Early leukocytosis in trauma patients: what difference does it make?

Can the use of whole-body CT be reduced in cases of kinetic-based polytrauma patients without a clinical severity criterion? A bi-center retrospective study

OBJECTIVE

To identify clinical and biological criteria predictive of significant traumatic injury in only kinetic-based polytrauma patients without clinical severity criteria. To propose a decisional algorithm to assist the emergency doctor in deciding whether or not to perform a WBCT in the above population.

METHODS

Retrospective bi-center study. 1270 patients with high velocity trauma without clinical severity criteria, for whom a WBCT was performed in 2017, were included. Patients with hemodynamic, respiratory or neurological severity criterion or those requiring pre-hospital resuscitation measures were excluded. Our primary endpoint was the identification of a significant lesion, i.e. any lesion that led to hospitalization > 24 h for monitoring or medico-surgical treatment. Data collected were age, sex, mechanism of injury, Glasgow Coma Scale score, number of symptomatic body regions, blood alcohol level, and neutrophil count.

RESULTS

Multivariate analysis found independent predictors of significant injury: fall > 5 m (OR: 14.36; CI: 2.3-283.4; p = 0.017), Glasgow score = 13 or 14 (OR: 4.40; CI:1.30-18.52; p = 0.027), presence of 2 symptomatic body regions (OR: 10.21; CI: 4.66-23.72; p = 0.05), positive blood alcohol level (OR: 2.81; CI: 1.13-7.33; p = 0.029) and neutrophilic leukocytosis (OR: 8.76; CI: 3.94-21.27; p = 0.01). A composite clinico-biological endpoint predictive of the absence of significant lesion was identified using a Classification and Regression Tree: number of symptomatic regions < 2, absence of Neutrophilic leukocytosis and negative blood alcohol concentration.

CONCLUSION

A simple triage algorithm was created with the objective of identifying, in high velocity trauma without clinical severity criteria, those without significant traumatic injury.

The Posttraumatic Increase in the Adhesion of GPCR EMR2/ADGRE2 to Circulating Neutrophils Is Not Related to Injury Severity

Trauma triggers a rapid innate immune response to aid the clearance of damaged/necrotic cells and their released damage-associated molecular pattern (DAMP). Here, we monitored the expression of EMR2/ADGRE2, involved in the functional regulation of innate immune cells, on circulating neutrophils in very severely and moderately/severely injured patients up to 240 h after trauma. Notably, neutrophilic EMR2 showed a uniform, injury severity- and type of injury-independent posttraumatic course in all patients. The percentage of EMR2+ neutrophils and their EMR2 level increased and peaked 48 h after trauma. Afterwards, they declined and normalized in some, but not all, patients. Circulating EMR2+ compared to EMR2- neutrophils express less CD62L and more CD11c, a sign of activation. Neutrophilic EMR2 regulation was verified in vitro. Remarkably, it increased, depending on extracellular calcium, in controls as well. Cytokines, enhanced in patients immediately after trauma, and sera of patients did not further affect this neutrophilic EMR2 increase, whereas apoptosis induction disrupted it. Likely the damaged/necrotic cells/DAMPs, unavoidable during neutrophil culture, stimulate the neutrophilic EMR2 increase. In summary, the rapidly increased absolute number of neutrophils, especially present in very severely injured patients, together with upregulated neutrophilic EMR2, may expand our in vivo capacity to react to and finally clear damaged/necrotic cells/DAMPs after trauma.

Dissecting contributions of individual systemic inflammatory response syndrome criteria from a prospective algorithm to the prediction and diagnosis of sepsis in a polytrauma cohort

Background

Sepsis is the leading cause of death in intensive care units (ICUs), and its timely detection and treatment improve clinical outcome and survival. Systemic inflammatory response syndrome (SIRS) refers to the concurrent fulfillment of at least two out of the following four clinical criteria: tachycardia, tachypnea, abnormal body temperature, and abnormal leukocyte count. While SIRS was controversially abandoned from the current sepsis definition, a dynamic SIRS representation still has potential for sepsis prediction and diagnosis.

Objective

We retrospectively elucidate the individual contributions of the SIRS criteria in a polytrauma cohort from the post-surgical ICU of University Medical Center Mannheim (Germany).

Methods

We used a dynamic and prospective SIRS algorithm tailored to the ICU setting by accounting for catecholamine therapy and mechanical ventilation. Two clinically relevant tasks are considered: (i) sepsis prediction using the first 24 h after admission to our ICU, and (ii) sepsis diagnosis using the last 24 h before sepsis onset and a time point of comparable ICU treatment duration for controls, respectively. We determine the importance of individual SIRS criteria by systematically varying criteria weights when summarizing the SIRS algorithm output with SIRS descriptors and assessing the classification performance of the resulting logistic regression models using a specifically developed ranking score.

Results

Our models perform better for the diagnosis than the prediction task (maximum AUROC 0.816 vs. 0.693). Risk models containing only the SIRS level average mostly show reasonable performance across criteria weights, with prediction and diagnosis AUROCs ranging from 0.455 (weight on leukocyte criterion only) to 0.693 and 0.619 to 0.800, respectively. For sepsis prediction, temperature and tachypnea are the most important SIRS criteria, whereas the leukocytes criterion is least important and potentially even counterproductive. For sepsis diagnosis, all SIRS criteria are relevant, with the temperature criterion being most influential.

Conclusion

SIRS is relevant for sepsis prediction and diagnosis in polytrauma, and no criterion should a priori be omitted. Hence, the original expert-defined SIRS criteria are valid, capturing important sepsis risk determinants. Our prospective SIRS algorithm provides dynamic determination of SIRS criteria and descriptors, allowing their integration in sepsis risk models also in other settings.

Increased Enzymatic Activity of Acetylcholinesterase Indicates the Severity of the Sterile Inflammation and Predicts Patient Outcome following Traumatic Injury

Traumatic injury induces sterile inflammation, an immune response often associated with severe organ dysfunction. The cholinergic system acts as an anti-inflammatory in injured patients. Acetylcholinesterase (AChE), an enzyme responsible for the hydrolysis of acetylcholine, plays an essential role in controlling cholinergic activity. We hypothesized that a change in the AChE activity might indicate the severity of the traumatic injury. This study included 82 injured patients with an Injury Severity Score (ISS) of 4 or above and 40 individuals without injuries. Bedside-measured AChE was obtained on hospital arrival, followed by a second measurement 4-12 h later. C-reactive protein (CRP), white blood cell count (WBCC), and Sequential Organ Failure Assessment (SOFA) score were simultaneously collected. Injured patients showed an early and sustained increase in AChE activity. CRP remained unaffected at hospital admission and increased subsequently. Initially elevated WBCC recovered 4-12 h later. AChE activity directly correlated with the ISS and SOFA scores and predicted the length of ICU stay when measured at hospital admission. An early and sustained increase in AChE activity correlated with the injury severity and could predict the length of ICU stay in injured patients, rendering this assay a complementary diagnostic and prognostic tool at the hand of the attending clinician in the emergency unit.

Longitudinal assessment of the inflammatory response: The next step in personalized medicine after severe trauma

Infections in trauma patients are an increasing and substantial cause of morbidity, contributing to a mortality rate of 5-8% after trauma. With increased early survival rates, up to 30-50% of multitrauma patients develop an infectious complication. Trauma leads to a complex inflammatory cascade, in which neutrophils play a key role. Understanding the functions and characteristics of these cells is important for the understanding of their involvement in the development of infectious complications. Recently, analysis of neutrophil phenotype and function as complex biomarkers, has become accessible for point-of-care decision making after trauma. There is an intriguing relation between the neutrophil functional phenotype on admission, and the clinical course (e.g., infectious complications) of trauma patients. Potential neutrophil based cellular diagnostics include subsets based on neutrophil receptor expression, responsiveness of neutrophils to formyl-peptides and FcγRI (CD64) expression representing the infectious state of a patient. It is now possible to recognize patients at risk for infectious complications when presented at the trauma bay. These patients display increased numbers of neutrophil subsets, decreased responsiveness to fMLF and/or increased CD64 expression. The next step is to measure these biomarkers over time in trauma patients at risk for infectious complications, to guide decision making regarding timing and extent of surgery and administration of (preventive) antibiotics.

Moderate to severe leukocytosis with vasopressor use is associated with increased mortality in trauma patients

Background

Leukocytosis is a rise in white blood cell (WBC) count and clinical outcomes of moderate to severe leukocytosis in trauma patients have not been described. We hypothesized that trauma patients with severe leukocytosis (SL; ≥40.0 × 109 leukocytes/L) have higher rates of in-hospital complications and mortality than those with moderate leukocytosis (ML; 25.0-39 × 109 leukocytes/L).

Methods

We performed a retrospective analysis (2010-2017) on trauma patients developing ML or SL at a single Level-I trauma center. A multivariable logistic regression analysis for risk factors were performed.

Results

From 15,807 trauma admissions, 332 (2.1%) had ML or SL. Of these, 308 (92.8%) were ML and 24 (7.2%) were SL. Patients with ML and SL reached their peak WBC count in 1 and 10 days after admission respectively (p < 0.001). SL patients suffered higher rates of in-hospital complications (p < 0.05) and mortality compared to those without ML or SL (14.5% vs. 3.3%, p < 0.001). Between ML and SL, mortality rates rose with leukocytosis severity (13.3% vs. 29.2%, p = 0.03). Among all patients with ML or SL, vasopressor use was the strongest independent risk factor for mortality (OR 12.61, p < 0.001).

Conclusion

Clinicians should be weary of the increased mortality rates and in-hospital complications in SL patients. Among patients with ML or SL, vasopressor use, rather than SL, was the strongest predictor of mortality. Patients with ML had a quicker time course to peak leukocytosis compared to SL, suggesting these two entities to be distinct in etiology and outcome, warranting future research.

Initial leucocytosis and other significant indicators of poor outcome in severe traumatic brain injury: an observational study

Background

Globally, severe traumatic brain injury (TBI) has been the principal cause of mortality among individuals aged 45 and below. The incidence of road traffic accidents in Malaysia is one of the highest in the world with thousands of victims sustaining severe disabilities. The aim of this study is to determine the association between leucocytosis and extended Glasgow Outcome Scale (GOSE) scores as well the relationship of other factors and the outcomes of severe TBI.

Methods

This was a retrospective observational study. A total of 44 consecutive patients who were admitted to Sarawak General Hospital from January 1, 2018, to September 30, 2018, with severe TBI were included. Data were collected from discharge summaries and hospital medical records. Chi-square and t test were used. SPSS was employed.

Results

Of a total of 44 patients with severe TBI, 18 patients (41%) died during the same admission. The mean age of patients was 37.1 years with 93.2% of affected patients being male. 56.9% of patients presented with a Glasgow Coma Scale (GCS) of 6 and less. A large percentage (86.3%) were discharged with a GOSE of less than 7. Older age and low admission GCS (6 and less) were significantly associated with poor GOSE scores on discharge and after 6 months (p < 0.05) on multivariate analysis. Leucocytosis on admission was also associated with poor outcomes where patients with higher total white counts on presentation attaining lower GOSE scores (p < 0.05).

Conclusion

We concluded that leucocytosis was significantly associated with poor outcomes in severe TBI patients in addition to other factors such as advanced age and poor GCS on arrival.

Incidence and risks for surgical site infection after closed tibial plateau fractures in adults treated by open reduction and internal fixation: a prospective study

Background

Surgical site infection (SSI) was the most common complication of tibial plateau fracture after open reduction and internal fixation (ORIF). Severe infections even required repeat surgeries, which would cause serious psychological harm to patients and increased the economic burden of treatment. In order to identify the characteristics of the SSI and to avoid the occurrence of SSI, we conducted a prospective study to investigate the incidence and independent risk factors of SSI after ORIF for closed tibial plateau fractures in adults.

Methods

This study was performed at a first-level trauma center. From October 2014 to December 2018, the study subjects were adult patients with closed fractures of the tibial plateau, all of whom underwent open reduction and internal fixation (ORIF) treatment. Finally, a total of 1108 patients were followed up. We collected patient demographics information, surgery-related variables, and indexes from preoperative laboratory examinations. Univariate and multivariate logistic analysis models were used to investigate the potential risk factors.

Results

Twenty-five patients (2.3%, 25/1108) developed SSI. A total of 15 of 25 infections (60.0%) were due to Staphylococcus aureus and 3 (12.0%) were due to MRSA. Independent risk factors of SSI identified by multivariate logistic analysis model were bone grafting: autograft (OR 6.38; 95% CI 2.155–18.886; p = 0.001) and allograft (OR 3.215; 95% CI 1.009–10.247; p = 0.048), fracture type (Schartzker V–VI) (OR 8.129; 95% CI 2.961–22.319; p < 0.001), aspartate aminotransferase (>40 U/L) (OR 5.500; 95% CI 2.191–13.807; p < 0.001), white blood cell (>10*10⁹/L) (OR 2.498; 95% CI 1.025–6.092; p = 0.044), and anion gap (>16 mmol/L) (OR 8.194; 95% CI 1.101–60.980).

Conclusions

We should pay enough attention to patients who carried one or more of these factors at admission and adopt more reasonable treatment strategies to reduce or avoid the occurrence of SSI.

Racial Disparities in Adult Blunt Trauma Patients With Acute Respiratory Distress Syndrome

OBJECTIVE

Study incidence and mortality for blunt trauma patients developing acute respiratory distress syndrome (ARDS) across race and insurance.

DESIGN

The National Trauma Data Bank (2007-2015) was queried for blunt trauma patients age >16. Covariates (age >65, injury severity score [ISS] >25, traumatic brain injury, lung injury, pneumonia, severe sepsis, hypotension on admission, and blood transfusion) were included in a multivariable logistic regression analysis.

SETTING

Despite progress in the treatment for ARDS, it remains a significant concern. Racial differences in response to trauma and ARDS have been inconsistently demonstrated. Since these prior studies, ARDS has been redefined by the Berlin Criteria, advances in care have been made, and health-care accessibility has changed.

PATIENTS

Adult blunt trauma patients with ISS > 15 and length of stay ≥ 3 days to examine patients at high risk of ARDS.

MEASUREMENTS AND MAIN RESULTS

There were 28 727 patients with ARDS. Most were white (76.2%), followed by blacks (11.5%), Hispanics (11.3%), and Asians (1.8%). Overall mortality was 20.5%. Compared to whites, blacks (odds ratio [OR]: 1.15, confidence interval [CI]: 1.10-1.20, P < .001) had higher risk of ARDS, being Hispanic was protective (OR: 0.80, CI: 0.76-0.83, P < .001). Asians with ARDS were at greater risk of death (OR: 1.31, CI: 1.07-1.61, P < .05) while being black was not associated with risk of death. Patients with private insurance had less diagnosed ARDS and those with ARDS had lower mortality than other insurances (OR: 0.86, CI: 0.79-0.92, P < .001).

CONCLUSIONS

Data from the National Trauma Data Bank (2007-2015) demonstrates racial and insurance disparities in the development of ARDS in blunt trauma patients. When compared to whites, blacks are at higher risk of developing ARDS while being Hispanic is protective. Likewise, Asians are at greatest risk of death and blacks have no difference in mortality when compared to whites. Patients with private insurance have lower risk of incidence and mortality.

Delta neutrophil index for predicting mortality in trauma patients who underwent emergent abdominal surgery: A case controlled study

Background

Delta neutrophil index (DNI) can be used as a biomarker for infection to predict patient outcomes. We aimed to investigate the relationship between DNI and clinical outcomes in trauma patients who underwent abdominal surgery.

Materials and methods

We retrospectively analyzed injured patients who underwent emergent abdominal surgery in the regional trauma center of Wonju Severance Christian Hospital between March 2016 and May 2018. Patient characteristics, operation type, preoperative and postoperative laboratory findings, and clinical outcomes were evaluated. Logistic regression analysis was performed for risk factors associated with mortality.

Results

Overall, 169 patients (mean age, 53.8 years; 66.3% male) were enrolled in this study, of which 19 (11.2%) died. The median injury severity score (ISS) was 12. The non-survivors had a significantly higher ISS [25(9–50) vs. 10(1–50), p<0.001] and serum lactate level (9.00±4.10 vs. 3.04±2.23, p<0.001) and more frequent shock (63.2% vs 23.3%, p<0.001) and solid organ injury (52.6% vs. 25.3%, p = 0.013) than the survivors. There were significant differences in postoperative DNI between the two groups (p<0.009 immediate post-operation, p = 0.001 on postoperative day 1 [POD1], and p = 0.013 on POD2). Logistic regression analysis showed that the independent factors associated with mortality were postoperative lactate level (odds ratio [OR] 1.926, 95% confidence interval [CI] 1.101–3.089, p = 0.007), postoperative sequential organ failure assessment score (OR 1.593, 95% CI 1.160–2.187, p = 0.004), and DNI on POD1 (OR 1.118, 95% CI 1.028–1.215, p = 0.009). The receiver operating characteristics curve demonstrated that the area under the curve of DNI on POD1 was 0.887 (cut-off level: 7.1%, sensitivity 85.7%, and specificity 84.4%).

Conclusions

Postoperative DNI may be a useful biomarker to predict mortality in trauma patients who underwent emergent abdominal surgery.

Diagnostic and predictive value of white blood cell count, erythrocyte sedimentation rate, and coagulation tests in patients with blunt head trauma

Introduction: Head trauma is the third leading cause of death and one of the most common causes of referral to the emergency department. Prognosis in these patients identifies individuals at higher risk and provides them with faster and more complete treatment, so it is of particular importance. The aim of this study is to evaluate the diagnostic and predictive value of white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and coagulation tests in the outcome of patients with blunt head trauma. Methods: In this retrospective study, 91 patients referred to the emergency department of Imam Reza hospital of Tabriz, with a complaint of DAI type of blunt head trauma, were enrolled in a complete and sequential study during the first six months of the year 2017. The patientswere divided into two groups according to good or poor prognosis and their association with leukocytosis status and other paraclinical factors at the baseline. Results: The final outcome in high consciousness group was 13.3% need for intubation,26.7% need for surgery, 50% improvement without complications, and 10% mortality. In the low consciousness group, 16.7% required intubation, 20.0% required surgery, 10% had no complications, and 53.3% experienced mortality. The significance level of the chi-squaretest was 0.001. Independent t test results showed that the WBC and ESR values in the lowconsciousness group were significantly higher than the high consciousness group. But the international normalized ratio (INR) in the high consciousness group was significantly higher than the low consciousness group (P<0.05). Conclusion: There is a significant relationship between severity of injury and leukocytosis, ESRelevation, and related coagulopathy after major trauma.

Changes in admission laboratory tests in patients with maxillofacial fractures and the influence of dento-alveolar trauma

BACKGROUND/AIM

There are few studies in the literature evaluating possible alterations in laboratory tests in patients with maxillofacial fractures. The aim of this study was to analyze the changes in admission laboratory tests of patients with maxillofacial fractures with indications for surgical treatment, including the influence of dento-alveolar trauma.

MATERIAL AND METHODS

Data from complete blood counts, blood coagulation tests, blood chemistries, and urinalysis results were obtained. The occurrence of concomitant dento-alveolar trauma was noted. The medical records were also re-evaluated later to verify the treatment outcome and the occurrence of complications. Statistical analyses were performed using the likelihood-ratio test to verify significant changes in the evaluated parameters (P ≤ .050).

RESULTS

There was a prevalence of males (78%) with a mean age of 35.9 years. Lower erythrocyte counts, hemoglobin levels, and/or hematocrit were observed in males with associated fractures and with simultaneous dento-alveolar fractures. Higher mean neutrophil, segmented neutrophil, and lymphocyte counts were observed in patients with simultaneous dento-alveolar trauma. A higher mean activated partial thromboplastin time (aPTT) ratio was also observed. Lower potassium levels were observed for patients in the fourth decade of life. Higher leukocyte counts not associated with trauma were observed in the urinalysis results of females and in the group of patients aged 20 or younger. Verification of treatment outcome showed two cases of infections and two cases that needed re-operation after mandible fractures. These four cases showed no significant changes in laboratory tests regarding the predisposition for complications.

CONCLUSION

Patients with maxillofacial fractures had neutrophilia, increased aPTT, and non-traumatic leukocyturia. There was an influence of associated fractures and dento-alveolar trauma on the decrease in red blood cell parameters, neutrophilia, and lymphocytosis and of age on hypokalemia.

Are Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Associated with Mortality in Pediatric Trauma Patients? A Retrospective Study

BACKGROUND

There are very limited data on the prognostic capacity of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) for the systemic inflammatory response in pediatric trauma (PT) patients. The purpose of this study was to evaluate the prognostic ability of NLR and PLR on mortality in pediatric trauma patients.

METHODS

This study looked at 358 PT patients who were admitted to the Cumhuriyet University Hospital's Emergency Department between January 2010 and June 2018. The NLR and PLR were calculated by dividing the blood neutrophil count and blood platelet count, respectively, by the lymphocyte count, at the time of admission. After performing a stepwise logistic regression analysis to determine the predictive factors on the mortality risk of post-traumatic systemic inflammatory response syndrome (SIRS), receiver operating characteristic (ROC) curve analysis was used to define the optimum cut-off values of the NLR and the PLR parameters for survival.

RESULTS

The NLR, and PLR values were significantly higher in survivors than in non-survivors (NLR, 6.2±5.7 versus 2.6±2.5, P<0.001; PLR, 145.3±85.0 versus 46.2±25.2, P<0.001 ). The NLR (odds ratio [OR], 3.21; P=0.048), PLR (OR, 0.90; P=0.032), blood glucose (OR, 1.02; P=0.024), and Injury Severity Score (ISS) (OR, 1.28; P=0.011) were independent predictors of the mortality risk in PT patients. The area under the curve in the ROC curve analysis was 0.764 with a cut-off of 2.77 (sensitivity 70%, specificity 77%) for the NLR; and 0.928 with a cut-off of 61.83 (sensitivity 90%, specificity 85%) for the PLR.

CONCLUSION

Acquiring the NLR and PLR at the time of admission could be a useful predictor for mortality in PT patients.

Postoperative leukocyte changes in facial fracture patients: a randomized prospective study with short-term dexamethasone

PURPOSE

We investigated leukocyte changes in facial fracture patients undergoing surgery. Of specific interest was the effect of perioperative dexamethasone on leukocyte changes.

METHODS

Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone, whereas patients in the control group received no glucocorticoid. All patients received antibiotics until postoperative days 7-10. Leukocyte count was measured on postoperative days 1 and 2. Clinical infections were observed during the follow-up.

RESULTS

A total of 110 adult patients were included in the study. Postoperative leukocytosis was found in 91.2% of patients receiving dexamethasone and in 67.9% of controls. Dexamethasone was associated strongly with leukocyte rise (p < 0.001) on both postoperative days. Transoral surgery and younger age (≤40 years) showed significant associations with leukocytosis on the first postoperative day (p = 0.002). In regression analyses, dexamethasone associated with leukocytosis most significantly (p < 0.001). No association was found with infections.

CONCLUSIONS

Dexamethasone use was the most significant predictor of leukocyte rise. As a drug response, perioperative dexamethasone caused sixfold postoperative leukocytosis. High-dose dexamethasone-induced leukocytosis may confuse the clinical decision-making especially in assessment of early infections.

Admission Leukocytosis in Intracerebral Hemorrhage: Associated Factors and Prognostic Implications

BACKGROUND AND PURPOSE

Leukocytosis is a reaction that is usually, but not always, associated with an infectious process. There is very little data on the significance of admission leukocytosis (AL) in patients with intracerebral hemorrhage (ICH). The purpose of this study was to investigate the associated clinical and radiologic findings and prognostic significance of AL in patients with ICH.

METHODS

We retrospectively reviewed the records of consecutive ICH patients admitted over a 2-year period. Key data we collected included ICH size, location, intraventricular hemorrhage (IVH), age, admission Glasgow Coma Scale (GCS0) score, peak leukocyte count and temperature in the first 24 h of hospitalization, and outcomes on discharge. Severity of IVH was calculated using the Graeb Scale. Logistic regression was performed to determine association of variables.

RESULTS

In 128 consecutive ICH patients, AL was present in 41.4 %. AL was significantly associated with presence (OR 2.28, 95 % CI 1.11-4.68; p = 0.024), but not severity of IVH and with admission GCS0. Leukocyte count showed a strong association with IVH (p = 0.01) and with decreasing GCS0 (p = 0.007). There was no correlation between AL and poor outcome at discharge. There was also no evidence of infection in any patient with AL.

CONCLUSION

AL in ICH patients is often non-infectious, strongly associated with the presence of IVH, but not specifically an ominous indicator for outcome. Leukocyte count has an inverse relationship with GCS0. Prospective studies are needed to confirm these findings.

Serial white blood cell counts in trauma: do they predict a hollow viscus injury?

BACKGROUND

The significance of serial white blood cell (WBC) counts in trauma patients with a suspected hollow viscus injury (HVI) is unknown. The purpose of this study was to examine the role of serial WBC counts in the diagnosis of a HVI.

METHODS

After institutional review board approval, all injured patients admitted to a Level I trauma center from January 2003 to December 2007 with at least one WBC measurement were included in a retrospective analysis. The WBC profiles for patients with a HVI were compared against those without HVI. All WBC counts are reported as [x10(3)/microL].

RESULTS

The mean WBC count of the overall study population (n = 5,950) on admission was 11.6 +/- 5.3. Overall, 59.2% had an elevated WBC count on admission. A significant relationship between increasing Injury Severity Score and increasing WBC count on admission was found by linear regression. When comparing patients with HVI (n = 267) with patients without HVI (n = 5,683), no significant difference was found for admission WBC count. The highest WBC count within the first 24 hours for patients with HVI was 16.7 +/- 4.7. This was significantly higher than that for the 4,520 patients without any intraabdominal injury (13.0 +/- 5.2, adjusted p < 0.001). Penetrating injury, a concomitant severe thoracic trauma (chest Abbreviated Injury Scale value >or=3), and highest WBC count >or=20.0 in the first 24 hours were independent risk factors for HVI. A maximal WBC count <or=12.5 in the first 24 hours was independently associated with a lower incidence of HVI. The area under the receiver operating characteristic curve for the highest WBC count in the first 24 hours for predicting HVI was 0.723 (95% CI: 0.656-0.790).

CONCLUSION

Multiple variables likely impact the WBC count in trauma patients. WBC count elevation on admission is nonspecific and does not predict the presence of a HVI. With serial measurements, WBC counts >or=20.0 are independently associated with a HVI, whereas counts <or=12.5 rule against the presence of HVI. However, the sensitivity of these cutoff values to predict a HVI is poor. The diagnostic value of serial WBC counts for predicting a HVI within the first 24 hours after trauma is very limited.

Racial disparities in emergency surgical care

Socioeconomic factors and differences in access to health care systems, perhaps more so than physiologic differences, play a significant role in race-based differences faced by acute care practitioners.