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Udagawa K, Yamamoto R, Shimatani N, Nishida Y, Ono S, Niki Y, Sasaki J. Simple parameters to identify patients treatable with early definitive fixation: A nationwide study. Injury 2024; 55:111117. [PMID: 37872009 DOI: 10.1016/j.injury.2023.111117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Early appropriate care (EAC) is widely accepted as a safe strategy to perform early definitive fracture fixation, and good clinical outcomes have been reported in selected, multiply injured patients, although the optimal candidate for early definitive fixation (EDF) has not been validated. The aim of this study was to identify simple clinical parameters to help select patients who could undergo EDF. METHODS Patients with extremity injuries who underwent open reduction and internal fixation were retrospectively identified, using data from the Japan Trauma Data Bank (JTDB). Age, vital signs on hospital presentation, and the injury severity score (ISS) were examined by transforming these variables to binary categories. Patients were divided into categories based on these variables, and in-hospital mortality was compared between patients treated with EDF (EDF group) and those treated without EDF (non-EDF group) in each category. RESULTS Of the 12,735 patients who were eligible for the analyses, 3706 (29.1 %) were managed with EDF. In-hospital mortality was significantly higher in the EDF group than in the non-EDF group among patients with a low Glasgow Coma Scale (GCS) score (<13), low systolic blood pressure (sBP) (<90 mmHg), and ISS≥15, whereas in-hospital mortality was comparable between the EDF and non-EDF groups among patients with GCS scores ≥13, sBP ≥90 mmHg, and ISS <15. DISCUSSION In this large nationwide database of trauma patients, EDF was performed without affecting mortality in patients with GCS scores ≥13 and sBP ≥90 mmHg on hospital presentation, as well as ISS <15. These parameters might be useful as screening tools to select the candidates who could be treated with EDF safely.
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Affiliation(s)
- Kazuhiko Udagawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan; Department of Orthopedic Surgery, Keio University School of Medicine, Japan.
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Naotaka Shimatani
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yusho Nishida
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Soichiro Ono
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yasuo Niki
- Department of Orthopedic Surgery, Keio University School of Medicine, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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Halvachizadeh S, Pfeifer R, Duncan J, Klingebiel FKL, Kalbas Y, Berk T, Neuhaus V, Pape HC. Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures? J Trauma Acute Care Surg 2024; 96:931-937. [PMID: 38196119 DOI: 10.1097/ta.0000000000004252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). CONCLUSION Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sascha Halvachizadeh
- From the Department of Trauma, University Hospital Zurich, University of Zurich, Zurich, Switzerland; and Department of Trauma and Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Kalbas Y, Heining SM, Kaiser A, Klingebiel FKL, Pfeifer R, Wanner GA, Pape HC. Fracture fixation in polytraumatized patients-From an interdisciplinary early total/appropriate care to the safe definitive surgery concept. Front Med (Lausanne) 2024; 11:1362986. [PMID: 38707191 PMCID: PMC11069308 DOI: 10.3389/fmed.2024.1362986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/18/2024] [Indexed: 05/07/2024] Open
Abstract
The strategies for the timing of fracture fixation in polytrauma patients have changed with improvements in resuscitation and patient assessment. Specifically, the criteria for damage control have been formulated, and more precise parameters have been found to determine those patients who can safely undergo primary definitive fixation of major fractures. Our current recommendations are supported by objective and data-based criteria and development groups. Those were validated and compared to existing scores. This review article introduces the concept of "safe definitive surgery" and provides an update on the parameters used to clear patients for timely fixation of major fractures.
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Affiliation(s)
- Yannik Kalbas
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandro-Michael Heining
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anne Kaiser
- Department of Anesthesia, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Roman Pfeifer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Guido A. Wanner
- Department of Spine and Trauma Surgery, Bethanien Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Yamamoto R, Udagawa K, Yusho Nishida, Soichiro Ono, Junichi Sasaki. Clinical parameters and optimal candidates for early definitive fixation of extremity injury: A nationwide study. J Orthop Sci 2023; 28:255-260. [PMID: 34728113 DOI: 10.1016/j.jos.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/09/2021] [Accepted: 10/12/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND While various strategies of fracture fixation for trauma patients have been discussed, optimal candidates remain unclear for early definitive fixation. The aim of this study was to integrate several clinical parameters into a scoring system and determine a cut-off value for safe early definitive surgery for extremity fractures. METHODS We retrospectively identified patients with fracture in an extremity in Japanese Trauma Data Bank from 2004 to 2019. We included adult patients who underwent open reduction and internal fixation for extremity injury before any other surgical intervention and excluded those who arrived with cardiac arrest. Several clinical parameters, such as age, vital signs, abbreviated injury scale (AIS) in the chest, and injury severity score (ISS), were examined with multivariate logistic regression models to predict in-hospital mortality, and then integrated into a scoring system based on each odds ratio. To determine a cut-off value of the scoring system for safe early definitive surgery, in-hospital mortality and/or postoperative complications were compared between patients who underwent definitive fixation within 24 h of injury and patients who did not in subgroups based on the scores. RESULTS Of 50,631 patients eligible for this study, 16,119 (31.8%) underwent early definitive fixation. A 0-15 scoring system with parameters including age >70 years, GCS <8, systolic blood pressure <90 mmHg, AIS in the chest ≥3, ISS ≥20, and transfusion requirement within 24 h of arrival was developed. At scores ≥10, early definitive fixation was found to be significantly associated with high in-hospital mortality, and at scores <10, in-hospital mortality was comparable between the two groups. CONCLUSIONS We integrated clinical parameters into the scoring system with a scale of 0-15 and determined that a score of 10 is the cut-off score. We determined that patients with a score <10 can safely undergo early definitive fixation.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Kazuhiko Udagawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Yusho Nishida
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Soichiro Ono
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Kalbas Y, Pape HC. What factors determine a "major fracture"? Injury 2022; 53:2701-2703. [PMID: 35870807 DOI: 10.1016/j.injury.2022.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Yannik Kalbas
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Hans-Christoph Pape
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland.
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Tan JH, Wu TY, Tan JYH, Sharon Tan SH, Hong CC, Shen L, Loo LMA, Iau P, Murphy DP, O'Neill GK. Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation. J Orthop Trauma 2021; 35:e234-e240. [PMID: 33252447 DOI: 10.1097/bot.0000000000001999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5. INTERVENTION These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days). MAIN OUTCOME MEASURES Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications. RESULTS Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications. CONCLUSIONS Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jiong Hao Tan
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Tian Yi Wu
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Joel Yong Hao Tan
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Si Heng Sharon Tan
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Choon Chiet Hong
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore ; and
| | - Lynette Mee-Ann Loo
- Division of General Surgery, University Surgical Cluster, National University Health System (NUHS), Singapore
| | - Philip Iau
- Division of General Surgery, University Surgical Cluster, National University Health System (NUHS), Singapore
| | - Diarmuid P Murphy
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
| | - Gavin Kane O'Neill
- Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), Singapore
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Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis? Orthop Traumatol Surg Res 2021; 107:102864. [PMID: 33621700 DOI: 10.1016/j.otsr.2021.102864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/29/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles. MATERIALS AND METHODS This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression. RESULTS Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality. DISCUSSION Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients. CONCLUSION Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management. LEVEL OF EVIDENCE IV; retrospective study.
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Grant M, Mehdian-Staffell R, Webb M, Scott S. Hip fractures in the young polytrauma patient: a review and the latest data from the UK. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:817-823. [PMID: 33748883 DOI: 10.1007/s00590-021-02923-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 12/11/2022]
Abstract
Managing a hip fracture in a young adult patient in the setting of polytrauma is a particularly challenging prospect. In the UK between 2018 and 2020, 11,969 patients were recorded in the Trauma Audit and Research Network as a patient with polytrauma. Of these patients, 611 (5.1%) had a hip fracture. In this article, we discuss the initial assessment and management of these patients and common problems that are encountered and how the evidence available can help guide management.
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Affiliation(s)
- Michael Grant
- Liverpool University Foundation Teaching Hospital, Aintree, Lower Lane, Liverpool, L9 7AL, Merseyside, UK.
| | | | - Mark Webb
- St George's University Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Sharon Scott
- Liverpool University Foundation Teaching Hospital, Aintree, Lower Lane, Liverpool, L9 7AL, Merseyside, UK
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Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates. J Clin Orthop Trauma 2021; 12:101-112. [PMID: 33716435 PMCID: PMC7920327 DOI: 10.1016/j.jcot.2020.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022] Open
Abstract
Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.
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Affiliation(s)
- Ramesh Perumal
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Sivakumar S. P
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Ramesh Kumar Sen
- Institute of Orthopedic Surgery, Max Super Specialty Hospital, Mohali, 160055, India
| | - Vivek Trikha
- Department of Orthopedics, All India Institute of Medical Science, New Delhi, 110029, India
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Giordano V, Giannoudis VP, Giannoudis PV. Current trends in resuscitation for polytrauma patients with traumatic haemorrhagic shock. Injury 2020; 51:1945-1948. [PMID: 32829760 DOI: 10.1016/j.injury.2020.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Vincenzo Giordano
- Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
| | - Vasileios P Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.
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Halvachizadeh S, Baradaran L, Cinelli P, Pfeifer R, Sprengel K, Pape HC. How to detect a polytrauma patient at risk of complications: A validation and database analysis of four published scales. PLoS One 2020; 15:e0228082. [PMID: 31978109 PMCID: PMC6980592 DOI: 10.1371/journal.pone.0228082] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 01/07/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Early accurate assessment of the clinical status of severely injured patients is crucial for guiding the surgical treatment strategy. Several scales are available to differentiate between risk categories. They vary between expert recommendations and scores developed on the basis of patient data (level II). We compared four established scoring systems in regard to their predictive abilities for early (e.g., hemorrhage-induced mortality) versus late (Multiple Organ Failure (MOF), sepsis, late death) in-hospital complications. Methods A database from a level I trauma center was used. The inclusion criteria implied an injury severity score (ISS) of ≥16 points, primary admission, and a complete data set from admission to hospital-day 21. The following four scales were tested: the clinical grading scale (CGS; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mCGS; covers CGS with modifications), the polytrauma grading score (PTGS; covers shock, coagulation, and ISS), and the early appropriate care protocol (EAC; covers acid–base changes). Admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. Statistics Shapiro-Wilk test for normal distribution, Pearson Chi square, odds ratios (OR) for all endpoints, 95% confidence intervals. Fitted, generalized linear models were used for prediction analysis. Krippendorff was used for comparison of CGS and mCGS. Alpha set at 0.05. Results In total, 3668 severely injured patients were included (mean age, 45.8±20 years; mean ISS, 28.2±15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (MOF), 1.9%; mortality rate, 26.8%). Our data show distinct differences in the prediction of complications, including mortality, for these scores (OR ranging from 0.5 to 9.1). The PTGS demonstrated the highest predictive value for any late complication (OR = 2.0), sepsis (OR = 2.6, p = 0.05), or pneumonia (OR = 2.0, p = 0.2). The EAC demonstrated good prediction for hemorrhage-induced early mortality (OR = 7.1, p<0.0001), but did not predict late complications (sepsis, OR = 0.8 and p = 0.52; pneumonia, OR = 1.1 and p = 0.7) CGS and mCGS are not comparable and should not be used interchangeably (Krippendorff α = 0.045). Conclusion Our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid–base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). When acid–base changes alone were tested in terms of complications, they were predictive of complications within 72 hours but failed to predict late complications. These findings should be considered when performing early assessment of trauma patients or for the development of new scores.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
- * E-mail:
| | - Larissa Baradaran
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
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Damage control orthopedics and decreased in-hospital mortality: A nationwide study. Injury 2019; 50:2240-2246. [PMID: 31591006 DOI: 10.1016/j.injury.2019.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/20/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While various strategies of fracture fixation in trauma victims have been discussed, the effect of damage control orthopedics (DCO) on significant clinical outcome is inconclusive. We examined the mortality of patients managed with DCO, comparing those without DCO, using a nationwide trauma database. PATIENTS AND METHODS We retrospectively identified patients with extremity injury, defined as patients with an Abbreviated Injury Scale (AIS) of ≥2 in an upper or lower extremity, in the database that included more than 200 major hospitals from 2004 to 2016. We included those who were age ≥15 years and underwent ORIF. Patients with missing survival data or invalid vital signs at hospital arrival were excluded. Patient data were divided into DCO or non-DCO groups, and propensity scores were developed to estimate the probability of being assigned to the DCO group, using multivariate logistic regression analyses adjusted for known survival predictors, such as age, vital signs at arrival, Abbreviated Injury Scale in extremity, ISS, presence of vascular injury, surgical procedure before fracture treatment, and transfusion requirement. The primary outcome, in-hospital mortality, was compared between the two groups after propensity score matching. Survival analyses were performed, and hazard ratio was adjusted according to age, systolic blood pressure on arrival, and Injury Severity Score. RESULTS Of the 19,319 patients included in this study, 4407 (22.8%) underwent DCO. After the propensity score matching, 3858 pairs were selected. In-hospital mortality was significantly lower among patients in the DCO than those in the non-DCO groups (40 [1.0%] vs. 66 [1.7%]; odds ratio = 0.60; 95% confidence interval [CI] = 0.41-0.89; P = 0.01). Survival analyses showed that DCO was independently associated with decreased mortality in patients with extremity injury (adjusted hazard ratio = 0.30; 95% CI = 0.20-0.46; P < 0.01). CONCLUSIONS DCO was associated with decreased in-hospital mortality in patients with major fractures. Further clinical study on DCO by selecting patient population should be considered eventually to develop an appropriate strategy for major fractures.
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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Determining the patient at risk - are scoring systems helpful to develop individualized concepts for safe definitive fracture fixation and damage control techniques? Injury 2019; 50:1269-1271. [PMID: 31280866 DOI: 10.1016/j.injury.2019.06.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Early Immunologic Response in Multiply Injured Patients With Orthopaedic Injuries Is Associated With Organ Dysfunction. J Orthop Trauma 2019; 33:220-228. [PMID: 31008819 DOI: 10.1097/bot.0000000000001437] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To quantify the acute immunologic biomarker response in multiply injured patients with axial and lower extremity fractures and to explore associations with adverse short-term outcomes including organ dysfunction and nosocomial infection (NI). DESIGN Prospective cohort study. SETTING Level 1 academic trauma center. PATIENTS Consecutive multiply injured patients, 18-55 years of age, with major pelvic and lower extremity orthopaedic injuries (all pelvic/acetabular fractures, operative femur and tibia fractures) that presented as a trauma activation and admitted to the intensive care unit from April 2015 through October 2016. Sixty-one patients met inclusion criteria. INTERVENTION Blood was collected upon presentation to the hospital and at the following time points: 8, 24, 48 hours, and daily during intensive care unit admission. Blood was processed by centrifugation, separation into 1.0-mL plasma aliquots, and cryopreserved within 2 hours of collection. MAIN OUTCOME MEASUREMENTS Plasma analyses of protein levels of cytokines/chemokines were performed using a Luminex panel Bioassay of 20 immunologic mediators. Organ dysfunction was measured by the Marshall Multiple Organ Dysfunction score (MODScore) and nosocomial infection (NI) was recorded. Patients were stratified into low (MODS ≤ 4; n = 34) and high (MODS > 4; n = 27) organ dysfunction groups. RESULTS The MODS >4 group had higher circulating levels of interleukin (IL)-6, IL-8, IL-10, monocyte chemoattractant protein-1 (MCP-1), IL-1 receptor antagonist (IL-1RA), and monokine induced by interferon gamma (MIG) compared with the MODS ≤4 group at nearly all time points. MODS >4 exhibited lower levels of IL-21 and IL-22 compared with MODS ≤4. Patients who developed NI (n = 24) had higher circulating concentrations of IL-10, MIG, and high mobility group box 1 (HMGB1) compared with patients who did not develop NI (n = 37). CONCLUSIONS Temporal quantification of immune mediators identified 8 biomarkers associated with greater levels of organ dysfunction in polytrauma patients with major orthopaedic injuries. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Guerado E, Bertrand ML, Cano JR, Cerván AM, Galán A. Damage control orthopaedics: State of the art. World J Orthop 2019; 10:1-13. [PMID: 30705836 PMCID: PMC6354106 DOI: 10.5312/wjo.v10.i1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Maria Luisa Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Ana María Cerván
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Adolfo Galán
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
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Weber CD, Hildebrand F, Kobbe P, Lefering R, Sellei RM, Pape HC. Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications. Eur J Trauma Emerg Surg 2018; 45:445-453. [PMID: 29396757 DOI: 10.1007/s00068-018-0916-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/31/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. METHODS A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). RESULTS Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. CONCLUSION Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.
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Affiliation(s)
- Christian David Weber
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany.
| | - Frank Hildebrand
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Richard M Sellei
- Department of Trauma Surgery and Orthopaedics, Sana Klinikum, Offenbach, Germany
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Giannoudis PV, Giannoudis VP, Horwitz DS. Time to think outside the box: 'Prompt-Individualised-Safe Management' (PR.I.S.M.) should prevail in patients with multiple injuries. Injury 2017; 48:1279-1282. [PMID: 28551051 DOI: 10.1016/j.injury.2017.05.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- P V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom.
| | - Vasileios P Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Robertson-Preidler J, Biller-Andorno N, Johnson TJ. What is appropriate care? An integrative review of emerging themes in the literature. BMC Health Serv Res 2017; 17:452. [PMID: 28666438 PMCID: PMC5493089 DOI: 10.1186/s12913-017-2357-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 06/06/2017] [Indexed: 01/16/2023] Open
Abstract
Background Health care improvement efforts should be aligned in order to make a meaningful impact on health systems. Appropriate care delivery could be a unifying goal to help coordinate efforts to improve health outcomes and ensure system sustainability. A more complete understanding of how appropriate care is currently conceived in research and clinical practice could help inform a more integrated and holistic concept of appropriate care that could guide health care policy and delivery practices. We examined the current understanding of appropriate care by identifying its use and definitions in recently published literature. Methods An integrated review of the practices, goals and perspectives of appropriate care in English language peer-reviewed articles published from 2011 to 2016. Inductive content analysis was used to describe emerging themes of appropriate care in articles meeting inclusion criteria. Results This integrative review included empirical studies, reviews, and commentaries with various health care settings, cultural contexts, and perspectives. Conceptualizations of appropriate care varied, however most descriptions fell into five main categories: evidence-based care, clinical expertise, patient-centeredness, resource use, and equity. These categories were often used in combination, indicating an integrated understanding of appropriate care. Conclusions An understanding of how appropriate care is conceptualized in research and policy can help inform an integrated approach to appropriate care delivery in policy and practice according to the relevant priorities and circumstances.
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Affiliation(s)
- Joelle Robertson-Preidler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zürich, Switzerland.
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zürich, Switzerland
| | - Tricia J Johnson
- Department of Health Systems Management, Rush University, 1700 W. Van Buren Street, Suite 126B, Chicago, IL, 60612, USA
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Paradigm shifts in diagnostics and treatment of multiply injured patients - How does it affect visceral injuries? Injury 2017; 48:565-567. [PMID: 28340794 DOI: 10.1016/j.injury.2017.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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