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Pfeifer R, Klingebiel FKL, Balogh ZJ, Beeres FJP, Coimbra R, Fang C, Giannoudis PV, Hietbrink F, Hildebrand F, Kurihara H, Lustenberger T, Marzi I, Oertel MF, Peralta R, Rajasekaran S, Schemitsch EH, Vallier HA, Zelle BA, Kalbas Y, Pape HC. Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review. J Trauma Acute Care Surg 2024:01586154-990000000-00776. [PMID: 39085995 DOI: 10.1097/ta.0000000000004428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
BACKGROUND The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE Delphi-Consensus/Systematic Review; Level IV.
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Affiliation(s)
- Roman Pfeifer
- From the Department of Trauma Surgery (R.Pf., F.K.-L.K., Y.K., H.-C.P.), Harald-Tscherne Laboratory for Orthopaedic and Trauma Research (R.Pf., F.K.-L.K., Y.K., H.-C.P.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia; Department of Orthopaedic and Trauma Surgery (F.J.P.B.), Lucerne Cantonal Hospital, Lucerne, Switzerland; Riverside University Health System Medical Center and Loma Linda University School of Medicine (R.C.), Loma Linda, California; Department of Orthopaedics and Traumatology (C.F.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong; Academic Department of Trauma and Orthopaedics (P.V.G.), School of Medicine, University of Leeds; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom; Department of Trauma Surgery (F.Hie.), University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Orthopaedics (F.Hil.), Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany; Emergency Surgery Unit (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Trauma Surgery (T.L.), Aarau Cantonal Hospital, Aarau, Switzerland; Department of Trauma (I.M.), Hand, and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany; Department of Neurosurgery (M.F.O.), Clinical Neuroscience Center (M.F.O.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Surgery (R.Pe.), Trauma Surgery, Hamad Medical Corporation, Doha, Qatar; Department of Surgery (R.Pe.), Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic; Department of Orthopedics and Spine Surgery (S.R.), Ganga Hospital, Coimbatore, India; Department of Surgery, Division of Orthopaedic Surgery (E.H.S.), University of Western Ontario, London, Ontario, Canada; Department of Orthopaedic Surgery (H.A.V.), Case Western Reserve University, Cleveland, Ohio; and Department of Orthopaedics (B.A.Z.), UT Health San Antonio, San Antonio, Texas
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Kumabe Y, Kalbas Y, Halvachizadeh S, Teuben M, Cesarovic N, Weisskopf M, Hülsmeier A, Hornemann T, Cinelli P, Pape HC, Pfeifer R. Occult hypoperfusion and changes of systemic lipid levels after severe trauma: an analysis in a standardized porcine polytrauma model. Eur J Trauma Emerg Surg 2024; 50:107-114. [PMID: 35819473 PMCID: PMC10924008 DOI: 10.1007/s00068-022-02039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Occult hypoperfusion describes the absence of sufficient microcirculation despite normal vital signs. It is known to be associated with prolonged elevation of serum lactate and later complications in severely injured patients. We hypothesized that changes in circulating lipids are related to responsiveness to resuscitation. The purpose of this study is investigating the relation between responsiveness to resuscitation and lipidomic course after poly trauma. METHODS Twenty-five male pigs were exposed a combined injury of blunt chest trauma, liver laceration, controlled haemorrhagic shock, and femoral shaft fracture. After 1 h, animals received resuscitation and fracture stabilization. Venous blood was taken regularly and 233 specific lipids were analysed. Animals were divided into two groups based on serum lactate level at the end point as an indicator of responsiveness to resuscitation (<2 mmol/L: responder group (R group), ≧2 mmol/L: occult hypoperfusion group (OH group)). RESULTS Eighteen animals met criteria for the R group, four animals for the OH group, and three animals died. Acylcarnitines showed a significant increase at 1 h compared to baseline in both groups. Six lipid subgroups showed a significant increase only in R group at 2 h. There was no significant change at other time points. CONCLUSIONS Six lipid groups increased significantly only in the R group at 2 h, which may support the idea that they could serve as potential biomarkers to help us to detect the presence of occult hypoperfusion and insufficient resuscitation. We feel that further study is required to confirm the role and mechanism of lipid changes after trauma.
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Affiliation(s)
- Yohei Kumabe
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Miriam Weisskopf
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Andreas Hülsmeier
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
| | - Thorsten Hornemann
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland.
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland.
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Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury 2022; 53:2400-2412. [PMID: 35577600 DOI: 10.1016/j.injury.2022.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - E E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Aurora, CO, USA.
| | - T McKinley
- Department of Orthopaedics, Indiana University, 200 Hawkins Dr, Iowa City, IA 52242, USA.
| | - A Sauaia
- Schools of Public Health and Medicine, University of Colorado, Aurora, Colorado, USA.
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