediate surgery. The decisive factors for a possible infection lie outside the emergency room: 

for infectiologic reasons, do not repeatedly open. This is because resistant hospital germs are 

more dangerous than the germs collected at the accident scene. A direct correlation between 

frequency of infection and exposure could not be proven by Merritt [35, 36]. 



Pulseless extremity 


If there is no peripheral pulse (Doppler/palpation) in an extremity, further 

diagnostic tests should be carried out. 

Depending on the finding and condition of the patient, conventional arterial 

digital subtraction angiography (DSA), duplex ultrasonography or angio-CT 

(CTA) should be performed. 

Intraoperative angiography should be given priority in vascular injuries to the 

extremities that were not diagnosed in the emergency room in order to shorten 

the period of ischemia. 

Explanation: 

GoR B 

GoR B 

GoR B 

Compared to the sensitivity of the other diagnostic equipment, the duplex ultrasonography 

examination is at least equivalent to invasive arteriography [19]. Good results from 

ultrasonography are to a large extent dependent on the examiner [20. 21]. 

The period of ischemia is crucial for the prognosis of the extremity as well as the whole body. A 

quick diagnosis with localization of potential injuries is essential to then enable rapid surgical 

management. 

The diagnosis of a vascular lesion cannot be made solely on the basis of the clinical examination. 

Vascular injuries require a rapid, definite emergency room diagnostic study. Depending on the 

examiner, the duplex ultrasound examination best fulfills the above requirements. If there is 

already a clear clinical indication for surgery, preference should be given to intraoperative 

angiography over the emergency room diagnostic tests. Here, as in the above-mentioned studies 

on ultrasonography, the hospital structure plays a considerable role so that a generally valid 

recommendation can only be made with reservations. 

More recent papers show that preference should be given to CT angiography over conventional 

arterial digital subtraction angiography (DSA) in appropriately stable patients. The procedure of 

computed tomography angiography (CTA) takes up markedly less time and is also cheaper [31]. 

It is less invasive than DSA and the rapid development in technology now permits visualization 

of all arteries in a short time. However, its value is limited by the large quantity of iodinated 

contrast agent and the high radiation exposure. Calcified plaques also compromise the detailed 

visualization of medium and small arteries (33, 34). The extent of ischemia in peripheral 

extremities depends on the localization and length of the vascular obstruction as well as on the 

possible presence of developed collaterals. In a healthy vascular system, even a short length of 

obstruction or an isolated break in an extremity artery can lead to necrosis of the dependent 

musculature. 



The tolerated ischemia period is shorter the healthier the vascular system. 

In polytrauma, there is the added difficulty that the injury to the extremity triggers arterial 

vascular spasms, which themselves entail a marked decrease in blood flow to the extremity [22]. 

If there is insufficient blood flow to the peripheral muscle tissue after 3 hours, the risk of 

compartment syndrome following revascularization must be taken in to account. Very 

pronounced direct soft tissue trauma can worsen the prognosis of revascularization. 

Compartment syndrome 


If there is suspected compartment syndrome, the invasive compartment 

pressure measurement can be used in the emergency room. 

Explanation: 

GoR 0 

Compartment syndrome is a time-dependent noxious agent and can develop dynamically. It 

arises from an increase in intrafascial pressure in the compartments. It can affect all regions of 

the extremities, primarily the ankle. Burns and positioning damage as well as injuries are also 

part of the etiology. In the clinical examination, there are many compartment signs which are 

nevertheless not all evidentiary: pain, intensified through passive exertion of the muscle part 

involved, swelling of the muscle part involved, sensitivity disorders in the muscle dermatome. 

In a suspected diagnosis, based on the above-mentioned clinical signs, the intrafascial pressure is 

measured objectively without delay, if applicable as the baseline value in the emergency room. It 

is advantageous to carry out continuous pressure measurements. A diastolic blood pressure in 

mmHg minus the compartment measurement value in mmHg less than 30 mmHg is given as the 

pathologic value [23, 24]. 

Particularly in polytrauma, the onset of compartment syndrome must be taken into account in 

massive infusion and massive transfusion. The possibility of clinically assessing a threatening or 

manifest compartment syndrome is often inadequate in anesthetized patients so that only the 

blood measurement of the intrafascial pressure permits an indicatory statement. It must be noted 

here that the accuracy of the compartment pressure measurement depends on the examiner and 

can be false-positive/negative. 

Amputation injuries 

In the multiply injured, the meaningfulness of attempting to salvage the extremity needs to be 

discussed for soft tissue damage grade 3 of closed and grade 4 of open fractures. Particularly in 

the multiply injured patient, it must be taken into account that a protracted salvage attempt with 

long surgery times can endanger the patient’s vital functions. 



The decision to attempt to salvage an injured extremity is advisable only after the primary survey 

according to ATLS ® and ETC has been completed. Only then can the complete injury pattern be 

evaluated with regard to a stable patient for extended surgical management. 

On the other hand, from experience, the indication for attempting to salvage an extremity should 

only be made by a competent surgeon after a detailed inspection of the injured soft tissue. This 

can only be done in the operating room. 

Thus, emergency completion of a subtotal amputation on an unstable patient in the emergency 

room remains an unresolved issue. These are case-by-case decisions, which depend more on the 

remainder of the injury pattern and less on the extremity finding. There are many case histories 

to be found on this topic in the literature, such as successful reconstructions or replantation of 

extremities. It is not possible to conclude recommendations. It appears unrealistic to conduct a 

study. 

In the case of open extremity injuries, a decision should be taken in the emergency room on the 

operability in relation to the expected operating time to salvage the extremity in the multiply 

injured patient. 

An emergency completion of an amputation in the emergency room remains subject to the 

unstable patient and requires an individual decision from the trauma surgery team leader. 

CT diagnostic test 

The use of computed tomography (CT) in emergency room diagnostic tests primarily concerns 

torso injuries including pelvic fractures. Ultimately, the CT diagnostic test in emergency room 

management is being increasingly preferred over conventional diagnostic radiology of the 

extremities because of structural measures and ongoing software development. 

Whether this allows conventional diagnostic radiology to be dispensed with can only be decided 

on a case-by-case basis at present. A generally valid recommendation is not possible. In a 

retrospective study, Wurmb et al showed that, in a comparative patient collective of a first group 

of 82 patients who received a complete CT work-up of their injuries and a second group of 79 

patients who first received conventional conservative diagnostic radiology and then a focused 

CT scan, there was a time saving of 23 minutes versus 70 minutes in the second group [27]. 

However, Ruchholtz et al. in their study highlight missed injuries in the CT as well and also cite 

the increased radiation exposure [28]. 

A CT diagnostic test can be performed after conventional diagnostic radiology in the emergency 

room on a stable patient with a suspected talus or scaphoid fracture in order to plan surgery and 

so as not to miss fractures in this region [29, 30]. 



References 

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patient. J Bone Joint Surg Br. 1996.78(5):840-5 [LoE 

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3. Enderson BL, Reath DB, Meadors J, Dallas W, 

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30(6):666-9 [LoE 3b] 

4. McLaren CA, Robertson C, Little K. Missed 

orthopaedic injuries in the resuscitation room. J R 

Coll Surg Edinb. 1983 28(6):399-401 

5. Born CT, Ross SE, Iannacone WM, Schwab CW, 

DeLong WG. Delayed identification of skeletal injury 

in multisystem trauma: the 'missed' fracture. J 

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6. Laasonen EM, Kivioja A. Delayed diagnosis of 

extremity injuries in patients with multiple injuries. J 

Trauma. 1991 31(2):257-60 [LoE 3b] 

7. Metak G, Scherer MA, Dannöhl C. Missed injuries 

of the musculoskeletal system in multiple trauma--a 

retrospective study Zentralbl Chir. 1994 119(2):88-94 

[LoE 3b] 

8. Kremli MK Missed musculoskeletal injuries in a 

University Hospital in Riyadh: types of missed 

injuries and responsible factors.Injury. 1996 

27(7):503-6 [LoE 3b] 

9. Hoyt DB, Shackford SR, Fridland PH, Mackersie RC, 

Hansbrough JF, Wachtel TL, Fortune JB Video 

recording trauma resuscitations: an effective teaching 

technique. J Trauma. 1988 28(4):435-40 [LoE 3b] 

10. Ruchholtz S, Zintl B, Nast-Kolb D, Waydhas C, 

Schwender D, Pfeifer KJ, Schweiberer L. Quality 

management in early clinical polytrauma 

management. II. Optimizing therapy by treatment 

guidelines Unfallchirurg. 1997 100(11):859-66 


11. Lerner EB, Moscati RM The golden hour: scientific 

fact or medical "urban legend"? Acad Emerg Med 

2001; 8(7): 758-60 [LoE 3a] 

12. Bauer SJ, Hollander JE, Fuchs SH, Thode HC A 

clinical decision rule in the evaluation of acute knee 

injuries. The Journal of Emerg. Med. 1995 13/5:611- 

615 [LoE 1b] 

13. Verma A, Su A, Golin AM, O`Marrah B, Amorosa JK 

(2001) The Lateral View. Acad Radiol 8:392-397 

[LoE 3b] 

14. American College of Surgeons Advanced Trauma 

Life Support (Chicago) 1997 

15. Beck A, Gebhard F, Kinzl L, Strecker W. Principles 

and techniques of primary trauma surgery 

management at the site Unfallchirurg. 2001 

104(11):1082-96 [LoE 3a] 

16. Willett KM, Dorrell H, Kelly P ABC of major trauma. 

Management of limb injuries BMJ. 1990 

28;301(6745):229-33 [LoE 3b] 

17. Schlickewei W, Kuner EH, Mullaji AB, Gotze B 

Upper and lower limb fractures with concomitant 

arterial injury. J Bone Joint Surg Br 1992 74(2): 181-8 

[LoE 3b] 

18. Vollmar J Bone fracture and vascular lesion (author's 

transl) Langenbecks Arch Chir. 1975 339:473-7 [LoE 

5] 

19. Ruppert, V., M. Sadeghi-Azandaryani, et al..Vascular 

injuries in extremities. Chirurg 2004 75(12): 1229-38 

[LoE 3a] 

20. Panetta TF, Hunt JP, Buechter KJ, Pottmeyer A, Batti 

JS (1992) Duplex Ultrasonography versus 

arteriography in the diagnosis of arterial injury: an 

experimental study. J Trauma 33:627-636 [LoE 1b] 

21. Kuzniec S, Kauffmann P, Molnár LJ, Aun R, Puech- 

Leão P Diagnosis of limbs and neck arterial trauma 

using duplex ultrasonography. Cardiovascular Surgery 

1998 6/4:358-366 [LoE 3b] 

22. Glass GE, Pearse MF, Nanchahal J. Improving lower 

limb salvage following fractures with vascular injury: 

a systematic review and new management algorithm. J 

Plast Reconstr Aesthet Surg. 2009 62(5):571-9 [LoE 

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23. Elliott KGB, Johnstone AJ Diagnosting acute 

compartment syndrome. J Bone Joint Surg 2003 85- 

B:625-32 [LoE 3b] 

24. Kosir R, Moore FA, Selby JH, Cocanour CS, Kozar 

RA, Gonzalez EA, Todd SR Acute lower extremity 

compartment syndrome (ALECS) screening protocol 

in critically ill trauma patients. J Trauma. 2007 

63(2):268-75 [LoE 3b] 

25. Aufmkolk M, Dominguez E, Letsch R, Neudeck F, 

Niebel W. Results of peripheral arterial vascular 

injury in polytraumatized patients Unfallchirurg 1996. 

99(8):555-60 [LoE 4] 

26. Leidner B, Adiels M, Aspelin P, Gullstrand P, Wallen 

S Standardized CT examination of the 

multitraumatized patient. Eur Radiol 1998; 8(9): 

1630-8 [LoE 3b] 

27. Wurmb, T. E., P. Fruhwald, et al.Whole-body 

multislice computed tomography as the first line 

diagnostic tool in patients with multiple injuries: the 

focus on time. J Trauma 2009 66(3): 658-65 [LoE 3b] 

28. Ruchholtz S, Waydhas C, Schroeder T, Piepenbrink 

K, Kuhl H, Nast-Kolb D The value of computed 

tomography in the early treatment of seriously injured 

patients. Chirurg 2002; 73(10): 1005-12 [LoE 3b] 

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scaphoid fractures: review of the literature. J Radiol 

2007 88(5 Pt 2): 741-59 [LoE 3a] 

30. Boack, D. H., S. Manegold, et al.Treatment strategy 

for talus fractures. Unfallchirurg 2004 107(6): 499- 

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31. Seamon MJ, Smoger D, et al. A prospective validation 

of a current practice: the detection of extremity 

vascular injury with CT angiography. J Trauma. 2009 

67(2):238-43 [LoE 2b] 

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delayed diagnosis of lesions in multiply traumatised 

patients. A study of 1,187 shock room patients. 

Unfallchirurg. 2006 109(11):964-74 



33. Jakobs TE, Wintersperger BJ, Becker CR: MDCTimaging 

of peripheral arterial disease. Semin 

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34. Ota H, Takase K, Igrashi K, Chiba Y, Haga K, Saito 

H et al: MDCT compared with digital subtraction 

angiography for assessment of lower extremity arterial 

occlusive disease: importaance of reviewing crosssectional 

images. AJR Am J Roentgenol 2004 182 

(1):201-209 

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patients with open fractures. J Trauma 1988 28:823- 

827 

36. Rojczyk M: Keimbesiedlung und Keimverhalten bei 

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J Trauma 2002 53: 1109-1114 



2.11 Hand 

There are no studies above a Level of Evidence 4 on the diagnostic tests and surgical treatment 

for hand injuries, particularly in polytrauma. The available literature describes only injury 

frequencies and combinations. Recommendations on diagnosis and treatment methods exist only 

in the form of expert opinions. The following evidence-based recommendations must therefore 

be based on studies in which monotrauma in the hand have been studied. 

Hand injuries, especially fractures, can occur in up to 25% of cases of multiply injured patients 

[1, 12, 15, 18]. The most common injury here involves fractures of the hand skeleton including 

the distal radius; the latter occurs in 2-16% of all multiply injured patients [1, 4, 10, 13, 19]. 

Tendon and nerve injuries are less common at 2-11% and 1.5%, respectively [15]. Amputations 

to the hand occur in only 0.2-3% of polytrauma cases [3, 11]. Severe combination hand injuries 

are also seldom found in polytrauma [17]. 

Primary diagnosis 


The clinical evaluation of the hands should be carried out during the basic 

diagnostic work-up as it is crucial for establishing the indication for carrying 

out further examinations requiring the use of equipment. 

Explanation: 

GoR B 

The probability of the occurrence of a hand injury does not depend on the severity of the 

polytrauma. In addition, it cannot be assumed that the probability for missing a hand injury 

increases with the injury severity [15]. However, primary missed and untreated hand injuries can 

later lead to considerable function impairments [8]. During the emergency diagnostic study, 

closed tendon injuries (tractus intermedius, distal extensor tendon, avulsion of deep flexor 

tendon), carpal fractures, and dislocations are frequently missed [6, 9, 16]. The clinical basic 

diagnostic work-up should comprise the examination for skin damage, swelling, hematoma, 

abnormal position and mobility, and monitoring perfusion (radial and ulnar arteries, capillary 

refill in finger pads) [17]. 

Emergency room – Hand 248



If there is clinical suspicion of a hand injury, basic radiologic work-up should 

consist of a radiographic examination of the hand and wrist on 2 standard 

planes for each. 

Explanation: 

GoR B 

Radiographs of the hand and wrist should be taken on 2 planes in unconscious patients with 

clinical evidence of a hand injury (see above). Special attention should be paid to the possible 

presence of carpal fractures and dislocations. If there is clinical evidence of phalangeal fractures 

and if radiographs of the full hand cannot definitely exclude these or define them in a clear 

morphologic way, particularly in the case of a series fracture of several digits, it is advisable to 

radiograph the injured digit in isolation on 2 planes at the earliest possible opportunity [16, 17]. 


If there is clinical suspicion of an arterial vascular injury, Doppler or duplex 

ultrasonography should be performed. 

Explanation: 

GoR B 

If there is clinical suspicion of an arterial vascular injury, a rapid, accurate diagnosis can be 

made by Doppler or duplex examination [5, 7, 14]. In the remaining unclear cases with urgent 

clinical suspicion of an arterial injury, angiography is only indicated if the general condition of 

the patient forbids surgical exploration [7] or the localization of the lesion is uncertain [2]. The 

Allen test permits definite confirmation of the patency of the arterial radio-ulnar link and the two 

forearm arteries [5]. 



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Ashmead D 4th, Dunn R. (1993) Radial and ulnar 

artery repairs: assessing patency rates with color 

Doppler ultrasonographic imaging. J Hand Surg. 

18(4):626-8 [LoE 4] 

15. Schaller P, Geldmacher J (1994) Die Handverletzung 

beim Polytrauma. Eine retrospektive Studie an 728 

Fällen. Handchir Mikrochir Plast Chir 26 307-312 

[LoE 4] 

16. Skroudies B, Wening VJ, Jungbluth KH (1989) 

Perilunäre Luxationen und Luxationsfrakturen beim 

Polytraumatisierten – Diagnostik und Therapie. 

Unfallchirurgie 15 236-242 [LoE 4] 

17. Spier W. (1971) Die Handverletzung bei 

Mehrfachverletzten. Med Welt 22, 169-172 [LoE 5] 

18. Vossoughi, F., B. Krantz, et al. (2007). Hand injuries 

as an indicator of other associated severe injuries. Am 

Surg 73(7): 706-8 [LoE 4] 

19. Welkerling H, Wening JV, Langendorff HU, Jungbluth 

KH. (1991) Computergestützte Datenanalyse von 

Verletzten des knöchernen Bewegungsapparates beim 

polytraumatisierten Patienten. Zbl Chir 116 1263- 

1272 [LoE 4] 



2.12 Foot 

Diagnostic study of foot injuries 

In the unconscious multiply injured patient, foot injuries can be excluded by repeated clinical 

examinations. Foot injuries are initially missed with an above average frequency in multiply 

injured patients. The reasons for this are more eye-catching and life-threatening injuries, 

deficient radiography technique in the emergency situation, extremely variable clinical 

standards, lack of experience on the part of the examiner with to some extent low case numbers 

of different foot injuries, and breakdown in communication in the treatment of the multiply 

injured by several teams [4–6, 9, 11, 16]. In the unconscious patient, repeated clinical 

examinations are thus necessary in the case of partially subtle injury signs in order not to miss 

foot injuries with potentially serious late complications [6, 17]. In a retrospective analysis, Metak 

et al. [9] found that 50% of all missed injuries to the lower extremities related to the foot and 

recommended a thorough clinical examination every 24 hours. If foot injuries are clinically 

suspected, radiography follow-up in the standardized settings (see below) is initially indicated 

and, if this does not provide adequate clarification, then stress views and a foot CT. 

Standard projections on the foot (review in [16, 17]): 

� Pilon, ankle joint ankle joint ┴ 

� Talus ankle joint ┴, foot dorsoplantar (beam tilted 30 ° in craniocaudal 

direction) 

� Calcaneus calcaneus lateral, axial, foot dorsoplantar (beam tilted 30 ° in 

craniocaudal direction) 

� Chopart/Lisfranc foot true lateral, foot dorsoplantar (beams for Chopart tilted 30 °, 

for Lisfranc tilted 20 ° in caudocranial direction), 45 ° oblique view 

midfoot 

� Midfoot/toes mid/forefoot a. p., 45 ° oblique views, true lateral 

The occurrence of tension blisters on the foot must also be taken as an indicator for ischemic 

damage to the skin [10]. Besides clinical criteria, Doppler ultrasonography is recommended for 

the initial assessment of the vascular status of the foot [2, 12]. Controversy surrounds routine 

angiography where there is no Doppler signal [13] but it is indicated if the goal is for more 

complex reconstructions [7]. An important indicator for skin nutrition is the ankle brachial 

index. If the Doppler flow detects at least 50% of the brachial artery value, the wound healing 

rate is 90% [14]. The same was confirmed for transcutaneously measured oxygen tension 

exceeding 30 mmHg [15]. Poorer healing rates after surgical interventions can be expected in 

elderly persons (peripheral arterial obstructive disease [pAOD]), in diabetics, and in smokers [1, 

3, 8]. 

Emergency room – Foot 251


References 

1. Abidi, NA et al. (1998) Wound-healing risk 

factors after open reduction and internal fixation 

of calcaneal fractures. Foot Ankle Int, 19: 856- 

61 [LoE 4] 

2. Attinger C (1995) The use of skin grafts in the 

foot. J Am Podiatr Med Assoc 85: 49-56 [LoE 4] 

3. Folk JW, Starr AJ, Early JS (1999) Early wound 

complications of operative treatment of 

calcaneus fractures: analysis of 190 fractures. J 

Orthop Trauma 13: 369-372 [LoE 4] 

4. Haapamaki V, Kiuru M, Koskinen S (2004) 

Lisfranc fracture-dislocation in patients with 

multiple trauma: diagnosis with multidetector 

computed tomography. Foot Ankle Int 25: 614- 

619 [LoE 4] 

5. Kremli MK (1996) Missed musculoskeletal 

injuries in a University Hospital in Riyadh: types 

of missed injuries and responsible factors. Injury 

27: 503-506 [LoE 4] 

6. Kotter A, Wieberneit J, Braun W, Ruter A 

(1997) Die Chopart-Luxation. Eine häufig 

unterschätzte Verletzung und ihre Folgen. Eine 

klinische Studie. Unfallchirurg 100: 737-741 

[LoE 4] 

7. Levin LS, Nunley JA (1993) The management 

of soft tissue problems associated with calcaneal 

fractures. Clin Orthop 290: 151-160 [LoE 4] 

8. McCormack RG, Leith JM (1998) Ankle 

fractures in diabetics. Complications of surgical 

management. J Bone Joint Surg Br 80: 689-692 

[LoE 4] 

9. Metak G, Scherer MA, Dannohl C (1994) 

Übersehene Verletzungen des Stütz- und 

Bewegungsapparates beim Polytrauma – eine 

retrospective Studie. Zentralbl Chir 119: 88-94 

[LoE 4] 

10. Peterson WC, Sanders WE (1996) Principles of 

fractures and dislocations. In: Rockwood CA, 

Green DP, Bucholz RW eds) Fractures in 

adults. J B Lippincott, Philadelphia, 365-368 

[LoE 5] 

11. Rammelt S, Biewener A, Grass R, Zwipp H 

(2005) Verletzungen des Fußes beim 

polytraumatisierten Patienten. Unfallchirurg 

108: 858-865 [LoE 5] 

12. Sanders LJ (1987) Amputations in the diabetic 

foot. Clin Podiatr Med Surg 4: 481-501 [LoE 4] 

13. Shah DM, Corson JD, Karmody AM, Fortune 

JB, Leather RP (1988) Optimal management of 

tibial arterial trauma. J Trauma 28: 228-234 

[LoE 4] 

14. Wagner FW (1979) Transcutaneous Doppler 

ultrasound in the prediction of healing and the 

selection of surgical level for dysvascular lesions 

of the toes and forefoot. Clin Orthop: 110-114 

[LoE 3] 

15. Wyss CR, Harrington RM, Burgess EM, Matsen 

FA, 3rd (1988) Transcutaneous oxygen tension 

as a predictor of success after an amputation. J 

Bone Joint Surg Am 70: 203-207 [LoE 3] 

16. Zwipp H (1994) Chirurgie des Fußes. Springer- 

Verlag, Wien - New York [LoE 5] 

17. Zwipp H, Rammelt S (2002) Frakturen und 

Luxationen. In: Wirth CJ, Zichner, L. (Hrsg.): 

Orthopädie und Orthopädische Chirurgie. Vol. 8. 

Georg Thieme Verlag, Stuttgart, New York, 

531-618 [LoE 5] 

Emergency room – Foot 252


2.13 Mandible and midface 

The frequency of injuries to the mandible and midface in multiply injured patients is about 18% 

[2, 19]. 

The most common concomitant injuries in craniofacial fractures are cerebral hematomas at over 

40% followed by pulmonary contusions at over 30% [1]. 

Examination 


Functional and esthetic injuries should be excluded in the clinical examination 

of the head-neck region in multiply injured patients. 

Explanation: 

GoR B 

Calling on qualified specialists (maxillofacial specialists/otorhinolaryngologists, depending on 

availability or in-house arrangement) is considered advisable for all patients with evidence of 

mandible and maxillofacial injuries, even if this naturally depends on the qualifications of the 

physicians involved and the physical and organizational conditions [12, 15, 22]. 

The examination should comprise a thorough inspection and palpation [3, 7]. It serves inter alia 

to confirm external and internal injuries (e.g., bruising, hematomas, abrasions, soft tissue 

injuries, bleeding, tooth injuries, eye injuries, cerebrospinal fluid leak, intracranial leak, and 

mandible and maxillofacial fractures). 



If there is clinical evidence of mandible and maxillofacial injuries, further 

diagnostic interventions should be carried out to provide a complete 

evaluation of the situation. 

Explanation: 

GoR B 

Conventional radiography and/or computed tomography are used for the diagnostic tests [13]. In 

order to visualize corresponding regions, a panoramic slice view (orthopantomogram), paranasal 

sinuses view, specific dental X-rays, and a Clementschitsch p.a. view of the skull or a lateral 

view of the skull are taken. Using computed tomography, progressive intracranial pressure signs, 

asymmetries, fractures, and larger maxillofacial defects as well as the degree of dislocation can 

be visualized [9, 11, 23, 24]. Axial, sagittal, and coronal slices can be calculated [9, 18] (EL 3, 

EL 4). Preoperative planning can be carried out in more detail using computed tomography [4, 

9]. This entails a reduction in operating time and higher quality [9, 21]. 

Emergency room – Mandible and midface 253


For small deformities, preference can be given to radiographic visualization on 2 planes with 

lower radiation exposure [17]. Pages et al. point out that, especially in children who are more 

sensitive than adults to the effects of ionizing rays by a factor of 3, particular attention should be 

paid because of the danger to eyes [14]. 

The methods of the imaging diagnostic test (radiography or CT) are usually determined by the 

type of concomitant injuries and the local availability of equipment. 

In the case of orbita involvement, some authors recommend visually evoked potentials (VEP) or 

electroretinograms (ERG) to evaluate the optic nerves [5, 6, 8]. Particularly in the cases where 

the clinical function diagnosis of the optic path is not possible or uncertain (as a result of 

unconsciousness, morphine doses, massive swelling), this can serve to objectify the optic path 

function and thus enable an early intervention. 



Literature 

1. Alvi A, Doherty T, Lewen G (2003) Facial fractures 

and concomitant injuries in trauma patients. 

Laryngoscope 113:102-106 

2. Cannell H, Silvester Kc, O'regan Mb (1993) Early 

management of multiply injured patients with 

maxillofacial injuries transferred to hospital by 

helicopter. Br J Oral Maxillofac Surg 31:207-212 

3. Cantore Gp, Delfini R, Gambacorta D et al. (1979) 

Cranio-orbito-facial injuries: technical suggestions. J 

Trauma 19:370-375 [LoE 4] 

4. Carls Fr, Schuknecht B, Sailer Hf (1994) Value of 

three-dimensional computed tomography in 

craniomaxillofacial surgery. J Craniofac Surg 5:282- 

288 [LoE 3] 

5. Coutin-Churchman P, Padron De Freytez A (2003) 

Vector analysis of visual evoked potentials in 

migraineurs with visual aura. Clin Neurophysiol 

114:2132-2137 [LoE 4] 

6. Dempf R, Hausamen Je (2000) [Fractures of the facial 

skull]. Unfallchirurg 103:301-313 [LoE 5] 

7. Ellis E, 3rd, Scott K (2000) Assessment of patients 

with facial fractures. Emerg Med Clin North Am 

18:411-448, vi [LoE 4] 

8. Gellrich Nc, Gellrich Mm, Zerfowski M et al. (1997) 

[Clinical and experimental study of traumatic optic 

nerve damage]. Ophthalmologe 94:807-814 [LoE 5] 

9. Holmgren Ep, Dierks Ej, Homer Ld et al. (2004) 

Facial computed tomography use in trauma patients 

who require a head computed tomogram. J Oral 

Maxillofac Surg 62:913-918 [LoE 3] 

10. Larcan A, Bollaert Pe, Audibert G et al. (1990) 

[Polytraumatized patient. First aid care, transport and 

resuscitation]. Chirurgie 116:615-621; discussion 622 

11. Lewandowski Rj, Rhodes Ca, Mccarroll K et al. 

(2004) Role of routine nonenhanced head computed 

tomography scan in excluding orbital, maxillary, or 

zygomatic fractures secondary to blunt head trauma. 


12. Mathiasen Ra, Eby Jb, Jarrahy R et al. (2001) A 

dedicated craniofacial trauma team improves 

efficiency and reduces cost. J Surg Res 97:138-143 

[LoE 2] 

13. Merville Lc, Diner Pa, Blomgren I (1989) 

Craniofacial trauma. World J Surg 13:419-439 [LoE 

5] 

14. Pages J, Buls N, Osteaux M (2003) CT doses in 

children: a multicentre study. Br J Radiol 76:803-811 

[LoE 2] 

15. Perry M (2008) Advanced Trauma Life Support 

(ATLS ® ) and facial trauma: can one size fit all? Part 

1: dilemmas in the management of the multiply 

injured patient with coexisting facial injuries. Int J 

Oral Maxillofac Surg 37:209-214 [LoE 3] 

16. Perry M, Morris C (2008) Advanced trauma life 

support (ATLS ® ) and facial trauma: can one size fit 

all? Part 2: ATLS ® , maxillofacial injuries and airway 

management dilemmas. Int J Oral Maxillofac Surg 

37:309-320 

17. Ploder O, Klug C, Backfrieder W et al. (2002) 2D- 

and 3D-based measurements of orbital floor fractures 

from CT scans. J Craniomaxillofac Surg 30:153-159 

[LoE 4] 

18. Pozzi Mucelli Rs, Stacul F, Smathers Rl et al. (1986) 

[3-dimensional craniofacial computerized 

tomography]. Radiol Med 72:399-404 

19. Regel G, Tscherne H (1997) [Fractures of the facial 

bones--second most frequent concomitant injury in 

polytrauma]. Unfallchirurg 100:329 




21. Santler G, Karcher H, Ruda C (1998) Indications and 

limitations of three-dimensional models in craniomaxillofacial 

surgery. J Craniomaxillofac Surg 26:11- 

16 [LoE 3] 

22. Schierle Hp, Hausamen Je (1997) [Modern principles 

in treatment of complex injuries of the facial bones]. 


23. Thai Kn, Hummel Rp, 3rd, Kitzmiller Wj et al. (1997) 

The role of computed tomographic scanning in the 

management of facial trauma. J Trauma 43:214-217; 


24. Treil J, Faure J, Braga J et al. (2002) [Threedimensional 

imaging and cephalometry of craniofacial 

asymmetry]. Orthod Fr 73:179-197 [LoE 4] 



2.14 Neck 


Securing the airway must take priority when treating injuries to the neck. GoR A 

In the case of tracheal tears, avulsions or open tracheal injuries, surgical 

exploration with insertion of a tracheostoma or direct reconstruction should 

be carried out. 

In the case of all neck injuries, intubation or, if not possible, insertion of a 

tracheostoma should be given early consideration. 

Explanation: 

GoR B 

GoR B 

Depending on the injury pattern, intubation must be given early consideration. This can be done 

transorally, transnasally, transvulnar or via tracheostomy. Even in the case of complete rupture 

of the trachea, distal sections can be intubated with defect bridging via endoscopic intubation. If 

oral or transnasal intubation is not possible, a tracheotomy must be considered [2]. 

A tracheostomy is always an elective operation; in the acute emergency, access should be made 

via a coniotomy as an emergency tracheotomy [13]. In the case of tracheal tears, avulsions or 

open tracheal injuries, surgical exploration with insertion of a tracheostoma or direct 

reconstruction is recommended. In the case of injuries of short length not involving all layers, 

conservative treatment can be attempted [6]. The same applies to trauma in the region of the 

larynx [2, 3, 14]. 

Emergency room – Neck 256




To confirm the type and severity of the injury, computed tomography of the 

neck soft tissues should be performed on hemodynamically stable patients. 

In the case of clinically or CT suspected neck injury, an endoscopic 

examination should be carried out on the traumatized region. 

Explanation: 

GoR B 

GoR B 

In order not to generate any additional trauma through diagnostic or therapeutic measures, a 

search should first be made for injuries to the cervical spine or these should be minimized as 

much as possible through immobilization techniques [10, 12, 14]. Although the resulting injury 

sequelae from tracheal tears or avulsions can be visualized by means of imaging diagnostic tests 

(CT/MRI/conventional radiography), part of the actual lesion is often difficult to see. Skin 

emphysema after tracheal injury is given as an example, whereby the actual lesion can often not 

be identified in the imaging or cannot be visualized in conservative imaging if there is a 

pronounced hematoma on the neck without detectable source of bleeding. In addition, 

endoscopic examinations are recommended in the diagnostic evaluation of cervical injuries [1]. 

If there are suspected vascular injuries, an alternative diagnostic procedure is duplex 

ultrasonography, which is a non-invasive examination procedure and equivalent to angiography 

[7, 8]; both thus represent the gold standard for injuries to the neck vessels. This applies 

especially to the neck zones I and III according to Roon and Christensen [12]. Surgical 

exploration is additionally recommended for zone II. Although this is hotly debated in the 

literature, it is not in dispute that 100% of defects can be identified and if necessary treated in 

this way [7, 12]. 



Treatment 


Open neck trauma with acute bleeding should be compressed initially and 

then managed by surgical exploration thereafter. 

In the case of closed neck trauma, an assessment of the vascular status should 

be carried out. 

Explanation: 

GoR B 

GoR B 

The angiography or alternatively duplex ultrasonography represent the gold standard for injuries 

to the neck vessels, especially in zones I and III according to Roon and Christensen [12]. 

Surgical exploration is additionally recommended for zone II. 

The first-line choice for function and trauma diagnostic tests is Doppler ultrasonography, being 

the least invasive, rapid, and not cost-intensive examination method. This is at least equal in 

diagnostic evidence to angiography and computed tomography, and even superior due to its 

lesser invasiveness and lower costs and higher speed [7, 8, 12]. 



References 

1. Demetriades D, Velmahos GG, Asensio JA. Cervical 

pharyngoesophageal and laryngotracheal injuries. 

World J Surg. 2001 Aug;25(8):1044-8 [LoE 2b] 

2. Dienemann H, Hoffmann H (2001). Tracheobronchial 

injuries and fistulas. Chirurg 72(10):1131-6 [LoE 3a] 

3 Donald, Paul J. Trachealchirurgie: Kopf – und Hals 

Chirurgie (H.H. Naumann et al) 1998 Georg Thieme 

Verlag (S. 243 - 57) 

4. Erhart J, Mousavi M, Vecsei V. Penetrating injuries of 

the neck, injury pattern and diagnostic algorithm. 

Chirurg. 2000 Sep;71(9):1138-43 

5. Etl S, Hafer G, Mundinger A. Cervical vascular 

penetrating trauma. Unfallchirurg. 2000 

Jan;103(1):64-7. German 

6. Gabor S, Renner H, Pinter H, Sankin O, Maier A, 

Tomaselli F, Smolle Juttner FM (2001). Indications 

for surgery in tracheobronchial ruptures. Eur J 

Cardiothorac Surg 20(2):399-404 [LoE 4] 

7. Ginzburg E, Montalvo B, LeBlang S, Nunez D, 

Martin L. The use of duplex ultrasonography in 

penetrating neck trauma. Arch Surg. 1996 

Jul;131(7):691-3 [LoE 1a] 

8. LeBlang SD, Nunez DB Jr. Noninvasive imaging of 

cervical vascular injuries. AJR Am J Roentgenol. 

2000 May;174(5):1269-78 [LoE 4] 

9. Munera F, Soto JA, Palacio D, Velez SM, Medina E. 

Diagnosis of arterial injuries caused by penetrating 

trauma to the neck: comparison of helical CT 

angiography and conventional angiography. 

Radiology. 2000 Aug;216(2):356-62 

10. Oestreicher E, Koch O, Brucher B. Impalement injury 

of the neck. HNO 2003 Oct;51(10):829-32 [LoE 4] 

11. Pitcock, J. Traumatologie der Halsweichteile:Kopf – 

und Hals Chirurgie (H.H. Naumann et al) 1998 Georg 

Thieme Verlag (S. 459 - 75) 

12. Roon AJ, Christensen N. Evaluation and treatment of 

penetrating cervical injuries. J Trauma. 1979 

Jun;19(6):391-7 [LoE 2a] 

13. Walz MK. Tracheostomy: indications, methods, 

risks.Chirurg. 2001 Oct;72(10):1101-10 [LoE 2a] 

14. Welkoborsky, H. – J. Verletzungen der Halsregion 

und der Halswirbelsäule: Praxis der HNO – 

Heilkunde, Kopf- und Halschirurgie (J. Strutz, W. 

Mann) 2001 Georg Thieme Verlag (S. 843-6) [LoE 4] 



2.15 Resuscitation 

Criteria for cardiac arrest 


In the case of definitive cardiac arrest, uncertainties in detecting a pulse or 

other clinical signs that make cardiac arrest likely, resuscitation must be 

started immediately. 

Explanation: 

GoR A 

A cardiac cause accounts for around 70-90% of patients affected by cardiac arrest. A posttraumatic 

cause accounts for only 3.1% of cases [1] and these patients have a markedly worse 

prognosis. Based on retrospective analyses of patient collectives, mainly from the 1980s to 

1990s, an average survival rate of about 2% and, in the absence of serious neurologic deficits, 

only 0.8% is given in the “ERC Guidelines for Resuscitation 2005”, with slightly better survival 

for penetrating injuries than for blunt trauma [2]. Somewhat better prognoses have been 

published in more recent studies [3-5]. In an analysis of the DGU Trauma Registry of 10,359 

patients from the period 1993-2004, 17.2% of the multiply injured patients were successfully 

resuscitated after traumatic cardiac arrest, 9.7% of whom with a moderate to good neurologic 

outcome (Glasgow Outcome Scale [GOS] ≥ 4, Table 12). Seventy-seven (10%) of the 

resuscitated patients received an emergency thoracotomy with a survival rate of 13% [6]. In 

some studies, survival after traumatic and non-traumatic cardiac arrest was even comparable [7]. 

Table 12: Glasgow Outcome Scale (GOS) [8]: 

Classification of course after traumatic brain injury with intracranial lesions and neuronal 

damage (point scale 1-5): 

1. Died as a result of acute brain damage 

2. Apallic, permanent vegetative condition 

3. Severely disabled (mentally and/or physically), requiring permanent care, no earning 

capacity 

4. Moderately disabled, mostly independent but marked neurologic and/or psychiatric 

disorders, considerable restriction in earning capacity 

5. Not/mildly disabled, normal life despite possible minor deficits, only slight or no 

restriction in earning capacity 

The criteria for detecting cardiac arrest in trauma patients do not differ from the criteria in nontraumatic 

cardiac arrest. The diagnosis to resuscitate the trauma patient must be made according 

to the guidelines of the European Resuscitation Council and, when indicated, must be started or 

continued [37]. The main criterion in the diagnosis of cardiac arrest in a traumatized patient in 

the emergency room is also apnea in combination with absence of pulse with/without electrical 

activity of the heart. In earlier resuscitation guidelines, the conscious state, breathing, and 

circulation were checked first [8, 9]. However, studies have meanwhile shown that both 

Emergency room - Resuscitation 260


checking for the absence of spontaneous breathing [10, 11] and particularly checking for absence 

of pulse [11, 12] is beset with a high error rate even by trained personnel. Low specificity in 

particular could lead to a delay in resuscitation. 

Medical personnel in the emergency room should search for a maximum of 10 seconds for the 

presence or absence of a central pulse. In case of doubt or if there are other clinical signs that 

make cardiac arrest likely, resuscitation should be started immediately [13]. 

An allegedly normal ECG does not exclude cardiac arrest in terms of an electromechanical 

decoupling (pulseless electrical activity) any more than a pathologic or even possibly artificially 

altered ECG provides evidence of blood circulation [13]. Nevertheless, an immediate ECG 

recording is an essential component in monitoring in the emergency room and is always included 

in the evaluation of the cardiovascular situation. 

If there is suspicion or evidence of cardiac arrest, the ECG and its changes also determine the use 

and timing of defibrillation treatment [13]. Pulse oxymetry and particularly also capnography are 

essential components in monitoring a multiply injured patient. Both procedures are able to 

indicate cardiac arrest (absent pulse wave in pulse oxymetry, rapidly falling etCO2 in 

capnography). However, the limitations of pulse oxymetry in shock, centralization, and 

hypothermia should be noted. 



Are there special features to note when resuscitating trauma patients? 


During resuscitation, trauma-specific reversible causes of cardiac arrest (e.g., 

airway obstruction, esophageal intubation, hypovolemia, tension 

pneumothorax or pericardial tamponade) should be diagnosed and treated. 

An intraarterial catheter should be inserted for invasive continuous blood 

pressure measurement. 

Explanation: 

GoR A 

GoR B 

In principle, establishing the indication for resuscitation even in the trauma patient must be done 

according to the guidelines of the ERC [2, 13]. More recent analyses on trauma-associated 

cardiac arrest show much better survival [3-6]. This is chiefly due to more advanced emergency 

systems and more consistent application of resuscitation guidelines (see Figure 4) as well as to 

adherence to emergency room algorithms. The survival rates correlate above all with the 

prehospital rescue time and the period of cardiopulmonary resuscitation [2, 14–17]. 

The main causes of cardiac arrest after a trauma are severe traumatic brain injury and massive 

bleeding [2, 18, 19]. The success of cardiopulmonary resuscitation is only ensured if the cause of 

cardiac arrest can be treated. To ascertain the trauma-specific reversible causes of cardiac arrest, 

the tube placement should be monitored by auscultation and capnometry/capnography, 

ultrasonography of the abdomen, pleural space, cardiac ventricles, and pericardium (standardized 

procedure if possible, e.g., FAST), and the hemoglobin value in the BGA measured during 

ongoing cardiopulmonary resuscitation. 

Current studies in the Federal Republic of Germany have detected a frequency of esophageal 

intubations in up to 7% of cases, and so immediate monitoring of the correct placement of the 

tracheal tube by auscultation and capnometry/capnography is indispensable immediately after 

intubation both by the emergency physician and after the patient has arrived in the emergency 

room [20]. 

With emergency ultrasonography (e.g., FAST) [21, 22] and with recording the hemoglobin value 

in the (arterial or venous) blood gas analysis, etiologic abdominal or thoracic massive bleeding 

should be recorded during resuscitation and appropriate aggressive volume replacement and 

specific surgical treatment carried out. With pronounced hypovolemia, the use of hyperosmolar 

solutions and dispensing with PEEP ventilation can be expedient to improve preload and cardiac 

fill rapidly. If hypovolemia is the cause of cardiac arrest, the success rate of cardiopulmonary 

resuscitation can be increased with these measures [19, 23]. 

Retrospective analyses showed that the insertion of chest drains could be valued as a positive 

predictor for survival after post-traumatic cardiac arrest, which could be explained by the 

removal or prevention of a tension pneumothorax [6, 24–26]. 



According to expert opinion of the guideline project group, the early insertion of an intraarterial 

catheter into the femoral artery for invasive continuous blood pressure measurement can 

objectify the diagnosis of cardiac arrest and the efficiency of resuscitation efforts in the 

emergency room. In so doing, there must be no interruption or delay in cardiopulmonary 

resuscitation due to the insertion of the intraarterial catheter. 



Figure 4: CPR algorithm according to the ERC Guidelines [36] 

Shock indicated 

Ventricular fibrillation/ 

pulseless ventricular tachycardia 

1 shock 

Immediately resume: 

CPR for 2 min 

Minimize interruptions 

Advance Life Support for Adults (ALS): 

© by European Resuscitation Council (ERC) 2010 

During CPR 

• ensure highly qualified CPR: rate, depth, decompression 

• plan actions prior to CPR interruption 

• give oxygen 

• airway management; consider capnography 

• cardiac massage without interruption if airway secured 

• vascular access: intravenous, intraossary 

• inject adrenalin every 3-5 min 

• treat reversible causes 

Unresponsive? 

Respiratory arrest or only gasping breaths 

Cardiopulmonary resuscitation 

(CPR) 30 : 2 

Attach defibrillator/ECG monitor 


Assess 

ECG rhythm 

Circulation 

re-starts 

spontaneously 

Immediate treatment 

• use ABCDE algorithm 

• give oxygen + ventilation 

• 12-lead ECG 

• treat trigger factors 

• temperature control/ 

therapeutic hypothermia 

Immediately resume: 

CPR for 2 min 


Emergency room - Resuscitation 264 

X 

Notify resuscitation team/ 

emergency services 

Shock not indicated 

(PEA/asystole) 

Reversible causes 

• Hypoxia 

• Hypovolemia 

• Hypo-/hyperkalemia/metabolic 

• Hypothermia 

• Pericardial tamponade 

• Intoxication 

• Thrombosis (AMI, LAE) 

• Tension pneumothorax


Failure and discontinuation criteria 


If resuscitation is unsuccessful after eliminating possible trauma-specific 

causes of cardiac arrest, cardiopulmonary resuscitation must be stopped. 

If there are definite signs of death or injuries that are not compatible with life, 

cardiopulmonary resuscitation must not be started. 

Explanation: 

GoR A 

GoR A 

Most multiply injured patients die in the early phase from the consequences of severe traumatic 

brain injuries and massive bleeding [2, 18, 19]. Injuries not compatible with life may be present 

(e.g., injuries to the great vessels). The success of cardiopulmonary resuscitation firstly depends 

on the time since cardiac arrest occurred and secondly on the possibility of eliminating traumaspecific 

causes of cardiac arrest during resuscitation. Despite implementation of the aforementioned 

therapeutic measures (e.g., insertion of a chest drain) to eliminate trauma-specific 

causes of cardiac arrest, cardiopulmonary resuscitation can be unsuccessful. If no causes can be 

established during cardiopulmonary resuscitation or if the elimination of possible traumaspecific 

causes does not lead to a return of spontaneous circulation [ROSC]), resuscitation must 

be discontinued. The recognized definite signs of death signal an irreversible cell death of organs 

essential for life and are therefore indicators for failure of cardiopulmonary resuscitation. If there 

are definite signs of death or injuries that are not compatible with life, cardiopulmonary 

resuscitation must not be started. The decision to continue or discontinue cardiopulmonary 

resuscitation is the responsibility of the treating physicians and must be made in consensus. A 

time limit for unsuccessful resuscitation cannot be given. 



What importance does the emergency thoracotomy have in post-traumatic cardiac arrest 

in the emergency room? 


Emergency thoracotomy should be performed in the case of penetrating 

injuries, particularly if the onset of cardiac arrest is recent and vital signs are 

initially present. 

Explanation: 

GoR B 

Performing an emergency thoracotomy is described as being relatively straightforward [27, 28] 

but requires, according to the ATLS ® criteria of the American College of Surgeons [29], a 

trained, experienced surgeon and, according to the DGU guidelines [30], the availability of a 

thoracotomy set in the emergency room. 

Based on a meta-analysis of 42 studies with a total of 7,035 documented “emergency department 

thoracotomies”, the American College of Surgeons has published a guideline on the indication 

for and performance of an emergency room thoracotomy under cardiopulmonary resuscitation 

[31]. The resulting statements are based chiefly on the finding that, with an overall survival rate 

of 7.8%, only 1.6% of patients survived after blunt trauma but 11.2% after penetrating trauma. 

An emergency room resuscitative thoracotomy can improve the prognosis particularly in the case 

of penetrating trauma and appears to be particularly expedient if vital signs are initially present 

[31-33]. Appropriate logistic equipment is mandatory [34]. In blunt trauma, on the other hand, an 

emergency thoracotomy should be carried out more reluctantly. If an emergency thoracotomy is 

performed and there is simultaneously intraabdominal massive bleeding, a laparotomy to arrest 

the bleeding should be performed parallel to the thoracotomy. Appropriate logistic equipment is 

mandatory [35]. 



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management, and outcome of out of hospital 

cardiopulmonary arrest: comparison by underlying 

aetiology. Heart 2003;89:839-42 

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Resuscitation Council Guidelines for Resusitation 

2005. Section 7. Cardiac arrest in special 

circumstaandes. Resusitation 2005 ;67S1:S135-S170 


3. Hess EP, Campell RL, et al. Epidemiology, trends, 

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6. Huber-Wagner S, Lefering R, Qvick M, et al. 

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7. David, JS, Gueugniaud PY, Riou B, et al. Does the 

prognosis of cardiac arrest differ in trauma patients? 

Crit Care Med 2007;35:2251-2255 

8. Handley AJ, Becker LB, Allen M, et al. Single rescuer 

adult basic life support. An advisory statement from 

the Basic Life Support Working Group of the 

International Liaison Committee on Resuscitation 

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9. Basic Life Support Working Group of the European 

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support. Resuscitation 1998;37:67-80 


10. Ruppert M, Reith MW, Widmann JH, et al. Checking 

for breathing: Evaluation of the diagnostic capability 

of emergency medical services personnel, physicians, 

medical students, and medical laypersons. Ann Emerg 

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11. Cummins RO, Hazinsk MF. Cardiopulmonary 

resuscitation techniques and instruction: When does 

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12. Eberle B, Dick WF, Schneider T, et al. Checking the 

carotid pulse check: diagnostic accuracy of first 

responers in patients with and without a pulse. 

Resuscitation 1996;33:107-116 [LoE 1b] 

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2005 International consensus on cardiopulmonary 

resuscitation and emergency cardiovascular care 

science with treatment recommendations. 

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14. Fulton RL, Voigt WJ, Hilakos AS. Confusion 

surrounding the treatment of traumatic cardiac arrest. 

J Am Coll Surg 1995;181:209-214 [LoE 2c] 

15. Gervin AS, Fischer RP. The importance of prompt 

transport of salvage of patients with penetrating heart 

wounds. J Trauma 1982;22:443-448 [LoE 2c] 

16. Durham III LA, Richardson RJ, Wall Jr MJ, Pepe PE, 

Mattox KL. Emergency center thoracotomy: impact of 

prehospital resuscitation. J Trauma 1992;32:775-779 

[LoE 2c] 

17. Powell DW, Moore EE, Cothren CC, et al. Is 

emergency department resuscitative thoracotomy 

futile care for the critically injured patient requiring 

prehospital cardiopulmonary resuscitation? J Am Coll 

Surg 2004;199:211-215 [LoE 2c] 

18. Søreide K, Krüger AJ, Vårdal AL, et al. Epidemiology 

and Contemporary Patterns of Trauma Deaths: 

Changing Place, Similar Pace, Older Face. World J 

Surg. 2007;31:2092-2103 

19. Bansal V, Fortlage D, Lee JG, et al. Hemorrhage is 

More Prevalent than Brain Injury in Early Trauma 

Deaths: The Golden Six Hours. Eur J Trauma Emerg 

Surg 2009;35:26–30 

20. Timmermann A, Russo SG, Eich C, et al. The out-ofhospital 

esophageal and endobronchial intubations 

performed by emergency physicians. Anesth Analg 

2007;104:619-623 

21. Geeraedts LM Jr, Kaasjager HA, van Vugt AB, Frölke 

JP. Exsanguination in trauma: A review of diagnostics 

and treatment options. Injury 2009 40:11-20 [LoE 1b] 

22. Ollerton JE, Sugrue M, Balogh Z, et al. Prospective 

study to evaluate the influence of FAST on trauma 

patient management. J Trauma 2006;60:785-791 [LoE 

1b] 

23. Herff H, Paal P, von Goedecke A, et. al. Ventilation 

strategies in the obstructed airway in a bench model 

simulating a nonintubated respiratory arrest patient. 

Anesth Analg 2009 ;108:1585-1588 

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thoracostomy avoids chest drain insertion in 

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25. Mistry N, Bleetman A, Roberts KJ. Chest 

decompression during the resuscitation of patients in 

prehospital traumatic cardiac arrest. Emerg Med J 

2009;26:738-740 [LoE 2a] 

26. Bushby N, Fitzgerald M, Cameron P et al. Prehospital 

intubation and chest decompression is associated with 

unexpected survival in major thoracic blunt trauma. 

Emerg Med Australas 2005;17:443-449 [LoE 2a] 

27. Wise D, Davies G, Coats T, et al. Emergency 

thoracotomy: ‘‘how to do it’’. Emerg Med J 

2005;22:22-24 

28. Voiglio EJ, Coats TJ, Baudoin YP, Davies GD, 

Wilson AW. Resuscitative transverse thoracotomy. 

Ann Chir 2003;128:728-733 

29. American College of Surgeons – Committee on 

Trauma (2008) ATLS ® : Advanced Trauma Life 

Support for Doctors, 8th ed. American College of 

Surgeons, Chicago [LoE 5] 

30. Arbeitsgruppe Unfallchirurgische Leitlinien der 

Deutschen Gesellschaft für Unfallchirurgie (DGU) in 



Zusammenarbeit mit der Arbeitsgemeinschaft 

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http://www.uniduesseldorf.de/WWW/AWMF/awmffrs.htm 

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American College of Surgeons-Committee on 

Trauma. Practice management guidelines for 

emergency department thoracotomy. J Am Coll Surg 

2001;193:303-309 [Evidenzbasierte Leitlinie] 

32. Karmy-Jones R, Nathens A, Jurkovich GJ, et al. 

Urgent and emergent thoracotomy for penetrating 

chest trauma. J Trauma 2004;56:664-668; discussion 

668-9 [LoE 2c] 

33. Powell DW, Moore EE, Cothren CC, et al. Is 

emergency department resuscitative thoracotomy 

futile care for the critically injured patient requiring 

prehospital cardiopulmonary resuscitation? J Am Coll 

Surg 2004;199:211-215 [LoE 2c] 

34. Seamon MJ, Fisher CA, Gaughan JP, et al. 

Emergency department thoracotomy: survival of the 

least expected. World J Surg 2008;32: 604-612 

35. Fialka C, Sebok C, Kernetzhofer P, et al. Open-chest 

cardiopulmonary resuscitation after cardiac arrest in 

cases of blunt chest or abdominal trauma: a 

consecutive series of 38 cases. J Trauma 2004;57:809- 

814 

36. Deakin CD, Nolan JP et al. Erweiterte Reanimationsmaßnahmen 

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support“). Notfall&Rettungsmedizin 2010; 13(7): 

p. 559-620 

37. Nolan JP, Deakin CD, Soar J et al. (2005) European 

Resuscitation Council Guidelines for Resuscitation 

2005. Section 4. Adult advanced life support. 

Resuscitation 67(1): S39-S86 



2.16 Coagulation system 

The term “polytrauma” refers to a very heterogeneous patient group. Perioperative coagulation 

therapy, particularly in this patient population, was carried out for decades according to gut 

instinct. The attempt to find a broader basis for medical management led to expert 

recommendations, which were based on physiologic concepts as well as pharmacologic and 

pharmacodynamic considerations. Increasingly, there are experimental and clinical studies on 

individual research questions. Even if the pathophysiologic correlations between the therapy 

choices described and the impaired coagulation can be presented conclusively and coherently, 

confirmation through randomized controlled trials is still awaited for virtually all 

recommendations. As with the 4th edition of the “Cross-Sectional Guideline on Therapy using 

Blood Components and Plasma Derivatives” by the German Medical Association (BÄK), the 

following recommendations are largely based on case observations and not randomized studies. 

Thus, the majority of conclusions can only be awarded a grade of recommendation [GoR] 0. For 

this reason, and also because of the partly considerable costs of the replacements described, it 

must be emphasized that the listed threshold values should in no way be seen as a cue for simply 

improving laboratory measurements. Rather, the indication for replacement using the cited drugs 

is only given in the event of massive, life-threatening bleeding [70]. 

Trauma-induced coagulopathy 


Trauma-induced coagulopathy is an autonomous clinical picture with clear 

influences on survival. For this reason, coagulation diagnostic tests and 

therapy must be started immediately in the emergency room. 

Thrombelastography and thrombelastometry can be carried out to guide the 

coagulation diagnostic test and coagulation replacement. 

Explanation: 

GoR A 

GoR 0 

The early trauma-induced mortality is usually a consequence of traumatic brain injury (40-50% 

of deaths) or of massive bleeding (20-40%). Bleeding is greatly increased by additional 

coagulopathy [102]. A coagulation disorder in multiply injured patients (trauma-induced 

coagulopathy [TIC]) has been known for over 20 years [61]. This coagulopathy was originally 

seen as a secondary occurrence, i.e. caused by loss/dilution and intensified by acidosis and 

hypothermia (“lethal triad”, “bloody vicious circle”) [55]. However, evidence of the existence of 

an autonomous, multifactorial, primary disease, which is intensified by the secondary factors 

(consumption, loss, dilutional coagulopathy), has been found in the present literature [9, 95], 

even in the Federal Republic of Germany [76]. TIC significantly influences the survival of 

multiply injured patients [72, 74]. It is independently correlated with a 4 to 8 times increased allcause 

case fatality rate [72] and 8 times increased case fatality rate within 24 hours [76]. Patients 

who are coagulopathic on admission to the emergency room remain longer in the intensive care 

Emergency room – Coagulation system 269


unit and in hospital, have a higher risk of renal insufficiency and multi-organ failure, have to be 

ventilated for longer, and exhibit a trend towards increased lung failure [8, 76]. An 

internationally valid, uniform term for this clinical picture is still lacking; suggestions are “acute 

traumatic coagulopathy” [10], “coagulopathy of trauma” [47], and “acute coagulopathy of 

trauma shock” [46]. The hypoperfusion and hyperfibrinolysis induced by the tissue injury and 

the shock are the triggers of TIC [9, 46]. The extent of hyperfibrinolysis appears to be correlated 

to the injury severity [67]. In a retrospective analysis, Schöchl et al. [102] found evidence of 

hyperfibrinolysis with an ISS > 25 in almost 15% of cases. TIC is already present on arrival in 

the emergency room in about 30% of the multiply injured and leads to an increased case fatality 

rate [10, 72, 74, 76, 95]. As there is no intravasal coagulation and thrombosis in the early phase 

of a trauma, this clinical picture does not involve disseminated intravasal coagulopathy (DIC) 

[34, 47]. 

The definition of massive bleeding consists of a blood loss of ≥ 100% of blood volume within 24 

hours, of ≥ 50% within 3 hours, and 150 ml/min or 1.5 ml/kg BW/min over 20 minutes [114]. 

Diagnostic test: While the clinical picture of TIC is characterized by non-surgical, diffuse 

bleeding from mucous membrane, serous membrane, and wound areas, occurrence of bleeding 

from puncture sites of intravasal catheters and bleeding from indwelling bladder catheters or 

abdominal tubes, there is a gross lack of suitable laboratory parameters [70]. The prothrombin 

time/Quick test/INR and the partial thromboplastin time are poor determinants of a reduced level 

of coagulation factors and weak predictors for bleeding tendency in critically ill patients [15, 66]. 

In addition, these parameters only measure the time to the start of clot formation. A conclusion 

on the clotting strength and quality, its fibrinolytic activity or platelet function is not possible [7]. 

A prompt diagnostic test on the patient is also not possible. 

The “classic” laboratory parameters are measured at 37 °C, buffered, with excess of calcium in 

serum and plasma. Thus, acidosis, hypothermia, hypocalcemia, and anemia are not included [36, 

71] although these factors can have a considerable effect [71]. However, due to the 

epidemiologically increasing number of elderly patients, anticoagulation must be assumed in the 

case of trauma in this clientele. An INR > 1.5 in the over-50s is thus correlated with a 

significantly increased case fatality rate; this applies particularly to traumatic brain injuries 

[134]. Data from trauma registries showed that a prolonged prothrombin time in traumatized 

patients is a predictor for mortality [10, 72, 94]. Hess et al. [48] were able to confirm that 

pathologic “classic” laboratory parameters occurred with increasing frequency with increasing 

injury severity. These pathologic values, particularly the Quick test/INR, were associated with an 

increased case fatality rate. 

Thrombelastography: (Rotational) thrombelastography (TEG) and (rotational) 

thrombelastometry (RoTEM) are being increasingly studied for the monitoring of multiply 

injured patients. In contrast to the standard coagulation test, this allows not only the time until 

onset of coagulation but also the speed of clot formation and the maximum clotting firmness to 

be recorded. This test procedure can be carried out without delay in the emergency room. Thus, 

treatment decisions can be made sooner [92, 95]. Several TEG/RoTEM-based algorithms for 

trauma management have already been published (e.g., [36, 59, 64]). 



In the pig model for massive bleeding, Martini et al. [80] found a better correlation of 

thrombelastographic parameters compared to the Quick test, to PTT (partial thromboplastin 

time) or to INR. In a prospective observation study, Rugeri et al. [95] showed in 88 patients that 

different RoTEM parameters with a sensitivity and specificity between 74 and 100% are suitable 

for visualizing in vivo the changes in coagulation. The results from Levrat et al. [67] on 87 

trauma patients lay in the same range for sensitivity and specificity. The trauma-induced 

hyperfibrinolysis in particular could be effectively confirmed. In 44 soldiers with penetrating 

injuries, Plotkin et al. [92] noted the TEG as a more precise indicator than the Quick test, PTT or 

INR for the need for blood products. Schöchl et al. [101] measured mortality-predicting 

hyperfibrinolysis using ROTEM in 33 critically injured patients: The time of fibrinolysis within 

30 minutes after the start of coagulation, after 30-60 minutes, and after more than 60 minutes 

correlated with the mortality rate (100%, 91%, 73%), late fibrinolysis allowing the best 

prognosis (p = 0.0031). The results were available within 10-20 minutes and showed an 

increasing number of hyperfibrinolyses with increasing injury severity. 

The use of thrombelastography and thrombelastometry in traumatized patients is very promising 

for guiding the coagulation diagnostic tests and replacement, particularly in the case of 

hyperfibrinolyses [11], but requires further prospective evaluation [70, 111]. 



Damage control resuscitation 


In patients who are actively bleeding, the goal can be set at permissive 

hypotension (mean arterial pressure ~ 65 mmHg, systolic arterial pressure 

~ 90 mmHg) until surgical hemostasis. This strategy is contraindicated in 

injuries of the central nervous system. 

Suitable measures should be taken and treatment given to avoid the patient 

cooling down. 

GoR 0 

GoR B 

Acidemia should be avoided and treated by suitable shock treatment. GoR B 

Hypocalcemia < 0.9 mmol/l should be avoided and can be treated. GoR 0 

Explanation: 

Similar to damage control surgery, where definitive anatomic management is temporarily 

deferred in favor of stabilizing the vital physiologic signs, the concept of damage control 

resuscitation was developed to prevent trauma-induced coagulopathy [2]. Permissive 

hypotension, the prevention of acidemia, hypocalcemia and hypothermia, and the administration 

of coagulation-promoting products are part of this procedure [111]. The prerequisite for 

determining these parameters is consistent, invasive hemodynamic monitoring and the possibility 

for prompt, repetitive blood gas analyses. 

Permissive hypotension: The term describes 2 approaches: firstly, to tolerate a lower than normal 

blood pressure and even to aim towards that in order to support thrombus formation and, 

secondly, to infuse only a small amount of fluid in order to prevent iatrogenic dilution while still 

ensuring adequate perfusion of the end organs. The correlation between “normal” blood pressure 

and bleeding tendency in trauma was already known by the end of the First World War [12]. The 

idea evolved in the military environment of tolerating low blood pressure values with a radial 

pulse that could still be felt as long as no surgical hemostasis is warranted [2]. 

The basis for the clinical application is a study by Bickell et al. [3] from 1994 of penetrating 

injuries in which patients with prehospital replacement therapy had an increased case fatality 

rate. The accompanying editorial [57] and a large number of readers’ letters mentioned the 

deficiencies in study design, conduct, and interpretation. Using the data from the German trauma 

registry, Maegele et al. [76] were able to show that an increasing frequency in coagulopathy 

occurred with increasing prehospital fluid therapy. In a randomized controlled trial with 

paramedics, Turner et al. [127] found no evidence in trauma patients of either advantage or 

disadvantage in prehospital fluid therapy (odds ratio [OR] for death from volume administration: 

1.07 with 95% CI: 0.73-1.54; with exclusion of ambiguous patient data: OR 1.04; 95% CI: 0.70– 

1.53). Dutton et al. [28] noted no change in the duration of active bleeding in each of 55 



traumatized patients (51% penetrating injury), whose volume replacement was titrated to a 

systolic blood pressure of > 100 mmHg or 70 mmHg. However, the authors showed that a 

sudden reduction in fluid requirement with increasing blood pressure is a sign of arrested 

bleeding [26]. A Cochrane Review from 2003 [65] also found no evidence for or against early, 

greater volume therapy for uncontrolled bleeding. 

Due to pathophysiologic considerations, a target blood pressure of 65 mmHg as mean pressure or 

90 mmHg as systolic value is recommended in current review papers for patients with massive 

bleeding despite a lack of evidence-based proofs. As adequate perfusion pressure is necessary if 

there is damage to the central nervous system, this recommendation does not apply to patients 

with a traumatic brain injury [53, 74, 106, 123]. 

Warming up: Hypothermia ≤ 34 °C has a major effect on platelet function and the activity of 

coagulation factors [71]. For the cooling down of the patient to be kept to a minimum, the initial 

fluid therapy must be provided exclusively by warmed infusions [2, 124] and, from the 

emergency room onwards, any volume therapy must be administered only via infusion warming 

devices with an infusion temperature of 40–42 °C [97, 124]. Both passive (e.g., foil space 

blankets, blankets, removal of wet clothing) and active measures (e.g., replacing 

infusions brought in with warmed infusions, constant use of heating pads, radiant heaters, hot air 

fans) are helpful. Both during the diagnostic study and later in the operating room, the room 

temperature should be as high as possible - in the thermoneutral zone if possible, i.e. 28–29 °C 

[97, 106, 126]. 

In the pig model, hypothermia reduces thrombin formation in the initial phase and impairs 

fibrinogen formation [79]. The hypothermia-induced platelet dysfunction can be partially 

corrected in vitro with an infusion of desmopressin (DDAVP) in the typical dose of 0.3 µg/kg 

[135]. In a thrombelastography study, Rundgren et al. [96] found evidence of an increasing effect 

of coagulation with decreasing temperature in a temperature range of 25 to 40 °C. There are no 

randomized controlled trials on trauma patients. 

Acidosis balance: Acidosis ≤ 7.2 has a marked negative effect on coagulation [11, 71]. As the 

main cause of acidemia is hypoperfusion, acidosis will persist until adequate tissue perfusion is 

restored. Interventions that can intensify acidosis such as hypoventilation or NaCl infusion, for 

example, should be avoided [2]. The base excess (BE) also impairs coagulation [71] and can be 

used as prognostic evidence of complications and death [106]. Using data from Meng et al. [84], 

Zander et al. [137] showed that with a BE of - 15 the activity of various coagulation factors is 

halved. Critical values for the BE start in a range from - 6 to - 10 [106, 136]. 

In the pig model, Martini et al. [81] could not achieve any improvement in coagulopathy through 

buffering. As a single measure, buffering to pH values of ≥ 7.2 thus apparently leads to no 

improvement in coagulopathy [7] and is only meaningful from a hemostaseologic viewpoint in 

combination with the administration of coagulation products. Even a massive transfusion of 

stored PRBC can strongly increase acidosis [107]. The BE of fresh PRBC is - 20 mmol/l but 

after 6 weeks - 50 mmol/l [71]. Acidosis reduces thrombin formation in the propagation phase 

and accelerates fibrinogenolysis [79]. In the pig model, Martini et al. [82] proved that sodium 

bicarbonate balances pH and BE but cannot normalize either the fibrinogen level or the impaired 



thrombin formation. Tris(hydroxymethyl)aminomethane (TRIS, THAM) also did not impair the 

reduction in fibrinogen but stabilized the kinetics of thrombin generation in pigs. At present, it 

cannot be concluded which of the two substances is better suited for buffering for 

hemostaseologic reasons. 

Calcium replacement: The reduction in ionized calcium (Ca ++ ) after transfusions depends on the 

citrate used as anticoagulant in the banked blood and is particularly marked in fresh frozen 

plasma (FFP). The reduction is more marked the quicker the banked blood is transfused, 

particularly at a transfusion speed > 50 ml/min [11]. The calcium monoproducts available in 

Germany for intravenous use contain very variable amounts of calcium ions [69]. This must be 

taken into account during replacement. A marked impairment of coagulation must be assumed 

below an ionized Ca ++ concentration of 0.9 mmol/l [11]. 



Replacement of coagulation-promoting products 


A specific massive transfusion protocol should be introduced and continued. GoR B 

In an actively bleeding patient, the indication for transfusion can be made at 

hemoglobin levels below 10 g/dl or 6.2 mmol/l, and the hematocrit value 

maintained at 30%. 

If coagulation therapy in massive transfusions is carried out by administering 

FFP, the FFP:PRBC target ratio should be in the range of 1:2 and 1:1. 

Replacement of fibrinogen should be carried out if levels are at < 1.5 g/l 

(150 mg/dl). 

Explanation: 

GoR 0 

GoR B 

GoR B 

Packed red blood cells (PRBC): An increasing number of publications in the fields of trauma and 

intensive care point out the negative effect of PRBC administration on survival (see, for 

example, review in [2] or [125]). Malone et al. [77] noted in 15,534 trauma patients that a blood 

transfusion was a strong, independent predictor for mortality (OR 2.83; 95% CI: 1.82–4.40; 

p < 0.001). PRBC supplies aged > 14 days result in a significant worsening in survival both for 

mildly injured [131] as well as severely injured [130] trauma patients [110]. 

However, the involvement of red blood corpuscles in coagulation is confirmed (see, for example, 

review in [43] or [71]). In a TIC, a restrictive transfusion trigger can be unfavorable [83] as 

significant impairments to coagulation develop clearly before oxygenation has an effect [43]. 

While there are no randomized controlled data on hemostaseologically optimum hemoglobin and 

hematocrit values in polytrauma, target hemoglobin concentrations until arrest of bleeding 

should be in the range of 10 g/dl (6.2 mmol/l, hematocrit 30%) according to the German Medical 

Association, due to the favorable effects of higher hematocrit values on primary hemostasis in 

the case of massive, non-arrested hemorrhage [11]. The German Medical Association bases this 

recommendation on the review paper by Hardy et al. [42], which states that in bleeding patients 

experimental data indicate that hematocrit values of up to 35% are necessary to maintain 

hemostasis. 

Frozen fresh plasma (FFP): In a systematic review of randomized controlled trials, Stanworth et 

al. [116] found no evidence of efficacy of FFP transfusion either in the group of massive 

transfusions or in a wide variety of other indications but frequently found problems in study 

design. Chowdhury et al. [15] studied the efficacy of FFP administration in a cohort study of 22 

intensive patients. The often recommended volume of 10-15 ml/kg/BW did not lead to an 

adequate increase in factor concentration. This was only achieved with 30 ml/kg/BW, for which 



the patients required a median volume of 2.5 l FFP. A randomized double-blind trial of 90 

patients with severe, closed traumatic brain injury (GCS ≤ 8) was carried out by Etemadrezaie et 

al. [29]. One group received a slow transfusion 10–15 ml/kg BW FFP while the control group 

received the same amount of common salt. In the FFP group, a new intracerebral hematoma 

developed more frequently (p = 0.012), and the patients had a significantly elevated mortality 

rate (63% versus 35%, p = 0.006). Hedim et al. [44] achieved a plasma dilution of 21% for 2.9 

hours with an infusion of only 10 ml/kg BW FFP. 

The transfusion of FFP also contains a series of risks: Dara et al. [20] noted a more frequent 

occurrence of acute lung injuries (ALI; 18% versus 4%, p = 0.021) after FFP transfusion in 

patients in the medical intensive care unit. Sperry et al. [109] found prospectively in 415 patients 

approximately double the TRALI (transfusion-associated acute lung insufficiency) risk with a 

ratio of FFP:PRBC > 1:1.5 (47.1% versus 24.0%, p = 0.001). Sarani et al. [99] showed after FFP 

transfusion in non-traumatized patients in the surgical intensive care unit a relative risk for the 

occurrence of an infection of 2.99, severe, ventilator-associated pneumonia of 5.42, severe 

bacteriemia of 3.35, and sepsis of 3.2 (each p < 001). There was a cumulative risk of infection of 

~ 4% per FFP. Chaiwat et al. [14] identified the transfusion of FFP in trauma as an independent 

predictor for ARDS in 14,070 trauma patients: relative risk after transfusion of 1-5 FFP of 1.66 

(95% CI: 0.88–3.15) and at > 5 FFP of 2.55 (95% CI: 1.17–5.55). 

The German Medical Association regards the prevention and treatment of microvascular 

bleeding as an indication for FFP but described the treatment of coagulopathy with FFP alone as 

of little efficacy (increased rate, volume loading) [11]. It recommends rapid transfusion of 

initially 20 ml/kg BW but emphasizes that higher volumes may be necessary. There are no 

controlled studies to determine effective plasma doses [11]. 

FFP ratio to PRBC: The military field provided the first evidence that the replacement of lost 

blood volume by “full blood” can provide a survival advantage in critically injured patients with 

massive transfusions (> 10 PRBC/24 h) [93]. However, full blood is not available in the Federal 

Republic of Germany. 

Hirshberg et al. [51] showed the necessity of early FFP replacement on a computer model and 

they recommended an FFP:PRBC of 1:1.5 or the transfusion of 2 FFP with the first PRBC. Ho et 

al. [52] calculated on a mathematical model that a bleeding-induced heavy loss of coagulation 

factors can only be remedied with a transfusion of 1-1.5 FFP per PRBC; if the FFP 

administration starts before the factor concentration has dropped below 50%, then a 1:1 ratio is 

sufficient. Borgmann et al. [6] showed the advantage of a 1:1 replacement of FFP and PRBC in 

military personnel. A retrospective study was carried out on the survival of 246 soldiers who had 

received replacement in a ratio of 1:8, 1:2.5 or 1:1.4. The hemorrhage-induced case fatality rates 

were 92.5%, 78%, and 37% (p < 0001). In the regression analysis, the FFP:PRBC ratio was 

linked independently with survival and discharge from hospital (OR 8.6; 95% CI: 2.1–35.2). 

Dente et al. [21] prospectively compared 73 civil patients after introducing a massive transfusion 

protocol containing PRBC, FPP, and platelets in the ratio 1:1:1 with 84 patients before 

introducing the protocol. The results showed a drastic reduction in early coagulopathy (p 

= 0.023), 24-hour case fatality rate (17% versus 36%, p = 0.008), and 30-day case fatality rate 

for blunt trauma (34% versus 55%, p = 0.04). In 135 patients, Duchesne et al. [24] proved a 



significant survival advantage with an FFP-PRBC ratio of 1:1 compared to 1:4 (26% versus 

87.5%, p = 0.0001). Gonzalez et al. [39] compared the results of their massive transfusion 

protocol on 97 patients for the emergency room (PRBC:FFP > 2:1) with those of the ICU 

protocol (PRBC:FFP = 1:1). A TIC present on arrival in the emergency room could not be 

remedied until in the ICU, and the TIC at ICU admission correlated with the mortality rate (p 

= 0.02). A significantly reduced 30-day mortality was noted by Gunter et al. [41] for patients 

who received FFP and PRBC in a ratio ≥ 2:3 (41% versus 62%, p = 0.008). In a multicenter 

study of 466 patients, Holcomb et al. [54] showed that an FFP-PRBC ratio ≥ 1:2 compared to 

< 1:2 permitted better 30-day survival (40.4% versus 59.9%, p < 001). The combination of a 

high FFP-PRBC and a high platelet-PRBC ratio increased the 6-hour, 24-hour, and 30-day 

survival (p < 005). Kashuk et al. [60] showed the advantage of a 1:2 FFP-PRBC ratio (survivors: 

median 1:2, non-survivors: median 1:4, p < 0001) in 133 civil patients who received a massive 

transfusion within 6 hours. The authors nevertheless found a U-shaped curve: patients who 

received FFP and PRBC in the ratio 1:2 to 1:3 had the highest survival rate whereas the predicted 

mortality probability increased again with a ratio of 1:1. The authors thus recommended a ratio 

of 1:2 to 1:3. In 713 patients in the German trauma registry who required ≥ 10 PRBC until ICU 

admission, Maegele et al. [75] detected a survival advantage in relation to the PRBC-FFP ratio of 

> 1:1, 1:1 or < 1:1 (6 hours: 24.6% versus 9.6% versus 3.5%, p < 00001; 24 hours: 32.6% versus 

16.7% versus 11.3%, p < 00001; 30 days: 45.5% versus 35.1% versus 24.3%, p < 0001). The 

ratio < 1:1 led to a longer ventilation dependency and a longer stay in ICU (p < 00005). In 415 

patients with an FFP-PRBC ratio of > 1:1.5, Sperry et al. [109] found prospectively a significant 

24-hour survival advantage (3.9% versus 12.8%, p = 0.012) with increased TRALI risk (47.1% 

versus 24.0%, p = 0.001). Scalea et al. [100] prospectively studied 250 patients. No survival 

advantage with a PRBC-FFP ratio of 1:1 was registered either in the total population or in the 81 

massively transfused patients. With a total mortality within 24 hours of only 4% (6% with 

massive transfusions), the authors concluded that other (less severely injured) patients had been 

studied than in the majority of other studies. In 383 trauma patients (exclusion: severe TBI), 

Teixeira et al. [121] showed a linear increase in survival with increasing FFP-PRBC ratio up to a 

ratio of 1:3. After the admission GCS, the FFP-PRBC ratio was the second most important 

predictor for survival. Snyder et al. [105] retrospectively carried out an outcome study on 134 

patients who required transfusion ≥ 10 PRBC/24 h. They noted a significantly reduced 24-hour 

mortality of 40% when FFP and PRBC were administered in a ratio ≥ 1:2 (median 1:1.3) 

compared to 58% at < 1:2 (median 1:3.7) (relative risk [RR] 0.37, 95% CI: 0.22–0.64). However, 

the significance could no longer be confirmed if the exact time of FFP transfusion within the first 

24 hours was taken into account (RR 0.84, 95% CI: 0.47–1.50). The authors justified this with a 

potential “survival bias”: the patients did not die because they received less FFP but received less 

FFP because they died. In a randomized multicenter study, by means of a high FFP-PRBC ratio, 

Zink et al. [138] significantly improved survival in massive transfusions within 6 hours (37.3% 

at < 1:4 versus 15.2% at 1:4 to 1:1 versus 2.0% at ≥ 1:1; p < 0001) and lowered the total number 

of required PRBC (18 PRBC in the first 24 hours at < 1:1 versus 13 PRBC at > 1:1, p < 0001). 

The majority of studies available indicate that patients who (will) require massive transfusions or 

have a life-threatening shock gain from a high FFP-PRBC ratio [111]. 



Massive transfusion protocol: The term “massive transfusion” mostly implies the transfusion of 

≥ 10 PRBC per 24 hours [111]; but as the highest mortality of multiply injured patients occurs 

within the first 6 hours, some authors also recommend ≥ 10 PRBC per 6 hours [60]. In Cotton et 

al. [19], the introduction of a massive transfusion protocol with an FFP-PRBC ratio of 1:1.5 led 

to a 74% fall in mortality probability (p = 0.001) and to a higher 30-day survival rate (56.8% 

versus 37.6%, p < 0001) [18] with shorter stay (12 days versus 16 days, p = 0.049) and fewer 

ventilation days (5.7 days versus 8.2 days, p = 0.017). The authors attributed the improved 

survival to the earlier and faster infusion of the increased FFP-PRBC ratio. After introducing a 

massive transfusion protocol, Dente et al. [21] found evidence of an improved 24-hour survival 

(previously 36% versus 14%, p = 0.008) and 30-day survival (previously 55% versus 34%, p 

= 0.04) and a lower early mortality due to the coagulopathy (previously 21/31 versus 4/13, p 

= 0.023). 

The Trauma Associated Severe Hemorrhage (TASH) Score of the German DGU Trauma 

Registry [136] can be used in the civil arena for predicting a massive transfusion. It comprises 

the factors systolic blood pressure, hemoglobin (Hb), BE, heart rate, free intraabdominal fluid, 

pelvic and femoral fracture, and male sex (0-28 points). An increasing TASH score could be 

attributed with good accuracy and discrimination to an increasing probability for a massive 

transfusion (area under the curve [AUC] 0.89). Nunez et al. [88] developed a prediction system 

for massive transfusions [assessment of blood consumption (ABC)] with the parameters 

penetrating injury, positive finding from focused trauma sonography (FAST), systolic blood 

pressure on arrival ≤ 90 mmHg and heart rate ≥ 120/min. For a value ≥ 2, they could attribute a 

sensitivity of 75% and a specificity of 86% to this score. 

Platelet concentrates (PC): In the case of acute loss, platelets are initially increasingly released 

from bone marrow and spleen, which is why there is quite a delay before the platelet count falls 

after bleeding starts. After transfusion, the transferred vital platelets are distributed in the blood 

and the spleen so that the recovery rate in the peripheral blood is only about 60-70% and even 

lower with DIC [11]. 

In their retrospective multicenter study of civil trauma patients, Holcomb et al. [54] showed an 

improved 30-day survival with a PC-PRBC ratio of ≥ 1:2 (40.1% versus 59.9%, p < 001). The 

PC:PRBC ratio was an independent predictor for mortality. Perkins et al. [90] studied the effect 

on 694 soldiers who received massive transfusions of apharesis platelet concentrate (aPC) in 

relation to PRBC in 3 groups (aPC:PRBC 1:16, 1:18 to < 1:8 and > 1:8). The transfusion of aPC 

and PRBC in a ratio > 1:8 was characterized by a significantly higher 24-hour (64% versus 87% 

versus 95%, p < 0001) and 30-day survival (43% versus 60% versus 75%, p < 0001). In the 

multivariate analysis, the aPC-PRBC ratio was independently linked with the 24-hour and 30day 

survival. In a PRBC-FFP platelet ratio of 1:1:1, Dente et al. [21] noted a drastic reduction in 

early coagulopathy (p = 0.023), 24-hour case fatality rate (17% versus 36%, p = 0.008) and 30day 

case fatality rate in blunt trauma (34% versus 55%, p = 0.04). The randomized multicenter 

study by Zink et al. [138] with massive transfusion within 6 hours yielded significantly better 

values for the high ratio (6-hour survival: 22.8% versus 19% versus 3.2%, p < 0002; hospital 

survival: 43.7% versus 46.8% versus 27.4%, p < 003) for the 3 groups with a PC-PRBC ratio of 

< 1:4, 1:4 to 1:1 and ≥ 1:1. 



If the patient is in acute danger due to a massive blood loss or due to the location (intracerebral 

bleeding), the German Medical Association recommends platelet replacement if the value falls 

below 100,000/µl [11]. If there are resulting platelet dysfunctions and tendency to bleed, a 

concomitant therapy with antifibrinolytics or desmopressin can be indicated [11]. 

Fibrinogen: As the substrate of coagulation, factor I (= fibrinogen) is essential not only for the 

formation of the fibrin network but is also a ligand for the GPIIb-IIIa receptor at the platelet 

surface and thus responsible for platelet aggregation. During dilution or severe bleeding, 

fibrinogen appears to be the most vulnerable of all coagulation factors and is the first to reach its 

critical concentration [11, 50]. As early as 1995, Hiippala [50] had confirmed in patients who 

received a colloid transfusion that the measurement of derived fibrinogen (measured using the 

Quick test) as well as fibrinogen measured using the method according to Clauss produces 

significantly higher values than correspond to the actual fibrinogen levels. According to the 

German Medical Association, the administration of 3 g fibrinogen in a volume of 3 liters of 

plasma elevates the measured fibrinogen concentration by approximately 1 g/l; initial doses of 

(2–) 4 (–6) g are thus necessary in adults [11]. 

Singbartl et al. [104] illustrated in a mathematical model that the maximum permissible blood 

loss until the critical fibrinogen value has been reached is dependent on the baseline value. 

However, this is generally not known in the initial management during emergency admission. 

Fries et al. [35] showed in an in vitro study that dilution occurs through infusion of crystalloid or 

colloid solutions, inter alia also through 6% HES 130/0.4. Giving fibrinogen in a concentration 

which when converted was roughly equivalent to 3 g/70 kg BW was sufficient to achieve an 

improvement in the RoTEM parameters. The cause of this effect is regarded as an effect of the 

interaction between thrombin, factor XIII, and fibrinogen; this particularly applies for a dilution 

through HES [86]. Madjdpour et al. [73] proved in the pig that, with varying molecular weight 

(900, 500, 130) and the same degree of replacement (0.42), HES impairs coagulation in a similar 

way. In thrombocytopenia induced in the pig model, Velik-Salchner et al. [128] normalized the 

impaired coagulation parameters in the TEG by administering fibrinogen. Mittermayr et al. [85] 

proved in 61 randomized patients with major spinal interventions that colloids reduce the speed 

and quality of clot formation through impaired fibrin polymerization. Stinger et al. [119] showed 

a highly significant correlation between the amount of fibrinogen administered and survival in 

252 patients who had been injured during the fighting in the Iraq war. Injured patients who 

received less than 1 g of fibrinogen per 5 PRBC showed a case fatality rate of 52% compared to 

24% if more than 1 g/5 PRBC was given. In establishing a concentration of < 2 g/l as indication 

for fibrinogen replacement (average 2 g, range 1-5 g), Fenger-Eriksen et al. [31] found evidence 

in 35 severely bleeding patients of a significant reduction in the required PRBC (p < 00001), FFP 

(p < 00001) and PC (p < 0001) and blood loss (p < 005). In 30 massively bleeding patients with 

hypofibrinogenemia of varying genesis, Weinkove et al. [132] raised the level of 0.65 to 2.01 g/l 

by giving 4 g of fibrinogen (median, range 2-14 g) (measurement according to Clauss). Farriols 

Danes et al. [30] showed that patients with acute, bleeding-induced hypofibrinogenemia 

(compared to chronic deficiency) reacted to fibrinogen replacement with a more marked increase 

and a significantly better 7-day survival rate (p = 0.014). 



The widely used optical coagulation monitoring devices measure false elevated fibrinogen values 

when plasma is displaced by colloids [49]. Determining the derived fibrinogen is not sufficient 

for deciding whether there is an indication for replacement in massive bleeding [11]. The 

German Medical Association recommends that in massive bleeding the fibrinogen concentration 

is measured using the Clauss method and that target values are set at ≥1.5 g/l (150 mg/dl) and 

with prior colloid exposure ≥2 g/l (200 mg/dl) [11]. If hyperfibrinolysis is suspected, an 

antifibrinolytic drug should be given beforehand (e.g., 2 g tranexamic acid) [11]. 

Prothrombin concentrates (PPSB): The mixtures of vitamin K-dependent factors prothrombin = 

FII, proconvertin = FVII, Stuart factor = FX, and antihemophilic factor B = FIX, and protein C, 

protein S, and protein Z contain neither fibrinogen nor FV or FVIII [98] and are only 

standardized with regard to the factor IX content [11]. Activated coagulation factors and 

activated protein C or plasmin are virtually no longer contained in the PPSB products available 

now so that undesirable effects such as thromboembolic events, disseminated intravasal 

coagulation and/or hyperfibrinolytic bleeding are very unlikely even when larger quantities are 

administered [11]. The thromboembolisms described in the past were thought to be caused by a 

marked surplus in prothrombin in some PPSB concentrates no longer commercially available 

[40]. For this reason, it is no longer essential to replace antithrombin [11]. PPSB administration 

for DIC is only indicated if manifest bleeding exists which is partly caused by a lack of 

prothrombin complex factors and the cause of DIC is treated [11]. 

The rationale for the use of PPSB compared to FFP is the absence of risk of transfusion-induced 

(lung) injuries and viral safety. The main indication for PPSB is the elimination of the effect of 

vitamin K antagonists. This indication is proven by many studies and, in the case of 

marcumarized patients, the German Medical Association [11] recommends the preoperative 

administration of PPSB as a prophylaxis for bleeding. In the case of trauma-induced, 

consumption, loss or dilutional coagulopathy, the deficiency in the prothrombin complex can be 

so pronounced that, despite transfusion of FFP, replacement with PPSB is also necessary [11, 

98]. Fries et al. [33] carried out dilutional coagulopathy with 6% HES 130/0.4 in the pig model. 

Fibrinogen and PPSB replacement after a standardized liver laceration led to a significantly 

lower blood loss (240 ml, range 50-830 versus 1,800 ml, range 1,500-2,500, p < 00001) and the 

survival of all animals whereas 80% of the control group died (p < 00001). Also in the pig, 

Dickneite et al. [22] showed a significant shortening in the time to hemostasis (median 35 versus 

82.5 min; p < 00001) and a trend towards reduced blood loss (mean value 275 versus 589 ml) 

through the sole administration of PPSB after arterial bleeding (spleen incision) with dilutional 

coagulopathy. After venous bleeding (bone fracture), there were significant reductions both in 

the time to hemostasis (median 27 versus 97 min; p < 00011) and in the blood loss (mean value 

71 versus 589 ml, p < 00017). The same working group [23] studied the efficacy of PPSB 

compared to FFP administration (15 and 40 ml/kg BW) in pigs with HES-induced dilutional 

coagulopathy. In this instance as well, PPSB reduced the time to hemostasis (venous bone 

trauma p = 0.001; arterial spleen trauma p = 0.028) and blood loss (venous bone trauma p 

= 0.001; arterial spleen trauma p = 0.015). 

In the case of severe bleeding, the German Medical Association recommends initial bolus doses 

of 20-25 IU/kg BW; marked individual fluctuations in efficacy must be taken into account [11]. 



Antifibrinolytic drugs: Hyperfibrinolysis now appears to be more frequently assumed than before 

in multiply injured patients (~ 15% in [102]) and the extent correlates with the injury severity 

[67]. Hyperfibrinolysis is most common in patients with chest trauma, blunt abdominal trauma, 

pelvic trauma, and traumatic brain injury [58]. A prompt diagnosis of hyperfibrinolysis and also 

of the effectiveness of antifibrinolytic treatment is only possible by means of 

thrombelastography [67, 101]. The administration of the antifibrinolytic drug must be part of an 

overall therapeutic plan for the treatment of coagulopathies because hyperfibrinolysis can often 

involve heavy consumption of fibrinogen or even complete defibrination of the patient [58]. This 

fibrinogen deficiency must then be appropriately balanced after the manifestation of 

hyperfibrinolysis [58], i.e. the antifibrinolytic drug should be administered before the fibrinogen 

if hyperfibrinolysis is suspected [11]. Tranexamic acid is a synthetic lysine analogue, which 

inhibits the conversion of plasminogen into plasmin by blocking the plasminogen from binding 

to the fibrin molecule. The onset of effect of tranexamic acid is delayed compared to aprotinin as 

free plasmin continues to be active [102]. With a lack of evidence for multiply injured patients, it 

is recommended that initially 2–4 g (10–30 mg/kg BW [36, 58] is administered or a bolus dose 

of 10–15 mg/kg BW followed by 1–5 mg/kg BW/h [106]. 

Due to a lack of evidence-based data, a Cochrane Review from 2004 [17] could neither confirm 

nor refute the administration of antifibrinolytics in trauma patients. Another Cochrane Review 

from 2007 on the question of reducing perioperative blood transfusions through antifibrinolytic 

drugs [45] established for tranexamic acid a relative risk for PRBC administration of 0.61 (95% 

CI: 0.54-0.70) and a trend towards fewer re-operations. Tranexamic acid reduced the necessity of 

a blood transfusion relatively by 43% (RR 0.57; 95% CI: 0.49–0.66). A cumulative occurrence 

of serious side effects was not noted. A study published in The Lancet in 2010 (CRASH 

[Clinical Randomization of Antifibrinolytics in Significant Hemorrhage]-2 Study) [16] supports 

this conclusion: 1 g of tranexamic acid in 10 minutes + 1 g over 8 hours led to a significant 

reduction in all-cause mortality and in bleeding-induced mortality without an increased rate in 

thromboembolisms. 

Desmopressin (DDAVP): Desmopressin (1-deamino-8-D-arginine vasopressin) is a synthetic 

vasopressin analogue. Desmopressin (e.g., Minirin®) effectuates nonspecific platelet activation 

(increased expression of the platelet GpIb receptor [89]), releases the von Willebrand factor and 

FVIII from the endothelium of the hepatic sinusoids, and thus improves primary hemostasis [32]. 

The main indication lies in perioperative treatment of von Willebrand syndrome. DDAVP also 

shows good efficacy in patients after heparin administration and with restricted platelet function 

due to taking aspirin (acetyl salicylic acid) or ADP receptor antagonists/thienopyridine 

derivatives with uremia and with liver disease or thrombocytopenia [32]. The maximum effect 

after i.v. administration occurs only after about 90 minutes [68]. With repeated administration, 

the tissue plasminogen activator (tPA) can be released, thereby possibly leading to 

hyperfibrinolysis. Thus, with repeated administration, some authors recommend simultaneous 

administration of tranexamic acid [68]. In cardio-surgical patients, a not significantly increased 

rate in heart attacks was confirmed after DDAVP (OR 2.07; 95% CI: 0.74–5.85; p = 0.19) [68]. 

Ying et al. [135] corrected in vitro the hypothermia-induced dysfunctions in hemostasis at least 

partially through DDAVP. Whereas the Cochrane Review of 18 studies with 1,295 patients by 

Carless et al. [13] could not confirm any efficacy for the prophylactic administration of 



desmopressin, Zotz et al. [139] searched the same available data for the subgroup of patients who 

had either > 1 l blood loss or a history of taking aspirin. For the therapeutic use of DDAVP, there 

was thus a significantly reduced blood loss (weighted mean difference [WMD] = - 386 ml; 95% 

CI: - 542- - 231 ml per patient; p = 0.0001) and a likewise significantly reduced, transfused 

blood volume (WMD = - 340 ml, 95% CI = - 547- - 134 ml per patient; p = 0.0001). There are 

currently no controlled studies of trauma patients. 

From a pathophysiologic viewpoint, a treatment attempt with DDAVP can be considered in a 

dose of 0.3 µg/kg BW over 30 minutes in diffusely bleeding patients with suspected 

thrombocytopathy. 

Factor XIII: In the presence of calcium ions, FXIII effectuates the covalent crosslinking of the 

fibrin. A three-dimensional fibrin network is thus formed which effectuates definitive wound 

healing [11]. Factor XIII is not recorded by the Quick and aPTT (activated partial thromboplastin 

time) coagulation screening tests as these tests only measure the time fibrin formation starts but 

not fibrin crosslinking [11]. 

An acquired deficiency is not rare and can arise with a TIC as a result of increased rate 

(increased blood loss, hyperfibrinolysis, DIC) and consumption (in major surgery). In patients 

with existing coagulation activation, e.g., through having a tumor, a severe FXIII deficiency and 

subsequent massive bleeding can result from a trauma or intraoperatively [62]. A lower FXIII 

level has been shown as a risk factor for bleeding in intracranial [37] and cardio-surgical [4, 38] 

interventions as well. In elective patients with unexpected intraoperative bleeding, Wettstein et 

al. [133] established a significantly higher blood loss (1,350 ml versus 450 ml; p < 0001) and a 

markedly more rapid consumption of fibrinogen and FXIII (p < 0001) compared with a nonbleeding 

collective. Korte et al. [63] found evidence in a prospective, randomized, double-blind 

pilot study of 22 patients who were to receive surgery for colon cancer and had activated 

coagulation (elevated preoperative fibrin monomers) of a significantly smaller reduction in clot 

firmness) and a trend towards less blood loss with a single dose of 30 IU/kg FXIII. There are no 

randomized studies on trauma patients. 

If testing for FXIII cannot be done promptly, blind administration of FXIII should be considered, 

especially in severe, acute bleeding [11]. Initially, 15-20 IU/kg BW is recommended as a 

possible dose until hemostasis. As the concentrate is produced from human plasma, a residual 

risk of infection cannot be excluded. 

Recombinant activated factor VII (rFVIIa): The approval of rFVIIa is restricted to bleeding in 

antibody hemophilia (antibodies to factors VIII or IX), Glanzmann thrombasthenia (inherited 

dysfunction of the platelet GPIIb-IIIa receptor), and inherited FVII deficiency. In a 

supraphysiologic dose, rFVIIa binds to the activated platelets and there effectuates a “thrombin 

burst”, which leads to the formation of an extremely stable fibrin clot [34]. On activated 

platelets, rFVIIa can also enable tissue factor-independent thrombin generation. 

Off-label use has been described in a large number of case histories. Adverse side effects in the 

form of thromboembolic events in the arterial and venous vascular system and in perioperatively 

or traumatically damaged vessels have been reported particularly in off-label use [11]. Perkins et 



al. [91] showed in soldiers from the Iraq war that early administration of rFVIIa could lower 

PRBC consumption by 20%. Of 365 massive transfused patients, 117 received rFVIIa. Likewise, 

in patients in the military who received massive transfusions, Spinella et al. [113] noted a 

reduced 24-hour (14% versus 35%, p = 0.01) and 30-day mortality rate (31% versus 51%, 

p = 0.03) in early (median 2 hours after admission and 2.5 hours after trauma) administration of 

rFVIIa. However, the logistic options for preparation of, for example, blood components under 

war conditions cannot be compared with those of a European hospital. In the study in 2005 by 

Boffard et al. [5], the efficacy of 400 µg/kg BW rFVIIa (after the 8th PRBC initially 200 

µg/kg BW, then 100 µg/kg BW each after 1 and 3 hours) as adjunctive therapy was tested 

compared to placebo in 143 blunt and 134 penetrating trauma injuries. In blunt trauma, there was 

a significant reduction in the number of transfused PRBCs (calculated reduction by 2.6 PRBC, p 

= 0.02) and in the necessity for a transfusion of ≥ 20 PRBC (14% versus 33%; p = 0.03). In 

penetrating injuries, there was a trend in this direction for both parameters. Neither a lowering in 

the mortality rate nor an accumulation of thromboembolic side effects was observed. In 2009, 

Stein et al. [117] posed the question of costs. With the same rate of mortality and side effects, the 

authors could establish no significant difference in the costs (mean value US$63,403 

conventionally versus US$66,086 in rFVIIa) in 179 patients with traumatic brain injury. For the 

110 patients who were placed in the intensive care unit, there was even a significant cost 

reduction through rFVIIa (mean value US$108,900 conventionally versus US$77,907 in rFVIIa). 

However, really low doses were used in this study (5.9–115 µg/kg BW; mean value 

41.9 ± 35.5 µg/kg BW, median 25.1 µg/kg BW). Several meta-analyses of RCTs have studied 

the efficacy of off-label use: Stanworth et al. [115] found 13 placebo-controlled, double-blind 

RCTs on the use of rFVIIa in patients who were not hemophiliac. In prophylactic use (n = 724, 

379 received rFVIIa), there was a trend towards reduced transfusion frequency (pooled RR 0.85; 

95% CI: 0.72-1.01), which contradicts a trend towards increased thromboembolisms (pooled RR 

1.25; 95% CI: 0.76–2.07). In therapeutic use (n = 1,214; 687 received rFVIIa), there was a trend 

towards reduced mortality (pooled RR 0.82; 95% CI: 0.64-1.04) and again a trend towards 

increased thromboembolisms (RR 1.50; 95% CI: 0.86–2.62). In 2008, Hsia et al. [56] published 

the results of 22 RCTs on bleeding of different genesis in 3,184 non-hemophiliac patients (only 

the study by Boffard et al. [5] contains 301 trauma patients). The result was a reduced need for 

transfusion (OR 0.54; 95% CI: 0.34–0.86), a trend towards reduced case fatality rate (OR 0.88; 

95% CI: 0.71–1.09) and no change in venous but a trend towards cumulative arterial 

thromboembolisms (OR 1.50; 95% CI: 0.93–2.41). In 2008, Duchesne et al. [25] examined 19 

studies of trauma patients: Based on Boffard et al. [5], the authors gave a Level 1 

recommendation for the use of rFVIIa in blunt trauma. A Level 2 recommendation was given for 

trauma-associated hemorrhaging with 400 µg/kg BW (lower dose could also be effective) if 

other treatment options failed. Early use was assessed as Level 3. In 2009, Nishijima et al. [87] 

only found the above-mentioned study by Boffard [5] on the question of rFVIIa use in the 

emergency room. A large international phase III study on the use of rFVIIa in trauma patients 

was recently discontinued as the planned lowering in mortality could not be achieved [111]. 

The effectiveness of rFVIIa and of the coagulation sequences thus indicated is linked to a series 

of “framework conditions”, which should be attained before administration: fibrinogen value 

≥ 1 g/dl, Hb ≥ 7 g/dl, platelet count ≥ 50,000 (preferably ≥ 100,000)/µl), ionized calcium 

≥ 0.9 mmol/l, core temperature ≥ 34 °C, pH value ≥ 7.2, and the exclusion of hyperfibrinolysis 



or a heparin effect [11, 34, 106, 120]. A widely-used “standard dose” for off-label use is 

90 µg/kg BW [27, 56, 129]. However, the necessary dose remains ambiguous [106]; a very high 

total dose of 400 µg/kg BW is used in the only class 1 study by Boffard et al. [5]. Due to the very 

short half-life, a repeat dose can be considered after 2 hours [108] even if the need for a repeat 

dose is more likely to indicate a lack of effectiveness according to the review by Dutton et al. 

[27]. 

The German Medical Association refers in its guidelines to the review article by Mannucci et al. 

[78]. Its conclusion states that rFVIIa is no wonder substance but possesses efficacy in patients 

with trauma and excessive bleeding who do not respond to other treatment options. Its use, but 

only after conventional treatments have not been successful, is also propagated in current 

reviews [25, 27, 56]. The current summary of product characteristics from NovoNordisc (May 

2009) recommends that rFVIIa is not used off-label due to the risk of arterial thrombotic events 

in the range of ≥ 1/100 to < 1/10. 

Antithrombin: There are no prospective randomized studies on multiply injured patients. 

However, with persistent massive bleeding, administration of antithrombin (formerly ATIII) will 

only intensify it and cannot therefore be recommended [74, 106]. In their meta-analysis of 

randomized controlled trials of critically ill intensive care patients (AT: n = 1,447, control: n 

= 1,482), Afshari et al. [1] recorded a significant increase in the risk of bleeding through the 

administration of antithrombin (RR 1.52, 95% CI: 1.30–1.78, I2 = 0.3%). Even if this could not 

confirm any lowering in the case fatality rate, the German Medical Association recommends an 

off-label use of ATIII only in confirmed DIC with confirmed ATIII deficiency [11]. 



Summary table 

The above-described drug treatment options can be summarized as follows (modified according 

to [70, 118]): 

Table 13: Drug options for coagulation therapy 

1. Stabilization of framework 

conditions (prophylaxis and therapy) 

Core temperature ≥ 34 °C 

pH value ≥ 7.2 

ionized Ca ++ concentration ≥ 0.9 mmol/l 

2. Replacement of oxygen carriers PRBC administration (functional goal: Hb 6 [–8] g/dl 

but hemostaseologic goal in massive bleeding: 

Hct ≥ 30% and Hb ~10 g/dl [6.2 mmol/l]) 

3. Inhibiting potential 

(hyper)fibrinolysis 

(always BEFORE administering 

fibrinogen!) 

4. Replacement of coagulation factors 

(in the case of sustained tendency for 

severe bleeding) 

and (if suspected thrombocytopathy) 

nonspecific platelet activation + 

release of the “von Willebrand factor” 

and FVIII from the endothelium 

5. Replacement of platelets for 

primary hemostasis 

6. If necessary, thrombin burst with 

platelet and coagulation activation 

(please note requirements!!) 

if active bleeding no antithrombin 

Tranexamic acid initially 2 g (15–30 mg/kg BW) or 

1 g as saturation over 10 minutes + 1 g over 8 h 

FFP ≥ 20 (more likely 30) ml/kg BW 

If coagulation therapy in massive transfusions is 

carried out by administering FFP, the FFP:PRBC ratio 

should be in the target range of 1:2 and 1:1. 

and fibrinogen (2–) 4 (–8) g (30–60 mg/kg BW; 

goal: ≥ 150 mg/dl and ≥ 1.5 g/l) 

and if necessary PPSB initially 1,000–2,500 IU 

(25 IU/kg BW) 

if necessary 1–2x FXIII 1,250 IU (15–20 IU/kg BW) 

if necessary DDAVP = desmopressin 0.3 µg/kg BW 

over 30 minutes (“1 ampoule per 10 kg BW”) 

platelet concentrates (goal for transfusion-dependent 

bleeding: 100,000/µl) 

in the individual case & if all other treatment options 

are unsuccessful 

if necessary initially 90 µg/kg BW rFVIIa 



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Surg 197: 565-570 [LoE 2b] 

139. Zotz RB, Araba F, Bux I (2009) Desmopressin 

(DDAVP) for minimising perioperative allogenic 

blood transfusion: a stratified metaanalysis. 

Hamostaseologie 29: A53 [LoE 1a] 



2.17 Interventional control of bleeding 


If possible, embolization should be carried out on patients whose 

hemodynamics can be stabilized. 

A stent/a stent graft must be used if an intimal dissection, vessel tear, AV 

fistula, pseudoaneurysm or a traumatic aortic rupture is present. 

If a patient with unstable circulation has a ruptured iliac artery or distal 

abdominal aortic hernia, a balloon occlusion can be temporarily carried out 

for up to 60 minutes. 

If there is renewed bleeding after successful embolization, further treatment 

should also be interventional. 

Explanation: 

Indication for interventional treatment and decision algorithm 

GoR B 

GoR A 

GoR 0 

GoR B 

The basic requirement for carrying out interventional radiology to monitor bleeding should be 

the multi-slice CT scan (MSCT) with contrast agent. Generally, the source of bleeding can be 

identified using this examination. Embolization should only be considered if there is evidence of 

an active contrast agent extravasation in the MSCT as only then is there adequate prospect of a 

successful visualization of the source of bleeding and subsequent treatment. In particular, 

interventional treatment may be considered in the following injury patterns: 

� pelvic fractures with evidence of contrast agent extravasation in the MSCT 

� spinal fractures with clear contrast agent extravasation 

� injuries to the great vessels 

� parallel or supplementary to surgical control of bleeding 

Emergency room – Interventional control of bleeding 291


Technical and personnel requirements 

Carrying out interventional treatment to control bleeding is only advisable if the following 

requirements are met: 

� A conditional stabilization of the patient must be possible under massive transfusion and 

intensive medical treatment. 

� The personnel requirements must be met in the form of physicians on site who are 

experienced in angiography. 

� Supplies of the required embolization materials and stents must be available. 

Before carrying out a radiologic intervention, which generally lasts between 30 and 60 minutes 

including transport to the angiography unit, it is essential to clarify whether the patient can be 

stabilized with transfusions up to the time of the intervention and for the period of the 

intervention, whether the bleeding is located in an area that is typically accessible for 

embolization, and whether other sources of bleeding (e.g., extensive craniofacial injuries with 

massive diffuse bleeding), which are responsible for the blood loss, have been excluded. 

Materials and techniques for interventional control of bleeding 

In interventional radiology, the following materials are available for interventional control of 

bleeding: 

� non-covered and covered stents 

� metal coils 

� detachable balloons 

� solid particles 

− polyvinyl alcohol (Contour ® ) 

− gelatin foam (gel type) 

− microspheres (Embospheres ® ) 

� liquid embolization materials 

− ethanol 

− tissue adhesives (Bucrylat ® ) 

− occlusion gel (Ethiblock ® ) 



The coils are available in different diameters, shapes, and lengths. They are particularly suitable 

for the precise embolization of severely bleeding vessels of larger diameter. The positioning of 

the coils can be very precise and dislocations are very rare. 

Contour particles are also available in different sizes between 100 and 500 µm and are 

particularly suitable for the treatment of diffuse bleeding from fracture zones. Which of the 

above-mentioned materials are to be used depends on the bleeding and the experience of the 

interventional radiologist and requires an individual decision adapted to the situation. 

The goal of every embolization must be to carry out treatment without damaging the tissue if 

possible. In so doing, attention should be given to maintaining residual perfusion in the 

downstream organs and keeping damage to downstream tissue to the minimum. 

The main indication for implanting a non-covered stent in trauma management is the presence of 

an intimal dissection. There is an indication to implant a stent coated with polytetrafluroethylene 

(PTFE), dacron or polyester in vessel tears, AV fistulas, pseudoaneurysms or traumatic aortic 

ruptures in order to cover the vessel leak. 

Temporary balloon occlusion is available as a last resort. This can take the form of an occlusion 

of the infrarenal abdominal aorta for 30-60 minutes either under DSA or CT monitoring or a 

more selective occlusion in the internal iliac artery. However, if there is severe bleeding from the 

proximal internal iliac artery, preference should be given to coils for primary embolization. The 

goal of temporary balloon occlusion is to permit restoration of central circulation in patients with 

maximum circulation instability and thus to extend the timeframe until surgical or interventional 

care. 

Planning interventional control of bleeding 

A full-body MSCT scan is routinely performed before carrying out a radiologic intervention for 

controlling bleeding. There is a proven standardized examination protocol for this. Besides the 

plain examination of head and spine, the MSCT examination consists of a contrast-enhanced 

examination of thorax, abdomen, and pelvis. The primary contrast-enhanced examination after 

intravenous administration of 120 ml contrast agent at an injection rate of 2 ml/sec has been 

proven for the examination of thorax, abdomen, and pelvis. The examination should be carried 

out 85 seconds after contrast agent administration has started. This process ensures that, firstly, 

there is good, homogeneous contrasting of the parenchymatous organs but, secondly, sufficiently 

good contrasting of the great vessels is still ensured. In children and in a body weight less than 

60 kg, the quantity of contrast agent and the flow rate should be adjusted appropriately (e.g., 

child weighing 30 kg: 60 ml contrast agent, flow rate 1 ml/s, child weighing 15 kg: 30 ml 

contrast agent, flow rate 0.5 ml/s). The start delay for the scan should remain at 80-85 seconds. 

The MSCT is able to visualize minimal density gradients reliably. Thus, the MSCT allows 

differentiation between already coagulated blood (density values between 40 and 70 HU) and 

active bleeding (density values between 25 and 370 HU, mean value 132 HU) [7]. 



Discussion 

Embolization of the pelvis 

Overall, the embolization of pelvic fractures is only seldom indicated as most patients with 

pelvic fractures are hemodynamically stable. According to a study by Agolini et al. [8], only 15 

patients (1.9%) required embolization out of 806 patients with pelvic fractures. Other authors 

give the rate of necessary embolizations at 3% [9]. 

The management of patients with significant bleeding from pelvic fractures is very challenging. 

In addition to arterial bleeding, venous bleeding also represents a big problem. Arterial bleeding 

can be stopped by arterial embolization. The resulting hematoma then acts as a tamponade and 

also contributes towards arresting the venous bleeding. It is surgical hemostasis in arterial 

bleeding that frequently fails [10, 11] as the tamponade effect of the hematoma is removed 

during access to the iliac arteries, and massive, uncontrollable venous bleeding can occur. Even 

if definite evidence is still lacking, there are clear signs from clinical experience that arterial 

embolization can help even in diffuse venous bleeding as the arterial forward flow is cut off. 

According to our experience, the evidence here of active contrast agent extravasation in the 

MSCT greatly assists the decision-making process. If the personnel and logistic requirements are 

in place, embolization should be considered if there is evidence of active, relevant contrast agent 

extravasation in the presence of a critical circulation situation. If the examination technique is 

appropriate, the quantity of contrast agent sufficient, and the start delay 80-85 seconds after 

contrast agent administration has started, the lack of evidence of contrast agent extravasation in 

the MSCT is generally a reliable indication that arterial embolization could not promise success. 

The studies by Agolini et al. [8] also showed that early embolization leads to a more favorable 

result with regard to mortality. Thus, in this study with an admittedly relatively small patient 

collective which was embolized, there was an advantage for mortality in the group that was 

embolized within 3 hours (mortality 14%) compared to the group embolized later (mortality 

75%). 

Embolization of the spleen 

Arterial embolizations in splenic injuries are carried out only in isolated cases, usually as an 

alternative to surgical interventions to preserve the spleen [12]. Selective embolization without 

subsequent surgery is successful in 87-95% of cases [3, 13]. Proximal embolizations of the lienal 

artery should be avoided due to the risk of massive abdominal wall or pancreatic infarction. In 

addition, proximal embolization of the lienal artery is often not suited to achieving permanent 

hemostasis due to a reduction in pressure in the intrasplenic vessels. 

Embolization of the liver 

Embolization of the hepatic artery can be successfully used in the management of post-traumatic 

bleeding [14, 15, 16], involving overall relatively small series. Patients with sustained bleeding 

after primary surgical hemostasis to the liver in particular should undergo angiography and, if 

necessary, be embolized to avoid another operation [17]. 



If there is renewed bleeding after successful embolization, further treatment should also be 

carried out by angiography. In addition to the improved surgical results, arterial embolization has 

contributed particularly to improving the outcome after traumatic hepatic injuries [18]. 

Embolization of the kidneys 

Many kidney injuries can be treated conservatively. Avulsions to the vascular pedicle must be 

surgically managed within the first few hours in order to preserve renal function. Angiography is 

indicated if, during the MSCT, contrast agent extravasation could be visualized in the kidney or 

around the kidney. Hemorrhagic-induced extravasation of contrast agent must not be confused 

with a dense contrast agent collection, e.g., in a urinoma. The success of renal embolization 

depends on this being carried out rapidly and as selectively as possible. A proximal occlusion of 

the renal artery is only indicated when a nephrectomy is indicated due to the organ being 

damaged but this must only be done later when the patient is more stable. In any case, the search 

for pole vessels is important for the angiographic work-up of the traumatic kidney injury as these 

might also require embolization. Studies have shown that kidney embolization is successful as 

primary treatment in 82-100% of cases. 

Endovascular treatment of traumatic aortic rupture 

Numerous studies have been carried out during recent years on the value of endovascular 

treatment of traumatic aortic rupture [19–26]. Practically all come to the conclusion that in an 

acute situation preference should be given to endovascular treatment as opposed to the opensurgical 

procedure. Thus, Ott et al. [24] found evidence that the mortality and paraplegia rates in 

endovascular treatment are markedly better at 0% than the results of open-surgical treatment 

with a mortality of 17% and a paraplegia rate of 16%. 



References 

1. Gruen G, Leit M, Gruen R, Peitzman A. The acute 

management of hemodynamically unstable multiple 

trauma patients with pelvic ring fractures. J Trauma 

1994; 36:706-711; discussion 711-703. 

2. Nix J, Costanza M, Daley B, Powell M, Enderson B. 

Outcome of the current management of splenic 

injuries. J Trauma 2001; 50:835-842. 

3. Hagiwara A, Yukioka T, Ohta S, Nitatori T, Matsuda 

H, Shimazaki S. Nonsurgical management of patients 

with blunt splenic injury: efficacy of transcatheter 

arterial embolization. AJR Am J Roentgenol 1996; 

167:159-166. 

4. Saidi A, Bocqueraz F, Descotes J, et al. Blunt kidney 

trauma: a ten-year experience. Prog Urol 2004; 

14:1125-1131. 

5. Gourlay D, Hoffer E, Routt M, Bulger E. Pelvic 

angiography for recurrent traumatic pelvic arterial 

hemorrhage. J Trauma 2005; 59:1168-1173; 


6. Siritongtaworn P. Management of life threatening 

hemorrhage from facial fracture. J Med Assoc Thai 

2005; 88:382-385. 

7. Shanmuganathan K, Mirvis S, Sover E. Value of 

contrast-enhanced CT in detecting active hemorrhage 

in patients with blunt abdominal or pelvic trauma. 

AJR Am J Roentgenol 1993; 161:65-69. 

8. Agolini S, Shah K, Jaffe J, Newcomb J, Rhodes M, 

Reed J. Arterial embolization is a rapid and effective 

technique for controlling pelvic fracture hemorrhage. 

J Trauma 1997; 43:395-399. 

9. Mucha P, Welch T. Hemorrhage in major pelvic 

fractures. Surg Clin North Am 1988; 68:757-773. 

10. Ben-Menachem Y, Coldwell D, Young J, Burgess A. 

Hemorrhage associated with pelvic fractures: causes, 

diagnosis, and emergent management. AJR Am J 

Roentgenol 1991; 157:1005-1014. 

11. Panetta T, Sclafani S, Goldstein A, Phillips T, Shaftan 

G. Percutaneous transcatheter embolization for 

massive bleeding from pelvic fractures. J Trauma 

1985; 25:1021-1029. 

12. Chuang V, Reuter S. Selective arterial embolization 

for the control of traumatic splenic bleeding. Invest 

Radiol 1975; 10:18-24. 

13. Sclafani S, Weisberg A, Scalea T, Phillips T, Duncan 

A. Blunt splenic injuries: nonsurgical treatment with 

CT, arteriography, and transcatheter arterial 

embolization of the splenic artery. Radiology 1991; 

181:189-196. 

14. Yao D, Jeffrey R, Mirvis S, et al. Using contrastenhanced 

helical CT to visualize arterial extravasation 

after blunt abdominal trauma: incidence and organ 

distribution. AJR Am J Roentgenol 2002; 178:17-20. 

15. Kos X, Fanchamps J, Trotteur G, Dondelinger R. 

Radiologic Damage Control: evaluation of a 

combined CT and angiography suite with a pivoting 

table. Cardiovasc Intervent Radiol 1999; 22:124-129. 

16. Inoguchi H, Mii S, Sakata H, Orita H, Yamashita S. 

Intrahepatic pseudoaneurysm after surgical hemostasis 

for a delayed hemorrhage due to blunt liver injury: 

report of a case. Surg Today 2001; 31:367-370. 

17. De Toma G, Mingoli A, Modini C, Cavallaro A, Stipa 

S. The value of angiography and selective hepatic 

artery embolization for continuous bleeding after 

surgery in liver trauma: case reports. J Trauma 1994; 

37:508-511. 

18. Richardson D, Franklin G, Lukan J, et al. Evolution in 

the management of hepatic trauma: a 25-year 

perspective. Ann Surg 2000; 232:324-330. 

19. Duncan I, Wright N, Fingleson L, Coetzee J. 

Immediate endovascular stent-graft repair of an acute 

traumatic rupture of the thoracic aorta: case report and 

subject review. S Afr J Surg 2004; 42:47-50. 

20. Lawlor D, Ott M, Forbes T, Kribs S, Harris K, De 

RG. Endovascular management of traumatic thoracic 

aortic injuries. Can J Surg 2005; 48:293-297. 

21. Verdant A. Endovascular management of traumatic 

aortic injuries. Can J Surg 2006; 49:217; author reply 

217-218. 

22. Orend K, Pamler R, Kapfer X, Liewald F, Gorich J, 

Sunder-Plassmann L. Endovascular repair of 

traumatic descending aortic transection. J Endovasc 

Ther 2002; 9:573-578. 

23. Amabile P, Collart F, Gariboldi V, Rollet G, Bartoli J, 

Piquet P. Surgical versus endovascular treatment of 

traumatic thoracic aortic rupture. J Vasc Surg 2004; 

40:873-879. 

24. Ott M, Stewart T, Lawlor D, Gray D, Forbes T. 

Management of blunt thoracic aortic injuries: 

endovascular stents versus open repair. J Trauma 

2004; 56:565-570. 

25. Lin P, Bush R, Zhou W, Peden E, Lumsden A. 

Endovascular treatment of traumatic thoracic aortic 

injury--should this be the new standard of treatment? J 

Vasc Surg 2006; 43 Suppl A:22A-29A. 

26. Dunham M, Zygun D, Petrasek P, Kortbeek J, Karmy- 

Jones R, Moore R. Endovascular stent grafts for acute 

blunt aortic injury. J Trauma 2004; 56:1173-1178. 



3 Emergency surgery phase 


How would you decide? 

A 35-year-old cyclist has an accident. The patient is intubated and ventilated at the accident 

scene by the emergency physician. Volume replacement to support circulation is introduced. The 

patient is brought to you for primary management. After exclusion of relevant intraabdominal or 

intrathoracic bleeding and after a thorough diagnostic study, the following injury pattern 

manifests itself: traumatic brain injury II °, chest trauma with multiple rib fracture and 

pronounced left pulmonary contusion, I ° left open femoral shaft fracture, right distal lower leg 

fracture. The laboratory tests initially carried out show a hemoglobin value of 9.3 g/dl, INR of 

77%, and a base excess of - 4.5 mmol/l. 

You consider what care options exist in the first surgical phase for this patient and weigh up their 

advantages and disadvantages. The longer you think about it, the more questions arise: What is 

the first-line choice of surgery strategy for the femoral shaft fracture? Which care strategy is best 

for the distal lower leg fracture? Does the fibula have to be managed at the same time? Is 

primary definitive osteosynthesis sensible or is temporary osteosynthesis better? What role does 

the traumatic brain injury or the chest trauma play in the decision-making? You remember the 

management of similar cases in your department, the dogmatically repeated ideas of your 

“teacher” or other colleagues, the economic “restraints” of your hospital administration, and the 

perennial lack of time to deal properly for once with the almost limitless complex literature on 

polytrauma management. In the end, you opt once more to carry out the care based on your own 

experiences. 

How would other providers in Germany decide? 

By way of example, we will focus on the question of femoral shaft management. According to 

the available data in the trauma registry of the German Trauma Society, more than 65% of all 

multiple injuries involve injuries to the extremities and/or the pelvis (AIS > 2). It is, therefore, all 

the more astonishing that contradictory surgical management strategies for femoral shaft 

fractures in polytrauma are practiced and published [1]. According to analyses of the trauma 

registry, the primary management of femoral shaft fractures in multiply injured patients in 

Germany is, almost dogmatically, always with an external fixator in some hospitals, always with 

a medullary nail in other hospitals, and finally in many hospitals, in every conceivable 

combination, sometimes with fixators and sometimes with nails [1]. 

The aim of this “emergency surgery phase” guideline section 

Such depictions of “reality” refer to an alternative, often even contradictory range of decisions 

from different hospitals. They support the need for an overview of the evidence levels and grades 

of recommendation of differing management strategies. Thus, the aim of this section of the 

guideline is to gain an overview of the evidence levels of different management strategies in the 

emergency surgery phase after multiple injury, and from this either to derive clinical treatment 

Emergency surgery phase - Introduction 297


algorithms (if there is sufficient evidence) or to document the need for scientific verification of 

the evidence (grade of recommendation). 

Special notes: 

In this guideline section, the assessment of core questions is often hampered by the lack of 

“hard”, scientifically based data or by only results on mono-injuries being available. In this 

regard, the corresponding locations are explicitly referred to and attempts are made, despite the 

partly contradictory information from the literature, to provide the clearest possible 

recommendations for clinical routine in individual key recommendations. 

Moreover, in terms of fracture discussions, the initial assumption, if not explicitly mentioned 

elsewhere, is a closed fracture without vascular involvement and with no compartment 

syndrome. The open fracture, vascular involvement, and compartment syndrome are regarded as 

an indication for emergency surgery and require, if necessary, a different management strategy. 

In addition, in many surgically demanding fractures (e.g., distal complex femur or humerus 

condyle fracture), particularly in polytrauma, it should be taken into account that primary 

definitive care can only be considered if: a) careful planning has been carried out (if appropriate, 

on the basis of 3D CT); b) the expected duration of surgery is not too long; c) an experienced 

surgeon is present; d) a suitable implant is in stock in the hospital. For this reason, in many 

German trauma centers, such surgically demanding fractures in the multiply injured patient 

ought first to receive primary temporary stabilization before subsequently undergoing secondary 

definitive reconstruction. 

Finally, it is assumed hereafter that the patient has otherwise stable circulation with additional 

injuries of the extremities. The management strategy for a patient with multiple injuries and 

cardiopulmonary, metabolic, or coagulatory “instability” may be very different from this, 

depending on different priorities. Please refer to the relevant literature [1–7] for a risk assessment 

of the multiply injured patient as a decision aid in the management strategy. Damage control is a 

strategy for management of severely injured patients with the goal of minimizing secondary 

damage and maximizing the outcome for the patient. In the area of fracture treatment, for 

example, this would mean not carrying out primary definitive osteosynthesis but instead 

stabilizing the fracture temporarily with an external fixator. The smaller intervention and the 

shorter surgery time are intended to make it possible to limit the additional trauma burden to the 

maximum possible extent in terms of secondary damage. In precisely this respect, it must 

therefore be emphasized that individual biologic requirements (e.g., age), overall injury severity, 

but also additional severe injuries (e.g., severe traumatic brain injury), required surgery time, 

compensated dysfunctions in vital parameters (borderline patients), and the physiologic status of 

the patient (metabolism, coagulation, temperature, etc.) should also be included in the decisionmaking. 



References 

1. Rixen D, Grass G, Sauerland S, Lefering R, Raum 

MR, Yücel N, Bouillon B, Neugebauer EAM, and the 

„Polytrauma Study Group“ of the German Trauma 

Society (2005) Evaluation of criteria for temporary 

external fixation in risk-adapted Damage Control 

orthopaedic surgery of femur shaft fractures in 

multiple trauma patients: “evidence based medicine” 

versus “reality” in the trauma registry of the German 

Trauma Society. J Trauma 59:1375-1395 

2. Giannoudis PV (2003) Surgical priorities in Damage 

Control in polytrauma. J Bone Joint Surg (Br) 85: 

478-483 

3. Pape H, Stalp M, Dahlweid M, Regel G, Tscherne H, 

Arbeitsgemeinschaft „Polytrauma“ der Deutschen 

Gesellschaft für Unfallchirurgie (1999) Welche 

primäre Operationsdauer ist hinsichtlich eines 

„Borderline-Zustandes“ polytraumatisierter Patienten 

vertretbar? Unfallchirurg 102: 861-869 

4. Pape HC, van Griensven M, Sott AH, Giannoudis P, 

Morley J, Roise O, Ellingsen E, Hildebrand F, Wiese 

B, Krettek C, EPOFF study group (2003) Impact of 

intramedullary instrumentation versus Damage 

Control for femoral fractures on immunoinflammatory 

parameters: prospective randomized analysis by the 

EPOFF study group. J Trauma 55: 7-13 

5. Scalea TM, Boswell SA, Scott JD, Mitchell KA, 

Kramer ME, Pollak AN (2000) External fixation as a 

bridge to intramedullary nailing for patients with 

multiple injuries and with femur fractures: Damage 

Control orthopedics. J Trauma 48: 613-623 

6. Bouillon B, Rixen D, Maegele M, Steinhausen E, 

Tjardes T, Paffrath T (2009) Damage control 

orthopedics – was ist der aktuelle Stand? 

Unfallchirurg 112:860–869 

7. Pape HC, Rixen D, Morley J, Husebye EE, Mueller 

M, Dumont C, Gruner A,Oestern HJ, Bayeff-Filoff M, 

Garving C, Pardini D, van Griensven M, Krettek C, 

Giannoudis P and the EPOFF study group (2007) 

Impact of the method of initial stabilization for 

femoral shaft fractures in patients with multiple 

injuries at risk for complications (borderline patients). 

Ann Surg 246:491-501 



3.2 Thorax 

Surgical approach route 


Depending on the injury location, an anterolateral thoracotomy, a 

posterolateral thoracotomy or a sternotomy can be selected. If the injury 

location is unclear, the clamshell approach may be selected. 

Explanation: 

GoR 0 

The standard approach is the anterolateral or posterolateral thoracotomy on the injury side at the 

level of the 4th-6th intercostal space. If a bilateral chest injury is suspected, a bilateral 

anterolateral thoracotomy or a clamshell thoracotomy can be performed. If the injury can be 

located precisely, the appropriate approaches are used, e.g., posterolateral approach for 

interventions to the thoracic aorta or a higher intercostal approach for injuries to the subclavian 

vessels or to the intrathoracic trachea [8, 17, 51, 52]. 

The anterolateral thoracotomy appears to provide insufficient exposure of the injured organs in 

up to 20% of cases [25]. If required, this approach can thus be enlarged in the posterior direction 

or into a flap approach [51]. 

The median sternotomy is preferred for injuries to the heart, the ascending aorta, and the aortic 

arch as well as injuries to the great vessels [25, 50, 51]. 

In trauma surgery practice, the thoracoscopy is unsuitable in life-threatening emergencies. The 

video-based thoracoscopy can be used for the diagnostic work-up of diaphragm injuries or in the 

search for sources of bleeding but also for performing smaller interventions such as draining a 

hemothorax, etc. [17, 33, 51]. 

Emergency surgery phase - Thorax 300


Penetrating chest injuries 


If there are perforating chest injuries, embedded foreign bodies should only be 

removed during surgery under controlled conditions after opening up the 

chest. 

Explanation: 

GoR B 

If it can be assumed that the chest has been perforated, foreign bodies penetrating the chest must 

not be removed due to a possible tamponade effect. Removal is always performed during surgery 

via an exploratory thoracotomy. The airtight closure or bandaging of puncture openings is also 

contraindicated because it prevents the pleural space from being decompressed. In complicated 

injuries, the goal should be a two-step closure of the chest wall after thorough lavage and 

generous wound debridement to avoid septic complications [51]. 

Indication for thoracotomy 


A penetrating chest injury, which is the cause of hemodynamic instability in 

the patient, must undergo an immediate exploratory thoracotomy. 

A thoracotomy can be performed if there is an initial blood loss of > 1,500 ml 

from the chest drain or if there is persistent blood loss of > 250 ml/h over more 

than 4 hours. 

Explanation: 

GoR A 

GoR 0 

The indication for immediate thoracotomy in penetrating injuries arises if the following are 

already present on admission to the emergency room: severe hemodynamic shock states, signs of 

pericardial tamponade, diffuse bleeding, absence of peripheral pulses, and cardiac arrest [2–4, 

17, 25, 32, 51]. Hemodynamically stable patients can be monitored after insertion of a chest 

drain or can undergo further diagnostic tests such as helical CT. 

Studies during the Vietnam War showed a reduction in mortality and the complication rate in 

predominantly penetrating injuries with a thoracotomy performed after a blood loss of initially 

> 1,500 ml or exceeding 500 ml in the first hour after drain insertion [32]. 

In a multicenter study, there was evidence also of the dependence of mortality on thoracic blood 

loss irrespective of the mechanism of injury (blunt versus penetrating). Mortality rose here by a 

factor of 3.2 in the group with a blood loss of more than 1,500 ml in the first 24 hours compared 

with a blood loss from the chest drain of 500 ml/24 h. The mean time for performing the 



thoracotomy was 2.4 ± 5.4 hours after admission [24]. Other authors agree with the strategy of 

performing a thoracotomy for blunt or penetrating injuries after an initial blood loss of 1,500 ml 

or with continuous bleeding of 250 ml/h over 4 hours [12, 24, 29, 32, 50]. If the drainage volume 

per time unit is used as an indication criterion for thoracotomy, this requires the drains to be 

correctly positioned and have reliable patency [51]. 

In the case of a combination thoracic injury with high blood loss and marked metabolic 

derangement, a temporary chest closure consistent with damage control surgery can be carried 

out after acute management with controlling of bleeding. After stabilization of the patient in 

intensive care, the definitive surgical management and chest closure is carried out later [12, 19, 

22, 50]. 

Lung injuries 


If an indication for surgery exists for lung injuries (persistent bleeding and/or 

air leak), the intervention should be parenchymal-sparing. 

Explanation: 

GoR B 

Lung parenchymal injuries in a penetrating or blunt chest trauma with persistent bleeding and/or 

air leak require surgical management [16, 17, 51]. One of the main indicators for an exploratory 

thoracotomy is marked or persistent bleeding (1,500 ml initially or 500 ml/h) [24]. If necessary, 

appropriate surgical management of possible lung parenchymal injuries is then indicated for 

hemostasis. Compared to parenchymal-sparing surgical procedures such as oversewing, 

tractotomy, atypical resection or segment resection, the lobectomy and pneumonectomy carry a 

higher complication and mortality rate [12, 19, 22, 30, 50]. At the same time, blunt injuries 

appear to be associated with a worse prognosis with regard to number of days in situ, 

complications, and mortality [30]. 



Great vessel injuries 


In the case of aortic ruptures, preference should be given over open 

revascularization procedures to implantation of an endostent graft if 

technically and anatomically possible. 

A systolic blood pressure of 90-120 mmHg should be set until reconstruction 

of the aorta or if under conservative management. 

Explanation: 

GoR B 

GoR B 

The treatment for an aortic rupture traditionally consists of aortic reconstruction by direct suture 

with clamping of the aorta and using different bypass procedures to perfuse the lower body half 

and spinal cord during the clamping phase (left heart bypass, Gott shunt, heart-lung machine) [1, 

11, 18, 28, 31, 35, 42, 50]. 

Current studies identify acute stenting for aortic ruptures as a minimally invasive, time-saving 

treatment option with minimal access damage [1, 36]. Complications such as cerebral or spinal 

hypoperfusion with corresponding late complications such as paraplegia occur less often. In the 

long term, anticoagulation as required in most bypass procedures can be dispensed with [6, 9, 14, 

37, 47]. Also in a current meta-analysis which compares open aortic reconstruction with 

endovascular stenting, evidence was found of a significantly lower mortality rate and a 

significantly lower rate of post-operative neurologic deficits (paraplegia, strokes) with the same 

technical success rate for endovascular stenting [37]. However, there are to date no data on longterm 

survival after endovascular aortic reconstruction [21, 41]. Overall, according to the 

literature currently available, the implantation of an endostent graft appears to be preferable to 

the conventional procedure [15]. 

Complications such as paraplegia and acute kidney failure due to the open procedure are the 

result of operative-induced ischemia. The complication rate correlates with the aortic clamping 

time [23, 45]. 

If perfusion is maintained during bypass procedure surgery instead of clamping the aorta, the 

complication rate is reduced (paraplegia, kidney failure) [10, 11, 16, 35]. 

The hemodynamic status of the patient at the time of admission determines the timing for 

management of the aortic rupture. Patients in a hemodynamically unstable condition or in 

extremis must undergo surgery immediately [10]. In patients with concomitant traumatic brain 

injury, severe abdominal or skeletal injuries which require immediate surgery and in elderly 

patients with extensive cardiac and pulmonary comorbidities, the aortic injury can be managed 

with delayed urgency after treatment of additional life-threatening injuries and/or after 

stabilization [28, 50, 51]. In a series of 395 patients, Camp et al. showed that in 

hemodynamically stable patients the mortality was not significantly increased in non-urgent (> 4 



hours) or delayed surgery (> 24 hours) compared to emergency surgery (< 4 hours) [10]. Other 

authors agree with this opinion [10, 15, 16, 45]. Delays of up to 2 months are tolerated in some 

cases [39]. 

If surgery is not carried out as an emergency, strict pharmacologic control of blood pressure 

(systolic blood pressure between 90 and 120 mmHg and heart rate < 100/min) is required with 

beta blockers and vasodilators [15, 16]. 

Cardiac injuries 

Life-threatening cardiac injuries occur primarily due to penetrating trauma. Injuries to several 

chambers are particularly associated with high mortality [2, 3, 17, 51]. An intrathoracic injury to 

the inferior vena cava often causes a life-threatening pericardial tamponade. The surgical 

management of the vein is carried out after pericardial decompression via the right atrium by 

means of a direct suture or with a patch closure using extracorporeal circulation [49–52]. 

The approach is via a median sternotomy or, in the case of absolute urgency, by a left 

anterolateral thoracotomy. After decompression of the cardiac tamponade, which is present in 

more than 50% of cases, via a longitudinal incision of the pericardium, bleeding must be quickly 

controlled by staple or suture. After removal of the clamp from the bleeding atrial wall, this can 

be closed with a direct suture [34]. Ventricle lesions are closed by means of a pericardial patch 

or Teflon felt augmentation. Finally, the pericardial incision is adjusted by loosening to avoid a 

retamponade [2, 3, 17, 51]. Injuries that do not require an immediate thoracotomy are isolated 

septal defects, valve injuries or ventricle aneurysms [34]. 

Proximal lesions of the coronary vessels must be reconstructed or in an emergency managed 

with a coronary artery bypass using a heart-lung machine. Distal lesions of the coronaries can be 

ligated [17, 51]. 

The patient’s cardiac rhythm and cardiorespiratory function on arrival in the emergency room are 

important factors in prognosis [2, 3]. At all times, attempts must therefore be made to maintain 

cardiac pump function and treat cardiac arrhythmias as this lowers mortality [2, 3]. 



Injuries of the tracheobronchial system 


If there is clinical suspicion of an injury to the tracheobronchial system, a 

bronchoscopy should be carried out to confirm the diagnosis. 

Traumatic injuries to the tracheobronchial system should be surgically 

managed early following the diagnosis. 

In the case of localized injuries to the tracheobronchial system, conservative 

treatment can be attempted. 

Explanation: 

GoR B 

GoR B 

GoR 0 

Injuries to the tracheobronchial system are rare and there is often a delay in making the diagnosis 

[5, 7, 26, 40, 44]. Occasionally, tracheobronchial injuries also occur as a complication in 

orotracheal intubation [43]. Penetrating injuries predominantly affect the cervical trachea 

whereas blunt injuries usually give rise to intrathoracic injuries. The right main bronchus in the 

immediate vicinity of the carina is affected more often [7, 26, 40]. If there are persistent 

pneumothoraces despite a functioning chest drain and despite the presence of soft tissue 

emphysema or atelectases, a tracheobronchoscopy should be performed to confirm the suspected 

diagnosis of a tracheobronchial injury [5, 7, 26, 27, 40]. Fiberoptic intubation with placement of 

the cuff distal to the defect can be directly connected to secure the airway. In a retrospective 

study, Kummer et al. established that a large number of patients require a definitive airway 

(tracheostomy) [27]. The emphasis here was on penetrating injuries. Surgical management of the 

tracheobronchial system should be carried out as soon as possible after making the diagnosis as 

delayed management is associated with an increased complication rate [7, 13, 26, 34, 40]. 

Surgical management of airway injuries is associated with a markedly lower mortality compared 

to conservative treatment [7, 26, 40]. Conservative treatment should be considered after 

bronchoscopic inspection only in patients with small bronchial tissue defects (defect smaller than 

1/3 of the bronchial circumference) and well adapted bronchial margins [7, 13, 26, 34, 40]. In a 

retrospective study, Schneider and colleagues found no difference between the conservative and 

the surgical method in iatrogenic tracheal injuries without ventilation disorders and superficial or 

covered tracheal tears [43]. 

Cervical injuries are managed by a collar incision. A right-sided posterolateral thoracotomy 

should be performed in the 4th-5th ICS as an approach to intrathoracic tracheal injuries [5, 7, 26, 

34, 40]. In simple transverse tears, tension-free end-to-end anastomosis of the bronchus is 

performed after its immobilization and, if necessary, resection of the cartilaginous bridge. If a 

direct suture is not possible, longitudinal tears with a defective formation of the membrane wall 

are closed with a patch to avoid bronchial stenoses developing [7, 26, 34, 40]. Managing the 

tracheobronchial injuries with a stent appears to have no role to play according to current 

literature. 



Injuries to the bony thorax (excluding spine) 


The majority of injuries to the bony thorax including flail chest should be 

conservatively treated. 

Explanation: 

GoR B 

The vast majority of multiple rib fractures with an unstable thorax can be non-surgically treated 

by internal pneumatic splinting, CPAP (continuous positive airway pressure) ventilation, 

sensible bronchial toilet, and adequate pain therapy [38, 48]. Surgical treatment should be 

considered in patients with persistent respiratory insufficiency due to chest instability despite 

existing ventilation, in patients with extensive chest wall defects, and flail chest with threatening 

intrathoracic injury [38, 46, 48]. Voggenreiter et al. showed that primary surgical stabilization of 

multiple rib fractures with flail chest and respiratory insufficiency without pulmonary contusion 

has better results with a shorter ventilation period or a lower complication rate than conservative 

treatment. However, patients with a marked pulmonary contusion do not gain from surgical 

stabilization of the bony thorax [50]. 

In a prospective randomized study of surgically managed multiple rib fractures in patients with 

flail chest and respiratory insufficiency, Tanaka et al. found evidence of a shorter ventilation 

time, a shorter stay in the intensive care unit, and a lower complication rate in the group 

surgically stabilized with Judet clamps compared to the control group who received internal 

pneumatic splints [46]. 



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8. Branney Sw, Moore Ee, Feldhaus Km et al. (1998) 

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9. Buz S, Zipfel B, Mulahasanovic S et al. (2008) 

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10. Camp Pc, Shackford Sr (1997) Outcome after blunt 

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11. Cardarelli Mg, Mclaughlin Js, Downing Sw et al. 

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12. Cothren C, Moore Ee, Biffl Wl et al. (2002) Lungsparing 

techniques are associated with improved 

outcome compared with anatomic resection for severe 

lung injuries. J Trauma 53:483-487 [LoE 4] 

13. Dienemann H, Hoffmann H (2001) [Tracheobronchial 

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14. Dunham Mb, Zygun D, Petrasek P et al. (2004) 

Endovascular stent grafts for acute blunt aortic injury. 

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15. Fabian Tc, Davis Ka, Gavant Ml et al. (1998) 

Prospective study of blunt aortic injury: helical CT is 

diagnostic and antihypertensive therapy reduces 

rupture. Ann Surg 227:666-676; discussion 676-667 

[LoE 2b] 

16. Fabian Tc, Richardson Jd, Croce Ma et al. (1997) 

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Trial of the American Association for the Surgery of 

Trauma. J Trauma 42:374-380; discussion 380-373 

[LoE 4] 

17. Feliciano Dv, Rozycki Gs (1999) Advances in the 

diagnosis and treatment of thoracic trauma. Surg Clin 

North Am 79:1417-1429 [LoE 4] 

18. Fujikawa T, Yukioka T, Ishimaru S et al. (2001) 

Endovascular stent grafting for the treatment of blunt 

thoracic aortic injury. J Trauma 50:223-229 [LoE 4] 

19. Gasparri M, Karmy-Jones R, Kralovich Ka et al. 

(2001) Pulmonary tractotomy versus lung resection: 

viable options in penetrating lung injury. J Trauma 


20. Go Mr, Barbato Je, Dillavou Ed et al. (2007) Thoracic 

endovascular aortic repair for traumatic aortic 

transection. J Vasc Surg 46:928-933 

21. Hoornweg Ll, Dinkelman Mk, Goslings Jc et al. 

(2006) Endovascular management of traumatic 

ruptures of the thoracic aorta: a retrospective 

multicenter analysis of 28 cases in The Netherlands. J 

Vasc Surg 43:1096-1102; discussion 1102 [LoE 4] 

22. Huh J, Wall Mj, Jr., Estrera Al et al. (2003) Surgical 

management of traumatic pulmonary injury. Am J 

Surg 186:620-624 [LoE 4] 

23. Jahromi As, Kazemi K, Safar Ha et al. (2001) 

Traumatic rupture of the thoracic aorta: cohort study 

and systematic review. J Vasc Surg 34:1029-1034 

[LoE 3b] 

24. Karmy-Jones R, Jurkovich Gj, Nathens Ab et al. 

(2001) Timing of urgent thoracotomy for hemorrhage 

after trauma: a multicenter study. Arch Surg 136:513- 

518 [LoE 3b] 

25. Karmy-Jones R, Nathens A, Jurkovich Gj et al. (2004) 

Urgent and emergent thoracotomy for penetrating 

chest trauma. J Trauma 56:664-668; discussion 668- 

669 [LoE 4] 

26. Kiser Ac, O'brien Sm, Detterbeck Fc (2001) Blunt 

tracheobronchial injuries: treatment and outcomes. 

Ann Thorac Surg 71:2059-2065 [LoE 4] 

27. Kummer C, Netto Fs, Rizoli S et al. (2007) A review 

of traumatic airway injuries: potential implications for 

airway assessment and management. Injury 38:27-33 

[LoE 2b] 

28. Maggisano R, Nathens A, Alexandrova Na et al. 

(1995) Traumatic rupture of the thoracic aorta: should 

one always operate immediately? Ann Vasc Surg 

9:44-52 [LoE 3b] 

29. Mansour Ma, Moore Ee, Moore Fa et al. (1992) 

Exigent postinjury thoracotomy analysis of blunt 

versus penetrating trauma. Surg Gynecol Obstet 

175:97-101 [LoE 3b] 

30. Martin Mj, Mcdonald Jm, Mullenix Ps et al. (2006) 

Operative management and outcomes of traumatic 

lung resection. J Am Coll Surg 203:336-344 [LoE 2b] 

31. Marty-Ane Ch, Berthet Jp, Branchereau P et al. 

(2003) Endovascular repair for acute traumatic rupture 



of the thoracic aorta. Ann Thorac Surg 75:1803-1807 

[LoE 4] 

32. Mcnamara Jj, Messersmith Jk, Dunn Ra et al. (1970) 

Thoracic injuries in combat casualties in Vietnam. 

Ann Thorac Surg 10:389-401 [LoE 3b] 

33. Mcswain Ne, Jr. (1992) Blunt and penetrating chest 

injuries. World J Surg 16:924-929 [LoE 4] 

34. Meredith Jw, Hoth Jj (2007) Thoracic trauma: when 

and how to intervene. Surg Clin North Am 87:95-118, 

vii [LoE 2a] 

35. Miller Pr, Kortesis Bg, Mclaughlin Ca, 3rd et al. 

(2003) Complex blunt aortic injury or repair: 

beneficial effects of cardiopulmonary bypass use. Ann 

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36. Ott Mc, Stewart Tc, Lawlor Dk et al. (2004) 

Management of blunt thoracic aortic injuries: 

endovascular stents versus open repair. J Trauma 

56:565-570 [LoE 4] 

37. Peterson Bg, Matsumura Js, Morasch Md et al. (2005) 

Percutaneous endovascular repair of blunt thoracic 

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38. Pettiford Bl, Luketich Jd, Landreneau Rj (2007) The 

management of flail chest. Thorac Surg Clin 17:25-33 

[LoE 4] 

39. Reed Ab, Thompson Jk, Crafton Cj et al. (2006) 

Timing of endovascular repair of blunt traumatic 

thoracic aortic transections. J Vasc Surg 43:684-688 

[LoE 4] 

40. Rossbach Mm, Johnson Sb, Gomez Ma et al. (1998) 

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41. Rousseau H, Dambrin C, Marcheix B et al. (2005) 

Acute traumatic aortic rupture: a comparison of 

surgical and stent-graft repair. J Thorac Cardiovasc 

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42. Rousseau H, Soula P, Perreault P et al. (1999) 

Delayed treatment of traumatic rupture of the thoracic 

aorta with endoluminal covered stent. Circulation 

99:498-504 [LoE 4] 

43. Schneider T, Storz K, Dienemann H et al. (2007) 

Management of iatrogenic tracheobronchial injuries: a 

retrospective analysis of 29 cases. Ann Thorac Surg 

83:1960-1964 [LoE 2b] 

44. Schneider T, Volz K, Dienemann H et al. (2009) 

Incidence and treatment modalities of 

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45. Symbas Pn, Sherman Aj, Silver Jm et al. (2002) 

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repair? Ann Surg 235:796-802 [LoE 2b] 

46. Tanaka H, Yukioka T, Yamaguti Y et al. (2002) 

Surgical stabilization of internal pneumatic 

stabilization? A prospective randomized study of 

management of severe flail chest patients. J Trauma 

52:727-732; discussion 732 [LoE 4] 

47. Tang Gl, Tehrani Hy, Usman A et al. (2008) Reduced 

mortality, paraplegia, and stroke with stent graft repair 

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48. Vodicka J, Spidlen V, Safranek J et al. (2007) [Severe 

injury to the chest wall--experience with surgical 

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49. Voggenreiter G, Neudeck F, Aufmkolk M et al. 

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contusion. J Am Coll Surg 187:130-138 [LoE 4] 

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51. Wall Mj, Jr., Soltero E (1997) Damage control for 

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[LoE 4] 

52. Xenos Es, Freeman M, Stevens S et al. (2003) 

Covered stents for injuries of subclavian and axillary 

arteries. J Vasc Surg 38:451-454[LoE 4] 



3.3 Diaphragm 


When detected during the primary diagnostic study and/or intraoperative 

diagnosis, a traumatic diaphragmatic rupture should be quickly closed. 

Explanation: 

GoR B 

A diaphragmatic rupture in up to 1.6% of cases due to blunt injuries is mainly caused by a lateral 

collision in road traffic accidents and predominantly affects the left diaphragm side [1–7]. 

There are no valid data available on the ideal time for surgery in the multiply injured patient. 

Only a pragmatic recommendation can be made that the rupture should be quickly closed if there 

is intrathoracic displacement of abdominal organs. This also applies to the intraoperative 

identification of a diaphragmatic rupture in the case of a cavity opening due to other injuries. 

There is currently no clear evidence that a deferred closure increases the case fatality rate. With 

an all-cause mortality of 17%, the random effects meta-regression of 22 studies (n = 980) from 

1976-1992 [7] showed no correlation between the frequency of deferred management and the 

case fatality rate (beta -0.013, 95% CI: - 0.67– - 0.240). In a current analysis of 4,153 patients on 

the National Trauma Database, pleural empyema was also not associated with the timing of the 

surgical intervention [8]. 

In the acute situation in patients with unstable circulation and if there are no thoracic lesions, 

surgical access is ideally via a transabdominal approach [9]. A thoraco-abdominal approach is 

used in confirmed combination injuries or if the suture is technically difficult to carry out. If 

management is delayed for 7-10 days, a thoracotomy is recommended due to intrathoracic 

adhesions [7, 10]. 

The diaphragm defect can usually be closed using a direct suture; defect grafting is only rarely 

necessary [1, 6, 10]. On the basis of the available data, no conclusions can be drawn on the 

success rates of specific suturing techniques (continuous versus single knot) or suturing materials 

(monofilament versus braided, absorbable versus non-absorbable). There are numerous reports in 

the literature on endoscopic techniques for closing post-traumatic diaphragmatic hernias [11, 

12]; at present, however, no importance can be ascribed to these in the emergency surgery phase. 

Emergency surgery phase - Diaphragm 309


References 

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2. Bergeron E, Clas D, Ratte S et al. Impact of deferred 

treatment of blunt diaphragmatic rupture: a 15-year 

experience in six trauma centers in Quebec. J Trauma 

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3. Brasel KJ, Borgstrom DC, Meyer P, Weigelt JA. 

Predictors of outcome in blunt diaphragm rupture. J 

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4. Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S. 

Update on managing diaphragmatic rupture in blunt 

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of the diaphragm: mechanism, diagnosis, and 

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[LoE 4]. 

6. Mihos P, Potaris K, Gakidis J et al. Traumatic rupture 

of the diaphragm: experience with 65 patients. Injury 

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10. Matsevych OY. Blunt diaphragmatic rupture: four 

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231. 

13. Waldschmidt ML, Laws HL. Injuries of the 

diaphragm. J Trauma 1980;20(7):587-592 

Emergency surgery phase - Diaphragm 310


3.4 Abdomen 

Surgical approach path 


In the trauma situation, preference should be given to the midline laparotomy 

over other approach paths. 

Explanation: 

GoR B 

The midline laparotomy represents an anatomically justified universal surgical approach path to 

the traumatized abdomen. It can be performed quickly causing little bleeding and permits a good 

overview of all 4 quadrants [9, 10]. 

There is only one quasi-randomized study, which is over 25 years old (treatment group allocation 

according to even or odd admission number), in which the midline laparotomy was compared 

with a transverse upper abdominal laparotomy in patients with abdominal trauma [11]. The 

wound infection rates in patients with negative and positive laparotomy were 2% and 11% 

irrespective of the selected approach path. The mean period under anesthesia was 25 minutes 

shorter after positive midline laparotomy than after the transverse upper abdominal laparotomy 

(Table 14). This difference was statistically significant according to the published data (p 

= 0.02). However, there were no standard deviations reported nor was a further breakdown of 

surgery times undertaken. The study cannot serve as proof in favor of a specific type of incision 

but supports the possibility of surgical preferences (“Adequacy of organ exposure is still a matter 

of personal preference”). 

Indirect evidence comes from randomized studies of elective abdominal interventions. A 

Cochrane Review suggests an advantage of the transverse incision with regard to the 

postoperative requirement for morphine equivalents, lung function, and the rate of incisional 

hernias [12]. A difference in the rate of pulmonary complications or in wound infections could 

not be detected. The multicenter randomized POVATI (Postsurgical Pain Outcome of Vertical 

and Transverse Abdominal Incision) Study published in 2009 showed an equivalence in the 

primary endpoint of postoperative analgesia requirement and lack of differences in secondary 

endpoints such as pulmonary complications, mortality, and incisional hernias after 1 year [13]. 

The authors also stress here the possibility of a situation-dependent approach to the abdomen 

(“The decision about the incision should be driven by surgeon preference with respect to the 

patient’s disease and anatomy”). 

Emergency surgery phase - Abdomen 311


Table 14: Midline laparotomy versus transverse upper abdominal laparotomy in abdominal 

trauma 

Study LoE Patients Results 

Stone et al. 1983 

[11] 

2b 339 patients with 

blunt or penetrating 

abdominal trauma 

Midline laparotomy (n = 

177) 

Mean period under 

anesthesia: positive 

laparotomy (n = 66) 

215 min, negative 


126 min 

Transverse upper 

abdominal laparotomy (n 

= 162) 

Mean period under 

anesthesia: positive 


240 min, negative 

laparotomy (n = 101) 132 

min 

Indications for a diagnostic laparoscopy are dealt with in the subsection “Emergency room: 

diagnostic study of the abdomen”. The recommendations updated in 2007 of the Society of 

American Gastrointestinal and Endoscopic Surgeons (SAGES) also apply [14]. Reference is 

made to the evidence-based guideline of the European Association for Endoscopic Surgery 

(EAES) for therapeutic laparoscopy in abdominal trauma [15]. Numerous authors report on 

laparoscopic and hand-assisted laparoscopic abdominal surgery interventions performed on blunt 

and penetrating abdominal trauma (e.g., hemostasis, oversewing, and resection of hollow organs) 

[16–20]. There are no clinical studies in which laparoscopy was compared with a laparotomy or 

used in the particular case of polytrauma. The consensus of the EAES should be followed, 

namely that the currently available data prohibits a clear recommendation in favor of therapeutic 

laparoscopic interventions for abdominal trauma (“Nevertheless, the scarceness of clinical data 

prohibits a clear recommendation in favor of therapeutic laparoscopy for trauma”). 

Damage control: General principles 


In patients with unstable circulation and complex intraabdominal damage, 

priority should be given to the damage control principle (hemostasis, 

packing/wrapping, temporary abdominal wall closure) over attempted 

definitive treatment. 

Explanation: 

GoR B 

The term “damage control” (DC) was coined by the US navy and originally referred to the 

capacity of a ship to absorb damage yet maintain mission integrity [21]. The basis and indication 

for DC or an abbreviated/truncated laparotomy is the AHC triad consisting of acidosis (pH 

< 7.2), hypothermia (< 34 °C), and coagulopathy (International Normalized Ratio [INR] > 1.6 or 

transfusion requirement during surgery > 4 l) [22]. There is currently no standardized or uniform 

DC algorithm. Major accepted elements are 1) rapid hemostasis in injuries to the 

parenchymatous upper abdominal organs and avoiding peritoneal contamination through the 



simple repair of hollow organ injuries, if necessary also discontinuance of resection, 2) 

temporary closure of the abdomen, 3) intensive medical stabilization of body temperature, 

hemodynamics, and coagulation, 4) planned re-surgery to repair and reconstruct organ injuries, 

and 5) definitive abdominal wall closure [22–25]. 

An important element in bleeding from the liver is the perihepatic packing. The liver should be 

completely mobilized from its suspensory ligaments and the packing inserted around the 

posterior paracaval surface and subhepatic between liver and hepatic flexure in order to achieve 

compression against the diaphragm without hindering the venous outflow from the hepatic veins 

[26–30]. 

Despite the existence of an AHC triad, a survival advantage for patients after DC compared to 

one-step, definitive surgical treatment (definitive laparotomy, DL) was confirmed in 3 small 

retrospective cohort studies [31–33]. On the other hand, another retrospective cohort study 

showed a survival advantage in the DL group [34] (Table 15). The pooled relative risk (random 

effects) is 0.79 (95% CI: 0.48–1.33) in favor of DC. If only the maximum injured in the study by 

Rotondo are considered [32], the pooled relative risk is 0.60 (95% CI: 0.30–1.19). There was no 

multivariate adjustment in any of these studies for differences in injury severity or other 

confounders; the results are thus subject to bias. 

In a current Cochrane Review, the authors could not identify any randomized studies despite a 

comprehensive search strategy in 9 databases (including congress abstracts and “gray” literature) 

and a hand search [35]. 

Individual reports suggest survival rates of 90% after DC even in a prognostically unfavorable 

baseline situation [36]. In the majority of larger case series, on the other hand, the case fatality 

rate of the injured who required a DC laparotomy is 25-50% [37–39]. 



Table 15: Damage Control versus definitive management 

Study LoE Patients Result 

Stone et al. 

1983 [31] 

Rotondo et al. 

1993 [32] 

MacKenzie et 

al. 2007 [33] 

Nicholas et al. 

2003 [34] 


penetrating or blunt 

abdominal injuries 

and intra-operative 

development of a 

coagulopathy 


penetrating 




hepatic injuries, 

grade 4/5 


penetrating 


Definitive management 

(n = 14) 

Overall survival rate: 

1/14 (7%) 

Damage control 

(n = 17) a 


11/17 (65%) 

RR 0.11 (95% confidence interval: 0.02–0.75) 


(n = 22) 


12/22 (55%) 

Damage Control (n = 24) b 


14/24 (58%) 


Survival rate for max. 

injury: 1/9 (11%) c 

Survival rate for max. 

injury: 10/13 (77%) c 



(n = 30) 


19/30 (63%) 


(n = 7)¶ 


7 /7 (100%) 



(n = 205) 


184/205 (90%) 


(n = 45) 


33/45 (73%) 

RR 1.22 (95% confidence interval: 1.02–1.47, p = 

0.0032) 

a: Immediate arrest, packing, abdominal closure under tension, mean time until second look: 27 h 

b: four-quadrant packing, hemostasis, ligature or simple (clamp) suture for hollow organ injuries, 

temporary abdominal wall closure, mean time until second look: 32h 

c: Injury to great vessels + ≥ 2 visceral injuries; packing + angioembolization 

The Pringle maneuver with clamping of the portal vein and common hepatic artery is possibly 

one of the oldest DC techniques for the temporary hemostasis of severe hepatic injuries [40]. 

Although an ischemia time of 45-60 minutes through the hepatic parenchyma is tolerated in 

patients with no preoperative shock event without serious postoperative function deficit, the full 

utilization of this ischemia period would seem to increase noticeably the risk of postoperative 

liver failure in the multiply injured patient [41]. In a Chinese case series, 5 out of 7 patients who 

had undergone a Pringle maneuver died because of a retrohepatic caval tear [42]. 



Damage control: Temporary abdominal wall closure 


After DC laparotomy, the abdomen should be closed only temporarily and not 

using a fascial suture. 

The temporary abdominal wall closure in DC laparotomy should be 

performed using synthetic material which enables a stepwise convergence of 

the fascial edges. 

Explanation: 

GoR B 

GoR B 

Primary fascial closure after DC laparotomy increases the risk of abdominal compartment 

syndrome (ACS). After primary fascial suture, a 6-fold increased risk for ACS was reported 

compared to only skin closure and insertion of a 3-liter irrigation bag for cystoscopies (Bogotá 

bag) [43]. Against the reduced risk for ACS by using a temporary closure, there is fluid loss and 

disturbed temperature regulation due to the large exchange surface and the difficulty of 

reconstructing the abdominal wall. Bogotá bag equivalents or commercial products with zip or 

hook-and-loop closure (Wittmann patch or Artificial Burr) have established themselves as 

temporary materials [44]. In addition, there is widespread use of vacuum sealing. The results of 

case series were summarized in a current systematic review paper [45]. According to this, the 

Wittmann patch is associated with the highest success rate for an abdominal wall closure. A 

retrospective cohort study comes to similar results [46]. In a small randomized study, no 

difference between a temporary closure using a vacuum dressing and polyglactin-910 mesh 

could be detected [47]. 



Table 16: Methods for abdominal wall closure 

Study LoE Patients Method Result 

van 

Hensbroek 

et al. 2009 

[45] 

Weinberg 

et al. 2008 

[46] 

Bee et al. 

2008 [47] 

4 Systematic 

review of case 

series 

2b 59 patients 

with blunt or 

penetrating 

abdominal 

trauma 

1b 59 patients 

with blunt or 

penetrating 

abdominal 

trauma 

a: using foil, abdominal sheets and Redon drains 

Wittmann patch 

KCI-VACTM 

Vacuum dressing a 

Skin closure 

Zip closure 

Silo (Bogotá bag) 

Net or sheet 

“Pre-Wittmann 

patch” (n = 23) 

“Wittmann patch” 

(n = 36) 

Polyglactin-910 

mesh 

(n = 20) 

Vacuum dressing 

(n = 26) a 

KCI-VACTM 

(n = 5) 

Survival rate: 

146/180 (81%) 


19/251 (78%) 


846/1,186 

(71%) 


62/101 (61%) 


89/135 (66%) 


61/109 (56%) 


844/1,176 

(72%) 

Case fatality 

rate: 

5/20 (25%) 

Abscess: 

9/15 (60%) 

Case fatality 

rate: 

8/31 (26%) 

Abscess: 12/23 

(52%) 

Abdominal wall 

closure: 

127/146 (88%) 

Abdominal wall closure 

118/195 (60%) 


444/846 (53%) 


27/62 (43%) 


32/89 (36%) 


21/61 (34%) 


214/844 (25%) 

Fascial closure: 

7/23 (30%) 


28/36 (78%) 


4/15 (27%) 


7/23 (30%) 



Damage control: Second look after packing 


After packing intraabdominal bleeding, a second look should be undertaken 

and the tamponade replaced between 24 and 48 hours after the first 

intervention. 

Explanation: 

GoR B 

After packing and intensive medical stabilization as part of the damage control sequence, a relaparotomy 

is necessary to replace the abdominal sheets and also for definitive injury 

management, if applicable. A balance must be maintained here between the risk of fresh 

bleeding and the possible complications (infections, fistula, restricted pulmonary function, 

abdominal compartment syndrome) from the foreign material. 

The available data from retrospective cohort studies show that unpacking after 24-36 hours is 

associated with an increased risk of bleeding (pooled relative risk, fixed effects: 3.51, 95% 

confidence interval: 1.39–8.90) [48, 49]. There is no clear evidence that leaving the abdominal 

sheets for a period of 48 hours increases the risk of septic complications (pooled relative risk, 

fixed effects: 1.01; 95% CI: 0.59–1.70) [48–51]. In the study by Abikhaled, however, leaving the 

tamponades > 72 hours was associated with an almost 7-fold increase in the relative risk for 

intraabdominal abscesses (6.77; 95% CI: 0.84–54.25) [50]. From a pragmatic viewpoint, 

therefore, the re-laparotomy should be planned for not sooner than 24 hours and not later than 48 

hours after the first intervention. 



Table 17: Second look after packing 


Nicol et al. 

2007 [48] 

Cué et al. 

1990 [51] 

Caruso et al. 

1999 [49] 

Sharp et al. 

1992 [52] 

Abikhaled et 

al. 1997 [50] 


penetrating or 

blunt hepatic 

trauma 



blunt hepatic 

trauma 



blunt hepatic 

trauma 



blunt hepatic 

trauma 



blunt abdominal 

trauma 

Definitive abdominal wall closure 


Second look 

24h: 

(n = 25): 

Subsequent 

bleeding: 

8/25 (32%) 

Packing in situ 24 

h (n = 8): 


5/8 (63%) 


h (n = 7): 

Abscess: 

2/7 (29%) 

Second look 

48h: 

(n = 44): 

Subsequent 

bleeding 5/44 

(11%) 


h (n = 44): 


6/44 (14%) 


h (n = 6): 

Abscess: 

2/6 (33%) 

Second look < 36 h (n = 39): 

Subsequent bleeding: 8/39 

(21%) 


13/39 (33%) 

Case fatality rate: 7/39 (18%) 

6 patients with septic 

complications: 

Packing in situ 2.2 ± 0.4 (2– 

3) days 

Packing in ≤ 72 h (n = 22): 

Abscess 1/22 (5%) 

Sepsis 11/22 (50%) 

Case fatality rate 1/22 (5%) 

Second look 72 h 

(n = 3): 

Subsequent 

bleeding: 

0/3 


h (n = 20): 


3/20 (15%) 


h (n = 8): 

Abscess: 

3/8 (38%) 

Second look 36-72 h 

(n = 24): 

Subsequent bleeding: 1/24 

(4%) 


7/29 (29%) 


6 patients without septic 

complications: 

Packing in situ 2.0 ± 1.0 (1– 

7) days 

Packing in situ > 72 h 

(n = 13): 

Abscess 4/13 (31%) 

Sepsis 10/13 (77%) 


Definitive fascial closure should be continuous using slow absorbable or nonabsorbable 

suture material. 

Explanation: 

GoR B 

The technique of fascial closure after a laparotomy is well-known to be controversial and is often 

determined by the surgeon’s preference. The best available evidence on decision-making is 

obtained from randomized studies of elective abdominal interventions. It appears pragmatic and 

expedient to transfer any clear trends in favor of a specific method to the trauma scenario. 



There are 2 meta-analyses of randomized studies for which the data pool only partially overlaps. 

Both show a significant reduction in risk for incisional hernias through non-absorbable suture 

material and continuous sutures [53, 54]. The results of the multicenter INSECT (Interrupted or 

Continuous Slowly Absorbable Sutures – Evaluation of Abdominal Closure Techniques) trial 

published in 2009 show a similar though not significantly statistical trend [55]. 

The updated common Peto odds ratio from all available randomized studies on the comparison 

of continuous slowly absorbable and rapidly absorbable single knot sutures is 0.79 for incisional 

hernias (95% CI: 0.61–1.01) and for wound infections 1.49 (95% CI: 1.15–1.94). 

Angioembolization 


If, in the case of a patient with hepatic injury who can be hemodynamically 

stabilized, there is evidence of arterial bleeding in a contrast agent CT, 

selective angioembolization or a laparotomy should be performed. 

In the case of splenic injuries grade 1-3 which require intervention, selective 

angioembolization can be performed instead of surgical hemostasis. 

In the case of retroperitoneal bleeding which requires intervention, selective 

angioembolization can be performed instead of or in addition to surgical 

hemostasis. 

Explanation: 

GoR B 

GoR 0 

GoR 0 

Interventional radiology has an established value in polytrauma management and is used both in 

primary non-surgical treatment of organ injuries and as a neo-adjuvant and adjuvant intervention 

[56, 57]. If there is evidence of active bleeding from the contrast agent enhanced CT scan which 

cannot or must not be addressed operatively and if there is a good response to fluid and blood 

replacement in the emergency room, angioembolization can contribute towards sustained 

stabilization of the circulation [58, 59]. 

There are no randomized studies. The currently best available evidence is on blunt and 

penetrating hepatic injuries and suggests a reduction in case fatality rate through additional 

angioembolization during DC management compared to operative treatment only (common RR 

[fixed effects] 0.47, 95% CI: 0.28–0.78) [60–65]. The bias due to lack of multivariate adjustment 

must be taken into consideration. Currently, there is no answer to the question as to whether 

angioembolization in hepatic injuries should be performed before or after the DC laparotomy. 

Two studies support early neoadjuvant angioembolization based on the lower complication rates 

[63, 65]. In 2 other studies, on the other hand, mortality was lowered if angioembolization was 

performed after a DC laparotomy [64, 66]. 



Decision-making must be on an individual case basis on the availability and presence of an 

experienced interventional radiologist, the success of circulation-stabilizing measures in the 

emergency room, the intraoperative finding, and the postoperative hemodynamics. 

The same applies to angioembolization in the case of bleeding from the spleen, where more upto-date 

data now seems to call for caution [67–70]. Compared to nonoperative treatment, 

angioembolization did not lead to a reduction in either the treatment failure rate (common RR 

[random effects] 1.13; 95% CI: 0.86-1.48) or mortality (common RR [fixed effects] 1.19; 95% 

CI: 0.66–1.15). 



Table 18: Angioembolization 


Asensio et 

al. 

2007 [61] 

Johnson et 

al. 

2002 [62] 

Asensio et 

al. 

2003 [60] 

Wahl et al. 

2002 [65] 



hepatic trauma grade 4/5 

Angioembolization directly after DC laparotomy (n = 17) DC laparotomy without angioembolization (n = 58) 

Case fatality rate 2/17 (12%) Case fatality rate 21/58 (36%) 




hepatic trauma grade 1–5 Case fatality rate 1/8 (13%) Case fatality rate 4/11 (36%) 



hepatic trauma grade 4/5 

2b 126 patients with blunt 

hepatic trauma grade 1–6 



(grade 4: 4/14 [28%], grade 5: 3/9 [33%]) 

RR 0.51 (95% confidence interval 0.27-0.98) 


(grade 4: 15/37 [39%], grade 5: 37/43 [86%]) 

OR (multivariate adjusted for RTS, direct surgical access to hepatic veins and packing): 

0.20 (95% confidence interval 0.05-0.72) 

Early AE 

before/instead of 

DC laparotomy 

(n = 6) 

Case fatality rate 

0/6 (0%), 

complications 

3/6 (50%) 

Late AE after DC 


Case fatality rate 3/6 

(50%), complications 

6/6 (100%) 

DC laparotomy (n = 20) Nonoperative treatment (n = 94) 

Case fatality rate 7/20 (35%), 

complications 9/20 (45%) 

Case fatality rate 2/94 (2%), 

complications 2/94 (2%) 

(continued) 



Table 18: Angioembolization - (continued) 


Mohr et al. 

2003 [63] 

Monnin et 

al. 

2008 [64] 



Early AE before/instead of DC laparotomy (n = 11) Late AE after DC laparotomy (n = 15) 

hepatic trauma grade 3–5 Case fatality rate 2/11 (18%), complications 5/11 (45%) Case fatality rate 5/15 (33%), complications 6/15 (40%) 

2b 

Table 19: Angiography 

14 patients with blunt 

hepatic trauma grade 3–5 


Velmahos 

et al. 2000 

[66] 

2b 137 patients with blunt or 

penetrating abdominal 

trauma 

(36 hepatic injuries) 

Early AE before/instead of DC laparotomy (n = 10) Late AE after DC laparotomy (n = 4) 

Case fatality rate 1/10 (10%) Case fatality rate 0/4 (0%) 

Emergency room 

angiography 

(n = 49) 

Case fatality rate: 

14/49 (29%) 

Emergency room ICU 

angiography 

(n = 15) 


3/15 (20%) 

Operating room 

angiography 

(n = 32) 


7/32 (22%) 

Operating room ICU 

angiography (n = 21) 


2/21 (10%) 



Table 20: Interventions after blunt splenic injuries 


Cooney et 

al. 

2005 [69] 

Harbrecht 

et al. 

2007 [67] 

Smith et 

al. 

2006 [68] 

Duchesne 

et al. 

2008 [70] 

Wei et al. 

2008 [71] 


splenic injuries grade 

1–5 



1–5 



1–5 



1–5 



1–5 


(n = 9) 

Success rate: 6/9 (67%) 



(n = 46) 


Success rates: 

grade 2: 16/17 (94%), grade 3: 76%, 

a, b 

grade 4: 88% 


(n = 41) 

Success rate: 

30/41 (73%) 

Nonoperative treatment 

(n = 137) 

Success rate: 126/137 (92%) 



(n = 303) 


Success rates: 

grade 2: 225/236 (95%), grade 3: 86%, 

grade 4: 63% a 


(n = 303) 

Success rate: 

114/124 (92%) 

Splenectomy 

(n = 48) 

Success rate: 48/48 (100%) 


Splenectomy 

(n = 221) 


Splenectomy 

(n = 56) 

Success rate: 

56/56 (100%) 

Before carrying out angioembolization (n = 78) After carrying out angioembolization (n = 76) 


Sepsis: 4/78 (5%) 

ARDS: 4/78 (5%) 


(n = 55) 


abdominal complications: 2/55 (5%) 


Sepsis: 9/76 (9%) 

ARDS: 17/76 (22%) 

Splenectomy 

(n = 37) 


abdominal complications: 13/37 (35%) 

a: No. of patients unclear b: No effect of angioembolization on success rates after multivariate adjustment for age, AIS and abdominal concomitant injuries 



Spleen-salvaging operations 


The goal can be spleen-salvaging surgery in the case of splenic injuries of 

severity grade 1-3 according to AAST/Moore that require surgery. 

Preference should be given to splenectomy over a salvage attempt in patients 

with splenic injuries of severity grade 4-5 according to AAST/Moore that 

require surgery. 

Explanation: 

GoR 0 

GoR B 

The risk of an “overwhelming postsplenectomy syndrome (OPSI)” after a splenectomy is estimated 

at 2.5% [72]. In patients with stable circulation, splenic injuries only rarely represent an indication 

for laparotomy. Thus, only when surgery becomes necessary (e.g., in the case of unstable 

circulation or high transfusion requirement) does the question arise for the surgeon as to the 

possibility and the certainty of salvaging an organ. Complete mobilization of the spleen after 

separating the lienorenal and phrenicolienal ligaments is definitive for operative success [73]. 

Unsurprisingly, due to different patient populations and injury severity scores, it is difficult to 

conduct a direct comparison between the results after splenectomy and salvage procedures. With 

stable splenorrhaphy frequency between 1988 and 1993, an analysis of the North Carolina Trauma 

Registry showed a trend in favor of primary nonoperative management and a rejection of the 

splenectomy. The comparison between the methods yielded, not surprisingly, a lower mortality 

after splenorrhaphy compared to splenectomy (RR 0.36, 95% CI: 0.18-0.73) at higher mean ISS in 

the splenectomy group (25 ± 12 versus 19 ± 11, p < 0001) [74]. In this cohort there were also 10 

patients with a mean ISS of 33 ± 15 where the salvage attempt failed. After the splenectomy, 2 

patients died. In another study with comparable injury severity, considerably fewer infections 

occurred after splenorrhaphy (RR 0.30, 95% CI: 0.13–0.70) [75]. A non-significant trend to overall 

higher complication rates after splenorrhaphy (RR 1.81; 95% CI: 0.36-9.02) despite lower injury 

severity was observed in another study [76]. 

In a series of 326 patients from the early 1980s, the rates of spleen-salvaging operations for Moore 

I/II, III and IV/V injuries were 88.5%, 61.5%, and 7.7% [77]. A similar trend in relation to the ISS 

was also demonstrated in a more recent study with inclusion of 2,258 adult patients [78]. The failure 

quota (subsequent bleeding, secondary splenectomy) after a spleen salvage attempt was 7 out of 240 

(2.9%; 95% CI: 1.2–5.9%). A splenectomy was necessary in 66.4% of all patients with an ISS ≥ 15. 

In a multivariate analysis of 546 patients from a 17-year period, Carlin derived injuries of grade 4 

and 5 as independent predictive variables for a splenectomy [79]. However, whether this depicts the 

actual necessity of removing a spleen or merely the surgeon’s strong feelings cannot be 

conclusively evaluated. In the special case of 25 multiply injured patients with a mean ISS of 32.0 

(95% CI: 28.2-35.8), Aidonopoulos and colleagues observed subsequent bleeding requiring a 



splenectomy in 2 patients with injury grade 3 after suturing with a ‘figure of eight’ (0-0 chromic cat 

gut) [80]. 



Table 21: Interventions after blunt or penetrating splenic injuries 


Clancy et al. 

1997 [81] 

Gauer et al. 

2008 [82] 

Kaseje et al. 

2008 [83] 

a: Subsequent bleeding: 

b: Pancreas leaks and fistulas 

2b 1,255 patients with blunt 

or penetrating splenic 

injuries grade 

1–5 


splenic injuries 

requiring surgery 


and penetrating splenic 

injuries requiring 

surgery 

Splenorrhaphy 

(n = 150) 

Shock: 26/150 (17%) 

mean ISS: 19 ± 11 

Splenectomy after splenorrhaphy 

(n = 10) 

Shock: 2/10 (20%) 

mean ISS: 33 ± 15 

Splenectomy 

(n = 596) 

Shock: 149/596 (25%) 

mean ISS: 25 ± 12 

Case fatality rate: 8/150 (5%) Case fatality rate: 2/10 (20%) Case fatality rate: 88/596 (15%) 

Splenorrhaphy 

(n = 34) 

Splenectomy 

(n = 57) 

Mean ISS: 31 Mean ISS: 33 

Infections (total): 5/34 (15%) 

Pneumonias: 3/34 (9%) 

Splenorrhaphy 

(n = 16) 

Infections (total): 28/57 (49%) 

Pneumonias: 19/57 (33%) 

Splenectomy 

(n = 58) 

Mean ISS: 21 Mean ISS: 28 

Complications: 2/16 (13%) a Complications: 4/58 (7%) b 



Hollow organ injuries 


In the case of penetrating colon injuries, if technically possible, preference 

must be given over a two-step procedure with temporary stoma to oversewing 

only or to primary anastomosis in order to reduce the risk of intraabdominal 

infections. 

Explanation: 

GoR A 

Due to the contamination of the sterile abdominal cavity with mixed anaerobic flora, penetrating 

colon injuries represent a potentially life-threatening clinical picture. Thus, patients with 

abdominal gunshot wounds who must undergo immediate surgical treatment have a 100-fold 

higher relative risk of dying compared to patients with injuries that can be treated non-surgically 

or during secondary surgery [84]. 

Since 1979, 6 randomized trials (RCTs) have been published in which the results after primary 

operative management to maintain continuity were compared with those after temporary 

insertion of an ileostomy [85–90]. These studies were summarized in a Cochrane Review 

updated in 2009 [91]. The observed trends were also reproduced in the multicenter study of the 

American Association for the Surgery of Trauma (AAST) [92]. 

Based on the best available evidence, there is a non-significant trend in mortality in favor of 

primary anastomosis (RR 0.67; 95% CI: 0.31-1.45) with a marked reduction in complication 

rates (RR 0.73; 95% CI: 0.52-1.02). The risk of intraabdominal infections could possibly be 

reduced by 23% through primary anastomosis (RR 0.77; 95% CI: 0.55-1.06) even though clear 

scientific proof from an appropriately designed randomized study is unavailable. Current data 

from the US Iraq operations support the trends in favor of primary anastomosis [93]. It is unclear 

whether the available data can be transferred to blunt injuries. In this situation, however, biologic 

and clinical considerations argue more in favor of maintaining continuity. 

Stapling instruments represent a major valuable addition to the equipment for elective 

gastrointestinal interventions. Deep colorectal anastomoses were first made possible through the 

availability of circular staplers; laparoscopic intestinal surgery also gained from the option of 

stapled anastomoses. 

In a meta-analysis of 9 randomized studies (1,233 patients), however, there was no evidence of 

advantage from staplers compared to a hand suture in the endpoints mortality, anastomosis 

failure, wound infection, re-operation, and length of stay in hospital [94]. On the other hand, 

there was a significantly increased risk of strictures after stapled anastomosis (Peto OR 3.59; 

95% CI: 2.02–6.35). The multicenter studies of the Western Trauma Association and AAST 

have produced evidence of a possible disadvantage from stapled colon anastomoses in the 

trauma situation [95, 96]. The weighted relative risk for all complications after hand suture 

compared to stapled anastomosis from both studies is 0.72 (95% CI: 0.45-1.15). For anastomosis 



failures and intraabdominal abscesses, the common RR can be estimated at 0.90 (95% CI: 0.36- 

2.28) and 0.74 (95% CI: 0.42-1.28). 

Two multicenter studies yielded similar, again non-significant trends for small intestine 

anastomoses [95, 97]. The hand suture is possibly associated with a reduction in all 

complications (RR 0.75; 95% CI: 0.31-1.82). Anastomosis failures and intraabdominal abscesses 

were also observed less frequently after hand suturing (RR 0.43; 95% CI: 0.08–2.42 and RR 

0.54; 95% CI: 0.18–1.64). 

The results of a randomized trial conducted under elective conditions suggest that a single-layer, 

continuous hand suture can be carried out without risk. In this study [98], no difference could be 

detected in the failure rates between a single-layer (2/65) and a two-layer/Lembert suture (1/67). 

The observed frequency of abscesses was also identical between the two treatment arms (2/65 

and 2/67). Nineteen and 12 trauma patients were also included in the study. 



Table 22: Primary anastomosis versus ileostomy after penetrating colon injury 


Nelson et al. 

2009 [91] 

Demetriades 

et al. 2001 

[92] 

Vertrees et 

al. 2009 [93] 

1a Meta-analysis of 6 

RCTs (n = 707) 


penetrating colon 

injuries 

2b 65 wounded (Enduring 

Freedom/ Iraqi 

Freedom) with 

penetrating colon 

injuries 

Primary anastomosis 

(n = 361) 

Ileostomy 

(n = 344) 

Case fatality rate: 7/361 (2%) Case fatality rate: 6/344 (2%) 

All complications: 135/361 (37%) All complications: 173/346 (50%) 

Infections: 120/361 (33%) Infections: 144/346 (42%) 


(n = 197) 

Ileostomy 

(n = 100) 





(n = 38) 

Ileostomy 

(n = 27) 


all colon-associated complications: 11/38 (29%) all colon-associated complications: 10/27 (37%) 




Table 23: Hand suture versus stapler after penetrating colon injury 


Brundage et 

al. 2001 

[95] 

Demetriades 

et al. 2002 

[96] 

2b 29 patients with blunt and 

penetrating colon injuries 


penetrating colon injuries 

Hand suture 

(n = 12) 

Emergency surgery phase - Abdomen 330 

Stapler 

(n = 17) 


Anastomosis failure: 0/12 (0%) Anastomosis failure: 3/17 (18%) 

Abscess: 2/12 (17%) Abscess: 5/17 (29%) 

Hand suture: 

(n = 128) 

Stapler: 

(n = 79) 



Abscess: 20/128 (16%) Abscess: 16/79 (20%)


Table 24: Hand suture versus stapler after penetrating colon injury 


Brundage 

et al. 1999 

[95] 

Kirkpatrick 

AW et al. 

2003 [97] 


and penetrating small 

intestine injuries 


and penetrating small 

intestine injuries 

Hand suture 

(n = 44) 

Emergency surgery phase - Abdomen 331 

Stapler 

(n = 70) 



Abscess: 0/44 (0%) Abscess: 6/70 (9%) 

Hand suture 

(n = 25) 

Stapler 

(n = 55) 



Abscess: 3/25 (12%) Abscess: 6/55 (11%)


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Surgical management 

Emergency surgical management 


Compressive intracranial injuries must be surgically managed as an 

emergency. 

Explanation: 

GoR A 

The goal of the treatment after a TBI is to limit the extent of secondary brain damage and to 

provide the brain cells whose function is impaired but not destroyed with the best conditions for 

functional regeneration. Injury sequelae requiring surgery must be treated in a timely manner. 

The indication for surgical decompression of traumatic intracranial compression has never been 

tested in prospective randomized controlled trials. There are several retrospective analyses [3-9, 

13] from which the benefit of surgical decompression can be derived. Due to the decades of 

consensual experience, the need for a surgical procedure can be regarded as a basic 

incontrovertible assumption of good clinical practice. 

Compressive intracranial injuries represent an absolute urgent indication for surgery. This 

applies both to traumatic intracranial bleeding (epidural hematoma, subdural hematoma, 

intracerebral hematoma/contusion) and to compressive impression fractures. The definition of 

compression refers to the shift of cerebral structures, particularly the 3rd ventricle normally 

located at the midline. In addition to the finding in the computed tomography (layer thickness, 

volume, and location of hematoma, extent of midline shift), the clinical finding is key to 

establishing the indication and the speed with which surgical management should be carried out. 

If there are signs of a transtentorial herniation, every minute can make a difference to the clinical 

outcome. It is not considered meaningful to indicate the volumes at which an intervention should 

be performed as the individual situation of the patient (age, possible pre-existing brain atrophy 

inter alia) must be taken into account in establishing the indication. 

Operations with deferred urgency 

Open or closed impression fractures without shift of midline structures, penetrating injuries or 

basal fractures with liquorrhea constitute operations with deferred urgency. Their surgical 

conduct requires neurosurgical competence. The timing of the surgical intervention depends on 

many factors and must be decided on an individual basis. 

Decompressive craniectomy 

An effective option for lowering elevated intracranial pressure is surgical decompression by 

craniectomy and, if necessary, expansive duraplasty. The necessity mainly arises from the 

Emergency surgery phase – Traumatic brain injury 336


development of marked (secondary) brain edema and thus frequently has several days’ latency. 

According to a prospective randomized controlled trial, the method shows good treatment 

success despite an increased complication rate [23]. Further prospective studies [10, 18] are 

ongoing so that no final recommendation can yet be made [26]. 

Nonoperative treatment of intracranial bleeding 

In noncompressive bleeding and stable neurologic finding, a nonoperative procedure can be 

justified in individual cases [5, 7]. However, these patients must undergo close clinical and 

computed tomography follow-up observation. In the event of clinical deterioration or increase in 

compression, it must be possible to carry out immediate surgical decompression. 

Measuring intracranial pressure 


Intracranial pressure can be measured in unconscious brain-damaged 

patients. 

Explanation: 

GoR 0 

Internationally in recent decades, the measurement of intracranial pressure has found its way into 

the acute management of unconscious brain-damaged patients and has meanwhile been adopted 

in several international guidelines [2, 21, 30]. For pathophysiologic reasons, this seems sensible 

as clinical monitoring of many cerebral functions is only possible to a limited extent. As a 

monitoring instrument in sedated patients, it can indicate imminent midbrain incarceration due to 

progressive brain swelling or compressive intracranial hematomas and thus permits early 

counter-measures to be taken. Even if there is currently no prospective randomized controlled 

trial that compares the clinical outcome with carrying out ICP monitoring [15], several cohort 

studies in recent years as well as clinical practice indicate its value in neurosurgical intensive 

medicine [1, 17, 20, 22]. The introduction of guidelines which, inter alia, stipulate this type of 

ICP monitoring has also led to an increase in favorable courses in TBI patients [24, 11]. 

Intracranial measurement is used for monitoring and treatment control of unconscious patients 

while taking into account the clinical course and morphologic image findings after TBI. 

However, it is not required in every unconscious patient. 

The prerequisite for adequate brain perfusion is adequate cerebral perfusion pressure (CPP), 

which can be calculated simply from the difference between the mean arterial blood pressure and 

the mean ICP. The literature contains divergent opinions on whether lowering the ICP or 

maintaining the CPP should be the focus of the treatment in the case of elevated ICP. The 

currently available evidence argues in favor that, 

� on the one hand, the CPP should not fall below 50 mmHg if possible [30]. 

� on the other hand, the CPP should not be raised to above 70 mmHg by aggressive treatment 

[30]. 



Invasive ICP measurement is necessary for continuous determination of the CPP. Provided the 

ventricles are not completely compressed, ICP monitoring via a ventricle drain offers the 

possibility of lowering elevated ICP through draining cerebrospinal fluid. 

Determining the individual optimum CPP requires simultaneous knowledge of brain blood 

supply, oxygen supply and demand and/or brain metabolism. Regional measurements (using 

brain tissue probes, transcranial Doppler examinations or perfusion-weighted imaging) for 

estimating this value are currently the subject of scientific studies [19, 27]. 



References 

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Impact of intracranial pressure and cerebral perfusion 

pressure on severe disability and mortality after head 

injury. Neurocrit.Care 4:8-13, 2006 

2. Bullock R, Chesnut RM, Clifton G, et al: Guidelines 

for the management of severe head injury. Brain 

Trauma Foundation. Eur.J.Emerg.Med. 3:109-127, 


3. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, 

Newell D, Servadei F, Walters BC, Wilberger JE. 

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58(3) Supplement:S2-1-S2-3, March 2006 

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10. Cooper DJ, Rosenfeld JV, Murray L, Wolfe R, 

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injury and refractory intracranial hypertension‐a pilot 

randomized trial. J Crit Care. 2008:387-93. 

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value of initial computerized tomography scan, 

intracranial pressure, and state of autoregulation in 

patients with traumatic brain injury. J.Neurosurg. 

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18. Hutchinson PJ, Corteen E, Czosnyka M, Mendelow 

AD, Menon DK, Mitchell P, Murray G, Pickard JD, 

Rickels E, Sahuquillo J, Servadei F, Teasdale GM, 

Timofeev I, Unterberg A, Kirkpatrick PJ. 

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Continuous assessment of cerebrovascular 

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34:1783-1788, 2006 

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pressure monitoring and outcomes after traumatic 

brain injury. Can.J.Surg. 43:442-448, 2000. 

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severe head injury in adults. Acta Neurchir. (Wien) 

139, 286-294, 1997 [Evidenzbasierte Leitlinie] 

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Traumatic Brain Injury in Austria IV: Intensive care 

management. Wien.Klin.Wochenschr. 119:46-55, 

2007. 

23. Qiu W, Guo C, Shen H, Chen K, Wen L, Huang H, 

Ding M, Sun L, Jiang Q, Wang W. Effects of 

unilateral decompressive craniectomy on patients with 



unilateral acute post‐traumatic brain swelling after 

severe traumatic brain injury. Crit Care. 

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outcomes in a community hospital setting of using the 

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25. Rotondo MF, Schwab CW, McGonigal MD, et al.: 

“Damage control”: an approach for improved survival 

in exsanguinating penetrating abdominal injury. J 

Trauma 1993, 35:375–382. 

26. Sahuquillo J, Arikan F. Decompressive craniectomy 

for the treatment of refractory high intracranial 

pressure in traumatic brain injury. The Cochrane 

Database of Systematic Reviews 2006, Issue 1. 

27. Steiner LA, Czosnyka M, Piechnik SK, et al: 

Continuous monitoring of cerebrovascular pressure 

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Critical renal injuries (grade 5 according to the AAST classification) should 

be surgically explored. 

In the case of renal injuries < grade 5, a primary conservative procedure 

should be introduced in stable circulation conditions. 

If other injuries necessitate a laparotomy, renal injuries of average severity 

grade 3 or 4 can be surgically explored. 

Explanation: 

GoR B 

GoR B 

GoR 0 

The indication to operate on renal injuries is now regarded with more restraint than a few years ago. In most 

cases, the decision to perform a laparotomy is already dictated by the intraabdominal concomitant injuries. 

However, life-threatening renal bleeding also represents an absolute indication for surgery [116]. The injury 

severity score according to AAST (American Association for the Surgery of Trauma) [117] has established 

itself as the basis of decision-making as this classification is closely correlated to the need for surgery and 

the possibility of salvaging the kidney [118]. Grade 5 renal injuries represent an indication for surgery 

because of the blood loss and/or threatening loss of renal function. In contrast, it is usually the case that 

grade 2 to grade 4 injuries can definitely be managed conservatively unless the patient has unstable 

circulation due to their renal injury; then the kidney should be surgically freed [119–133]. In the meantime, 

there are even individual reports by authors who have successfully treated grade 5 injuries conservatively 

[134, 135]. Provided pelvic or abdominal injuries require a laparotomy anyway, non-trivial renal injuries (> 

grade 2) can be surgically explored as this increases therapeutic certainty and may even make second 

interventions superfluous. 

In particular, controversy has long surrounded the procedure for severe renal injuries with urine discharge 

and devitalized fragments. However, individual smaller studies have shown that even here non-surgical 

management is possible [136–138] even if the complication and revision rate here turns out to be markedly 

higher [139]. 

Pathologic pyelogram findings with additional evidence of a pulsating or expanding retroperitoneal 

hematoma should be surgically explored in cases where only i.v. pyelography can be carried out because of 

prioritizing. The evidence of hematuria and ideally also the ultrasound finding should be used here in the 

evaluation. Ichigi et al. showed that the size of the perirenal hematoma is closely linked to the severity of the 

renal injury [140] so that this criterion can also be used in the decision between a surgical or conservative 

procedure [4, 6, 9]. 

Emergency surgery phase – Genitourinary tract 341


Table 25: Grading classification of renal trauma according to the American Association for the Surgery of 

Trauma (AAST) [117] 

Grade Properties 

1 Renal contusion, perirenal or subcapsular hematoma, no other lesion in the imaging 

2 Grade I lesion and laceration of the parenchyma up to 1 cm, collecting system not involved 

3 Laceration > 1 cm without urine extravasation 

4 Penetrating parenchymal lesion involving collecting system and/or hilar vessels 

5 Shattered kidney and/or renal vascular pedicle avulsion, bleeding/sequestration 


Selective angiographic embolization of a renal artery injury can be attempted 

as a therapeutic option in the patient with stable circulation. 

Explanation: 

GoR 0 

Up till now, the importance of angiographic embolization has been documented in a few case series and case 

reports [95, 141, 142] but which also partly include non-traumatic bleeding of the renal arteries [143–145]). 

These studies also refer partly not only to the primary phase of polytrauma management but also describe 

the treatment of pseudoaneurysms or arteriovenous fistulas in the secondary phase [94, 146, 147]. According 

to these case series, bleeding is successfully arrested in about 82% [94] to 94% [95] of patients. In more 

recent review papers as well, the angiographic embolization of renal injuries in patients with stable 

circulation is increasingly accepted as the first intervention step albeit with reference to the monotrauma 

situation [9, 41, 47]. Usually, it involved branches of the renal artery which required embolization. It is 

undisputed that the selection of patients, the technical equipment, and the individual medical experience 

have a decisive influence on the success rate. Primarily because of the considerable amount of time required 

for embolization, selective angiographic embolization can only be successfully incorporated into the overall 

management in individual cases of multiply injured patients. 




Depending on the type and severity of injury and concomitant injuries, a renal 

injury can be surgically managed by oversewing or, if necessary, by partial 

renal resection and other procedures to salvage the organ. 

GoR 0 

Primary nephrectomy should be reserved for grade 5 injuries. GoR B 

Explanation: 

In the multiply injured patient with renal injury, the surgical approach is usually determined by the overall 

injury pattern and then normally consists of a midline laparotomy. In order to control renal bleeding, the 

renal pedicle is generally prepared before opening Gerota’s fascia. Individual zig-zag sutures and continuous 

sutures are then used to arrest the bleeding [116]. Fibrin adhesives can be advantageous here [148]. The 

surgical procedure for the multiply injured patient is largely identical to that for the monotrauma patient and 

there is no need to go into detail here. 

The effort expended in reconstruction attempts should be based on the overall situation of the patient. 

Primary nephrectomy should be reserved for grade 5 injuries [9]. No long-term reconstruction attempts 

should be undertaken unless both kidneys are at risk. For reasons of time and the fewer complication 

possibilities, the indication for nephrectomy in the multiply injured patient should be made sooner than for 

the monotrauma patient [9, 41]. 

Ureter injuries 

As ureter injuries are difficult to diagnose, if a laparotomy is being performed for another reason, it should 

be used for examining the ureters if such an injury is suspected [7]. Although macroscopic evaluation is also 

unreliable [102], it presents a huge advantage in that it allows a ureter injury to be treated early. Untreated 

ureter injuries lead to urine fistulas, urinomas, and infections so that the goal here should also be surgical 

management at the earliest opportunity [101]. The lesions are most frequently located in the proximal ureter 

[149]. A wide range of surgical procedures can be used [7]. 



Bladder injuries 


Intraperitoneal bladder ruptures should be surgically explored. GoR B 

Extraperitoneal bladder ruptures without involvement of the neck of the 

bladder can be conservatively treated through suprapubic urinary diversion. 

Explanation: 

GoR 0 

In most cases, the management of frequently numerous concomitant injuries should be given priority over a 

bladder injury. Numerically, extraperitoneal bladder ruptures are roughly twice common as intraperitoneal 

bladder ruptures [11, 60]. Combined extraperitoneal and intraperitoneal ruptures are markedly less 

frequently observed. Even taken on their own, intraperitoneal bladder ruptures represent a surgical 

indication since large tears are often found which can then lead to peritonitis and urinomas [150, 151]. The 

bladder should be closed and any urinomas drained. 

The majority of extraperitoneal bladder injuries can be treated conservatively by means of a catheter drain, 

even if large retroperitoneal or scrotal extravasates are present [150]. Based on a series of 30 extraperitoneal 

ruptures, Cass and Luxemberg report on a 93% success rate with this non-surgical method [152]. In another 

series of 41 patients, almost all extraperitoneal bladder ruptures healed successfully within 3 weeks [153]. 

However, if the bladder neck is injured [11], bony fragments lie in the bladder or the bladder is clamped 

between bony pelvic fragments, a primary surgical procedure is necessary [1]. In the sequence of operations, 

osteosynthesis of the pelvis comes first followed by urological management [38]. Routt et al. also emphasize 

that good cooperation between the trauma surgeon and the urologist is essential here [38]. 



Urethral injuries 


Complete ruptures of the urethra should be treated in the emergency surgery 

phase by suprapubic urinary diversion. 

GoR B 

Urinary diversion can be supplemented by urethral re-alignment. GoR 0 

Provided a pelvic fracture or another intraabdominal injury necessitates 

surgery anyway, urethral ruptures should be managed in the same session. 

Explanation: 

GoR B 

It should be particularly mentioned in the management of urethral injuries that the method described here 

refers explicitly only to the emergency surgery phase as other principles also apply in the further 

management. 

To date, there has been insufficient evidence as to whether primary, delayed or secondary re-anastomosing 

should be preferred in complete ruptures of the posterior urethra. In addition, primary and delayed urethral 

re-alignment is proposed [8]. The main problems in the post-traumatic course are urethral strictures, 

incontinence, and impotence so the treatment goal is to avoid them. 

In a literature review summarizing several case series and comparative studies [20, 154–163] on the 

treatment of the urethral rupture, Koraitim [31, 164] describes the following rates of stricture, incontinence, 

and impotence: suprapubic diversion on its own 97%, 4% and 19%; primary re-alignment 53%, 5% and 

36%; primary suture 49%, 21% and 56%. Accordingly, in the case of a complete urethral rupture in the 

male, he recommends suprapubic diversion on its own or re-alignment if there is a large gap between the 

ends of the urethra. However, as this literature review spans back more than 50 years, more recent studies on 

urethral re-alignment with better results are perhaps not sufficiently taken into account. Nevertheless, even 

current studies find both treatment options of equal value [165]. Accordingly, the EAST Guideline also 

comes to the conclusion that both primary re-alignment and also suprapubic diversion with secondary 

surgery are equally worthy of recommendation [10]. 

In the cases where surgery is necessary anyway due to other adjacent lesions, it appears expedient to manage 

the urethral rupture at the same time to avoid two-step management [166]. Particularly if the abdominal 

cavity is contaminated by large intestine injuries, primary suture of the urethra over a splinting catheter 

appears advisable to avoid complicating infections. Even if a conservative procedure actually appears to be 

possible, urethral injuries should be managed by primary surgery if the definitive osteosynthesis of the bony 

pelvis cannot otherwise be carried out [167]. 

Ruptures of the anterior urethra in the male are somewhat rarer than those of the posterior urethra. Primary 

surgical reconstruction may be necessary in open injuries. In the majority of cases, however, preference 

should also be given here to suprapubic urinary diversion followed by later reconstruction as reconstruction 

of the anterior urethra and the external male genitals, which are often injured as well, is usually difficult and 



time-consuming. However, in the case of a penile fracture with injury to the corpus spongiosum, it is 

recommended that the urethral injury also undergoes primary surgery [8, 168, 169]. The severity of the 

urological injury [170] and the overall severity of all injuries are crucial in deciding between primary 

surgery and conservative treatment. 

Urethral injuries occur markedly less frequently in women than in men. However, when they occur, they are 

mostly very pronounced and associated with bladder injuries. For this reason, primary treatment should 

consist only of suprapubic urinary diversion if the patient has unstable circulation and/or other injuries 

require more urgent surgical management [67]. On the other hand, in women with less severe polytrauma, 

ruptures in the proximal urethra can undergo primary reconstruction via retropubic approach [69, 70, 171]. 

These recommendations apply similarly to children as well, whereby again a distinction should be made 

between the sexes. In a series of 35 boys with posterior urethra tears, Podestá et al. (1997) compared 

suprapubic diversion (with later urethroplasty), suprapubic diversion with urethral catheter alignment, and 

primary anastomosis [172]. As the continence rate after primary anastomosis only reached 50%, and in the 

group with catheter alignment all 10 patients still required urethroplasty later, the authors recommend 

suprapubic urinary diversion on its own followed by secondary urethroplasty. In a study on urethral injuries 

in girls with pelvic fracture and other concomitant injuries, the same authors found deferred management to 

be advantageous as good results could be observed despite vesical and vaginal concomitant injuries. 



Figure 5: Algorithm on the diagnostic and therapeutic procedure for suspected renal injuries 

Grade 5 

Gross or microscopic 

Grade 3- 

hematuria? 

Computer 

tomography 

yes 

no 

yes 

(or other procedures) 

Severity grade 

of renal trauma 

according to 

AAST? 

Laparotomy necessary for 

another reason? 

5 

8 

9 

4 

Suspected 

blunt renal trauma 

Circulatory shock due to 

abdominal bleeding? 

no 

Primary 

conservative 

treatment 

Surgical exploration 

of renal injury 

Emergency surgery phase – Genitourinary tract 347 

1 

6 

2 

10 

no 

yes 

Emergency laparotomy 

Pulsating 

retroperitoneal 

hematoma? 

yes 

3 

7


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3.7 Spine 

Indication for surgery 


Unstable spinal injuries with confirmed or assumed neurologic deficits, with 

malpositions in which neurologic deficits can probably be prevented or 

improved by reduction, decompression, and stabilization, should be operated 

on as early as possible (“day 1 surgery”). 

Explanation: 

GoR B 

After life-threatening injuries to the body cavities and the head, and the long bones, spinal 

injuries occupy third place, or second place if there is a spinal cord injury, in management 

priority [1]. 

Surgical indications are atlanto-occipital dislocation, translatory atlanto-axial dislocation, 

unstable Jefferson fracture, unstable Dens fracture (particularly type II), Hangman fracture (rib 

fracture C2 and invertebral disc injury C2/C3), C3 to C7 fractures (A3, B and C types) also in 

terms of dislocation, and T1 to L5 fractures (A3, B and C types) also in terms of dislocation. 

According to prevailing opinion, an absolute primary surgical indication exists even if there is an 

open spinal injury [2, 3]. 

In addition, the indication for primary management of a spinal injury in polytrauma is assisted by 

the classification according to Blauth et al. (1998) into a) complex spinal injuries with an injury 

to essential neural pathways and organs such as the spinal cord, lung, great vessels and 

abdominal organs, b) unstable spinal injuries (type A3, B and C - in this case, functional 

treatment can lead to severe malpositions and neurologic damage), and c) stable spinal injuries. 

If a complex spinal injury or an unstable spinal injury is involved, the goal should be surgical 

stabilization at the earliest possible opportunity - in other words, on the day of the accident if 

none of the contraindications mentioned below are present [4]. 

According to Blauth et al. (1998), a complex spinal injury is a multi-level spinal injury or one 

accompanied by intrathoracic or intraabdominal injury or polytrauma. The fact that polytrauma 

makes a spinal injury a “complex” injury is substantiated inter alia by studies by Hebert and 

Burnham [5] which established that the length of stay in hospital was extended and the number 

of surgical interventions increased in these patients and that the combination of spinal 

injury/polytrauma is associated with an increased morbidity and mortality and an increased 

degree of disability. Nevertheless, according to a survey in North America by Tator et al. (1999), 

1/3 of spinal injuries with neurologic injuries were still conservatively treated and of those 

operated on only 60% received surgery before the 5th day and 40% after [6]. 

The goal of primary surgical management in unstable spinal injuries with confirmed or assumed 

neurologic deficits or with malpositions is firstly early spinal decompression and the avoidance 

Emergency surgery phase – Spine 354


of neurologic secondary damage and secondly to achieve positioning stability for the intensive 

treatment [1]. 

The indication for surgery to avoid neurologic damage is relatively clear in unstable fractures 

without spinal cord lesion. If there are spinal injuries which are unstable and which could be 

displaced by necessary positioning measures such as in chest trauma, the indication for primary 

spinal stabilization should be made [4, 7-9]. However, controversy surrounds the issue of 

whether early or later fracture management is advantageous in fractures where spinal cord injury 

has already occurred. As far as neurologic symptoms are concerned, animal experiments show 

advantages in spinal stabilization being carried out as early as possible [10, 11]. However, in the 

field of clinical research, several large systematic reviews (some with meta-analysis) could 

detect no clear correlation between the timing of surgery and the neurologic outcome [12-15]. 

Only the most recent meta-analysis by La Rosa et al. [12] revealed that early surgical 

decompression has advantages compared to late decompression or conservative treatment. In the 

early group (17 studies), an improvement in neurology could be found in 42% of patients with 

complete deficit, and in 90% with incomplete deficit. In the late group, the improvement quotas 

were 8% and 59%, in the conservative group 25% and 59%. However, as the results from the 

studies differ greatly, La Rosa et al. also describe early surgery only as a “practical option”. 

The only randomized controlled trial on this was conducted on 62 patients with cervical spinal 

injury only [16]. Although the authors found no difference between early (< 72 hours) versus late 

stabilization (> 5 days) in the neurologic outcome, they still recommended early stabilization. 

Levi et al. also found indifferent results concerning the early (< 24 hours) and late (> 24 hours) 

stabilization in the cervical spine injury but ultimately also recommend early surgery [17]. After 

Wagner and Chehrazi also found no correlation between the timing of surgery and neurologic 

outcome in cervical spine injuries, they concluded [18] that primary medullary damage 

determines the prognosis. McKinley et al. draw a similar conclusion [19]. In contrast, 

Papadopoulos et al. observed improved neurologic outcomes after early surgery [20]. Mirz et al. 

also described in 1999 [21] that early stabilization (< 72 hours) of a cervical spine injury is more 

favorable for the neurologic outcome than later stabilization (> 72 hours). However, all these are 

data from studies that did not study exclusively multiply injured patients. 

In addition to these studies focusing primarily on the neurologic outcome, there is a series of 

studies which have concentrated mainly on the non-neurologic effects of early stabilization. A 

study by Croce et al. found evidence in 2001 [7] that, in contrast to late stabilization (> 3 days 

after trauma), early stabilization (< 3 days after trauma) of the spinal injury offers advantages, 

especially in polytrauma (mean ISS 24) with thoracic spine injury, as the intensive care period, 

pneumonia rate, costs, and ventilation time can be reduced. The studies by Johnson et al. [8] also 

argue in favor of primary stabilization of unstable spinal fractures as this can lower the ARDS 

rate especially in multiply injured patients. Dai et al. also observed a reduction in pulmonary 

complications after early management [22]. According to results by Aebi et al. [23], the 

immediate surgical management of a cervical spine injury is more important for neurologic 

outcome than improved surgical techniques. In a study published in 2005, Kerwin et al. [24] 



found that primary stabilization of the spine in critically injured patients (ISS > 25) shortened the 

length of hospital stay from 29 to 20 days. 

The above-mentioned indications presume that a diagnostic study which adequately balances the 

injury could be performed in the emergency room phase. The patient should have stable 

cardiopulmonary parameters, and surgical bleeding sources should be excluded. Additional vital 

parameters such as intracranial pressure, core body temperature, and coagulatory function should 

lie within the normal range. If there is a substantiated risk that the condition of the casualty will 

worsen in a significantly (life-) threatening way by primary reduction, decompression, and 

stabilization of the spine, then spine stabilization is relatively contraindicated. 

If the patient has stable intracranial pressure, pulmonary, cardiac, and circulatory function, this 

multiply injured patient benefits especially from early management of the spinal injury: 

positioning stability is achieved, thereby avoiding second hits through subsequent surgery and 

also reducing the antigenic load through the instability of a fracture in proximity to the trunk. On 

the other hand, critical conditions with hypothermia, massive transfusion, coagulation 

derangement, lung failure, and high catecholamine dependency constitute relative 

contraindications for immediate spine stabilization. 

In this context, McLain and Benson (1999) [25] ascertained that immediate (< 24 hours after 

trauma) stabilization had the same outcomes as early stabilization (24-72 hours after trauma) of 

an unstable spinal fracture if the patients had multiple injuries, neurologic symptoms, and a 

concomitant thoracic-abdominal injury. Nevertheless, the authors recommend that stabilization is 

carried out as early as possible. Schlegel et al. [26] and Chipman et al. [27] also ascertained that 

surgical stabilization of unstable spinal fractures within 72 hours especially in polytrauma was 

associated with lower morbidity (fewer lung complications, fewer urinary tract infections, 

shorter hospitalization and intensive care stay). If there is an abdominal injury, which leads to 

laparotomy in up to 38% of patients with a spinal fracture [28], it must be weighed up after 

surgical management of the abdomen whether the unstable spinal fracture must or can be 

stabilized during the same session. 

In contrast, in the case of a hemothorax, the condition of bleeding in the ribcage alone supports 

early stabilization of a thoracic spine injury [29]. The results from the study by Petitjean et al. 

[30] also argue in favor of early stabilization of the thoracic spine fracture inter alia secondary to 

simultaneous chest trauma with pulmonary contusion. If there is a primary transverse lesion or 

irreducible dislocation, surgery can be postponed until organ functions are stabilized during 

intensive care treatment. 

In conclusion, therefore, there is an advantage in early surgery for the multiply injured patient 

particularly against the background of the publications in recent years between 2006 and 2008 

[31–45] Although the neurologic outcomes appear relatively unaffected by the timing of surgery, 

early fracture stabilization helps to minimize general complications and the length of hospital 

stay. As general complications, particularly lung-related, are common in the multiply injured 

patient, the result is the above recommendation for surgery at the earliest possible opportunity. 




Unstable thoracolumbar spine injuries without neurologic deficit should be 

surgically managed. 

Surgery should be performed on the day of the accident or alternatively later 

during the course. 

Explanation: 

GoR B 

GoR B 

Apart from the B and C injuries, this applies particularly to A2 and A3 fractures of the 

thoracolumbar spine which are not displaced by positioning measures during intensive care. 

There is no reason here for urgently stabilizing such an injury on the day of the accident. 

However, according to results from Jacobs et al. [46], it generally applies that the successes of 

surgical treatment on unstable thoracic and lumbar spine fractures are better than those of 

conservative treatment in respect of reduction, neurology, mobilization, rehabilitation period, 

and incidence of complications [47]. 


Stable spinal injuries without neurologic deficit should be treated 

conservatively. 

Explanation: 

GoR B 

The fracture type A1, if applicable also A2, which does not benefit from surgical stabilization, is 

regarded as stable [48, 49], particularly if the adjacent vertebral discs remain intact. Surgical 

stabilization is not indicated in polytrauma [50]. 



Surgery technique 


For injuries to the cervical spine, primary surgical methods that can be used 

are: 1) halo fixator, 2) ventral stabilization procedure. 

Explanation: 

GoR 0 

The halo fixator is indicated if there are contraindications to definitive internal osteosynthesis, 

which is actually necessary, and a soft cervical collar is insufficient for temporary stabilization 

[51, 52, 53, 54]. 

Ventral spondylodesis is indicated particularly in C3-C7 dislocation fractures. Generally, the 

first-line choice is corpectomy - removal of the invertebral disc, replacement with iliac crest 

bone graft, if necessary, a cage, and stabilization using a plate, if necessary, a fixed-angle one 

[55]. In polytrauma, preference should be given to the ventral management of unstable cervical 

spine fractures over the dorsal stabilizing procedure particularly on the day of the accident [56]. 

According to Brodke et al. [57], there are no significant differences in the knitting, in the success 

of reduction, in neurology, and in the long-term symptoms for ventral versus dorsal cervical 

spine procedures but the latter requires much more effort and time, which is why it should not be 

recommended in polytrauma. If there is an unstable Dens fracture, ventral screwing is generally 

indicated; if there is an unstable Jefferson fracture, dorsal screwing or occipitocervical fusion can 

be indicated. However, the latter procedure does not represent a good indication for Day 1 

Surgery and should be performed as an electively planned procedure. 


For injuries to the thoracolumbar spine, the dorsal internal fixator should be 

used as the primary surgical method. 

Explanation: 

GoR B 

Only the dorsal internal fixator can be recommended for the primary management of fractures to 

the thoracolumbar spine [59-61]. This procedure can achieve good reduction, decompression, 

and stabilization, sufficient for all positioning measures in intensive care. According to 

Kossmann et al., this measure is understood as damage control for the spine in polytrauma [62]. 

Ventral fusions are recommended only electively and then in the secondary surgery phase if they 

are necessary. Moreover, according to Been and Bouma, dorsal stabilization on its own can be 

sufficient in burst fractures of the thoracic/lumbar spine [63]. The logistic and technical effort 

plus surgery time must be taken into account for the various surgical methods on the spine. 

Laminectomy increases instability [23, 65–68] and at best can serve as access for dorsal 

decompression to push forward posterior edge fragments. There is dispute over whether 



removing bone fragments from the spinal canal (spinal clearance) is really clinically 

advantageous [69-71]. Insofar as there is an indication for laminectomy, it should be made very 

narrowly and only considered if there is neurologic deficit and compression caused by bone and 

invertebral disc fragments which cannot be removed ventrally. 



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26. Schlegel J, Bayley J, Yuan H, Fredricksen B. Timing 

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3.8 Upper extremity 


Surgical management of fractures to the long bones in the upper extremities 

should be carried out early. 

Explanation: 

GoR B 

There are no prospective comparative studies on the determination of the optimum timing for the 

surgical management of fractures of the long bones in the upper extremity in multiply injured 

patients. The data is based on studies which either focus on primary shaft fractures of the lower 

extremity in polytrauma or analyze multiply injured patients in the total collective with single 

fractures of the long bones of the upper extremity. 

Shaft fractures of the upper extremity must be surgically managed early, if possible directly after 

cardio-respiratory stabilization [1]. 

If concerns exist over primary internal fixation, the alternative option is provided by the external 

fixator or, in exceptional cases, even primary plaster cast and later change in procedure [2]. 

After initial stabilization by external fixator, plaster cast or re-applied dressing, even fractures 

close to the joint can be managed well by secondary surgery if planned, if the acute problems of 

other injuries make this necessary [3]. 

Open fractures are best operated on within the first 6 hours, if necessary with temporary 

stabilizing measures. 

In the hierarchy of urgency, however, there is also a correlation with the location of other 

fractures. In multiply injured patients, therefore, the priority of fractures in the upper extremity 

follows management of tibia, femur, pelvis, and spine but precedes complex joint 

reconstructions, definitive treatment of maxillofacial injuries, and soft tissue reconstructions [4]. 

There are no comparative studies that deal specifically with the most suitable procedure in 

fractures of the upper extremity in multiply injured patients. The multiply injured patient is 

always included in heterogeneous groups as an important indication for the surgical procedure. 

Thus, the conclusion by analogy is generally drawn from the totality of the patients with 

fractures of the long bones of the upper extremity. 

However, there are no large studies here either that reflect a high level of evidence. The AO 

multicenter study on the humerus shaft fracture also no longer represents all current procedures 

[5]. 

In the management of fractures of the upper extremity in multiply injured patients, the focus lies 

on the rapid but safe stabilization of the fracture to the upper extremity. Within this context, 

controversy surrounds the ranking between medullary nailing and plate osteosynthesis as the 

Emergency surgery phase – Upper extremity 363


competence of the surgeon in one or the other procedure appears to be more important than the 

procedure itself [3, 6–12]. 

In metaphyseal fractures to the humerus, radius, and ulna, specific intramedullary procedures are 

now also used; studies with informative value on their use in multiply injured patients are not 

available. 


The decision to amputate or to salvage the extremity in the critical injury to 

the upper extremity should be made on an individual basis. The local and 

general condition of the patient plays a crucial role here. 

In rare cases and in extremely severe injuries, an amputation can be 

recommended. 

Explanation: 

GoR B 

GoR 0 

In subtotal amputation injuries, fracture stabilization and reconstruction of nerves, vessels, and 

soft tissues should be carried out immediately after the resuscitation phase and management of 

vital sign injuries, if necessary also while shortening the extremity. 

In the case of total amputation injuries, the availability and condition of the lost extremity are 

key to deciding whether it makes sense to replant or definitively amputate to create a vital stump. 

Even extremely contaminated, severe open fractures do not represent per se an indication for 

primary amputation in multiply injured patients. Stabilization and debridement are important in 

this instance [15]. The literature contains mainly case histories on this subject [16]. 

The Mangled Extremity Severity Score (MESS) developed for the lower extremities [17] cannot 

be simply transferred to the upper extremity. 




Provided the severity of the overall injury permits, the surgical management 

of vascular injuries should be carried out at the earliest possible opportunity, 

i.e. directly after treating the injuries threatening the vital functions. 

Explanation: 

GoR B 

Due to the rapid onset and poor prognosis associated with ischemic sequelae, vascular 

reconstruction must be carried out rapidly in polytrauma as well [18–20]. 

Absent pulses in the pendant parts of the extremity affected can give information about an 

additional vascular injury or even a vascular injury without a fracture; Doppler and duplex 

supplement the diagnostic study [18, 19]. 

Schlickewei et al. recommend the generous use of preoperative angiography in injuries to the 

upper extremity and the urgent surgical restoration of perfusion to the extremities to reduce the 

period of ischemia [20]. In the case of those injuries that required secondary amputation in 

conjunction with the vascular injury, the period of ischemia exceeded 6 hours in 51.8% of cases, 

there was severe soft tissue damage in 81.4%, and a grade III open fracture in 85.2%. However, 

reconstructive interventions are put to one side if vital functions are at risk. Due to low case 

numbers, there are only isolated case series on this [18–20]. 


Depending on the type of nerve damage, injuries with nerve involvement 

should be managed together with stabilization. 

Explanation: 

GoR B 

The majority of multiply injured patients are ventilated and intubated on admission to hospital 

but the sensitivity and motor functions of the fractured upper extremity often cannot be clearly 

examined at the accident scene. The rate of primary non-discovered concomitant nerve damage 

is unclear. Provided it is not simply a question of decompression as part of the fracture 

management, the correct reconstruction of peripheral nerve lesions in the long bone region of the 

upper extremity is time-consuming and complex and should be planned and carried out in a 

stable environment. Thus, this should only be integrated into the primary management of 

multiply injured patients in exceptional cases. This does not only apply to the injury to isolated 

peripheral nerves but also to brachial plexus injuries [21–25]. 

Due to low case numbers, there are only isolated case series which are not exclusively limited to 

polytrauma. 

Compartment syndromes associated with fractures of long bones in the upper extremity are rare. 

Due to deleterious sequelae occurring within a few hours, however, they require rapid 



decompression during fracture stabilization. This applies equally to multiply injured and to nonmultiply 

injured patients and should take place within the first few hours after trauma and 

compartment syndrome development. Wippermann et al. [26] showed for the upper arm and 

Schmidt et al. [27] showed for the forearm that the prognosis depends on the totality of the 

injuries and is most favorable in the case of isolated compartment syndrome without fracture. 

Nevertheless, the conclusion of rapid action is based less on specific studies on compartment 

syndrome in the upper extremity in polytrauma but rather much more on the experiences with the 

lower extremity (Evidence Level 5). Open fractures and those with vascular injuries should thus 

undergo rapid surgical revision after restoration of cardiopulmonary stability. In closed fractures, 

those with impairment of the epiphyseal gaps represent an urgent surgical indication after 

stabilization of the vital functions. For logical reasons, shaft fractures in the long bone in 

multiply injured children are fixed outside the epiphyseal gaps by means of elastic 

intramedullary splinting[28]; alternatively, the external fixator can be used. Bennek [29] 

envisages its use particularly in open and long-segment fractures. As with Schranz [30], the case 

numbers are very small in this respect. Nevertheless, the procedure should be adapted to the age 

of the child as well as to his concomitant injuries [31, 32]. Due to low case numbers, there are 

only isolated case series which are not exclusively limited to polytrauma. 



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10. Rommens, P.M., J. Blum, and M. Runkel, Retrograde 

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17. Johansen, K., et al., Objective criteria accurately 

predict amputation following lower extremity trauma. 

J Trauma, 1990. 30(5): p. 568-72; discussion 572-3. 

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Wachstumsalter. 1996, Stuttgart, New York: Thieme 

[LoE 4] 



3.9 Hand 

Fractures and dislocations of the distal forearm, the carpals, metacarpals, and phalanges 


Closed fractures and dislocations should be conservatively treated in the 

emergency surgery phase. 

GoR B 

Dislocations must be reduced and stabilized in the emergency surgery phase. GoR A 

Explanation: 

In polytrauma, 75% of hand injuries are closed fractures [2, 91]. In principle, closed fractures 

and dislocations can be reduced according to clinical criteria without too much effort and 

immobilized by simple means (plaster, splints). However, in unstable, extremely dislocated 

fractures of the distal radius, metacarpals, and phalanges, primary stabilization via an external 

fixator and Kirschner wires is indicated after closed reduction. 

In the secondary phase (5th-12th day), the following injuries should be definitively operated on: 

unstable fractures and those remaining in intolerable malpositions, ligament injuries temporarily 

managed during the emergency surgery phase, and fractures. 

Dislocations of the finger joints represent important injuries in the prognosis of hand function. In 

principle, reduction must be carried out immediately [23, 69]. If closed reduction is not possible, 

then open reduction must be carried out in the emergency surgery phase. After primary 

successful reduction, a stable closed finger joint dislocation without articular fracture can be 

treated conservatively [4, 23, 45, 64, 66, 99, 105, 126, 134]. 


In the case of open fractures and dislocations, primary debridement and 

stabilization by wires or external fixator should be carried out. 

Explanation: 

GoR B 

Open fractures and dislocations should be managed in the emergency surgery phase. Here, the 

main procedure corresponds to the usual procedure for open bony injuries (dressing kept on until 

in surgery, wound cleaning, debridement, irrigation, fracture stabilization, soft tissue 

reconstruction). Fracture stabilization using the external fixator or Kirschner wires should be 

given preference over time-consuming primary definitive osteosynthesis (plates, screws) [5, 16, 

17, 38, 81, 101]. Wound irrigation and careful debridement make a crucial contribution to 

infection prevention [49, 112]. Carrying out a second look after 2-3 days depends on the primary 

Emergency surgery phase – Hand 368


local injury pattern and the clinical situation [49]. See the section on “Drug Treatment” for 

administration of antibiotics. 


In the case of perilunar dislocation/perilunar dislocation fractures, reduction, 

if necessary open, must be undertaken in the emergency surgery phase. 

Explanation: 

GoR A 

The long-term outcomes after perilunar dislocations/dislocations of the lunate bone depend on 

early diagnosis and correct treatment. Reduction of the dislocated carpals is undertaken early in 

the emergency surgery phase either closed or, if this is not possible, open. After primary closed 

or open reduction, stabilization must be undertaken using Kirschner wires and/or an external 

fixator [40, 53, 83, 95]. 

Definitive open reduction, internal fixation using drill wires and/or reconstruction of the torn 

ligaments should be undertaken in the secondary phase. Fractures as part of perilunar dislocation 

injuries should be managed osteosynthetically with screws or drill wires [39, 53, 56]. Whereas 

the injury morphology (course of fracture and dislocation line, extent of dislocation) is not 

important for the clinical and radiologic long-term outcome, the time until diagnosis and the 

accuracy and immobilization of the reduction represent relevant prognosis factors [40, 53]. 

Amputation injuries 


Establishing the indication for replantation must be based on the overall 

injury severity according to the “life before limb” principle. 

In establishing the indication, the local finding and patient-related factors 

should be taken into account. 

Explanation: 

GoR A 

GoR B 

Replantations in the hand region are possible and advisable in the multiply injured provided the 

severity score is 1-2 (polytrauma score [PTS]) [15, 111]. However, the indication for 

replantation should be kept very narrow for all those with life-threatening injuries as the surgery 

time is considerably extended and morbidity increased [13, 82]. 

Negative predictors are Crush or avulsion injuries, severe contamination, warm ischemia over 

12 hours or cold ischemia over 24 hours, arteriosclerosis, and smoking [3, 8, 13, 24, 32, 37, 48, 

82, 92, 120, 121]. In the case of replantations at the level of the wrist and proximal thereto, the 

serum potassium concentration measured 30 minutes after reperfusion in the amputated part can 

be used as a prognosis indicator (critical value 6.5 mmol/l) [129]. 




As with isolated hand injuries, the goal should be replantation particularly in 

the case of loss of thumb or several fingers, amputation at the level of 

metacarpals/carpals/wrist, and all amputation injuries in children. 

Explanation: 

GoR B 

Replantations for amputations of the thumb, several fingers, metacarpals, and wrist are priority 

indications [13, 32, 46, 48, 82, 92, 130, 135]. Revascularizations have a somewhat more 

favorable prognosis as tissue bridges still in place often improve the venous outflow [90, 100]. 

Provided the general condition allows it, the indication for replantation should also be made in 

children since good functional results can be expected [28, 48, 90, 116, 136]. Positive predictors 

here are smooth-edged separations and a body weight exceeding 11 kg [7]. Children’s fingers 

tolerate markedly longer ischemic periods than those of adults [22]. 


Individual fingers should not be replanted if amputations are proximal of the 

superficial tendon insertion (middle phalanx base). 

Explanation: 

GoR B 

The amputation level of a finger is crucial in establishing the indication for replantation. In 

amputations of an individual finger proximal of the superficial tendon insertion, no replantation 

is indicated because of the poor functional result expected as a consequence of the severe 

mobility restriction [24, 120, 135]. In contrast, replantations are expedient in amputations that 

are distally further away provided the dorsal veins can be reconstructed. Good results can be 

achieved on the distal phalanx even without venous reconstruction [21, 37, 47, 48, 60, 68, 113]. 



Complex hand injury 


Carrying out time-consuming salvage attempts on the hand is an individual 

decision. It must take into account the overall injury severity and the severity 

of the hand injury. 

Explanation: 

GoR A 

If there are complex hand injuries with involvement of bones, tendons, nerves, and skin, the 

additional strains on the patient caused by the reconstruction must be weighed up against the 

outlook for success and the functional gain that can be expected. Time-consuming salvage 

attempts in the hand region are indicated only in PTS severity grades 1 and 2 [111]. Establishing 

the indication for or against salvaging the hand must always take into account the individual 

circumstances of each patient. MESS (Mangled Extremity Severity Score), which was originally 

developed for the lower extremity, can serve as an additional decision aid. In prospective and 

retrospective studies, a positive predictor value of 100% for an amputation was also obtained for 

the upper extremity with a MESS value of at least 7 points [31, 52, 96]. 


Debridement and bony stabilization should be carried out in the emergency 

surgery phase. 

Explanation: 

GoR B 

Debridement and stabilization of the hand skeleton have priority in an open injury whereas 

nerve, tendon, and skin reconstruction can be carried out at a later time [17, 34, 81, 102, 114]. 

Time-consuming definitive reconstructions of soft tissue structures should be carried out in the 

secondary phase. The advantages and disadvantages (time required, operative traumatization, 

mobilization) of drill wire osteosyntheses should be weighed up against those of stable 

osteosyntheses by plates and screws [19, 20, 34]. 



Skin/soft tissue injury including thermal/chemical damage 


The initial treatment of circumferential skin-soft tissue damage should 

comprise thorough debridement followed by keeping moist the wound 

surfaces that cannot be closed in primary management. 

Explanation: 

GoR B 

During the emergency surgery phase, debridement of devitalized and contaminated tissue parts 

should be carried out [20, 101]. Keeping the wound surfaces and deeper structures moist by 

means of suitable dressing techniques is more important than attempting a soft tissue graft during 

the initial management [17]. 

If the wounds are clean and free of infection, the definitive defect covering should be carried out 

during the secondary phase (5th-12th day). In so doing, the procedure selected should always be 

the least technically demanding one with a good outlook for success, i.e. free flaps are always the 

last treatment option [43, 72]. 


Thermally/chemically damaged, fully devitalized skin areas should initially be 

debrided. 

In the case of deep-reaching and circumferential thermal/chemical damage, an 

escharotomy should be carried out similar to the procedure for compartment 

syndrome. 

For the conservative wound treatment of superficial burns (1-2a degree), 

preference should be given to sulfadiazine silver ointments or synthetic 

dressing materials and for the temporary treatment of deep burns (2b-3 

degree) preference should be given to hydrocolloid dressings or vacuum 

sealing. 

Explanation: 

GoR B 

GoR B 

GoR B 

Burns require initial debridement by removing all definitely devitalized areas to prevent 

circulatory disorders and infections. If full skin loss is subsequently present, a primary meshed 

graft covering should be given preference over secondary skin grafting. The primary grafting 

shortens the treatment period and reduces the frequency of secondary reconstructive operations 

[14, 67]. In the case of deep burns, the indication for escharotomy must be monitored within the 



first 36 hours by regularly monitoring local perfusion [1] (see section on Compartment 

Syndrome for indication and technique). 

Silver sulfadiazine cream is suitable for treating superficial areas not requiring debridement; it 

should be re-applied each time after daily wound cleaning. Alternatively, synthetic dressings can 

be used. In the case of deeper burns, preference should be given to hydrocolloid dressings or 

vacuum seals as these lead to shorter healing courses and a reduction in pain [6, 93, 94, 98, 117]. 

In a controlled trial, faster healing of partial burns could be achieved through the use of 

collagenase with local antibiotics than through conventional treatment with sulfadiazine [50]. If 

secondary demarcated necroses occur under this treatment, they must also be removed. If healing 

is uncertain after 3 weeks, a skin graft, possibly after debridement again, should be carried out to 

avoid hypertrophic scarring and contractures [14, 67]. 

Tendon injuries (flexor tendons, extensor tendons) 


Time-consuming tendon sutures should not be carried out as a primary 

procedure. 

Explanation: 

GoR B 

Whether a severed flexor tendon should be managed by primary or delayed primary suture is 

surrounded by controversy [61, 62, 65, 106–110]. However, time-consuming tendon sutures can 

be carried out in multiply injured patients in the secondary phase (5th-7th day) without 

disadvantages being expected [20, 101, 102, 104, 107, 109, 131]. On the other hand, secondary 

flexor tendon reconstructions are disadvantageous (after weeks) [125]. 

The same recommendations apply in principle to the timetable for reconstruction of extensor 

tendon injuries as for flexor tendon injuries. However, the extent of damage to the soft tissue 

sheath and open joint injuries can necessitate primary definitive management [30, 124]. 

The choice of flexor tendon suture technique to be used depends on the preference of the surgeon 

as individual experience and execution are more important than the choice of suturing technique 

[109]. 

In the case of both flexor tendons being severed, reconstruction of both tendons is favored [61, 

62, 71, 102, 106–110]. However, various authors prefer the sole reconstruction of the deep 

tendon in zone 2 because of better functional results [25, 57, 65]. In addition, there was evidence 

in a prospective randomized study that preference should be given to resection of the superficial 

flexor tendon and reconstruction only of the deep flexor tendon within zone 2 (Tang’s 

subdivision 2C), particularly in delayed primary management [115]. For this reason, only the 

deep tendon is to be reconstructed within zone 2 particularly in delayed primary flexor tendon 

suture. 

Routine administration of antibiotics is also not indicated in delayed primary flexor tendon 

suture. In a retrospective cohort study, Stone and Davidson [104] showed that not giving 



antibiotics in primary or delayed primary flexor tendon reconstruction does not increase the risk 

of infections occurring [104]. The administration of antibiotics to the multiply injured patient 

depends much more on the presence of other injuries or the occurrence of infectious 

complications. 

Nerve injuries of the hand 


In assumed closed nerve injuries, time-consuming diagnostic procedures or 

surgical release can be dispensed with in the primary phase. 

Explanation: 

GoR 0 

Closed nerve damage to the hand is the result of the effect of pressure or extension forces. A 

continuity disruption to the nerves is not to be expected. For this reason, primary surgical 

revision is not indicated here. The only exceptions are nerve lesions due to fractures or 

dislocations, where the nerve can be located and decompressed during surgical management of 

the skeletal injury. Thus, there is also no necessity to carry out time-consuming diagnostic 

measures to reveal assumed lesions while the patient is still unconscious [20]. The development 

of clinical symptoms and neurophysiologic parameters should be awaited. 


Surgical reconstruction of open nerve injuries should be carried out as a 

delayed primary suture. 

Explanation: 

GoR B 

Open nerve injuries require time-consuming microsurgical reconstruction. The best possible 

outcome must be achieved by initial nerve restoration [27]. For this reason, these interventions 

should be undertaken as delayed primary surgery in the secondary phase on 5th-7th day [18, 101, 

131]. Later secondary reconstruction leads to poorer outcomes [9, 58, 59, 70, 122]. It is helpful 

to identify the nerve stumps and mark as atraumatic during emergency surgery [20]. 



Compartment syndrome 


If there is clinical suspicion of compartment syndrome in the hand, a pressure 

measurement device can be used to take a measurement. 

Explanation: 

GoR 0 

If there is compartment syndrome, it is crucial to establish an early diagnosis because irreversible 

damage is done to musculature and nerves after 8 hours at the latest [133]. The diagnosis is made 

in the primary phase according to clinical criteria [54, 55]. Normal pallor and temperature in the 

fingers and the presence of distal pulses [10, 33, 51, 54, 77, 133] do not exclude compartment 

syndrome. The cardinal symptom of pain and pain-provoking muscle extension and sensitivity 

tests cannot be used in the multiply injured patient who is generally unconscious or analgesic 

sedated. Provided compartment syndrome has not already been clinically diagnosed, the 

definitive diagnosis can be established using a pressure measurement device [79, 89]. 

Compartment pressures exceeding 30 mmHg or, in the case of hypotension, exceeding the 

difference pdiastolic - 30 mmHg are classed as critical values and indication for a fasciotomy in the 

unconscious patient [51, 73, 77, 133]. 


If manifest compartment syndrome is present in the hand, fasciotomy must be 

performed immediately. 

Explanation: 

GoR A 

If the diagnosis of compartment syndrome has been established, an immediate fasciotomy is 

indicated. An early adequate dermatofasciotomy prevents ischemic contractures and represents 

an emergency intervention [33, 51, 54, 77, 133]. 

If compartment syndrome has been detected clinically or by using a device, all 10 compartments 

in the hand should be decompressed via 4 incisions whereas in the forearm a palmar fasciotomy 

is generally sufficient. In the forearm, the palmar fasciotomy is started as a parathenar carpal 

tunnel incision and continued up to the elbow by dividing the bicipital aponeurosis, whereby a 

median arch-shaped and a palmar-ulnar incision line are both equally effective [42, 133]. If this 

does not lead to a sufficient lowering in pressure in the dorsal compartment, additional 

decompression via a straight median incision line is required in the dorsal forearm [42, 89]. The 

10 compartments in the hand must be decompressed via several incisions. The dorsal and palmar 

interosseous compartments can be accessed by dorsal incisions over metacarpals 2 and 4. The 

incision line for the thenar and hypothenar compartments is on the radial side of metacarpal 1 

and the ulnar side of metacarpal 5, respectively [89]. 



The indication for fasciotomy on the fingers is made according to clinical criteria. As a pressure 

measurement device is not expedient for the fingers, the degree of swelling is used for 

establishing the indication for fasciotomy. The incision is made unilaterally, radial for the thumb 

and little finger and ulnar for the other fingers. Preference should be given to a mid-lateral 

incision line from the fingertip to the interdigital crease. While protecting the neurovascular 

bundle, the Cleland ligaments should be divided on both sides in the palmar flexor tendon canal 

[89]. 



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3.10 Lower extremity 


In polytrauma among adults, isolated and multiple shaft fractures of long 

bones in the lower extremity can be managed both with primary definitive as 

well as primary temporary and secondary definitive osteosynthesis. 

As an exception, isolated closed shaft fractures of the tibia can also receive 

primary temporary stabilization with a plaster cast. 

Explanation: 

GoR 0 

GoR 0 

There are 2 contradictory treatment strategies for isolated shaft fractures of the long bones in the 

lower extremities: a) primary definitive osteosynthesis and b) the two-step osteosynthesis with 

secondary definitive management. Out of 65 controlled studies published on the femoral shaft 

fracture in polytrauma (from 1964 through 2008; with n = 18 to n = 1582 documented patients), 

there were 10 studies with prospective or randomized study design. However, the majority of 

papers were based on retrospective-clinical data. In addition to the main endpoint of case fatality 

rate, there were numerous subsidiary endpoints: complication rates (from pseudarthrosis rate to 

incidence of sepsis and organ failure), number of days in situ in the intensive care unit, 

ventilation parameters, cardiopulmonary changes, and length of stay in hospital. Only a few 

authors substantiated their treatment regimens with prospectively collected laboratory chemical 

findings. No paper focused on the later quality of life of the patient in the decision criteria. A late 

management of long bones was preferred in 20 papers whereas 37 publications regarded early 

management as better. Eight authors were undecided. In addition, many authors emphasized that 

there are certain patient groups (patients with chest and/or brain injuries) in which a method is 

specifically indicated or contraindicated. Specific controlled studies on the isolated lower leg 

fracture management strategy in polytrauma were not identified. In summary, it must be stated 

that the results of the literature analysis on isolated upper and lower leg shaft fractures are 

contradictory and do not permit any generally valid conclusion. 

To date, there have been few scientific studies on the management strategy for multiple femur 

and lower leg shaft fractures in multiply injured patients. Although the alleged incidence of 

multiple femur and lower leg shaft fractures of 2-7% is suggestive of its clinical importance, 

there are few references to this in the literature. There was only 1 study with a prospective design 

(8 patients) out of 72 papers listed in the databases (MEDLINE, The Cochrane Library, and 

Knowledge Finder, as at 1/2004) on the research question of the surgical strategy for bilateral 

fracture of the lower extremity. The majority of papers were based on retrospective-clinical data 

(n = 42, 4–222 patients) and also case reports (n = 29). In addition to the main endpoint of case 

fatality rate, there were numerous subsidiary endpoints such as complication rates, number of 

days in situ, and concomitant injuries. The vast majority of authors see the advantages of early 

stabilization of fractures but the procedure and timing still remain under dispute. The high 

proportion of pulmonary complications in the group of multiple medullary nailing (8.2% versus 

Emergency surgery phase – Lower extremity 382


62.5%) was noticeable in the only prospective study to date [206]. As a consequence of the 

results of this paper, the author recommends a multi-step management strategy. In their 

retrospectively collected data, other authors were unable to document any increased pulmonary 

risk such as that of (fat) lung embolism following multiple medullary nailings. On the other 

hand, others revealed a shortened convalescence and lower complication rate in surgically 

stabilized (pediatric) patients and advocate primary definitive stabilization. In summary, surgical 

stabilization is increasingly favored in the literature but the type and timing of surgical 

stabilization still remains a matter of controversy; a generally-valid conclusion cannot be made. 

Within the context of polytrauma management, both isolated and multiple fractures of long 

bones of the lower extremity involve a clinically relevant research question which often has to be 

decided in everyday practice. Thus, there is an urgent necessity for additional prospective studies 

with appropriate study design to clarify the treatment strategy. 

Please refer to the introductory section of the emergency surgery phase for the risk assessment 

(damage control) of a multiply injured patient as a decision aid in the fracture management 

strategy. 


Proximal femoral fractures in polytrauma can be stabilized by primary 

osteosynthesis. 

GoR 0 

In justified cases, a temporary joint-bridging external fixator can be indicated. GoR 0 

Explanation: 

There are no controlled studies on the treatment of the proximal femoral fracture specifically in 

multiply injured patients. Studies cited below contain both patients with isolated femoral fracture 

and multiply injured patients with proximal femoral fracture [37, 103, 104]. Proximal femoral 

fractures are subdivided according to their location into intracapsular, extracapsular 

(trochanteric), and subtrochanteric fractures. 

Femoral head fractures (Pipkin fractures) are rare and often associated with hip dislocations 

and/or acetabular fractures. Surgical management ranges from removal of small osteochondral 

fragments to refixation and reconstruction of the femoral head. Although femoral neck fractures 

are common in elderly people after relatively trivial trauma, in young people they are mostly 

caused by a high energy trauma which is often associated with additional multiple injuries. The 

favored head salvage procedure is (cannulated) screw osteosynthesis [12, 93, 131, 133–135]. 

Prosthetic management is listed as equivalent [86, 133-135, 140, 152, 188]. In the meta-analyses 

conducted by Bhandari et al. [13] and Parker et al. [132, 136, 137], the osteosynthetic 

management of the isolated femoral neck fracture led to a considerably higher revision rate but 

the infection rate, blood loss, operating time, and trend in mortality [13] were higher in the group 

with joint replacement. To date, no advantage has been found for the bipolar prosthesis 

compared to total hip replacement [34, 39, 132, 136, 137]. 



The extracapsular fracture can be managed with extramedullary, fixed plate sliding hip screw 

(dynamic hip screw, Medoff sliding plate, etc.) or intramedullary procedure (proximal femur 

nail, gamma nail, etc.) [9, 29, 30, 38, 52, 65, 72, 73, 89, 99, 100, 102, 122, 130, 132–137, 139, 

144, 194]. In general, surgical management of the proximal femoral fracture is regarded as the 

standard treatment [9, 24, 43, 54, 64, 101, 132, 136–138, 199]. 

There is no evidence in randomized studies on the timing of fracture management, and 

observational studies lead to differing conclusions [23, 45, 71, 138, 191]. Early surgical 

management (within 24-36 hours) after physiologic stabilization is recommended for most 

patients. The unnecessary delay in operating can increase the complication rate (decubitus rate, 

pneumonia). Emergency indications for surgery are: open fracture; fracture with vascular injury; 

fracture with compartment syndrome. If surgery has to be significantly delayed (> 48 hours), a 

joint-bridging external fixator can be temporarily (or, if applicable, permanently) attached. 

Complication possibilities: bleeding, infection, wound healing disorder, avascular necrosis in the 

femoral head, pseudarthrosis, rotational malposition, mobility restriction, prosthesis dislocation, 

thrombosis, embolism [128]. 



strategy. 


For definitive management of a femoral shaft fracture in multiply injured 

patients, the first-line choice of surgical procedure should be locking 

medullary nailing. 

Explanation: 

GoR B 

Surgical stabilization of the femoral shaft fracture is regarded as the standard treatment (see Key 

Recommendation 1). Emergency indications for surgery are: open fracture; fracture with 

vascular injury; fracture with compartment syndrome. In a hemodynamically stable situation (see 

“Emergency room management”), the focus is on early definitive osteosynthesis with the 

intramedullary nail being preferred by most authors as the gold standard [27, 33, 96, 198]. The 

central argument of the proponents of the medullary nail is the early weight-bearing capacity. 

Nevertheless, in a retrospective study on 255 multiply injured patients with femoral fracture, 

Neudeck et al. [119] showed that, taking account of injury severity, injury pattern, and clinical 

course, only 29% of these patients could benefit from the advantage of early weight-bearing 

capacity after primary medullary nailing. Thus, the choice of primary surgical procedure (nailing 

versus plate osteosynthesis) in the multiply injured patient is also treated as a matter for debate 

by a few authors [6, 18, 20, 83, 90, 126, 159, 168, 174]. Bone et al. [18] showed that the 

incidence of pulmonary complications does not depend on the type of stabilization (nail/plate) of 

the femoral fracture but is solely caused by the lung injury. In a retrospective study on 217 

patients with drilled femur nailing and 206 patients with plate osteosynthesis, Bosse et al. [20] 



likewise found no differences in the incidence of lung failure (ARDS) in multiply injured 

patients with and without chest trauma. In a retrospective study for primary plate osteosynthesis, 

Auf´m Kolk et al. [6] also found evidence of no increase in case fatality rate and morbidity in 

patients with and without chest trauma (AIS thorax ≥ 3). In support of this, several animal 

models, including one by Wozasek et al. [200], found evidence of no significant pulmonaryhemodynamic 

effect between medullary nailing and plate osteosynthesis. There is no dispute 

surrounding the issue of fat embolization due to elevated intramedullary pressure as a result of 

medullary nailing, and there is evidence of this, particularly by echocardiography, in many 

clinical and animal experimental studies [145]. Ultimately, the question of clinical relevance still 

remains unclarified and thus also the question whether preference should be given to (non)drilled 

medullary nailing. Accordingly, several prospective randomized studies comparing drilled and 

nondrilled medullary nailing found evidence of no differences in the ARDS rate, pulmonary 

complications, and the survival rate [5, 35]. 

Open grade 3 femoral fractures with vascular involvement are regarded as contraindications of 

primary medullary nailing in hemodynamically stable patients [51, 119, 182]. In these cases, 

alternative procedures such as the external fixator are used as a type of stabilization [166]. 

Femoral shaft fractures are characterized by good callus formation and a low complication rate 

[26]. Ten to twenty percent of femoral shaft fractures are associated with ligamentous injuries in 

the knee joint. Complication possibilities are: bleeding, infection, wound healing disorder, 

avascular necrosis in the femoral head, pseudarthrosis, rotational malposition, mobility 

restriction, thrombosis, embolism. 



strategy. 




Unstable distal femoral fractures in polytrauma can be stabilized by primary 

surgery. 

Explanation: 

GoR 0 

There are no controlled studies on the treatment of the distal femoral fracture specifically in 

polytrauma. Studies cited below contain both patients with isolated femoral fracture and multiply 

injured patients with distal femoral fracture. Surgical management of the distal femoral fracture 

is regarded as the standard treatment. Emergency indications for surgery are: open fracture; 

fracture with vascular injury; fracture with compartment syndrome. In a hemodynamically stable 

situation, the focus is on early definitive osteosynthesis. Depending on the fracture type, both 

intra-articular fractures and fractures without intra-articular involvement of the distal femur can 

be managed by open or closed reduction and osteosynthesis by means of a plate (Less Invasive 

Stabilization System [LISS], angled plate, etc.) or retrograde nailing [67, 79, 88, 125, 169, 179, 

207]. A joint-bridging external fixator can be temporarily attached in a hemodynamically 

unstable situation or as part of a damage control strategy. 

Complication possibilities: bleeding, infection, wound healing disorder, pseudarthrosis, 

rotational malposition, mobility restriction, thrombosis, embolism, early arthrosis. 



strategy. 


Knee dislocations must be reduced at the earliest possible opportunity. GoR A 

Knee dislocations must be stabilized at the earliest possible opportunity. GoR B 

Explanation: 

There are no controlled studies on the treatment of knee dislocation specifically in polytrauma. 

Studies cited below contain both patients with isolated knee dislocation and multiply injured 

patients with knee dislocation. The highest management priority is given to any vascular injury 

(popliteal artery), which must be treated. The study by Green and Allen [56] with 245 patients 

with knee dislocation showed a vascular injury in 32% of cases. In 86% of patients who received 

vascular reconstruction beyond the 8-hour period, an amputation had to be performed; 2/3 of the 

remaining patients retained an ischemic contracture. Compartment release is recommended if the 

ischemia period exceeds the 6-hour limit and if there is a threat of compartment syndrome. 



In the hemodynamically stable and unstable multiply injured patient, the knee dislocation should 

be reduced at the earliest possible opportunity. If closed reduction is not successful, the 

dislocated joint is open reduced [77]. In planned conservative treatment and in planned early 

cruciate ligament reconstruction, the stabilization of the reduction result can be carried out by 

means of external fixator and transfixation with Steinmann nail or with brace/plaster. According 

to expert opinion, the external fixator reveals advantages over other methods [91]. 

Ligamentous injuries after knee dislocation can be treated by surgery or conservatively. The 

meta-analysis by Dedmond and Almekinders [40] studied the results from 12 retrospective and 3 

prospective studies on 132 surgically treated and 74 conservatively treated knee dislocations 

with respect to the clinical outcome. The surgically managed patients showed significantly better 

results in range of motion (123 ° versus 108 °), in the Lysholm score (85.2 versus 66.5), and a 

reduced flexion contracture (0.5 ° versus 3.5 °). Randomization of the treatment groups did not 

take place and the indication for surgical or conservative procedure is not substantiated. Two 

more retrospective studies also showed superiority in surgical compared to non-surgical 

treatment [113, 158]. 

Direct suture or cruciate ligament replacement is available for the surgical management of 

cruciate ligaments after knee dislocation. Regarding stability and range of motion, the 

retrospective study by Mariani et al. [105] with a small number of cases of knee dislocations 

showed superiority in anterior and posterior cruciate ligament reconstruction with patellar tendon 

or semitendinosus tendon compared to direct suture [105]. 


Unstable proximal tibial fractures and tibial head fractures can undergo 

primary stabilization. 

Explanation: 

GoR 0 

There are no controlled studies on the treatment of proximal tibial fracture specifically in 

polytrauma. Studies cited below contain both patients with isolated proximal tibial fracture and 

multiply injured patients with proximal tibial fracture. 

Primary management can be carried out by splint immobilization. Non-dislocated fractures are 

conservatively treated by decompression and functional treatment. If necessary, surgical fixation 

can be performed to prevent secondary dislocation. Surgical management of the dislocated 

proximal tibial fracture is regarded as the standard treatment [75, 114]. Rival procedures are 

plate systems (conventional, fixed-angle Less Invasive Stabilization System – LISS, etc.), tibia 

nails, screws, and fixator systems [10, 84, 121, 153], which are used depending on the 

complexity and joint surface involvement of the fracture. Requirements of osteosynthesis are the 

option for joint surface reconstruction and permanent fracture stabilization along with 

mobilization treatment while minimizing the perioperative soft tissue damage. In the case of 

minor dislocation, arthroscopically assisted, radiologically controlled reduction and percutaneous 

screw fixing can be carried out [58]. Emergency indications for surgery are: open fracture; 



fracture with vascular injury; fracture with compartment syndrome. If necessary, an external 

fixator can be attached until the soft tissue conditions permit definitive management. In the 

hemodynamically stable situation, the focus is on early definitive elective osteosynthesis after 

initial subsidence in swelling (e.g., after 3-5 days). Tibial plateau fractures are associated with 

meniscus injuries in up to 50% of cases and with ligamentous injuries in up to 25% of cases [11]. 

Complication possibilities [205]: bleeding, infection, wound healing disorder, pseudarthrosis, 

rotational malalignment, mobility restriction, thrombosis, embolism, early arthrosis. 



strategy. 


Tibial shaft fractures should undergo surgical stabilization. GoR B 

Explanation: 

There are no controlled studies on the best management procedure specifically for a tibial shaft 

fracture occurring in polytrauma. The core requirement is adapted management in relation to the 

overall condition. Due to the marginal soft tissue situation in the distal half of the tibia, the 

treatment strategy is often not dictated by the fracture per se but by the existing soft tissue 

situation. 

Stable fractures with minimum dislocation can be conservatively treated with plaster 

immobilization [164]. Surgical management of the unstable tibial shaft fracture is regarded as the 

standard treatment, usually by intramedullary nailing [159, 197, 201]. Emergency indications for 

surgery are: open fracture; fracture with vascular injury; fracture with compartment syndrome. In 

a hemodynamically stable situation, the focus is on early definitive osteosynthesis. If surgery has 

to be significantly delayed (> 48 hours) or there is an extensive open injury with severe 

contamination, an external fixator can be temporarily (or if necessary permanently) attached 

[80]. 

In a meta-analysis by Bhandari et al. [15], the treatment of open tibial shaft fractures was 

studied. The results showed that, compared to the external fixator, non-drilled medullary nails 

reduced the risk of re-operation, pseudarthrosis, and superficial infection. A smaller re-operation 

risk was revealed with drilled nails in comparison with non-drilled nails. In a prospective 

randomized study, evidence was also found in closed fractures of a lower rate of secondary 

operations and pseudarthroses after a drilled medullary nail compared to a non-drilled medullary 

nail [94]. Tibial shaft fractures are associated with ligamentous injuries in up to 22% of cases. 

Complication possibilities: bleeding, infection, wound healing disorder, soft tissue necrosis with 

the necessity of a skin graft (dermatoplasty), pseudarthrosis, rotational malalignment, mobility 

restriction, thrombosis, embolism. Please refer to the introductory section of the emergency 



surgery phase for the risk assessment (damage control) of a multiply injured patient as a decision 

aid in the fracture management strategy. 


Distal lower leg fractures including articular distal tibial fractures should 

undergo surgical stabilization. 

Explanation: 

GoR B 

There are no controlled studies on the isolated treatment of the distal tibial fracture specifically 

in polytrauma. Studies cited below contain both patients with isolated distal tibial fracture and 

multiply injured patients with distal tibial fracture. 

Surgical management of the distal tibial fracture is regarded as the standard treatment. Due to the 

marginal soft tissue situation in the distal tibia (and in the pilon), the treatment strategy is often 

not dictated by the fracture per se but by the existing soft tissue situation. Emergency indications 

for surgery are: open fracture; fracture with vascular injury; fracture with compartment 

syndrome. In a hemodynamically stable situation, the focus is on early definitive osteosynthesis. 

Distal tibial fractures without pilon involvement can be managed by medullary nail 

osteosynthesis. In addition to medullary nailing, fixed-angle plate osteosynthesis should be 

mentioned as a procedure option, particularly as an inserted plate. In the case of a distal fibular 

fracture as well, additional plate osteosynthesis of the fibula is recommended (in order to build a 

frame and to prevent distal axial deviation) [19, 41, 63, 97, 151, 155, 176, 186, 195]. In the case 

of pilon involvement, open reduction and osteosynthesis are regarded as the standard treatment 

[26, 69, 184, 202]. If the operation has to be significantly delayed (> 48 hours) (e.g., if there is 

severe swelling or open contamination), a joint-bridging external fixator can also be attached 

temporarily (or if necessary permanently), if necessary with percutaneous fixation of the joint 

surface (screws, K wires). Complication possibilities are: bleeding, infection, wound healing 

disorder, soft tissue necrosis with the necessity of a skin graft (dermatoplasty), pseudarthrosis, 

rotational malalignment, mobility restriction, thrombosis, embolism, early arthrosis. Please refer 

to the introductory section of the emergency surgery phase for the risk assessment (damage 

control) of a multiply injured patient as a decision aid in the fracture management strategy. 




Ankle fractures should undergo primary stabilization. GoR B 

Explanation: 

There are no controlled studies on the isolated treatment of ankle fractures specifically in 

polytrauma. Studies cited below contain both patients with isolated ankle fracture and multiply 

injured patients with ankle fracture. 

Surgical management in general and the type of osteosynthetic management of the fibula fracture 

depend not least on the rest of the injury pattern in the multiply injured patient. Thus, some 

authors prefer external fixation at an injury severity of ISS > 25 or 29 points and/or with a chest 

trauma of AIS > 3 [4, 118, 164]. In addition, the type of fracture determines the choice of 

osteosynthesis material. 

Proximal fibula: In Maisonneuve injuries, the distal fibula should be surgically fixed to the tibia 

in the upper ankle [47]. Here, 2 syndesmotic screws should be attached as, being tricortical, these 

screws have 5-fold greater tear and rotational strength than the sole suture of the syndesmosis 

[55, 203]. 

Fibula shaft: High fibula fractures in terms of a pronation-eversion injury according to Lauge- 

Hansen type III or IV should be surgically managed (plate osteosynthesis). The complex 

dislocation mechanism may have additionally led to other bony (medial malleolus fractures) and 

ligamentous injuries (syndesmoses, medial/lateral capsular ligament apparatus) [157]. 

Distal fibula: “Stable” and “unstable” fractures must be differentiated between in isolated lateral 

malleolus fractures. “Stable” fractures are those at the level of the syndesmosis (Weber B1) and 

supination-eversion fractures type SE II according to Lauge-Hansen [25, 44, 156, 204]. A stable 

lateral malleolus fracture exists if there is no fibula shortening, no fracture dislocation > 2 mm, 

no axis deflection, and an intact posterior syndesmosis [44, 156]. Stable lateral malleolus 

fractures can be conservatively immobilized, e.g., in a plaster cast or orthotic device 

manufactured from synthetic material. Types of fracture that deviate from this must be surgically 

managed. 

The type of osteosynthesis also depends on the concomitant soft tissue injury (contusion, 

swelling, compartment syndrome) [146]. In the case of relatively severe soft tissue damage or 

more complex types of fracture (e.g., dislocation fractures), the first goal must be external 

fixation irrespective of the extent of the remaining injuries in order to prevent imminent 

neurovascular damage [22]. In the case of stable lateral malleolus fractures and lateral malleolus 

fractures that have been made stable by osteosynthesis, a follow-up treatment strategy that 

provides early functionality and early weight-bearing capacity shows a significant improvement 

in the ankle’s range of motion and requires a shorter rehabilitation phase [148]. 





strategy. 


Perioperative antibiotic prophylaxis must be carried out in the surgical 

management of both close and open fractures of the lower extremity. 

Explanation: 

GoR A 

In open fractures, there is preoperative bacterial contamination in 48-60% of all wounds and in 

100% of all severe wounds [98]. 

Antibiotic administration in closed fractures: 

In the surgical management of closed fractures, the administration of antimicrobial prophylaxis 

(normally a single shot of a long-acting first-generation cephalosporin) is generally 

recommended when implanting foreign material [3, 78]. There is EL 1 data on the management 

of femoral neck fractures which confirm a significant reduction in postoperative wound 

infections through perioperative antibiotic treatment [21, 31, 32, 78]. The Cochrane Review of 

2003, which analyzes data from 8,307 patients from 22 studies, reveals a significant reduction in 

postoperative wound infections as well as also in infections of the genitourinary and respiratory 

tracts by preoperative single shot antibiosis during the surgical management of fractures to the 

long bones. Both in the Cochrane Review by Gillespie et al. [53] and in the meta-analysis by 

Slobogean et al. [173], no evidence could be found of further advantages from multi-dose 

compared to single shot antibiosis. 

Antibiotic administration in open fractures: 

The presence of open fractures provides sufficient evidence that antimicrobial prophylaxis 

should be carried out. According to the guideline of EAST (Eastern Association for the Surgery 

of Trauma), in addition to careful wound debridement - if possible within 6 hours of the trauma - 

it is recommended that coverage of gram-positive organisms is also started as early as possible. 

For fractures of grade 3 according to Gustilo, additional treatment for gram-negative triggers and 

also high-dose penicillin should be administered for farm-related injuries as a prophylaxis 

against clostridial infections. The treatment should be continued up to 24 hours after primary 

defect covering. With grade 3 fractures, the antibiotic treatment should be continued up to 72 

hours after the trauma and not more than 24 hours after soft tissue has been covered [98]. As 

with a series of other studies [68], Dellinger et al. [42] could not show any significant difference 

in infection rate in 248 patients in relation to the period of antibiotic prophylaxis (1 versus 5 

days). 

Although some authors recommend the administration of antibiotic-impregnated beads for local 

infection prophylaxis in addition to i.v. antibiosis, there is no supporting literature of EL 1 on 

this either [68, 70, 124, 170]. 




Provided the severity of the overall injury permits, the surgical management 

of vascular injuries in the lower extremity should be carried out at the earliest 

possible opportunity, i.e. directly after treating the injuries threatening the 

vital functions. 

Explanation: 

GoR B 

There are only few confirmed data on the incidence of arterial and venous vascular injuries of 

the lower extremity in multiply injured patients. There is wide variation worldwide among the 

individual collectives in degree of severity, the mechanism of generation, the location of the 

vascular injury (and of the other injuries), and the quality of the preoperative diagnostic study 

and management [147, 177, 181, 185, 190]. The morphologic damage to the vessels in relation to 

the mechanism of generation is accurately described in its importance for the type of 

management [192]. 

The management recommendations listed here are based predominantly on the experiences and 

recommendations of experts who have published their results and conclusions from individual 

collectives. Only one publication is based on a controlled randomized trial [193]. However, the 

published recommendations from different subdivisions of trauma surgery and vascular surgery 

permit only qualified conclusions on the treatment of severe injuries in the lower extremity with 

vascular involvement in multiply injured patients. Ultimately, therefore, it is an individual 

decision for the individual patient. 

Provided the severity of the overall injury permits, the surgical management of arterial and 

venous injuries in the lower extremity should also be carried out in multiply injured patients at 

the earliest possible opportunity, i.e. directly after treating the injuries threatening the vital 

functions. There is no consensus in the literature on whether a fracture must be stabilized first 

followed by vascular reconstruction or whether the reverse sequence is advantageous. Discussion 

also surrounds interim solutions (primary shunt insertion to preserve blood supply, fracture 

stabilization and later definitive vascular reconstruction or in terms of damage control through to 

physiologic recompensation of the patient after severe trauma) [81, 108, 117, 120, 123, 127, 143, 

180]. In complex trauma with a high prediction probability of vascular injury, primary vascular 

revision should be carried out with, if necessary, immediate vascular reconstruction [193]. The 

resources, principles of surgery, and operative techniques available correspond to those for nontrauma-induced 

management of arterial and venous reconstructions and partly exceed the 

indication range. 

Arterial injuries of the iliac and femoral vessels should be reconstructed and are usually 

technically easily accessible. An isolated crural artery injury can be ligated if the openness of the 

other distal main arteries is confirmed. If at least 2 vessels are affected, there is almost always a 

critical vascular disorder which requires primary revascularization. The combination with venous 

injuries increases the amputation rate, which is why the indication for venous reconstruction 

should be made broadly in combination injuries [50, 177, 181]. Arterial injuries of the lower 



extremity should be managed (in descending order) by means of direct suture, insertion of a 

continuity-preserving anastomosis, patch angioplasty (autologous, synthetic material) or bypass 

reconstruction (autologous, synthetic material, composite) [46, 190]. Venous injuries of the 

lower extremity should be managed (in descending order) by means of patch graft, autologous 

vein interposition graft, PTFE (polytetrafluorethylene) interposition graft or primary ligature [1, 

111, 129, 141, 142, 154, 183]. 

The indication for fasciotomy should be made early; if necessary it should be carried out even 

before vascular reconstruction [49, 177]. 

Endovascular treatment of arterial injuries represents another option for managing arterial 

injuries of the lower extremity even in the multiply injured patient. Established procedures 

applied proximal to the extremity (coiling, covered stents) can also be used peripherally in 

individual cases. The goal can even be temporary revascularizations until definitive surgical 

management [106, 116, 149, 167]. 


In the case of compartment syndrome in the lower extremity, immediate 

compartment decompression and fixation of a concomitant fracture must be 

carried out. 

Explanation: 

GoR A 

Compartment syndromes in relation to fractures of long bones in the lower extremity and 

particularly in the tibia are not rare. Due to the deleterious sequelae within a few hours, however, 

they require rapid decompression (fasciotomy) during fracture stabilization. Van den Brand et al. 

[187] even support prophylactic versus therapeutic fasciotomy. Establishing an early diagnosis is 

essential if there is compartment syndrome because irreversible damage to musculature and 

nerves results after 8 hours at the latest [196]. The diagnosis is made in the primary phase 

according to clinical criteria [74]. Normal pallor and skin temperature and the presence of distal 

pulses [66, 74, 115, 196] do not exclude a compartment syndrome. The cardinal symptom of 

pain and pain-provoking muscle extension and sensitivity tests are not usable in the multiply 

injured patient who is generally unconscious or analgesic sedated. For this reason, according to 

Rowland et al. [162], the definitive diagnosis must be established using a pressure measurement 

device. Compartment pressures exceeding 30 mmHg or, in the case of hypotension, exceeding 

the difference pdiastolic - 30 mmHg are classed as critical values and indication for fasciotomy [66, 

92, 110, 115, 196]. If the diagnosis of compartment syndrome has been established, immediate 

fasciotomy (emergency intervention) is indicated [66, 74, 115, 196]. All 4 compartments in the 

lower leg should be opened. The prognosis depends on the totality of the injuries and is most 

favorable in the case of isolated compartment without fracture. If there is a concomitant fracture, 

stable osteosynthesis should be carried out in addition to the fasciotomy. The preferred stable 

osteosynthesis is intramedullary nailing [48, 189] as, compared to other procedures, it causes the 

least irritation to the soft tissue and avoids the necessity of pin transfixation of the tissue. In a 

meta-analysis by Bhandari et al. [14], the drilled medullary nail was compared to the non-drilled 



medullary nail with regard to the relative risk of compartment syndrome. Although not 

significant (relative risk 0.45; 95% CI: 0.13-1.56), the authors concluded that the drilling of the 

medullary nail appears to lower the risk of compartment syndrome. Nevertheless, the conclusion 

of rapid action is based less on specific studies on compartment syndrome in polytrauma but 

rather much more on experience. 


The decision to amputate or to salvage the extremity in the critical injury to 

the lower extremity should be made on an individual basis. The local and 

general condition of the patient plays a crucial role here. 

Explanation: 

GoR B 

The critical injury to the lower extremity can represent a complex problem in the treatment of 

polytrauma. The critical decision between amputation and salvaging the extremity can be 

necessary here. The literature shows that loss of neurologic function is correlated with delayed 

amputation and increased morbidity as well as mortality [2]. Early amputation should be 

considered if there is a loss of function and sensitivity in the foot/extremity. Conversely, if there 

is function and sensitivity in the foot/extremity, the goal should be to salvage [2]. Thus, the focus 

should be on amputation for all patients, for example, with a type III-C fracture and a completely 

severed sciatic or tibial nerve. In the case of significant nerve severance, no studies have shown 

an advantage in salvaging the extremity compared to early amputation [17, 109, 163]. 

Vascular integrity increases the probability of salvaging the extremity [161]. The vascular 

disorder should be remedied as quickly as possible. An ischemic period of > 6 hours was 

correlated with irreversible nerve damage and loss of function [95, 178]. For logical reasons, 

necrotic extremities (or parts thereof) should be amputated. A delay in amputation leads to a 

significant increase in sepsis, immobility, number of surgical interventions required, mortality, 

and costs [17, 109, 163]. 

Many reports have been published about objective criteria for the decision to amputate or 

salvage the extremity [36, 57, 76, 85]. However, to date, no study could define guaranteed 

prediction instruments for this decision. Scoring systems (e.g., Predictive Salvage Index, 

Mangled Extremity Severity Score [MESS], Limb Salvage Score, NISSSA [Nerve Injury, 

Ischemia, Soft Tissue injury, Skeletal injury, Shock and Age of Patient] Scoring Index) can be 

used to supplement the clinical assessment. Thus, it is absolutely essential that an individual 

decision is taken for each patient and for each injury. The decision to amputate or to salvage the 

extremity should never be taken solely on the basis of a protocol or algorithm [16]. 

In summary, the primary and secondary amputation rate in injuries of the lower extremity 

(without them being predictable, e.g.,, through scoring systems) thus depends on the number and 

location level of the simultaneously injured arterial and venous vessels, the injured nerves, the 

overall severity of the injuries, and the extent of the concomitant soft tissue damage [7, 49, 50, 

82, 87, 107, 112, 123, 150, 171, 172, 175, 177, 181, 190]. 



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3.11 Foot 

The affected patients often have residual pains and restricted function in the foot after 

polytrauma management requiring a high level of staff and material resources. The reasons for 

foot injuries in polytrauma being missed or underestimated are more eye-catching and lifethreatening 

injuries, deficient radiography technique in the emergency situation, extremely 

variable clinical standards in the analgesic sedated patient, lack of experience on the part of the 

examiner in less common foot injuries, and breakdown in communication in the treatment of the 

multiply injured due to several teams working together [45, 60]. 

The number of studies with relatively high evidence on the topic of management of foot injuries 

in the multiply injured patient is remarkably small. This is all the more remarkable as the 

presence of foot injuries has a significant negative influence on the prognosis of multiply injured 

patients [84]. For the reasons cited, repeated attempts have been made to compile experiencebased 

treatment guidelines for these patient groups [52, 60, 76, 77, 92, 93], which, in the absence 

of controlled studies, form the basis of the following draft. The aim of this guideline section is 

therefore to provide an aid based on the available study data for the timely and appropriate 

treatment of foot injuries which is adapted to the extent of injury in the multiply injured patient. 

Emergency indications 

The necessity of emergency management of open fractures, neurovascular injuries, compartment 

syndrome, and an extreme soft tissue hazard is no different from the emergency indication in the 

remaining skeletal sections [16, 76, 77]. Accordingly, reference is made to the appropriate 

guideline parts. 

Topographic features in the foot arise from the danger of avascular necrosis even in closed 

dislocation fractures of the talus [15, 25, 34, 77], to a lesser degree also of the navicular bone 

[70], and in Lisfranc dislocation fractures and calcaneus fractures, which hold an increased 

danger of compartment syndrome [46, 51, 54, 64, 94]. In addition, the closed reduction of 

dislocation fractures of the talus and of the Chopart and Lisfranc joint is only possible in 

exceptional cases. The cited injuries should be managed immediately following the initial 

stabilization of the multiply injured patient. 

Emergency surgery phase – Foot 402


Compartment syndrome in the foot 


If a manifest compartment syndrome is present in the foot, a fasciotomy must 

be performed immediately. 

If there is clinical suspicion of compartment syndrome in the foot, a pressure 

measurement device can be used to take a measurement. 

Explanation: 

GoR A 

GoR 0 

Calcaneus fractures, Lisfranc dislocation fractures, and in general severe crush injuries are 

particularly at risk from compartment syndrome [39, 46, 51, 54, 76]. Most authors recommend a 

fasciotomy from a threshold of 30 mmHg [47, 50, 51, 87]. In contrast to the lower leg, other 

authors recommend compartment splitting even from a threshold of 25 mmHg as blisters develop 

more rapidly on the foot and the tolerance of the small foot muscles and terminal branches of the 

nerves and vessels is less compared to comparable pressures in the lower leg [93, 94]. 

In compartment syndrome of the lower leg, attention should be paid to a concomitant foot 

compartment syndrome as established by Manoli et al. [40] in a series of 8 cases. There were 

multiple injuries in 7 out of 8 cases. In experimental and clinical studies, both the dorsomedial 

and the medial fasciotomy (modified Henry approach) permit sufficient decompression of all 

foot compartments [40, 50]. In addition, 2 parallel dorsal incisions and a “three-incision 

decompression” with additional plantar fasciotomy are described which, however, offer no 

obvious advantage. 

Open injuries 

Soft tissue damage in the foot has a crucial effect on the functional outcome [26, 27, 86]. 

Aggressive debridement of contaminated and hypoperfused tissue and early soft tissue covering 

are essential in the treatment of open fractures in the foot in order to prevent prolonged infection 

courses [12, 16, 27, 35, 74, 75, 96]. 

Bones, joint cartilage, and tendons are at risk even if there is primary vitality if they are not 

sufficiently covered by tissue. Artificial skin products can guarantee a temporary closure if a 

secondary skin closure is expected after swelling has subsided and consolidation of the soft 

tissues or an additional second look is necessary due to severe contamination (farm-related 

injuries) [29]. Secondary split thickness skin grafts are suitable for superficial defects in nonweight-bearing 

regions. These require a clean (not sterile) wound surface without exposed bones, 

joint cartilage or tendons. In children, the requirements for the wound surface are 

disproportionately less [1]. The problems of marginal hyperkeratosis in the border region 

between transplant and local foot skin are still unresolved [13]. In degloving injuries, the upper 

layer (approx. 0.3 mm) of the hypoperfused and potentially avitalized abraded skin can be 

detached with the dermatome and be used for covering adjacent sections with vitalized wound 



substrate (split-thickness skin excision [89]). In addition, the extent of bleeding after raising the 

transplant permits a reliable conclusion to be made on its viability. 

Multi-layer defects require a local or free flap transfer [35, 44, 68]. The flap choice here depends 

on the size of defect and the blood supply pattern and takes into account the functional-anatomic 

foot zone divisions and the like with like principle [1, 28, 44]. Local pedicled flaps are suitable 

for covering smaller lateral, medial or plantar defects due to their limited action range [20]. Free 

flaps with microvascular anastomosis require an intact attachment point and attention must be 

paid to the type of shoe and cosmetic aspects in addition to technical feasibility [66]. 

Preoperative angiography (if necessary also phlebography) should generally be carried out [35]. 

More extensive defects on the flat dorsum of foot benefit from free fasciocutaneous flaps 

whereas deep, contaminated defect cavities need to be filled with muscle flaps covered with split 

thickness skin grafts (e.g., latissimus dorsi). The latter are less bulky than myocutaneous flaps 

[41]. The pedicle-rotated sural flap is a suitable salvage procedure in inadequate main vessels [6, 

12, 38]. 

Even in successful extremity salvage, considerable functional deficits often remain after open 

pilon, talus, and calcaneus fractures [27, 68, 73]. This is partly explained by arthrogenous and 

tendogenic fibroses with corresponding mobility deficit after the necessary longer 

immobilization. In open grade 2 and grade 3 lower leg fractures, early defect covering with free 

flap transfer is a proven technique compared to delayed covering [11, 17, 19]. In this regard, 

reference is made to the section “Open and closed soft tissue damage to the extremities”. 

The experiences with the foot are fewer due to smaller patient numbers. In initial series, patients 

with larger, contaminated defects due to open foot trauma achieved good functional outcomes 

through early flap coverage within 24-120 hours with primary stable osteosynthesis [12, 48]. 

However, this procedure is only possible in a patient in a stable general condition; in terms of an 

optimum functional outcome, all reconstructive options should then be exhausted for the 

multiply injured patient as well [56]. 

As with open fractures in other extremity sections, a single shot antibiotic prophylaxis is also 

recommended for open fracture in the foot to supplement the surgical debridement; depending on 

the expected, predominantly gram-positive bacteria range, first or second generation 

cephalosporins or an antibiotic with comparable effect range in terms of the calculated antibiosis 

are used [10, 14, 24, 27, 52, 53]. 



Complex trauma of the foot 


The decision to amputate the foot should be made on an individual basis. GoR B 

Replantation of the foot generally cannot be recommended in polytrauma. GoR 0 

Explanation: 

The definition of complex foot trauma is based both on the regional extent of the injury across 

the 5 anatomic-functional levels of the foot and on the extent of soft tissue damage [92]. 

According to Tscherne und Oestern [81], 1 point is awarded for each injured foot region and for 

each grade of soft tissue damage; the definition of a complex foot trauma is when 5 or more 

points are awarded. The absolute score simultaneously permits a prognostic statement [92]. 

If there is complex foot trauma, the criteria for amputation in relation to the overall injury 

severity in polytrauma are not defined precisely. Tscherne [81] recommends primary amputation 

with a PTS value (Hannover polytrauma key [65]) of 3-4, and an individual decision if the PTS 

is 2. Validated scores such as the Hannover fracture scale (HFS [83]), the MESS (Mangled 

Extremity Severity Score [32]) and the NISSSA Score (Nerve Injury, Ischemia, Soft Tissue 

Injury, Skeletal Injury, Shock and Age of Patient Score [43]), the Predictive Salvage Index (PSI) 

[30], and the Limb Salvage Index (LSI) [67] offer a certain amount of help in decision-making. 

In a prospective multicenter study on 601 patients with complex injuries of the lower extremity 

(Lower Extremity Assessment Project [LEAP]), a high specificity of all scores (HFS, MESS, 

NISSSA, PSI, LSI) was found but with low to moderate sensitivity [7]. This means that a low 

score can certainly reliably predict limb salvage but a high score is not predictive for an 

amputation. The authors therefore warn against an uncritical application of the scores in deciding 

in favor of amputation [7]. In addition, such scores cannot replace in particular individual 

consideration of the overall course in the polytrauma and the specific local injury pattern in the 

foot [94, 95]. 

In addition to general criteria such as age, concomitant diseases, and concomitant injuries, the 

following points regarding the foot are important in the decision to amputate: the loss of large 

parts of the sole of the foot with its unique chambered profile cannot be replaced by equivalent 

tissue and is potentially more serious than defects on the dorsum of foot. Vascular injuries 

endanger the vitality of distal foot sections and make the restoration of foot function 

considerably more difficult [8, 23, 72, 94]. The loss of the protective sensitivity of the sole of the 

foot due to a traumatic tibial nerve lesion involves a greater potential for soft tissue-induced late 

complications even if sensitivity can be regained within 2 years in about half the cases of blunt 

injury of the tibial nerve [9]. 

Severe comminutions of the bony foot skeleton and joint destruction which necessitate primary 

arthrodesis to support osteosynthesis potentially lead to a more rigid foot with non-physiologic 

pressure distribution on the sole of the foot, which is often compromised by the trauma anyway. 

The traumatic loss of the talus or its joint surfaces through the necessary tibiotalar, 



tibiotalocalcaneous or pantalar arthrodesis leads to a rigid foot with considerable functional 

impairment even if bones and wounds heal without problems [21, 68, 70]. In all cited cases, the 

indication for amputation should be verified early even if there are no life-threatening 

concomitant injuries [23, 52, 68]. In these cases, the Pirogoff amputation at least still permits the 

original sole of the foot to bear weight; it is also suitable in critical blood supply conditions [92]. 

In the LEAP Study on 8 North American Level I trauma centers, the most important amputation 

criteria in severe high-energy injuries of the lower leg and foot were severe muscle injury (OR 

8.74), severe vein injury (OR 5.72), absence of plantar sensitivity (OR 5.26), open foot fracture 

(OR 3.12), and absence of foot pulses (OR 2.02). Patient-related factors that influenced the 

decision in favor of amputation were hemorrhagic shock and concomitant diseases whereas the 

general injury severity (ISS) had no significant influence in this series [78]. 

In contrast to the vascular-surgical principles of waiting until hypoperfused extremity sections 

are demarcated, an early decision on the final amputation level is recommended in fresh trauma 

for an early definitive soft tissue closure [92, 93]. In principle, there should be no blood arrest 

during surgery in order to assess correctly the vitality of bones and musculature [52, 63]. 

The experiences with replantation are disproportionately fewer in the foot than in the hand and 

are restricted to case reports and small case series [4, 5, 18, 88]. The outlook for successful 

replantation is markedly greater in children than in adults [3, 31]. Essentially, the attempt should 

only be undertaken if a plantigrade, stable foot with protective sensitivity of the sole of the foot 

can be regarded as a realistic endpoint of treatment without endangering the patient. Important 

criteria for successful replantation are an anoxia period of less than 6 hours and high patient 

compliance in the face of slow, difficult rehabilitation [18]. It is almost impossible to estimate 

these criteria in the multiply injured patient and replantation that lasts several hours within the 

critical ischemia period is generally not indicated due to the general condition of the patient [72]. 



Specific injuries 


Dislocations and dislocated fractures of the tarsal bones and metatarsals 

should be reduced and stabilized as soon as possible. 

Explanation: 

GoR B 

Central dislocation fractures of the talus (aviator’s astragalus) are associated with a polytrauma 

with above-average frequency (according to the AO multicenter study in 52% of cases [34]). The 

relationship between the occurrence of avascular necrosis of the talus and initial dislocation 

extent has been confirmed in several large clinical series [15, 25, 34]. Closed reduction is only 

rarely possible in dislocated fractures of the talus, and repeated attempts damage the soft tissues 

which are compromised anyway. For this reason, the goal is immediate open reduction and 

(mostly minimally invasive) stabilization in dislocated fractures of the talus (if permitted by the 

general condition of the multiply injured patient) in order not to endanger further the vitality of 

the skin and the talus itself [15, 25, 62, 79]. The definitive management and osteosynthesis of 

minor dislocated talus fractures can be carried out later if the patient is in a stable general 

condition without there being an increased risk of avascular necrosis of the talus developing [36, 

85, 86]. 

Calcaneus fractures with open wound, manifest compartment syndrome, and incarcerated soft 

tissues should be managed by emergency surgery. After the diagnostic study in the case of open 

injuries, initial debridement, if necessary artificial skin covering, temporary percutaneous 

Kirschner wire osteosynthesis or medial transfixation (each with a Schanz screw in the distal 

tibia, in the tuber calcanei and metatarsal I) are carried out to prevent soft tissue retraction [27, 

63, 95]. In extensive, bony defects, insertion of PMMA (polymethyl methacrylate) beads is 

recommended. A second look operation must generally be carried out within 48-72 hours. The 

indication for early flap coverage should be made broadly [12, 48]. 

In closed grade 3 fractures with manifest compartment syndrome, the emergency 

dermatofasciotomy is performed in polytrauma via an extended dorsomedial approach with 

insertion of a triangular medial external fixator [63, 95]. The clinical relevance of the plantar 

calcaneal compartment, which has been presented in injection studies and in which an isolated 

increase in pressure can occur, is not finally clarified but the occurrence of hammer toe 

malalignments after isolated calcaneal fractures indicates this problem [39, 54, 96]. 

In the vast majority of fractures (closed soft tissue damage grade 1 and 2), osteosynthesis is 

recommended 6-10 days later after the swelling in the soft tissue has subsided [2, 58, 68, 71, 91, 

95]. Elevating the extremity by more than 10 cm above the level of the heart is not recommended 

so as to prevent ischemia [16]. A good indicator for surgery time is the onset of skin creasing due 

to the subsiding edematous swelling [68]. A surgery time beyond the 14th day is associated with 

an increased risk of complications if no reduction and transfixing has been carried out initially 

[58, 80]. Local contraindications for osteosynthesis exist if there are critical soft tissue 



conditions with high risk of infection such as tension blisters and skin necroses and advanced 

arterial or venous vascular disorders; general contraindications are lack of compliance and a 

manifest immune weakness [58, 92, 95]. Conservative treatment is indicated in these cases due 

to the risk of wound healing disorders and deep infections. 

Injuries at the level of the Chopart and Lisfranc joint are associated with multiple injuries with 

an above-average frequency (50-80%) [33, 64, 90]. They belong to the most commonly missed 

injuries of all, particularly in polytrauma [22, 33, 37, 57, 92]. 

The closed reduction of Chopart and Lisfranc dislocated fractures is generally not possible so 

that there is an indication for emergency surgery in most cases [37, 49]. Lisfranc dislocated 

fractures are also associated with an increased risk of compartment syndrome in the foot [51, 

64]. If the general condition of the patient permits no definitive osteosynthesis, the goal is 

Kirschner wire transfixation and/or the insertion of a tibiometatarsal external fixator; definitive 

management should be carried out later [57, 61, 63, 93]. 

After stabilization of the general condition of the multiply injured patient, fractures of the 

metatarsals and toes can be managed later by osteosynthesis according to the general treatment 

principles; the above-cited general principles apply to open injuries of the forefoot [59]. 



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3.12 Mandible and midface 

Securing the airways; bleeding 


In mandible and maxillofacial injuries, primary securing of the airways and 

hemostasis in the oral and maxillofacial region must be carried out. 

Explanation: 

GoR A 

The immediate securing of the airways and management of intense bleeding are vital to life [44]. 

There is often a danger of suffocation due to foreign bodies (e.g., dental prostheses, tooth and 

bone fragments, blood clots, mucus, vomit). This danger should be eliminated by manually 

cleaning the oral cavity and the throat and by suctioning the deeper airways [2]. If there is 

instability in the mandible as a result of comminutions or erosion of the middle piece, this can 

cause the tongue to fall back and displace the airways. The hazardous situation can be remedied 

by reduction and stabilization of the mandible with wire ligatures attached to available teeth [2]. 

If the airways in the craniocervical region are disabled by intense bleeding, tongue swelling and 

displacement, then intubation, a tracheotomy or coniotomy (cricothyroidotomy) is necessary 

depending on the urgency and feasibility [3, 28]. 

If larger vessels are affected (generally the origins of the external carotid artery), surgical 

hemostasis will be necessary. Open surgical hemostasis with vascular ligation and bipolar 

electrocoagulation or embolization with angiography is recommended [16, 18, 28]. The exact 

source of bleeding should be located for effective hemostasis [38]. Epistaxis is one of the 

commonest types of bleeding. Most bleeding can be arrested by primary compression using 

tamponades [26, 40]. In the case of persistent bleeding in the nasopharyngeal space, it is 

necessary to insert Bellocq packing or a balloon catheter [15]. In the case of bleeding from the 

maxillofacial region, particularly the maxillary artery, an attempt can be made to arrest the 

bleeding by compressing the maxilla dorsocranially against the base of the skull (e.g., spatula 

head bandage, dental impression tray with extraoral brace) [2]. In the case of sagittal maxillary 

fractures, compression can be necessary, e.g., by a transverse wire suture from the molars on one 

side to the molars on the contralateral side [2, 37]. Reduction and fixing of craniofacial fractures 

often represent the best causal treatment even for severe hemorrhages [15]. 

Emergency surgery phase – Mandible and midface 412


Soft tissue facial injuries 


Soft tissue injuries should be managed during the emergency surgery phase. GoR B 

Explanation: 

Injuries to the facial soft tissues occur either isolated in the form of abrasion, gash, cuts, crush, 

and defect wounds or in severe trauma in combination with craniofacial fractures. Gash and 

crush wounds are the commonest facial soft tissue injuries [43]. Soft tissue injuries, particularly 

those with exposed cartilage and/or bone surfaces, for example, should be managed at the 

earliest opportunity. Ideally, this can take place in the emergency room [20]. Rapid management 

of soft tissue injuries also contributes towards achievement of improved esthetic and functional 

outcomes [5, 17, 27, 31, 41, 45]. 

Appropriate hemostasis and cerebral decompression if there is intracranial pressure are the most 

important principles in the first hours after the trauma [24]. Craniofacial and soft tissue injuries 

are managed in the secondary phase [42]. In the case of combined soft tissue injuries with 

craniofacial fractures, definitive soft tissue management should be carried out after 

reconstruction of the bony structures if possible (“from inside to outside”) [22]. Functional 

structures such as eyelids, lips, the facial nerve, and the parotid gland should be reconstructed 

during primary wound management [39]. Gently cleansing the wound and removing foreign 

bodies should be carried out before reconstructive graft work so that good esthetic and functional 

results can be achieved later [21]. Bigger reconstructive measures or microvascular 

reconstructions are generally undertaken in two steps [32]. 

Tooth injuries, alveolar process fractures 


The goal should be immediate management, if necessary rapid management of 

the tooth-alveolar process trauma. 

Explanation: 

GoR B 

The treatment goal for tooth injuries and alveolar process fractures consists of restoring shape 

and function (esthetics, occlusion, articulation, phonation). This entails attempting to salvage 

both the tooth structure and the alveolar process. 

The treatment depends on the general salvage worth and vitality of the teeth [1]. 

The prognosis for preserving a tooth long-term after avulsion depends on the length of time and 

storage of the tooth (e.g., cell culture medium/Dentosafe, cold milk, physiologic saline solution, 

oral cavity) until successful replantation [9, 10]. The most favorable replantation results can be 



achieved within the first 30 minutes [46]. Avulsed teeth, which have been preserved dry for 

several hours, have the most unfavorable prognosis although successful replantations have also 

been reported in individual case reports. For this reason, a replantation attempt after a longer 

interval can also be justified in individual cases [13]. 

Management of alveolar process fractures should also be undertaken at the earliest opportunity 

[6, 46]. 

Acute treatment should be carried out within a few hours for extrusion, lateral dislocation or 

avulsion of a tooth, an alveolar process fracture or a root fracture [1, 6]. Careful handling of the 

periodontal ligament and swift fixation via splints or splint bandaging protect from infections 

and permanent tooth loss [9, 10, 48]. 

Managing complicated crown fractures after 3 hours and uncomplicated crown fractures with 

exposed dentine after 48 hours worsen the prognosis of vital teeth [6]. 

Mandible and midface 


Depending on the overall injury severity, maxillofacial and mandible fractures 

can be managed in the emergency surgery phase or secondary phase. 

Explanation: 

GoR 0 

The treatment goal consists of restoring shape and function. Particular value is placed on 

restoring occlusion, articulation, joint function, esthetics, and motor and/or sensory nerve 

function. Treatment strategies, surgery techniques, and procedure are comparable with those for 

isolated fractures or combination fractures of the mandible and/or midface. 

Ideally, maxillofacial and mandible fractures receive one-step early primary management [7, 36]. 

In maxillofacial fractures, early management with anatomic reduction and fixation led to a 

reduction in edema formation and better recontouring of the facial soft tissues [12, 23, 34]. 

However, the timing was very imprecisely stated by the authors with “immediately” or “within 

the first few days”. Bos et al. [4] require surgical management of maxillofacial fractures with 

open reduction and fixation within 48-72 hours in order to achieve a good esthetic and functional 

outcome and to avoid secondary corrections. Better reduction of bone fragments and faster 

healing and thus also more favorable esthetic results were observed in children with 

maxillofacial fractures who were operated on within a week after trauma [19]. 

With reference to a concomitant traumatic brain injury (TBI), the Glasgow Coma Scale (GCS) 

provides valuable information on the prognosis of the injured person. However, this does not 

mean that patients with a low GCS have to be automatically excluded from management of 

craniofacial fractures. Manson [23] reports that patients with head injuries can undergo surgery 

without increased complication rates provided that the intracranial pressure is kept below a value 

of 25 mmHg during the intervention. In a retrospective study on 49 patients with mandible 

and/or maxillofacial fractures with additional traumatic brain injury, Derdyn et al. [8] observed 



that patients with intracranial pressure below 15 mmHg after early surgical management (0- 

3 days after the accident) had comparable survival rates to comparison groups after medium-term 

(4-7 days) or later (> 7 days) surgical management. There were no significant differences in 

postoperative complications between the comparative patient collectives receiving early, 

medium-term, and late surgery. In contrast, craniofacially-injured patients with low GCS, 

intracranial bleeding, and shift in median brain structures after lateral and multisystem trauma 

had a significantly worse prognosis. 

Due to improvements in functional and esthetic outcomes through the use of mini- and 

microplates and by less invasive surgical techniques [14], early management within 24-72 hours 

is becoming increasingly controversial. 

If higher priority is given to the general condition or other injuries, then the definitive 

management of craniofacial injuries can be postponed by 7-10 days after the trauma event after 

management of soft tissue injuries and temporary stabilization (e.g., with splint bandaging, wire 

ligatures, splints) of fractures [7]. Ideally, soft tissue management and temporary stabilizations 

can take place in the emergency room [20]. 

In a retrospective study with comparable groups on a total of 82 multiply injured patients with 

mandible and/or maxillofacial fractures, Weider et al. [47] showed that delayed management 

(≥ 48 hours) did not lead to any extension in treatment time in the intensive care unit and in 

hospitalization. The infection rate was negligible and the complication rate comparable with that 

of patients who had been operated on within 48 hours. Schettler [35] did not observe any 

disadvantages in definitive management of maxillofacial fractures within 14 days. Neither 

infections nor residual disorders in eye motility were observed to a greater extent compared to 

immediate treatment. On the other hand, after the initial severe edema subsided, the complicated 

rejoining of even the smallest bone fragments was much easier to carry out. He regards the most 

favorable timing for definitive management as between the 5th and 10th day after the trauma. 

Kühne et al. [20] retrospectively analyzed a total of 78 patients with mandible and/or 

maxillofacial fractures who received surgery in the emergency room. There was a comparatively 

identical postoperative complication rate among the patients who received early primary (within 

72 hours) or delayed (after 72 hours) surgery. The group of patients who received delayed 

surgery had a markedly higher overall injury severity than those who received early primary 

management. 

Exceptions for delayed management are non-arrestable bleeding from fractures which require 

immediate reduction and osteosynthesis, and intraorbital or intracranial damage to the optic 

nerve, which necessitates therapeutic action within a few hours [7]. Retrobulbar hematomas, 

elevated eye pressure or direct compression on the optic nerve secondary to vision deterioration 

can necessitate the immediate introduction of a megadose of cortisone treatment over 48 hours 

(30 mg Urbason/kg BW i. v. as bolus and 5.4 mg Urbason/kg BW hourly over the following 47 

hours) and/or immediate surgical decompression of the optic nerve [7, 11, 30, 46]. 

In injuries covering several disciplines, the appropriate specialist disciplines must be involved in 

the treatment planning and treatment [25]. Depending on the injury severity, the sequence of 

measures to be taken should be established on an interdisciplinary basis [20, 25, 47]. 



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3.13 Neck 


Provided no intubation or tracheotomy has been carried out beforehand, all 

findings related to the airways must be examined and assessed before 

induction of intubation anesthesia. 

Intubation aids and a coniotomy set must be kept immediately available. 

Difficult airway algorithms must be heeded here. 

A coniotomy carried out previously must be surgically closed; if necessary, a 

tracheotomy must be carried out. 

Penetrating trauma to the esophagus should undergo primary reconstructive 

treatment within 24 hours. 

Explanation: 

GoR A 

GoR A 

GoR A 

GoR B 

If the upper airways are involved in a polytrauma, intubation difficulties from swelling, 

displacement and/or secretion and blood are to be expected. 

In the case of tracheal tears or avulsions or open tracheal injuries, surgical exploration with 

insertion of a tracheostoma or direct reconstruction is recommended [1]. The same applies to 

trauma in the region of the larynx. 

There is controversy surrounding conservative treatment of tracheal tears. Conservative 

treatment can be considered for non-gaping, short-segment lesions that can be bridged by the 

tube [3]. The majority of studies argue in favor of surgical reconstruction at the earliest 

opportunity via transcervical approach, thoracotomy or, as an exception, a transcervicaltranstracheal 

approach. The single-layer suture with absorbable material and single knot sutures 

is recommended [1, 2, 4–7]. The decision must be made on a case-by-case basis as to whether a 

tracheotomy in the conventional sense, in other words an epithelized tracheostoma, or a puncture 

tracheotomy is used. On the one hand, the exclusion criteria for a puncture tracheotomy must be 

heeded and, on the other hand, the risk of iatrogenic injury to adjacent structures [5]. The fact 

that cannula replacement is simpler is a particular advantage of the epithelized tracheostoma. In 

laryngeal trauma, attempts should be made to effectuate early reconstruction. There are no 

literature sources to be found which focus on a purely conservative treatment of laryngeal trauma 

[1, 2, 4–7], particularly against the background of preventing stenoses and voice disorders. In 

addition to removing stenoses and covering cartilage defects, the insertion of indwelling 

laryngeal stents for several weeks is recommended in order to prevent stenoses, strictures, and 

webbing [2, 4, 5]. 

An elective tracheotomy should be considered if ventilation treatment is expected to continue 

longer. Historical studies have shown that, even after 48 hours, orotracheal intubation can lead to 

Emergency surgery phase – Neck 418


irreversible damage to the larynx and tracheal cartilage with blood pressure, tube materials, and 

the use of vasoactive substances being important determinants. The main critical place is the 

cricoid cartilage; using modern cuffs (low-pressure high-volume), the risk of a tracheal stenosis 

can be lowered with simultaneous monitoring of the cuff pressure. Early tracheotomy thus serves 

primarily to prevent cricoid cartilage stenosis. 

Damage to the recurrent laryngeal nerve or the vagus nerve can be most easily detected by 

evaluating vocal cord mobility using a laryngoscope (direct and indirect) or stroboscope. There 

is no evidence in the literature for emergency surgical treatment for a suspected recurrent paresis 

as part of polytrauma. Here, the focus is on confirming airway stenosis possibly caused by 

posttraumatic vocal cord paralysis. No studies have been found on traumatically induced 

laryngeal paralysis. The conclusions are based on postoperative pareses after struma surgery. 

Here, contradictory successes in surgical decompressions and reconstructions are reported. A 

noticeable improvement in the situation for the patient cannot be deduced from the literature. 

Following on from the endoscopic functional diagnostic study (laryngoscopy/stroboscopy), 

imaging procedures such as computed tomography can provide evidence on the location of the 

damage [9, 10]. 

As an alternative to surgery, conservative treatment using antibiotic protection can be considered 

for localized perforations lying in the cervical section of the esophagus [11]. According to case 

series, a direct suture of all layers within the first 24 hours offers the best prognosis for the 

clinical course [12, 13]. According to the literature, intrathoracic esophageal injuries should 

always undergo surgical treatment; no studies have been found which support conservative 

treatment. For esophageal perforations not accessible by direct suture, partial resections, if 

necessary with interposition grafts, are recommended [12-18]; alternatively, an endoluminal 

bond with fibrin adhesive can be considered. With all these recommendations, it should be noted 

that no clinical studies have been found, only case series and individual reports. 

This should be carried out as surgical reconstruction, if necessary with interposition grafts of the 

arterial vessels. However, injuries not occluding the lumen can also be treated conservatively 

(e.g., dissections). A reconstruction of venous vessels must not be carried out/is not indicated. 

Angiography, computed tomography and duplex or Doppler ultrasonography represent the first 

line choice of examination procedures for injuries to the neck vessels [21]; this applies without 

restriction in zones I and III according to Roon and Christensen [23]. Surgical exploration is 

additionally recommended for zone II. Although this is hotly debated in the literature, it is not in 

dispute that 100% of defects can be detected by this method and if necessary treated [21, 23]. 

The largest clinically controlled study is by Weaver et al. [24] and comes to the conclusion that 

reconstructions of arterial vessels offer the best outcome for penetrating injuries. The restoration 

of arterial vessels must be carried out within a timeframe of 120 minutes [20]. However, injuries 

not occluding the lumen can be treated conservatively with success by duplex ultrasonography 

monitoring [24]. 

In addition to a surgical intervention, there is also the possibility of neuroradiologic endovascular 

treatment for pseudoaneurysms or fistulas [19]. No studies have been found that support 

reconstruction of injured venous vessels [22]. 



References 

1. Dienemann H, Hoffmann H (2001). Tracheobronchial 

injuries and fistulas. Chirurg 72 (2001): 1131-1136 

2. Donald PJ. Trachealchirurgie: Kopf – und Hals 

Chirurgie (H.H. Naumann et al) 1998 Georg Thieme 

Verlag (S. 243 - 57) 

3. Gabor S, Renner H, Pinter H, Sankin O, Maier A, 

Tomaselli F, Smolle Juttner FM. Indications for 

surgery in tracheobronchial ruptures. Eur J 

Cardiothorac Surg 20 (2001): 399-404 

4. Pitcock, J. Traumatologie der Halsweichteile: Kopf – 


Thieme Verlag (S. 459 - 75) 

5. Welkoborsky HJ. Verletzungen der Halsregion und 

der Halswirbelsäule. Praxis der HNO – Heilkunde, 

Kopf- und Halschirurgie (J. Strutz, W. Mann) 2010 

Georg Thieme Verlag 

6. Hwang SY, Yeak SC. Management dilemmas in 

laryngeal trauma. J Laryngol Otol 118 (2004) 325-328 

7. Bell RB, Verschueren DS, Dierks, EJ. Management of 

laryngeal trauma. Oral Maxillofac Surg Clin N Am 20 

(2008) 415-430. 

8. Robinson S, Juutilainen M, Suomalainen A. 

Multidetector row computed tomography of the 

injured larynx after trauma. Semin Ultrasound CT MR 

30 (2009) 188-194 

9. Thermann M, Feltkamp M, Elies W, Windhorst T. 

Recurrent laryngeal nerve paralysis after thyroid gland 

operations. Etiology and consequences. Chirurg. 1998 

Sep;69(9):951-6 

10. Welkoborsky HJ. Verletzungen der Halsregion und 

der Halswirbelsäule. Praxis der HNO – Heilkunde, 

Kopf- und Halschirurgie (J. Strutz, W. Mann) 2010 

Georg Thieme Verlag 

11. Demetriades D, Velmahos GG, Asensio JA. Cervical 

pharyngoesophageal and laryngotracheal injuries. 

World . J Surg 25 (2001): 1044-1048. 

12. Eroglu A, Can Kurkcuogu I, Karaoganogu N, 

Tekinbas C, Yimaz O, Basog M. Esophageal 

perforation: the importance of early diagnosis and 

primary repair. Dis Esophagus. 17 (2004): 91-94 

13. Kotsis L, Kostic S, Zubovits K. Multimodality 

treatment of esophageal disruptions. Chest. 112 

(1997): 1304-1309 

14. Lamesch P, Dralle H, Blauth M, Hauss J, Meyer 

HJ.Perforation of the cervical esophagus after ventral 

fusion of the cervical spine. Defect coverage by 

muscle-plasty with the sternocleidomastoid muscle: 

case report and review of the literature. Chirurg 68 

(1997): 543-547. 

15. Mai C, Nagel M, Saeger HD. Surgical therapy of 

esophageal perforation. A determination of current 

status based on 4 personal cases and the literature. 

Chirurg 68 (1997): 389-394 

16. Pitcock, J. Traumatologie der Halsweichteile. Kopf – 


Thieme Verlag (S. 459 - 475). 

17. Strohm PC, Muller CA, Jonas J, Bahr R. Esophageal 

perforation. Etiology, diagnosis, therapy. Chirurg 

73(2002): 217-222 

18. Sung SW, Park JJ, Kim YT, Kim JH. Surgery in 

thoracic esophageal perforation: primary repair is 

feasible. Dis Esophagus 15(2002): 204-209 

19. Diaz-Daza O, Arraiza FJ, Barkley JM, Whigham CJ. 

Endovascular therapy of traumatic vascular lesions of 

the head and neck. Cardiovasc Intervent Radiol 26 

(2003): 213-221. 

20. Etl S, Hafer G, Mundinger A. Cervical vascular 

penetrating trauma. Unfallchirurg 103 (2000): 64-67. 

21. Ginzburg E, Montalvo B, LeBlang S, Nunez D, 

Martin L. The use of duplex ultrasonography in 

penetrating neck trauma. Arch Surg. 131 (1996): 691- 

693. 

22. Pitcock J. Traumatologie der Halsweichteile Kopf – 


Thieme Verlag (S. 459 - 475). 

23. Roon AJ, Christensen N. Evaluation and treatment of 

penetrating cervical injuries. J Trauma 19 (1979): 

391-397 

24. Weaver FA, Yellin AE, Wagner WH, Brooks SH, 

Weaver AA, Milford MA. The role of arterial 

reconstruction in penetrating carotid injuries. Arch 

Surg 123(1988): 1106-1111. 



Date published: 2002 

Date revised: July 2011 

Next revision planned for: December 2014 

The “guidelines” of the Scientific Medical Societies are systematically developed aids for 

physicians in decision-making in specific situations. Based on current scientific knowledge 

and on procedures proven in practice, they ensure a greater degree of safety in medicine yet 

are also intended to cover economic aspects. The “guidelines” are not legally binding for 

physicians and therefore neither substantiate liability nor exempt from liability. 

The AWMF compiles and publishes the guidelines of the medical societies with the utmost 

care. Notwithstanding, the AWMF accepts no responsibility for the accuracy of the content. 

For information on dosages, in particular, the manufacturer’s data should always be heeded. 

©Deutsche Gesellschaft für Unfallchirurgie 

Authorized for electronic publication: AWMF online 

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