Current trends in resuscitation strategy for the multiply injured patient

The pathophysiology of pelvic ring injuries: a review

Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®

Background

Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay.

Methods

Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AIS_Thorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AIS_Spine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AIS_spine): AIS_LS = 3, AIS_LS = 4–5, AIS_TS = 3 and AIS_TS = 4–5, respectively.

Results

1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AIS_TS = 3) or lumbar spine (AIS_LS = 3) significantly benefit from early surgical intervention concerning ventilation time (AIS_LS = 3 only), ARDS, multiple organ failure, sepsis rate (AIS_TS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AIS_TS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital.

Conclusions

Multiply injured patients with at least serious thoracic trauma (AIS_Thorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study

Background

Although resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in trauma management, its effect in patients with severe multiple torso trauma remains unclear.

Methods

We performed a retrospective study to evaluate trauma management with REBOA in hemodynamically unstable patients with severe multiple trauma. Of 5899 severe trauma patients admitted to our hospital between January 2011 and January 2018, we selected 107 patients with severe torso trauma (Injury Severity Score > 16) who displayed persistent hypotension [≥ 2 systolic blood pressure (SBP) values ≤ 90 mmHg] regardless of primary resuscitation. Patients were divided into two groups: trauma management with REBOA (n = 15) and without REBOA (n = 92). The primary endpoint was the effectiveness of trauma management with REBOA with respect to in-hospital mortality. Secondary endpoints included time from arrival to the start of hemostasis. Multivariable logistic regression analysis, adjusted for clinically important variables, was performed to evaluate clinical outcomes.

Results

Trauma management with REBOA was significantly associated with decreased mortality (adjusted odds ratio of survival, 7.430; 95% confidence interval, 1.081–51.062; p = 0.041). The median time (interquartile range) from admission to initiation of hemostasis was not significantly different between the two groups [with REBOA 53.0 (40.0–80.3) min vs. without REBOA 57.0 (35.0–100.0) min ]. The time from arrival to the start of balloon occlusion was 55.7 ± 34.2 min. SBP before insertion of REBOA was 48.2 ± 10.5 mmHg. Total balloon occlusion time was 32.5 ± 18.2 min.

Conclusions

The use of REBOA without a delay in initiating resuscitative hemostasis may improve the outcomes in patients with multiple severe torso trauma. However, optimal use may be essential for success.

Blood transfusion management in the severely bleeding military patient

PURPOSE OF REVIEW

Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding.

RECENT FINDINGS

Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation.

SUMMARY

Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.

A systematic review of massive transfusion protocol in obstetrics

Post-partum obstetric haemorrhage is a leading cause of mortality among Japanese women, generally treated with haemostatic measures followed by supplementary transfusion. Commonly used in the setting of severe trauma, massive transfusion protocols (MTPs), preparations of red blood cell concentrate (RBC) and fresh frozen plasma (FFP) with additional supplements, have proved effective in decreasing patient mortality following major obstetric bleeding events. Although promising, the optimal configuration of RBC and FFP utilized for obstetric bleeding needs to be verified. Here, we conducted a systematic literature review to define the optimal ratio of RBC to FFP for transfusion therapy during instances of obstetric bleeding. Our analysis extracted four retrospective, observational studies, all demonstrating that an FFP/RBC ratio of ≥1 was associated with improved patient outcomes following obstetric haemorrhage. We therefore conclude that, from the standpoint of haemostatic resuscitation, an FFP/RBC ratio of ≥1 is a necessary condition for optimal clinical management during MTP administration in the field of obstetrics. Hence, we further propose an optimized MTP strategy to be utilized in the setting of severe obstetric bleeding.

Impact of emergency physicians competent in severe trauma management, surgical techniques, and interventional radiology on trauma management

Aim

Despite recent advancements in trauma management following introduction of interventional radiology (IVR) and damage-control strategies, challenges remain regarding optimal use of resources for severe trauma.

Methods

In October 2014, we implemented a trauma management system comprising emergency physicians competent in severe trauma management, surgical techniques, and IVR. To evaluate this system, of 5,899 trauma patients admitted to our hospital from January 2011 to January 2018, we selected 107 patients with severe trauma (injury severity score ≥ 16) who presented with persistent hypotension (two or more systolic blood pressure measurements <90 mmHg), regardless of primary resuscitation. Patients were divided according to the date of admission: Conventional (January 2011-September 2014) or Current (October 2014-January 2018). The primary end-point was in-hospital mortality. Secondary end-points included time from arrival to start of surgery/IVR.

Results

There were 59 patients in the Conventional group and 48 in the Current group. Although patients in the Current group were more severely ill compared with those in the Conventional group, mortality in the Current group was significantly lower (Conventional 64.4% versus Current 41.7%, P = 0.019), especially among patients whose first intervention was IVR (Conventional 75.0% versus Current 28.6%, P = 0.001). Time from arrival to initiation of surgery/IVR was shorter in the Current group (Conventional 71.5 [53.8-130.8] min versus Current 41.0 [26.0-58.5] min, P < 0.0001).

Conclusions

This trauma management system based on emergency physicians competent not only in severe trauma management, but also surgical techniques and IVR, could improve outcomes in patients with severe multiple lethal trauma.

Early Definitive Fracture Fixation is Safely Performed in the Presence of an Open Abdomen in Multiply Injured Patients

OBJECTIVE

To investigate the safety and feasibility of performing definitive fracture fixation in multiply injured patients in the presence of an open abdomen after laparotomy.

DESIGN

Retrospective observational cohort study.

SETTING

Level-I academic trauma center.

PATIENTS

Adult polytrauma patients with the presence of an open abdomen after "damage control" laparotomy and associated major fractures of long bones, acetabulum, pelvis, or spine, requiring surgical repair (n = 81).

INTERVENTION

Timing of definitive fracture fixation in relation to the timing of abdominal wall closure.

MAIN OUTCOME MEASURE

Incidence of orthopedic surgical site infections.

RESULTS

During a 15-year time window from January 1, 2000 until December 31, 2014, we identified a cohort of 294 consecutive polytrauma patients with an open abdomen after laparotomy. Surgical fixation of associated fractures was performed after the index laparotomy in 81 patients. In group 1 (n = 32), fracture fixation occurred significantly sooner despite a concurrent open abdomen, compared with group 2 (n = 49) with abdominal wall closure before fixation (mean 4.4 vs. 11.8 days; P = 0.01). The incidence of orthopaedic surgical site infections requiring a surgical revision was significantly lower in group 1 (3.1%) compared to group 2 (30.6%; P = 0.002).

CONCLUSIONS

Definitive fracture fixation in the presence of an open abdomen is performed safely and associated with a significant decrease in clinically relevant surgical site infections, compared with delaying fracture fixation until abdominal wall closure. These data suggest that the strategy of imposing a time delay in orthopaedic procedures while awaiting abdominal wall closure is unjustified.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessment and Resuscitation in Trauma Management

The golden hour of trauma represents a crucial period in the management of acute injury. In an efficient trauma resuscitation, the primary survey is viewed as more than simple ABCs with multiple processes running in parallel. Resuscitation efforts should be goal oriented with defined endpoints for airway management, access, and hemodynamic parameters. In tandem with resuscitation, early identification of life-threatening injuries is critical for determining the disposition of patients when they leave the trauma bay. Salvage strategies for profoundly hypotensive or pulseless patients include retrograde balloon occlusion of the aorta and resuscitative thoracotomy, with differing populations benefiting from each.

Fluid Management in Patients with Trauma: Restrictive Versus Liberal Approach

Massive hemorrhage remains a major cause of traumatic deaths. The ideal fluid resuscitative strategy is much debated. Research has provided inconsistent results regarding which fluid strategy is ideal; the optimum fluid type, timing, and volume remains elusive. Aggressive large-volume resuscitation has been the mainstay based on controlled hemorrhage animal models. For uncontrolled hemorrhagic shock, liberal fluid resuscitative strategies exacerbate the lethal triad, invoke resuscitative injury, and increase mortality while more restrictive fluid strategies tend to ameliorate trauma-induced coagulopathy and favor a greater chance of survival. This article discusses the current evidence regarding liberal and restrictive fluid strategies for trauma.

History of pelvic fracture management: a review

High-energy pelvic fractures represent potentially life-threatening injuries due to the risk of acute exsanguinating retroperitoneal hemorrhage. The first report of a severe pelvic ring disruption dates back to Charles Hewitt Moore’s seminal publication from 1851. Significant advantages in the understanding of injury mechanisms and treatment concepts of pelvic ring injuries evolved in the 20^th century, and provided the basis to current classification-guided treatment and life-saving “damage control” concepts. However, there is a paucity of reports in the current literature focused on the historic background on the treatment of pelvic ring injuries. The present review was designed to summarize the history and evolution of our current understanding of the mechanisms and management strategies for severe pelvic ring injuries (excluding acetabular fractures which represent a different entity outside of the scope of this article).

The Immediate Intramedullary Nailing Surgery Increased the Mitochondrial DNA Release That Aggravated Systemic Inflammatory Response and Lung Injury Induced by Elderly Hip Fracture

Conventional concept suggests that immediate surgery is the optimal choice for elderly hip fracture patients; however, few studies focus on the adverse effect of immediate surgery. This study aims to examine the adverse effect of immediate surgery, as well as to explore the meaning of mtDNA release after trauma. In the experiment, elderly rats, respectively, received hip fracture operations or hip fracture plus intramedullary nail surgery. After fracture operations, the serum mtDNA levels as well as the related indicators of systemic inflammatory response and lung injury significantly increased in the rats. After immediate surgery, the above variables were further increased. The serum mtDNA levels were significantly related with the serum cytokine (TNF-α and IL-10) levels and pulmonary histological score. In order to identify the meaning of mtDNA release following hip fracture, the elderly rats received injections with mtDNA. After treatment, the related indicators of systemic inflammatory response and lung injury significantly increased in the rats. These results demonstrated that the immediate surgery increased the mtDNA release that could aggravate systemic inflammatory response and lung injury induced by elderly hip fracture; serum mtDNA might serve as a potential biomarker of systemic inflammatory response and lung injury following elderly hip fracture.

Severe mutilating injuries with complex macroamputations of the upper extremity - is it worth the effort?

Introduction

An amputation of the upper extremity and the following replantation is still one of the most challenging operations in the field of reconstructive surgery, especially in extremely severe cases of combined mutilating macroamputations including avulsion and multilevel injuries. Specialists agree that macroamputations with sharp wound edges are an absolute indication for replantation. However, there is no agreement in disastrous cases including avulsion and multilevel injuries. The outcome of the operation is depending on several factors, including the type of accident, age and pre-existing disease of the patient, as well as time of ischemia and appropriate physical therapy.

Methods

Between January 1^st 2003 and December 31^st 2011 six patients underwent a macroreplantation with disastrous combined and complex injuries of the upper extremity in our department. We performed a follow up and evaluated the functional outcome of the upper extremity function using the DASH questionnaire (average follow up of 3.1 years).

Results

The mean time of ischemia was 04:50 h (02:46 h–06:17 h). The mean time for the operation was 05:30 h (01:55 h–08:20 h). The mean operations needed per patient were 7 (2–16). The average hospital stay was 29d (16–59d). According to the DASH-Score from five out of six patients the functional outcome of the replanted extremity has a mean score of 71 points. The versatility of the replanted extremity in the field of work had 95, and sport, music was assessed with a mean score of 96 points.

Conclusions

Severe and disastrous combined and complex macroamputations of the upper extremity may also have an absolute indication for replantation even though the functional outcome is poor. Not only the feeling of physical integrity can be restored, but the replantation of an amputated upper extremity enables complete or partial recovery of function and sensibility of the arm which is important for the individual. Although our results show a very high DASH-Score, those achievements justify time and person consuming operations. In most cases a replanted extremity is still superior to a secondary allotransplantation. Usually the use of prosthesis is not favored by the treated patients.

Trauma care inside and outside business hours: comparison of process quality and outcome indicators in a German level-1 trauma center

Background

Optimal care of multiple trauma patients has to be at a high level around the clock. Trauma care algorithms and guidelines are available, yet it remains unclear if the time of admission to the trauma room affects the quality of care and outcomes. Hence the present study intends to compare the quality of trauma room care of multiple severely injured patients at a level-1 trauma center depending on the time of admission.

Methods

A total of 394 multiple trauma patients with an ISS ≥ 16 were included into this study (observation period: 52 months). Patients were grouped by the time and date of their admission to the trauma room [business hours (BH): weekdays from 8:00 a.m. to 4:00 p.m. vs. non-business hours (NBH): outside BH]. The study analysed differences in patient demographics, trauma room treatment and outcome.

Results

The study sample was comparable in all basic characteristics [mean ISS: 32.3 ± 14.3 (BH) vs. 32.6 ± 14.4 (NBH), p = 0.853; mean age: 40.8 ± 21.0 (BH) vs. 37.7 ± 20.2 years (NBH), p = 0.278]. Similar values were found for the time needed for single interventions, like arterial access [4.8 ± 3.9 min (BH) vs. 4.9 ± 3.4 min (NBH), p = 0.496] and quality-assessment parameters, like time until CT [28.5 ± 18.7 min (BH), vs. 27.3 ± 9.5) min (NBH), p = 0.637]. There was no difference for the 24 h mortality and overall hospital mortality in BH and NBH, with 13.5% vs. 9.1% (p = 0.206) and, 21.9% vs. 15.4% (p = 0.144), respectively. The Glasgow Outcome Scale (GOS) comparison revealed no difference [3.7 ± 1.6 (BH) vs. 3.9 ± 1.5 (NBH), p = 0.305]. In general, the observed demographic, injury severity, care quality and outcome parameters revealed no significant difference between the two time periods BH and NBH.

Conclusions

The study hospital provides multiple trauma patient care at comparable quality irrespective of time of admission to the trauma room. These results might be attributable to the standardization of the treatment process using established principles, algorithms and guidelines as well as to the resources available in a level-1 trauma center.

A novel trauma model: naturally occurring canine trauma

In human trauma patients, most deaths result from hemorrhage and brain injury, whereas late deaths, although rare, are the result of multiple organ failure and sepsis. A variety of experimental animal models have been developed to investigate the pathophysiology of traumatic injury and evaluate novel interventions. Similar to other experimental models, these trauma models cannot recapitulate conditions of naturally occurring trauma, and therefore therapeutic interventions based on these models are often ineffective. Pet dogs with naturally occurring traumatic injury represent a promising translational model for human trauma that could be used to assess novel therapies. The purpose of this article was to review the naturally occurring canine trauma literature to highlight the similarities between canine and human trauma. The American College of Veterinary Emergency and Critical Care Veterinary Committee on Trauma has initiated the establishment of a national network of veterinary trauma centers to enhance uniform delivery of care to canine trauma patients. In addition, the Spontaneous Trauma in Animals Team, a multidisciplinary, multicenter group of researchers has created a clinical research infrastructure for carrying out large-scale clinical trials in canine trauma patients. Moving forward, these national resources can be utilized to facilitate multicenter prospective studies of canine trauma to evaluate therapies and interventions that have shown promise in experimental animal models, thus closing the critical gap in the translation of knowledge from experimental models to humans and increasing the likelihood of success in phases 1 and 2 human clinical trials.

Resuscitation with amiodarone increases survival after hemorrhage and ventricular fibrillation in pigs

Supplemental digital content is available in the text.

BACKGROUND

The aim of this experimental study was to compare survival and hemodynamic effects of a low-dose amiodarone and vasopressin compared with vasopressin in hypovolemic cardiac arrest model in piglets.

METHODS

Eighteen anesthetized male piglets (with a weight of 25.3 [1.8] kg) were bled approximately 30% of the total blood volume via the femoral artery to a mean arterial blood pressure of 35 mm Hg in a 15-minute period. Afterward, the piglets were subjected to 4 minutes of untreated ventricular fibrillation followed by 11 minutes of open-chest cardiopulmonary resuscitation. At 5 minutes, circulatory arrest amiodarone 1 mg/kg was intravenously administered in the amiodarone group (n = 9), while the control group received the same amount of saline (n = 9). At the same time, all piglets received vasopressin 0.4 U/kg intravenously administered and hypertonic-hyperoncotic solution 3-mL/kg infusion for 20 minutes. Internal defibrillation was attempted from 7 minutes of cardiac arrest to achieve restoration of spontaneous circulation. The experiment was terminated 3 hours after resuscitation.

RESULTS

Three-hour survival was greater in the amiodarone group (p = 0.02). After the successful resuscitation, the amiodarone group piglets had significantly lower heart rate as well as greater systolic, diastolic, and mean arterial pressure. Troponin I plasma concentrations were lower and urine output was greater in the amiodarone group.

CONCLUSION

Combined resuscitation with amiodarone and vasopressin after hemorrhagic circulatory arrest resulted in greater 3-hour survival, better preserved hemodynamic parameters, and smaller myocardial injury compared with resuscitation with vasopressin only.

Perioperative coagulopathy monitoring

Coagulopathy is common in orthopedic surgery patients either due to acquired factors, such as surgery, trauma, medications, or hemorrhage. Perioperative monitoring of blood coagulation is critical to diagnose the causes of hemorrhage, guide hemostatic therapies, predict the risk of bleeding during surgical procedures, and reduce risk of postoperative cardiac and thromboembolic events. In contrast to previous interventions that measure specific portions of the clotting cascade (such as intrinsic or extrinsic pathways or platelet aggregation), "Point-of-care" coagulation monitoring devices assess the viscoelastic properties of whole blood. These techniques have the potential to measure the entire clotting process, starting with fibrin formation, clot retraction, and fibrinolysis. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Improved monitoring of coagulopathy is particularly important as new anticoagulant drugs emerge that affect the clotting cascade in novel ways, including the inhibition of intrinsic and extrinsic pathways and platelet function. It is important for orthopedic surgeons to understand the pharmacology and reversal of these drugs in the perioperative setting. The purpose of this review is to review the current techniques to monitoring perioperative coagulopathy and to identify the manner in which novel anticoagulant medications affect the clotting cascade with particular interest in trauma and spine surgery.

Prevention of tissue hypoperfusion in the trauma patient: initial management

This article outlines the challenges of identification and management of tissue hypoperfusion as a consequence of haemorrhagic shock in civilian polytrauma cases. It also describes damage resuscitation, but does not cover specific trauma cases such as pregnancy, burns, head injuries, children and elderly trauma.

Traumatic coagulopathy--part 2: Resuscitative strategies

OBJECTIVE

To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC).

ETIOLOGY

Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models.

DIAGNOSIS

Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements.

SUMMARY

Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.

Critical care paramedics: where is the evidence? A systematic review

OBJECTIVES

Paramedic-delivered prehospital critical care is an established concept in a number of emergency medical services around the world and, more recently, has been introduced to the UK. This review identifies and describes the available evidence relating to paramedics who routinely provide prehospital critical care as primary scene response (critical care paramedics, or CCP).

METHODS

A systematic search of electronic databases was performed: CENTRAL, EMBASE, MEDLINE (through EMBASE and Web of Knowledge) and Web of Science (through Web of Knowledge).

RESULTS

The search identified 12 relevant publications, one of which was a randomised controlled trial. The remaining 11 were retrospective studies. Five studies compared CCPs with physician-led care. Three of these publications demonstrated improved outcomes with physician care, while two showed no difference. Four further publications examined CCPs versus non-physician-led care and found improved outcomes (two studies), mixed effects (one study) and no difference (one study) for CCPs. Finally, three publications addressed the addition of skills to CCP competencies. A randomised controlled trial of CCP rapid sequence induction (RSI) and tracheal intubation demonstrated improved neurologic outcomes. CCP tube thoracostomy was shown to have similar complication rates to the same procedure performed in the emergency department, while addition of a non-invasive ventilation protocol to CCP practice had no effect on long-term mortality.

CONCLUSIONS

There is limited evidence to support the concept of paramedic-delivered prehospital critical care. The best available evidence suggests a benefit from prehospital RSI carried out by CCPs in patients with severe traumatic brain injury, but the impact of CCPs remains unclear for many conditions. Further high-quality research in this area would be welcome.

The definition of polytrauma: variable interrater versus intrarater agreement--a prospective international study among trauma surgeons

BACKGROUND

The international trauma community has recognized the lack of a validated consensus definition of "polytrauma." We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed.

METHODS

A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either "yes" or "no" for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either "yes" or "no" for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions.

RESULTS

A total of 52 trauma patients were included. Results for each stage were as follows: (1) κ score of 0.50, moderate agreement; (2) κ score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (κ score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (κ scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (κ score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (κ scores, 0.27 and 0.39, respectively).

CONCLUSION

Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions.

Management strategies for acute spinal cord injury: current options and future perspectives

PURPOSE OF REVIEW

Spinal cord injury is a devastating acute neurological condition with loss of function and poor long-term prognosis. This review summarizes current management strategies and innovative concepts on the horizon.

RECENT FINDINGS

The routine use of steroids in patients with spinal cord injuries has been largely abandoned and considered a 'harmful standard of care'. Prospective trials have shown that early spine stabilization within 24  h results in decreased secondary complication rates. Neuronal plasticity and axonal regeneration in the adult spinal cord are limited due to myelin-associated inhibitory molecules, such as Nogo-A. The experimental inhibition of Nogo-A ameliorates axonal sprouting and functional recovery in animal models.

SUMMARY

General management strategies for acute spinal cord injury consist of protection of airway, breathing, oxygenation and control of blood loss with maintenance of blood pressure. Unstable spine fractures should be stabilized early to allow unrestricted mobilization of patients with spinal cord injuries and to decrease preventable complications. Steroids are largely considered obsolete and have been abandoned in clinical guidelines. Nogo-A represents a promising new pharmacological target to promote sprouting of injured axons and restore function. Prospective clinical trials of Nogo-A inhibition in patients with spinal cord injuries are currently under way.

High-energy proximal femur fractures in geriatric patients: a retrospective analysis of short-term complications and in-hospital mortality in 32 consecutive patients

BACKGROUND

There is limited information in the literature on the outcomes and complications in elderly patients who sustain high-energy hip fractures. As the population ages, the incidence of high-energy geriatric hip fractures is expected to increase. The purpose of this study was to analyze the outcomes and complications in patients aged 65 years or older, who sustained a high-energy proximal femur fracture.

METHODS

Retrospective review of a prospective trauma database from January 2000 to April 2011 at a single US academic level-1 trauma center. Inclusion criteria consisted of all patients of age 65 years or older, who sustained a proximal femur fracture related to a high-energy trauma mechanism. Details concerning injury, acute treatment, and clinical course and outcome were obtained from medical records and radiographs.

RESULTS

We identified 509 proximal femur fractures in patients older than 65 years of age, of which 32 (6.3%) were related to a high-energy trauma mechanism. The mean age in the study group was 72.2 years (range 65-87), with a mean injury severity score of 20 points (range 9-57). Three patients died before discharge (9.4%), and 22 of 32 patients sustained at least one complication (68.8%). Blunt chest trauma represented the most frequently associated injury, and the main root cause of pulmonary complications. The patients' age and comorbidities did not significantly correlate with the rate of complications and the 1-year mortality.

CONCLUSIONS

High-energy proximal femur fractures in elderly patients are not very common and are associated with a low in-hospital mortality rate of less than 10%, despite high rate of complications of nearly 70%. This selective cohort of patients requires a particular attention to respiratory management due to the high incidence of associated chest trauma.

The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study

BACKGROUND

In contrast to the established principles of "damage-control orthopedics" for temporary external fixation of long bone or pelvic fractures, the "ideal" timing and modality of fixation of unstable spine fractures in severely injured patients remains controversial.

METHODS

A prospective cohort study was designed to evaluate the safety and efficacy of a standardized "spine damage-control" (SDC) protocol for the acute management of unstable thoracic and lumbar spine fractures in severely injured patients. A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and Injury Severity Score (ISS) of greater than 15 were prospectively enrolled in this study from October 1, 2008, to December 31, 2011. Acute posterior spinal fixation within 24 hours was performed in 42 patients (SDC group), and 70 patients underwent definitive operative spine fixation in a delayed fashion ("delayed surgery"[DS] group). Both cohorts were prospectively analyzed for baseline demographics, length of operative time, amount of intraoperative blood loss, total hospital length of stay, number of ventilator-dependent days, and incidence of early postoperative complications.

RESULTS

The mean time to initial spine fixation was significantly decreased in the SDC group (8.9 [1.7] hours vs. 98.7 [22.4] hours, p < 0.01). The SDC cohort had a reduced mean length of operative time (2.4 [0.7] hours vs. 3.9 [1.3] hours), length of hospital stay (14.1 [2.9] days vs. 32.6 [7.8] days), and number of ventilator-dependent days (2.2 [1.5] days vs. 9.1 [2.4] days), compared with the DS group (p < 0.05). Furthermore, the complication rate was decreased in the SDC group with regard to wound complications (2.4% vs. 7.1%), urinary tract infections (4.8% vs. 21.4%), pulmonary complications (14.3% vs. 25.7%), and pressure sores (2.4% vs. 8.6%), compared with the DS cohort (p < 0.05).

CONCLUSION

A standardized SDC protocol represents a safe and efficient treatment strategy for severely injured patients with associated unstable thoracic or lumbar fractures.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Trauma care services in the United Kingdom: past, present and future

Current provision of trauma services in the United Kingdom is insufficient, resulting in a high mortality of trauma patients. Multiple studies proved that regionalisation of the trauma care can significantly reduce mortality and morbidity by avoiding unnecessary transfer and reducing delay in delivering definitive surgery. This evidence led to changes in delivering trauma care in London which showed a significant reduction in mortality from severe injuries.

New strategies for massive transfusion in the bleeding trauma patient

Trauma continues to be the leading cause of death among those younger than 40 years. A major cause of death within the first 24 hours is hemorrhage. Many of these patients present with severe coagulopathy and require massive transfusion. Earlier control of coagulopathy has been shown to improve survival. To address coagulopathy sooner, changes in the way we identify and resuscitate the exsanguinating trauma patient have evolved. These changes include early identification of at-risk patients and early, aggressive transfusion of plasma and platelets. This article reviews the key massive transfusion triggers and resuscitation strategy of damage control resuscitation.

Critical care considerations in the management of the trauma patient following initial resuscitation

Background

Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented.

Methods

A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012.

Results and conclusion

Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.

Low-Volume Resuscitation for Severe Intraoperative Hemorrhage: A Step in the Right Direction

The impact on outcomes resulting from crystalloids used with hemostatic close ratio resuscitation (HCRR) in intraoperative hemorrhage (IOH) has not been analyzed. We hypothesize a survival advantage in patients with IOH managed with a low-volume resuscitation (LVR) protocol during HCRR. A 4-year case-control study was conducted to determine the impact on mortality of LVR versus conventional resuscitation efforts (CRE) during HCRR. A total of 45 patients managed with a HCRR + LVR protocol (combination Hextend® and 3% hypertonic saline) and 55 historical cohorts managed with HCRR + CRE (lactated Ringer's) were included. Patient demographics, number of intraoperative units of packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) received, and FFP:PRBC ratio were similar between groups. The mean intraoperative fluid volume was 0.76 L in the HCRR + LVR group versus 4.7 L in the HCRR + CRE group ( P = 0.003). In a linear regression model HCRR + LVR versus HCRR + CRE, mean trauma intensive care unit length of stay was ± versus 11 days ( P = 0.009); 30-day overall mortality was 11.1 versus 32.7 per cent ( P = 0.009); perioperative mortality was 2.2 to 10.9 per cent ( P = 0.13); and intensive care unit mortality 8.8 to 21.8 per cent ( P = 0.07). LVR protocol conveyed a survival benefit to patients undergoing HCRR (odds ratio for mortality, 0.07 [95% confidence interval 0.07–0.54]). This is the first civilian study to analyze the impact of LVR in patients managed with HCRR during IOH. Patients with IOH managed with HCRR and a predefined LVR protocol with Hextend® and 3 per cent hypertonic saline had an overall survival advantage and shorter trauma intensive care unit length of stay. LVR can be an effective alternative to CRE when used in combination with HCRR in patients with IOH.

Thoracic hyperextension injury with complete "bony disruption" of the thoracic cage: Case report of a potentially life-threatening injury

Background

Severe chest wall injuries are potentially life-threatening injuries which require a standardized multidisciplinary management strategy for prevention of posttraumatic complications and adverse outcome.

Case presentation

We report the successful management of a 55-year old man who sustained a complete “bony disruption” of the thoracic cage secondary to an “all-terrain vehicle” roll-over accident. The injury pattern consisted of a bilateral “flail chest” with serial segmental rib fractures, bilateral hemo-pneumothoraces and pulmonary contusions, bilateral midshaft clavicle fractures, a displaced transverse sternum fracture with significant diastasis, and an unstable T9 hyperextension injury. After initial life-saving procedures, the chest wall injuries were sequentially stabilized by surgical fixation of bilateral clavicle fractures, locked plating of the displaced sternal fracture, and a two-level anterior spine fixation of the T9 hyperextension injury. The patient had an excellent radiological and physiological outcome at 6 months post injury.

Conclusion

Severe chest wall trauma with a complete “bony disruption” of the thoracic cage represents a rare, but detrimental injury pattern. Multidisciplinary management with a staged timing for addressing each of the critical injuries, represents the ideal approach for an excellent long-term outcome.

Polytrauma – new horizons for management

The management of polytrauma has evolved considerably in the last century. Advances have been made in all disciplines involved in trauma care from pre-hospital care and resuscitation protocols to diagnostics, surgical techniques, administration of novel pharmacological agents and late reconstruction procedures. Improved understanding of the altered physiology and the induced response at the molecular level offers the potential for novel management strategies and prevention of post-traumatic complications.

The dangers of damage control orthopedics: a case report of vascular injury after femoral fracture external fixation

BACKGROUND

Placement of external fixation frames is an expedient and minimally invasive method of achieving bone and joint stability in the setting of severe trauma. Although anatomic safe zones are established for placement of external fixation pins, neurovascular structures may be at risk in the setting of severe trauma.

CASE REPORT

We present a case of a 21-year-old female involved in a high speed motorcycle accident who sustained a Type IIIB open segmental femur fracture with significant thigh soft tissue injury. Damage control orthopedic principals were applied and a spanning external fixator placed for provisional femoral stabilization. Intraoperative vascular examination noted absent distal pulses, however an intraoperative angiogram showed arterial flow distal to the trifurcation. Immediately postoperatively the dorsalis pedis pulse was detected using Doppler ultrasound but was then non-detectable over the preceding 12-hours. Femoral artery CT angiogram revealed iatrogenic superficial femoral artery occlusion due to kinking of the artery around an external fixator pin. Although the pin causing occlusion was placed under direct visualization, the degree of soft tissue injury altered the appearance of the local anatomy. The pin was subsequently revised allowing the artery to travel in its anatomic position, restoring perfusion.

CONCLUSION

This case highlights the dangers associated with damage control orthopedics, especially when severe trauma alters normal local anatomy. Careful assessment of external fixator pin placement is crucial to avoiding iatrogenic injury. We recommend a thorough vascular examination pre-operatively and prior to leaving the operating room, which allows any abnormalities to be further evaluated while the patient remains in a controlled environment. When an unrecognized iatrogenic injury occurs, serial postoperative neurovascular examinations allow early recognition and corrective actions.

Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality

The purpose of this study was to examine the acute outcomes and mortality rates of an Advanced Trauma Life Support guideline approach for managing hemodynamically unstable pelvic ring injuries. We retrospectively reviewed the acute outcomes of 48 consecutive patients with hemodynamically unstable pelvic fractures. Patients underwent treatment via the advanced trauma life support protocol, with primary angiography based on trauma surgeon preference. Mean patient age was 51.2 years, with a mean injury severity score of 43.2±14.3. Mean systolic blood pressure was 74.8±16.1 mm Hg at presentation. Patients received an average of 7.0±6.6 units of red blood cells and 4.2±2.3 units of fresh frozen plasma in the first 6 hours. Fourteen patients underwent emergent angiography, and 12 patients were treated with embolization. Mean time to angiography was 3 hours and 55 minutes (range, 2-19 hours). Twenty patients died during hospitalization, with an overall mortality rate of 41.7%; 13 (27.1%) of them died within 24 hours. Advanced Trauma Life Support guidelines with angiography are not adequate for the management of hemodynamically unstable pelvic ring injuries and result in unacceptably high mortality rates compared with more specific approaches using transfusion protocols and interventions, such as pelvic packing.

The role of toll-like receptor-4 in the development of multi-organ failure following traumatic haemorrhagic shock and resuscitation

Haemorrhagic shock and resuscitation (HS/R) following major trauma results in a global ischaemia and reperfusion injury that may lead to multiple organ dysfunction syndrome (MODS). Systemic activation of the immune system is fundamental to the development of MODS in this context, and shares many features in common with the systemic inflammatory response syndrome (SIRS) that complicates sepsis. An important advancement in the understanding of the innate response to infection involved the identification of mammalian toll-like receptors (TLRs) expressed on cells of the immune system. Ten TLR homologues have been identified in humans and toll-like receptor-4 (TLR4) has been studied most intensively. Initially found to recognise bacterial lipopolysaccharide (LPS), it has also recently been discovered that TLR4 is capable of activation by endogenous 'danger signal' molecules released following cellular injury; this has since implicated TLR4 in several non-infectious pathophysiologic processes, including HS/R. The exact events leading to multi-organ dysfunction following HS/R have not yet been clearly defined, although TLR4 is believed to play a central role as has been shown to be expressed at sites including the liver, lungs and myocardium following HS/R. Multi-organ dysfunction syndrome remains an important cause of morbidity and mortality in trauma patients, and current therapy is based on supportive care. Understanding the pathophysiology of HS/R will allow for the development of targeted therapeutic strategies aimed at minimising organ dysfunction and improving patient outcomes following traumatic haemorrhage. A review of the pathogenesis of haemorrhagic shock is presented, and the complex, yet critical role of TLR4 as both a key mediator and therapeutic target is discussed.

Influence of preoperative 7.5% hypertonic saline on neutrophil activation after reamed intramedullary nailing of femur shaft fractures: a prospective randomized pilot study

OBJECTIVES

Femoral reaming and intramedullary nailing (IMN) primes polymorphonuclear leukocytes (PMNL) and thereby increases the posttraumatic systemic inflammatory response. Resuscitation with hypertonic saline (HTS) attenuates PMNL activation after trauma-hemorrhage. We hypothesized that preoperative administration of 7.5% HTS attenuates PMNL priming after IMN of unilateral femur shaft fractures compared with 0.9% normal saline.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Level I trauma center.

PATIENTS

Twenty patients between 18 and 80 years of age with an Injury Severity Score less than 25 and a unilateral femur shaft fracture amenable to IMN fixation within 24 hours after injury.

INTERVENTION

Patients were allocated to equally sized HTS or normal saline treatment groups (n = 10) before surgery. Solutions were administered in a blinded bag as a single bolus of 4 mL/kg body weight immediately before surgery. Whole blood samples were collected directly before saline application (t0) and at 6, 12, and 24 hours after surgery.

MAIN OUTCOME MEASUREMENTS

PMNL surface expression of CD11b and CD62L, as determined by flow cytometry analysis.

RESULTS

Demographic characteristics of both treatment groups were comparable. Baseline expression of CD11b and CD62L cell markers was in a similar range in the two cohorts. The expression levels of CD11b were comparable between the two groups throughout the observation time, whereas CD62L levels were significantly higher in the HTS group at 6 and 24 hours after surgery.

CONCLUSION AND SIGNIFICANCE

Preoperative infusion of HTS appears to exert an anti-inflammatory effect by attenuating the extent of postoperative PMNL activation after reamed IMN for femoral shaft fractures.

Aged plasma transfusion increases mortality in a rat model of uncontrolled hemorrhage

INTRODUCTION

Recent data have associated improved survival after hemorrhagic shock with the early use of plasma-based resuscitation. Our laboratory has shown that FFP5 has decreased hemostatic potential compared with freshly thawed plasma (FFP0). We hypothesized that FFP5 would increase bleeding and mortality compared with FFP0 in a rodent bioassay model of uncontrolled liver hemorrhage.

METHODS

Hemostatic potential of plasma was assessed with the Calibrated Automated Thrombogram (CAT) assay. Rats underwent isovolemic hemodilution by 15% of blood volume with the two human plasma groups (FFP0 and FFP5) and two controls (sham and lactated Ringers). A liver injury was created by excising a portion of liver resulting in uncontrolled hemorrhage. Rats that lived for 30 minutes after liver injury were resuscitated to their baseline blood pressure and followed for 6 hours. Hemostasis was assessed by thromboelastography.

RESULTS

Hemostatic potential of FFP5 decreased significantly in all areas measured in the CAT assay as compared with FFP0 (p < 0.01). In the FFP5 group, overall survival was 54%, compared with 100% in the FFP0 and sham group (p = 0.03). For animals that survived 30 minutes and were resuscitated, there was no difference in bleeding and/or coagulopathy between groups. Irrespective of treatment, animals that died after resuscitation demonstrated increased intraperitoneal fluid volume (14.85 mL ± 1.9 mL vs. 7.02 mL ± 0.3 mL, p < 0.001).

CONCLUSION

In this model of mild preinjury hemodilution with plasma, rats that received FFP5 had decreased survival after uncontrolled hemorrhage from hepatic injury. There were no differences in coagulation function or intraperitoneal fluid volume between the two plasma groups.

Molecular mechanisms of inflammation and tissue injury after major trauma--is complement the "bad guy"?

Trauma represents the leading cause of death among young people in industrialized countries. Recent clinical and experimental studies have brought increasing evidence for activation of the innate immune system in contributing to the pathogenesis of trauma-induced sequelae and adverse outcome. As the "first line of defense", the complement system represents a potent effector arm of innate immunity, and has been implicated in mediating the early posttraumatic inflammatory response. Despite its generic beneficial functions, including pathogen elimination and immediate response to danger signals, complement activation may exert detrimental effects after trauma, in terms of mounting an "innocent bystander" attack on host tissue. Posttraumatic ischemia/reperfusion injuries represent the classic entity of complement-mediated tissue damage, adding to the "antigenic load" by exacerbation of local and systemic inflammation and release of toxic mediators. These pathophysiological sequelae have been shown to sustain the systemic inflammatory response syndrome after major trauma, and can ultimately contribute to remote organ injury and death. Numerous experimental models have been designed in recent years with the aim of mimicking the inflammatory reaction after trauma and to allow the testing of new pharmacological approaches, including the emergent concept of site-targeted complement inhibition. The present review provides an overview on the current understanding of the cellular and molecular mechanisms of complement activation after major trauma, with an emphasis of emerging therapeutic concepts which may provide the rationale for a "bench-to-bedside" approach in the design of future pharmacological strategies.

Survival following a vertical free fall from 300 feet: the crucial role of body position to impact surface

We report the case of a 28-year old rock climber who survived an "unsurvivable" injury consisting of a vertical free fall from 300 feet onto a solid rock surface. The trauma mechanism and injury kinetics are analyzed, with a particular focus on the relevance of body positioning to ground surface at the time of impact. The role of early patient transfer to a level 1 trauma center, and "damage control" management protocols for avoiding delayed morbidity and mortality in this critically injured patient are discussed.