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Pre-hospital and early in-hospital management of severe injuries: Changes and trends

      Abstract

      The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly. In addition, the introduction of training and education programmes such as Pre-hospital Trauma Life Support (PHTLS®), Advanced Trauma Life Support (ATLS®) concept or the TEAM® concept has increased the quality of treatment of most severely injured trauma patients both in the preclinical field and in the emergency trauma room. Today, all emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The advancements described in this article provide examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU “Weißbuch” have contributed to a more structured management of most severely injured patients.

      Keywords

      Introduction

      The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly – not any treatment that is possible should be conducted at the accident site, unless it is vital for life [
      • Geeraedts Jr., L.M.
      • Kaasjager H.A.
      • van Vugt A.B.
      • Frölke J.P.
      Exsanguination in trauma: a review of diagnostics and treatment options.
      ,
      • Clarke J.R.
      • Trooskin S.Z.
      • Doshi P.J.
      • Greenwald L.
      • Mode C.J.
      Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes.
      ]. This, for example, applies to preclinical intubation and volume therapy, both of which will be discussed in this article.
      Besides these paradigm changes regarding the treatment of most severely injured patients, the introduction of training and education programmes has increased the quality of treatment of most severely injured trauma patients – both in the preclinical field and in the emergency trauma room. Examples are the Pre-hospital Trauma Life Support (PHTLS®) programme for the preclinical field and the Advanced Trauma Life Support (ATLS®) concept or the TEAM® training for the initial in-hospital phase. The latter is a globally established concept for the treatment of most severely injured trauma patients in the emergency trauma room, which was established in Germany in 2003. Nowadays, the ATLS® concept is used extensively on a national level. Furthermore, the strategies of Damage Control Surgery are taught in the Definitive Surgical Trauma Care (DSTC™) programme. Altogether, this has not only led to improvements of the factor time but also of the treatment's quality.
      Important advancements regarding the structural prerequisites have been achieved by introducing the “Weißbuch of the German Trauma Society (DGU)” in 2006 and by establishing comprehensive trauma networks. The extent and content regarding the treatment of most severely injured patients have been brought to a maximum level by completing the S3 polytrauma guidelines of the DGU in 2011 [
      • Deutsche Gesellschaft für Unfallchirurgie
      Weißbuch Schwerverletztenversorgung.
      ,

      Deutsche Gesellschaft für Unfallchirurgie S3-Leitlinie Polytrauma/Schwerverletztenbehandlung. AWMF Registrierungsnummer 012-019. http://www.awmf.org/Leitlinien.

      ,
      • Ruchholtz S.
      • Kühne C.A.
      • Siebert H.
      Arbeitskreis Umsetzung Weißbuch/Traumanetzwerk in der DGU Akut das Traumanetzwerk der Deutschen Gesellschaft für Unfallchirurgie.
      ,
      • American College of Surgeons Committee on Trauma
      ATLS student course manual.
      ]. A few articles have already shown that the implemented restructuring of the management of most severely injured patients in combination with the latest guidelines can lead to improved patient outcomes [
      • Schoeneberg C.
      • Schilling M.
      • Burggraf M.
      • Fochtmann U.
      • Lendemans S.
      Reduction in mortality in severely injured patients following the introduction of the “treatment of patients with severe and multiple injuries” guideline of the German society of trauma surgery – a retrospective analysis of a level 1 trauma center (2010–2012).
      ]. Particularly the implementation of empirical knowledge, experience, and evidence-based contents into clinical processes as well as the meaningful communication of these insights within predefined programmes have created a fairly wide basis for the improvement of the management of severely injured patients. Continuous evaluation and improvement of this content and its rapid communication is a crucial aspect in this context. Identifying adverse events and errors within these processes plays a vital role [
      • Brennan T.A.
      • Leape L.L.
      • Laird N.M.
      • Hebert L.
      • Localio A.R.
      • Lawthers A.G.
      • et al.
      Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I.
      ,
      • Cales R.H.
      • Trunkey D.D.
      Preventable trauma deaths: a review of trauma care systems development.
      ,
      • Gruen R.L.
      • Jurkovich G.J.
      • McIntyre L.K.
      • Foy H.M.
      • Maier R.V.
      Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.
      ], as well as the identification of errors and deaths that could have been prevented. According to Davis et al., [
      • Davis J.W.
      • Hoyt D.B.
      • McArdle M.S.
      • Mackersie R.C.
      • Eastman A.B.
      • Virgilio R.W.
      • et al.
      An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement.
      ] up to 6% of trauma-related deaths could have been prevented. Gruen et al. [
      • Gruen R.L.
      • Jurkovich G.J.
      • McIntyre L.K.
      • Foy H.M.
      • Maier R.V.
      Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.
      ] were able to show that the delayed treatment of active torso haemorrhages (pelvis, abdomen, and thorax) was the most common cause for preventable deaths. The delayed diagnosis and treatment of pelvic haemorrhages seems to be the number one “killer”. Soreide et al. [
      • Søreide K.
      • Krüger A.J.
      • Vårdal A.L.
      • Ellingsen C.L.
      • Søreide E.
      • Lossius H.M.
      Epidemiology and contemporary patterns of trauma deaths: changing place, similar pace, older face.
      ] showed that this type of bleeding – besides traumatic brain injuries – is responsible for most of the deaths, particularly during the early trauma phase, and that it is feasible and mandatory to improve the treatment of such bleeding. This is also true with regard to the paramount importance of a structured and meaningful transfusion and coagulation management for which multiple improvements are expected in the future [
      • Rossaint R.
      • Bouillon B.
      • Cerny V.
      • Coats T.J.
      • Duranteau J.
      • Fernández-Mondéjar E.
      • et al.
      Task force for advanced bleeding care in trauma management of bleeding following major trauma: an updated European guideline.
      ].

      Advancements in airway management

      Endotracheal intubation still represents the gold standard in terms of maintaining a safe airway and ventilation. However, intubation is an invasive procedure potentially causing considerable risks. Moreover, there are some specific aspects that must be considered in the preclinical field: level of experience (existing education), conditions at the incident scene (jammed patients etc.), type of patient transfer (air transportation vs. ground-based), duration of patient transfer, and comorbidities in the respiratory tract plus (assessable) intubation barriers. Therefore, preclinical intubation should only be performed after the strict consideration of alternative indications. The uncritical use of preclinical intubation – as a so-called “must” of the preclinical management of trauma patients – even appears to be harmful rather than beneficial. The following ATLS® principle should always be considered: Do not cause further harm! [
      • American College of Surgeons Committee on Trauma
      ATLS student course manual.
      ] Based on TraumaRegister DGU®, it was possible to show in patients with thoracic injuries that preclinical intubation may result in disadvantages even in patients without respiratory insufficiency [
      • Ruchholtz S.
      • Waydhas C.
      • Ose C.
      • Lewan U.
      • Nast-Kolb D.
      Working Group on Multiple Trauma of the German Trauma Society
      Prehospital intubation in severe thoracic trauma without respiratory insufficiency: a matched-pair analysis based on the Trauma Registry of the German Trauma Society.
      ]. A recent study about Anglo-American emergency medical services demonstrated that intubation – for example when conducted due to the aggressiveness of patients rather than based on clear intubation criteria – was associated with significantly increased rates of pneumonia and extended hospitalisation [
      • Muakkassa F.F.
      • Marley R.A.
      • Workman M.C.
      • Salvator A.E.
      Hospital outcomes and disposition of trauma patients who are intubated because of combativeness.
      ].
      A 2011 AUC matched-pair analysis based on TraumaRegister DGU® that was conducted in moderately injured patients (mean ISS score of 15.1) showed even clearer that the outcome of preclinically intubated patients was significantly worse (higher rates of multi-organ failure and organ failure, sepsis, etc.) despite similar baseline conditions [
      • Hussmann B.
      • Lefering R.
      • Waydhas C.
      • Ruchholtz S.
      • Wafaisade A.
      • Kauther M.D.
      • et al.
      Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1200 patients from the DGU Trauma Registry.
      ]. This analysis is of particular relevance for emergency medical services in German-speaking countries.
      This change over the last 20 years – from routine intubation in most severely injured patients to an intubation based on clearer indications – resulted in an improved quality of care. However, the prerequisites for intubation during the further course in the hospital and in the emergency trauma room, respectively, are still unclear. Generally, the same indications certainly apply in the hospital as well. However, essential diagnostic measures (such as CT scans) may be required in agitated and constantly moving patients, in order to prevent life-threatening conditions or severe functional damages.

      Advancements in volume and coagulation management

      Uncontrollable bleeding following trauma is considered as the most common preventable death cause [
      • Hess J.R.
      • Brohi K.
      • Dutton R.P.
      • Hauser C.J.
      • Holcomb J.B.
      • Kluger Y.
      • et al.
      The coagulopathy of trauma: a review of mechanisms.
      ]. The immediate effects of bleeding and shock may result in direct and indirect sequelae in surviving patients. 20% of patients develop multi-organ failures during hospitalisation and 20% experience septic episodes. Multi-organ failures and septic conditions – besides thromboembolic complications – lead to a significant increase of mortality following polytrauma [
      • Lendemans S.
      • Kreuzfelder E.
      • Waydhas C.
      • Nast-Kolb D.
      • Flohé S.
      Clinical course and prognostic significance of immunological and functional parameters after severe trauma.
      ]. The fastest possible and targeted substitution of blood and coagulation products has high priority when treating patients in the initial phase following trauma. However, this treatment must be meaningful and take into account the preclinical treatment, e.g. preceding fluid therapy [
      • Spahn D.R.
      • Bouillon B.
      • Cerny V.
      • Coats T.J.
      • Duranteau J.
      • Fernández-Mondéjar E.
      • et al.
      Management of bleeding and coagulopathy following major trauma: an updated European guideline.
      ].
      Unfortunately, there is no worldwide consistency with regard to a structured treatment of haemorrhages. However, it has been established for the preclinical management following trauma that a rather restrictive volume substitution seems to be beneficial for both, adults and most severely injured children [
      • Hußmann B.
      • Taeger G.
      • Lefering R.
      • Waydhas C.
      • Nast-Kolb D.
      • Ruchholtz S.
      • et al.
      Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma: influence of preclinical volume replacement – an analysis of 604 patients from the trauma registry of the DGU.
      ,
      • Hussmann B.
      • Lefering R.
      • Waydhas C.
      • Touma A.
      • Kauther M.D.
      • Ruchholtz S.
      • et al.
      Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site.
      ,
      • Hußmann B.
      • Lefering R.
      • Taeger G.
      • Waydhas C.
      • Ruchholtz S.
      • Lendemans S.
      • et al.
      Influence of prehospital fluid resuscitation on patients with multiple injuries in hemorrhagic shock in patients from the DGU trauma registry.
      ,
      • Hussmann B.
      • Lefering R.
      • Kauther M.D.
      • Ruchholtz S.
      • Moldzio P.
      • Lendemans S.
      • et al.
      Influence of prehospital volume replacement on outcome in polytraumatized children.
      ]. Recent studies based on TraumaRegister DGU® have also demonstrated for blunt traumas that non-indicated preclinical volume therapy may be associated with worsened outcomes and with increased mortality. The same studies also suggest that the patient's baseline characteristics upon reaching the hospital (e.g. coagulation or initial haemoglobin value) are significantly worse compared to a control group with identical baseline characteristics [
      • Hußmann B.
      • Taeger G.
      • Lefering R.
      • Waydhas C.
      • Nast-Kolb D.
      • Ruchholtz S.
      • et al.
      Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma: influence of preclinical volume replacement – an analysis of 604 patients from the trauma registry of the DGU.
      ,
      • Hussmann B.
      • Lefering R.
      • Waydhas C.
      • Touma A.
      • Kauther M.D.
      • Ruchholtz S.
      • et al.
      Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site.
      ,
      • Hußmann B.
      • Lefering R.
      • Taeger G.
      • Waydhas C.
      • Ruchholtz S.
      • Lendemans S.
      • et al.
      Influence of prehospital fluid resuscitation on patients with multiple injuries in hemorrhagic shock in patients from the DGU trauma registry.
      ,
      • Hussmann B.
      • Lefering R.
      • Kauther M.D.
      • Ruchholtz S.
      • Moldzio P.
      • Lendemans S.
      • et al.
      Influence of prehospital volume replacement on outcome in polytraumatized children.
      ]. Furthermore, it was shown that the administration of higher volumes (>1500 ml) has been associated with an extended scope of therapy (e.g. insertion of thoracic catheter). And this resulted in an increase of the preclinical emergency treatment time. It must be emphasised in this context that patients with blunt trauma, in particular, only benefit from in-hospital therapy, while mortality increases by 1% with every 3 min of time to emergency surgery, as shown by Clarke et al. [
      • Clarke J.R.
      • Trooskin S.Z.
      • Doshi P.J.
      • Greenwald L.
      • Mode C.J.
      Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes.
      ] in a study with patients following abdominal trauma. A more restrictive volume therapy is widely established in Anglo-American countries and has recently been supported by Haut et al. [
      • Haut E.R.
      • Kalish B.T.
      • Cotton B.A.
      • Efron D.T.
      • Haider A.H.
      • Stevens K.A.
      • et al.
      Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis.
      ]. This article will not contribute to the discussion of the “stay and play” and “load and go” approaches, because the positive experiences and arguments regarding the emergency medical system in German-speaking countries – well functioning for decades – do not need to be repeated. However, it should be emphasised that the factor time is crucial to the therapy, and that any extensive and possibly non-indicated therapy in individual cases may harm the patient. The recommendations for patients with penetrating trauma, however, are clear: rapid transfer into an appropriate hospital, and no extensive volume therapy.
      The current algorithms (that are used in hospitals for coagulation and transfusions) range from undirected treatment and strict transfusion protocols to the ROTEM-based substitution of single components depending on the clinical bleeding tendency. In the US, the concept of administering red blood cells packs and fresh frozen plasma in a ratio of 1:1–1:1.5 has been favoured. This resulted in significantly reduced mortality rates in some studies [
      • Holcomb J.B.
      • Wade C.E.
      • Michalek J.E.
      • Chisholm G.B.
      • Zarzabal L.A.
      • Schreiber M.A.
      • et al.
      Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients.
      ]. In contrast, a point-of-care-based, calculated, targeted coagulation management using coagulation factor concentrates – which was shown to be extremely efficiently – has been established in some European centres [
      • Görlinger K.
      • Hanke A.
      • Dirkmann D.
      • Müller-Beißenhirtz H.
      • Piepenbrink K.
      Impact of a thrombelastometry-based algorithm for point-of-care coagulation management on blood transfusion rate in trauma patients.
      ]. In addition to the more targeted use of coagulation factors, fibrinogen substitution seems to play a decisive role. In trauma patients, this is the first factor that drops down to critical levels, e.g. after increased consumption. Therefore, the early and efficient administration of fibrinogen (e.g. 2–6 g for adult patients) in the emergency trauma room is as useful as the administration of single factors.
      Another important factor of the coagulation management is the administration of tranexamic acid. A controlled randomised study of the Crash-2 trial showed that the early administration (<1 h following trauma) in most severely injured bleeding patients reduced the mortality risk due to bleeding by 5.3% (vs. 7.7% in the placebo group) [
      • CRASH-2 Collaborators
      • Roberts I.
      • Shakur H.
      • Afolabi A.
      • Brohi K.
      • Coats T.
      • et al.
      The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial.
      ]. Therefore, it is currently discussed to use tranexamic acid for substitution already in the preclinical field, e.g. in the ambulance vehicle. It is not possible yet to give any recommendations, but it is expected that substances such as tranexamic acid, fibrinogen concentrate, and prothrombin complex concentrate will be evaluated in the near future regarding their useful administration in the preclinical field [
      • Pham H.P.
      • Shaz B.H.
      Update on massive transfusion.
      ,
      • Schöchl H.
      • Schlimp C.
      • Maegele M.
      Tranexamic acid fibrinogen concentrate and prothrombin complex concentrate: data to support prehospital use?.
      ,
      • Harvey V.
      • Perrone J.
      • Kim P.
      Does the use of tranexamic acid improve trauma mortality?.
      ]. Scientific societies are currently trying to resolve the problem of identifying the best coagulation management using randomised and controlled studies.

      Advancements with abdominal trauma

      All emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The objective is to avoid any secondary damages that may develop due to an extensive duration of surgical procedures during extended terminal care that may have a negative impact on the outcome [
      • Pape H.C.
      • Tornetta 3rd, P.
      • Tarkin I.
      • Tzioupis C.
      • Sabeson V.
      • Olson S.A.
      Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery.
      ].
      In accordance with the ATLS® recommendations, the initial focused assessment sonography in trauma (FAST) and CT scanning using contrast media are generally accepted as the gold standard [
      • Pal J.D.
      • Victorino G.P.
      Defining the role of computed tomography in blunt abdominal trauma: use in the hemodynamically stable patient with a depressed level of consciousness.
      ]. These procedures can help to identify injuries of both the parenchymatous and hollow organs. In order to perform CT scans, it is usually required that the patient is stable. If relevant amounts of free fluid have been detected with the FAST procedure, the therapy in patients with circulatory instability and with possible haemoglobin loss includes life-saving emergency laparotomy in the emergency trauma room or in the operating theatre [
      • Nast-Kolb D.
      • Trupka A.
      • Ruchholtz S.
      • Schweiberer L.
      Abdominal trauma.
      ]. Peritoneal lavage – which was recommended in Anglo-American countries only a few years ago – is no longer advised and also of minor importance in the ATLS® educational concept. It must be considered with regard to emergency CT scanning that CT scans are mentioned as a basis for possible embolisation for bleeding control. Over the last few years, there has been a change in the treatment management by using contrast media for CT scanning. Thus, active haemorrhages can be detected and – if the patient's clinical status allows doing so – stopped afterwards by selectively searching for the affected vessel. This concept has been shown to be effective e.g. for the control of haemorrhages of parenchymatous organs (splenic or hepatic ruptures) or in cases of bleeding after pelvic fractures. The targeted use of embolisation may contribute to minimise the so-called “second hit”, which often cannot be prevented by surgical procedures. This procedure has been widely established in Anglo-American countries, and has also been increasingly used in German-speaking countries. However, as a limitation, it must be noted that a certain infrastructure is required (e.g. radiologist with specific embolisation experience).
      However, surgery or embolisation is not necessary in each patient with abdominal organ laceration. A number of authors have shown in their studies that more than 85% of all stable patients following liver trauma were suitable for undergoing conservative treatment [
      • Lendemans S.
      • Heuer M.
      • Nast-Kolb D.
      • Kühne C.A.
      • Dammann M.
      • Lefering R.
      • et al.
      Significance of liver trauma for the incidence of sepsis, multiple organ failure and lethality of severely injured patients. An organ-specific evaluation of 24,771 patients from the trauma register of the DGU.
      ,
      • Matthes G.
      • Stengel D.
      • Seifert J.
      • Rademacher G.
      • Mutze S.
      • Ekkernkamp A.
      Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography.
      ]. Improved coagulation management has partially contributed to this. The surgical therapy approach that was propagated a few years ago is increasingly taking a backseat.

      Advancements with pelvic injury

      Uncontrollable bleeding after severe injuries is the main cause for deaths in traumatology [
      • Sauaia A.
      • Moore F.A.
      • Moore E.E.
      • Moser K.S.
      • Brennan R.
      • Read R.A.
      • et al.
      Epidemiology of trauma deaths: a reassessment.
      ]. Blunt traumas are the most common entity in Western Europe (95%) in this context. It has been shown that the mortality of most severely injured patients is impaired by additional pelvic injuries. Haemorrhagic shock is the most common (80–90%) cause for deaths in patients with severe pelvic ring injuries [
      • Holcomb J.B.
      Methods for improved hemorrhage control.
      ,
      • Kauvar D.S.
      • Wade C.E.
      The epidemiology and modern management of traumatic hemorrhage: US and international perspectives.
      ,
      • Nast-Kolb D.
      • Waydhas C.
      • Kastl S.
      • Duswald K.H.
      • Schweiberer L.
      The role of an abdominal injury in follow-up of polytrauma patients.
      ,
      • White C.E.
      • Hsu J.R.
      • Holcomb J.B.
      Haemodynamically unstable pelvic fractures.
      ]. Therefore, an initial examination of the pelvis should be conducted, e.g. using survey radiographs or CT scanning. Furthermore, an immediate mechanical emergency stabilisation should be established. Effective measures are pelvic belts, pelvic clamps, and external fixators. It has not been clarified yet as to which type of emergency stabilisation represents the best procedure, as there is no definite literature evidence available yet from. The pelvic belt has been shown to be effective and reliable in the preclinical field. During the in-hospital care, surgical haemostasis of pelvic haemorrhages can be sufficiently performed by extraperitoneal packing. However, in individual cases – particularly in patients with arterial bleeding – arterial surgical haemostasis might be difficult to control. Delayed angiography then represents a considerable risk for the patient, e.g. when the internal bleeding lesion does not allow for the patient to be moved into the angiography suite rapidly. Therefore, depending on the internal bleeding lesion and the expertise of the available staff, the most appropriate pathway to stop the bleeding should be selected for the individual patient in question [
      • Gruen R.L.
      • Jurkovich G.J.
      • McIntyre L.K.
      • Foy H.M.
      • Maier R.V.
      Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.
      ]. In this supplement, Burkhardt at co-workers elaborate further on this topic with regard to fluid resuscitation in multiple trauma with pelvic fracture.

      Computed tomography (CT) imaging

      Another basic innovation with regard to the management of most severely injured patients has been observed in the initial diagnostic process. CT scanning has been increasingly used for the primary diagnosis in the emergency trauma room. Huber-Wagner et al. [
      • Huber-Wagner S.
      • Lefering R.
      • Qvick L.M.
      • Körner M.
      • Kay M.V.
      • Pfeifer K.J.
      • et al.
      Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study.
      ] have shown that patients undergoing whole-body computed tomography have a lower standardised mortality rate. This has resulted in a more frequent use and represents another piece of the jigsaw in the improved prognosis process of severely injured patients [
      • Ruchholtz S.
      • Lefering R.
      • Paffrath T.
      • Oestern H.J.
      • Neugebauer E.
      • Nast-Kolb D.
      • et al.
      Reduction in mortality of severely injured patients in Germany.
      ]. In this supplement, the same authors report on the effect of scanner location during trauma resuscitation on survival in given local settings.

      Conclusions

      The advancements described in this article give examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU “Weißbuch” have contributed to a more structured management of most severely injured patients.

      Conflict of interest

      The authors declare that there is no conflict of interests.

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