Multiple significant trauma with craniotomy: What impacts mortality?

Investigation of the Effects of Large Bone Flap Craniotomy on Cerebral Hemodynamics, Intracranial Infection Rate, and Nerve Function in Patients with Severe Craniocerebral Trauma

In order to explore the clinical value of large bone flap craniotomy, the effects of standard large bone flap craniotomy on cerebral hemodynamic indexes, incidence of postoperative intracranial infection, and neurological function in patients with severe craniocerebral trauma are investigated. 89 patients with severe craniocerebral trauma admitted from January 2020 to June 2021 are analyzed retrospectively. All patients are divided into a large craniotomy group (n = 45) and control group (n = 44) according to different surgical methods. The large craniotomy group is treated with large craniotomy decompression, and the control group is treated with traditional craniotomy decompression. The incidence of intracranial infection in each group is recorded, and NIHSS is applied to observe the neurological function recovery of 2 groups before and 1 month after operation. Besides, the patients are followed up after surgery and the Kaplan-Meier survival curve is obtained to compare the survival rate of patients in the two groups. It is clearly evident that the two surgical methods have certain clinical efficacy in the treatment of patients with severe craniocerebral trauma. Comparatively, the large craniotomy can further improve brain blood supply and improve neurological function recovery. Also, it can obtain low incidence of postoperative adverse reactions and intracranial infection.

Vasopressors in Trauma: A Never Event?

Vasopressor use in severely injured trauma patients is discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients. Hypotensive resuscitation is advocated based on limited data that lower systolic blood pressure and mean arterial pressure will result in improved mortality. It is classically taught that hypotension and hypovolemia in trauma are associated with peripheral vasoconstriction. However, the pathophysiology of traumatic shock is complex and involves multiple neurohormonal interactions that are ultimately manifested by an initial sympathoexcitatory phase that attempts to compensate for acute blood loss and is characterized by vasoconstriction, tachycardia, and preserved mean arterial blood pressure. The subsequent hypotension observed in hemorrhagic shock reflects a sympathoinhibitory vasodilation phase. The objectives of hemodynamic resuscitation in hypotensive trauma patients are restoring adequate intravascular volume with a balanced ratio of blood products, correcting pathologic coagulopathy, and maintaining organ perfusion. Persistent hypotension and hypoperfusion are associated with worse coagulopathy and organ function. The practice of hypotensive resuscitation would appear counterintuitive to the goals of traumatic shock resuscitation and is not supported by consistent clinical data. In addition, excessive volume resuscitation is associated with adverse clinical outcomes. Therefore, in the resuscitation of traumatic shock, it is necessary to target an appropriate balance with intravascular volume and vascular tone. It would appear logical that vasopressors may be useful in traumatic shock resuscitation to counteract vasodilation in hemorrhage as well as other clinical conditions such as traumatic brain injury, spinal cord injury, multiple organ dysfunction syndrome, and vasodilation of general anesthetics. The purpose of this article is to discuss the controversy of vasopressors in hypotensive trauma patients and advocate for a nuanced approach to vasopressor administration in the resuscitation of traumatic shock.

Advantage of surgical intensive care unit (SICU) predominant by cardiothoracic surgeons in multiple trauma management in a primary hospital

PURPOSE

It is a challenge for the primary hospitals to manage multiple trauma patients. In this article, we explored the advantage of establishing a surgical intensive care unit (SICU) predominant by cardiothoracic surgeons in the early management of multiple trauma.

METHODS

This was a retrospective study and patients with multiple trauma in our hospital were collected and divided into two groups, based on time period and treat modes: group A (retrospective observation group) where patients were treated with the traditional treatment mode from January 2017 to December 2017 and group B (study group) where patients were treated in the SICU predominant by cardiothoracic surgeons from January 2018 to December 2018. Clinical data including demographics, injury severity score (ISS), causes of injury, time intervals from reception to entering SICU or operating room and mortality three days after injuries were collected. Data were analyzed by SPSS 20.0 software. Categorical variables were presented as number and/or frequency and continuous variables as mean ± SD.

RESULTS

Altogether 406 patients were included in this study, including 217 patients in group A and 189 patients in group B. General data between the two groups revealed no significant difference: mean age (years) (35.51 ± 12.97 vs. 33.62 ± 13.61, p = 0.631), gender distribution (mean/female, 130/87 vs. 116/73, p = 0.589) and ISS (15.92 ± 7.95 vs. 16.16 ± 6.89, p = 0.698). Fall from height were the dominant mechanism of injury, with 135 cases in group A (71.4%) and 121 cases in group B (55.8%), followed by traffic accidents. Injury mechanism showed no significant differences between two groups (p = 1.256). Introduction of the SICU significantly improved the care of trauma patients, regarding speed and mortality. Time intervals between reception and entering SICU or operating room was (108.23 ± 6.72) min and (45.67 ± 7.96) min in group A and B, respectively (p = 0.001). Mortality three days after injuries was 13.89% and 5.53% in group A and B, respectively (p = 0.005).

CONCLUSION

Establishing a SICU predominant by cardiothoracic surgeons can reduce the early mortality rates in multiple trauma patients.