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Background To which extent trauma- induced disturbances in ionized calcium (iCa2+) levels have a linear relationship with adverse outcomes remains controversial. The goal of this study was to determine the association between the distribution and accompanying characteristics of transfusion-independent iCa2+ levels versus outcome in a large cohort of major trauma patients upon arrival at the emergency department. Methods A retrospective observational analysis of the TraumaRegister DGU ® (2015–2019) was performed. Adult major trauma patients with direct admission to a European trauma centre were selected as the study cohort. Mortality at 6 h and 24 h, in-hospital mortality, coagulopathy, and need for transfusion were considered as relevant outcome parameters. The distribution of iCa2+ levels upon arrival at the emergency department was calculated in relation to these outcome parameters. Multivariable logistic regression analysis was performed to determine independent associations. Results In the TraumaRegister DGU ® 30 183 adult major trauma patients were found eligible for inclusion. iCa2+ disturbances affected 16.4% of patients, with hypocalcemia (< 1.10 mmol/l) being more frequent (13.2%) compared to hypercalcemia (≥ 1.30 mmol/l, 3.2%). Patients with hypo- and hypercalcemia were both more likely ( P  < .001) to have severe injury, shock, acidosis, coagulopathy, transfusion requirement, and haemorrhage as cause of death. Moreover, both groups had significant lower survival rates. All these findings were most distinct in hypercalcemic patients. When adjusting for potential confounders, mortality at 6 h was independently associated with iCa2+ < 0.90 mmol/L (OR 2.69, 95% CI 1.67–4.34; P  < .001), iCa2+ 1.30–1.39 mmol/L (OR 1.56, 95% CI 1.04–2.32, P  = 0.030), and iCa2+  ≥ 1.40 mmol/L (OR 2.87, 95% CI 1.57–5.26; P  < .001). Moreover, an independent relationship was determined for iCa2+ 1.00–1.09 mmol/L with mortality at 24 h (OR 1.25, 95% CI 1.05–1.48; P  = .0011), and with in-hospital mortality (OR 1.29, 95% CI 1.13–1.47; P  < .001). Both hypocalcemia < 1.10 mmol/L and hypercalcemia ≥ 1.30 mmol/L had an independent association with coagulopathy and transfusion. Conclusions Transfusion-independent iCa2+ levels in major trauma patients upon arrival at the emergency department have a parabolic relationship with coagulopathy, need for transfusion, and mortality. Further research is needed to confirm whether iCa2+ levels change dynamically and are more a reflection of severity of injury and accompanying physiological derangements, rather than an individual parameter that needs to be corrected as such. Graphical Abstract

Background Peripheral nerve injury (PNI) as an adjunct lesion in patients with upper extremity trauma has not been investigated in a Central European setting so far, despite of its devastating long-term consequences. This study evaluates a large multinational trauma registry for prevalence, mechanisms, injury severity and outcome characteristics of upper limb nerve lesions. Methods After formal approval the TraumaRegister DGU® (TR-DGU) was searched for severely injured cases with upper extremity involvement between 2002 and 2015. Patients were separated into two cohorts with regard to presence of an accompanying nerve injury. For all cases demographic data, trauma mechanism, concomitant lesions, severity of injury and outcome characteristics were obtained and group comparisons performed. Results About 3,3% of all trauma patients with upper limb affection (n = 49,382) revealed additional nerve injuries. PNI cases were more likely of male gender (78,6% vs.73,2%) and tended to be significantly younger than their counterparts without nerve lesions (mean age 40,6 y vs. 47,2 y). Motorcycle accidents were the most frequently encountered single cause of injury in PNI patients (32,5%), whereas control cases primarily sustained their trauma from high or low falls (32,2%). Typical lesions recognized in PNI patients were fractures of the humerus (37,2%) or ulna (20,3%), vascular lacerations (arterial 10,9%; venous 2,4%) and extensive soft tissue damage (21,3%). Despite of similar average trauma severity in both groups patients with nerve affection had a longer primary hospital stay (30,6 d vs. 24,2 d) and required more subsequent inpatient rehabilitation (36,0% vs. 29,2%). Conclusion PNI complicating upper extremity trauma might be more commonly encountered in Central Europe than suggested by previous foreign studies. PNI typically affect males of young age who show significantly increased length of hospitalization and subsequent need for inpatient rehabilitation. Hence these lesions induce extraordinary high financial expenses besides their impact on health related quality of life for the individual patient. Further research is necessary to develop specific prevention strategies for this kind of trauma.

The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing. There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not. In a retrospective, multicentre study, we used the data recorded in the trauma registry of the German Trauma Society to calculate the probability of survival according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardised mortality ratio (SMR, ratio of recorded to expected mortality) for 4621 patients with blunt trauma given whole-body or non-whole-body CT. 1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42·6 years (SD 20·7), 3364 (73%) were men, and mean injury-severity score was 29·7 (13·0). SMR based on TRISS was 0·745 (95% CI 0·633–0·859) for patients given whole-body CT versus 1·023 (0·909–1·137) for those given non-whole-body CT (p<0·001). SMR based on the RISC score was 0·865 (0·774–0·956) for patients given whole-body CT versus 1·034 (0·959–1·109) for those given non-whole-body CT (p=0·017). The relative reduction in mortality based on TRISS was 25% (14–37) versus 13% (4–23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p ≤ 0·002). The number needed to scan was 17 based on TRISS and 32 based on RISC calculation. Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma. Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma. None.

Mortality is the primary outcome measure in severely injured trauma victims. However, quality indicators for survivors are rare. We aimed to develop and validate an outcome measure based on length of stay on the intensive care unit (ICU). The TraumaRegister DGU of the German Trauma Society (DGU) was used to identify 108,178 surviving patients with serious injuries who required treatment on ICU (2014-2018). In a first step, need for prolonged ICU stay, defined as 8 or more days, was predicted. In a second step, length of stay was estimated in patients with a prolonged stay. Data from the same trauma registry (2019-2022, = 72,062) were used to validate the models derived with logistic and linear regression analysis. The mean age was 50 years, 70% were males, and the average Injury Severity Score was 16.2 points. Average/median length of stay on ICU was 6.3/2 days, where 78% were discharged from ICU within the first 7 days. Prediction of need for a prolonged ICU stay revealed 15 predictors among which injury severity (worst Abbreviated Injury Scale severity level), need for intubation, and pre-trauma condition were the most important ones. The area under the receiver operating characteristic curve was 0.903 (95% confidence interval 0.900-0.905). Length of stay prediction in those with a prolonged ICU stay identified the need for ventilation and the number of injuries as the most important factors. Pearson's correlation of observed and predicted length of stay was 0.613. Validation results were satisfactory for both estimates. Length of stay on ICU is a suitable outcome measure in surviving patients after severe trauma if adjusted for severity. The risk of needing prolonged ICU care could be calculated in all patients, and observed vs. predicted rates could be used in quality assessment similar to mortality prediction. Length of stay prediction in those who require a prolonged stay is feasible and allows for further benchmarking.

Preinjury anticoagulation therapy (AT) is associated with a higher risk for major bleeding. We aimed to evaluated the influence of preinjury anticoagulant medication on the clinical course after moderate and severe trauma. Patients in the TraumaRegister DGU ≥ 55 years who received AT were matched with patients not receiving AT. Pairs were grouped according to the drug used: Antiplatelet drugs (APD), vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC). The primary end points were early (< 24 h) and total in-hospital mortality. Secondary endpoints included emergency surgical procedure rates and surgery rates. The APD group matched 1759 pairs, the VKA group 677 pairs, and the DOAC group 437 pairs. Surgery rates were statistically significant higher in the AT groups compared to controls (APD group: 51.8% vs. 47.8%, p = 0.015; VKA group: 52.4% vs. 44.8%, p = 0.005; DOAC group: 52.6% vs. 41.0%, p = 0.001). Patients on VKA had higher total in-hospital mortality (23.9% vs. 19.5%, p = 0.026), whereas APD patients showed a significantly higher early mortality compared to controls (5.3% vs. 3.5%, p = 0.011). Standard operating procedures should be developed to avoid lethal under-triage. Further studies should focus on detailed information about complications, secondary surgical procedures and preventable risk factors in relation to mortality.

Background Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany. Methods The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included. Results The matching yielded two comparable cohorts ( n  = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group ( p  = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused ( p  = 0.022), but needed significantly less packed red blood cells ( p  ≤ 0.001) and fresh frozen plasma ( p  = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p  = 0.015). Mortality was similar except for early mortality after 6 h ( p  = 0.004) and 12 h ( p  = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p  = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p  = 0.080). Conclusion This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.

The current common and dogmatic opinion is that whole-body computed tomography (WBCT) should not be performed in major trauma patients in shock. We aimed to assess whether WBCT during trauma-room treatment has any effect on the mortality of severely injured patients in shock. In a retrospective multicenter cohort study involving 16719 adult blunt major trauma patients we compared the survival of patients who were in moderate, severe or no shock (systolic blood pressure 90-110,<90 or >110 mmHg) at hospital admission and who received WBCT during resuscitation to those who did not. Using data derived from the 2002-2009 version of TraumaRegister®, we determined the observed and predicted mortality and calculated the standardized mortality ratio (SMR) as well as logistic regressions. 9233 (55.2%) of the 16719 patients received WBCT. The mean injury severity score was 28.8±12.1. The overall mortality rate was 17.4% (SMR  = 0.85, 95%CI 0.81-0.89) for patients with WBCT and 21.4% (SMR = 0.98, 95%CI 0.94-1.02) for those without WBCT (p<0.001). 4280 (25.6%) patients were in moderate shock and 1821 (10.9%) in severe shock. The mortality rate for patients in moderate shock with WBCT was 18.1% (SMR 0.85, CI95% 0.78-0.93) compared to 22.6% (SMR 1.03, CI95% 0.94-1.12) to those without WBCT (p<0.001, p = 0.002 for the SMRs). The mortality rate for patients in severe shock with WBCT was 42.1% (SMR 0.99, CI95% 0.92-1.06) compared to 54.9% (SMR 1.10, CI95% 1.02-1.16) to those without WBCT (p<0.001, p = 0.049 for the SMRs). Adjusted logistic regression analyses showed that WBCT is an independent predictor for survival that significantly increases the chance of survival in patients in moderate shock (OR = 0.73; 95%CI 0.60-0.90, p = 0.002) as well as in severe shock (OR = 0.67; 95%CI 0.52-0.88, p = 0.004). The number needed to scan related to survival was 35 for all patients, 26 for those in moderate shock and 20 for those in severe shock. WBCT during trauma resuscitation significantly increased the survival in haemodynamically stable as well as in haemodynamically unstable major trauma patients. Thus, the application of WBCT in haemodynamically unstable severely injured patients seems to be safe, feasible and justified if performed quickly within a well-structured environment and by a well-organized trauma team.

To describe the incidence, therapy and outcome of traumatic tracheobronchial injuries (TTBI) in trauma patients with multiple injuries derived from the DGU TraumaRegister. We analyzed the data on all patients listed on the TraumaRegister DGU (TR-DGU) in Germany between 2002 and 2015 aged 16 years or older and with an Injury Severity Score (ISS) of ≥ 9. We analyzed the data on 136,389 trauma patients, 561 of whom had suffered tracheobronchial injuries (0.4%). The majority were male (73.4%) and had a mean age of 43.7 years. In total, 84.0% of all TTBI injuries occurred secondary to blunt trauma, caused mainly by accidents (71.2%). TTBI was accompanied by several concomitant thoracic injuries such as pneumo- (41.2%) and hemothorax (23.2%), lacerations (7.8%) and contusions (32.3%) of the lung, as well as multiple rib fractures (29.6%). The severity of injury was classified via the abbreviated injury scale (AIS): 39.3% with AIS = 3, 51.3% with AIS = 4 and 60% with AIS = 5 patients underwent surgical interventions. The mortality of patients with tracheobronchial injuries was higher: 24.6%, versus 13.7% in all patients (control group). This high percentage reflects their generally severe injury burden through concomitant injuries. The incidence of TTBI in this large cohort of trauma patients is very low. However, its high mortality rate emphasizes its importance. Mortality was associated with higher ISS and AIS scores. Higher rates of concomitant injuries were therefore associated with a higher mortality rate. TTBI injuries revealed a higher rate of progression to surgical management, with 35% undergoing surgery within the first 24 h. This excessive mortality rate demonstrates a high overall injury burden in patients with TTBI and high mortality of associated injuries. A surgical intervention’s impact on mortality cannot be assessed in this study, as it would need to be investigated in a case-matched study.

Injuries diagnosed after the emergency department period are a significant challenge to trauma care, since these delayed diagnosed injuries (DDI) may require specific additional treatment. The aim of this study was to obtain an overview of DDI in children and adolescents and to meticulously analyze the underlying reasons leading to initially missing injuries by evaluating data from the TraumaRegister DGU. TraumaRegister DGU data from the years 2010 to 2021 were evaluated. All patients up to the age of 20 were included. Patients older than 20 years of age and patients who died in the trauma room were excluded. All injuries diagnosed after the trauma room period were included in the statistics and defined as DDI, since we focus on the initial care phase and stress that injuries can be overlooked initially, but should be discovered during in hospital treatment. A total of 12,733 patients were included in this study, of whom 68.5% were male. In 1,246 patients (9.8%), at least one diagnosis was a DDI. Patients with DDI had an average age of 15.1 ± 5.3 years and had a longer stay in the intensive care unit with 9.4 ± 11.6 days than those without an initially missed injury (no-DDI) with 5.6 ± 9.1 days. The DDI-group’s mean ISS was 24.0 ± 14.5 and thus substantially higher than the mean ISS in the no-DDI group (17.5 ± 12.2). Independent risk factors for DDI were number of diagnoses per patient (OR 1.19; CI 1.16–1.22, p  < 0.001), hospital level 2/3 (OR 1.89; CI 1.61–2.22, p  < 0.001), relevant (AIS ≥ 2) injuries to the abdomen (OR 1.23; CI 1.06–1.42, p  = 0.006) or lower extremities (OR 1.25; CI 1.08–1.43, p  = 0.002). The present study demonstrates that injuries in pediatric and adolescent trauma patients are frequently missed initially during the context of trauma room treatment and diagnostics. These DDIs have an impact on the length of hospital and intensive care unit stay. We identified risk factors for DDI, i.e. higher numbers of trauma diagnoses, a higher injury severity score and treatment in level-2 or -3 trauma centers.