Impact of gender on outcomes after blunt injury: a definitive analysis of more than 36,000 trauma patients

EFFECT OF GENDER ON 28-DAY SURVIVAL RATES AND TRANSFUSION VOLUME IN SEVERE TRAUMA PATIENTS: A MULTICENTER OBSERVATIONAL STUDY

ABSTRACT

Background: This study clarified the relationship between sex with survival and transfusion volume in severe trauma cases. Methods: A multicenter, collaborative post hoc analysis of patients with trauma in Japan was conducted. Patients aged ≥18 years with severe trauma indicated by an Injury Severity Score (ISS) of 16 or higher were enrolled. Patients were matched and analyzed by gender based on propensity score with factors determined at the time of injury. Subgroup analysis was performed on patients younger than 50 years and older than 50 years. The significance level was defined as P < 0.05. Results: The 1,189 patients included in this registry were divided into adjusted groups of 226 male and female patients each. In the main analysis, 28-day survival rates in females were significantly higher than those in males ( P = 0.046). In the subgroup analyses, there was no statistically significant prognostic effect of gender. Secondary outcomes, including transfusion volume, showed no significant gender-based variations. Logistic regression analyses consistently demonstrated that female sex was a significant favorable prognostic factor in all ages. This was true for the over-50 group on subgroup analysis, but no significant gender-prognosis relationship was identified in the under-50 age group. High ISSs were associated with poorer outcomes across all age groups. Conclusion: In severe trauma, survival at 28 days was significantly lower in males. However, this trend was not observed in patients aged <50 years. Factors other than sex hormones may be responsible for differences in posttraumatic outcomes by gender.

Older females have increased mortality after trauma as compared with younger females and males, associated with increased fibrinolysis

INTRODUCTION

Female sex may provide a survival benefit after trauma, possibly attributable to protective effects of estrogen. This study aimed to compare markers of coagulation between male and female trauma patients across different ages.

METHODS

Secondary analysis of a prospective cohort study that was conducted at six trauma centers. Trauma patients presenting with full trauma team activation were eligible for inclusion. Patients with a penetrating trauma or traumatic brain injury were excluded. Upon hospital arrival, blood was drawn for measurement of endothelial and coagulation markers and for rotational thromboelastometry measurement. Trauma patients were divided into four categories: males younger than 45 years, males 45 years or older, females younger than 45 years, and females 45 years or older. In a sensitivity analysis, patients between 45 and 55 years old were excluded to control for menopausal transitioning. Groups were compared with a Kruskal-Wallis test with Bonferroni correction. A logistic regression was performed to assess whether the independent effect of sex and age on mortality.

RESULTS

A total of 1,345 patients were available for analysis. Compared with the other groups, mortality was highest in females 45 years or older, albeit not independent from injury severity and shock. In the group of females 45 years or older, there was increased fibrinolysis, demonstrated by increased levels of plasmin-antiplasmin complexes with a concomitant decrease in α2-antiplasmin. Also, a modest decrease in coagulation factors II and X was observed. Fibrinogen levels were comparable between groups. The sensitivity analysis in 1,104 patients demonstrated an independent relationship between female sex, age 55 years or older, and mortality. Rotational thromboelastometry profiles did not reflect the changes in coagulation tests.

CONCLUSION

Female trauma patients past their reproductive age have an increased risk of mortality compared with younger females and males, associated with augmented fibrinolysis and clotting factor consumption. Rotational thromboelastometry parameters did not reflect coagulation differences between groups.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Patient sex and outcomes in children with life-threatening hemorrhage

BACKGROUND

Recent data suggest female sex imparts a survival benefit after trauma in adults. The independent associations between patient sex and age with outcomes have not been examined in children with life-threatening hemorrhage (LTH) from all etiologies.

STUDY DESIGN AND METHODS

In a secondary analysis of a multicenter prospective observational study of children with LTH, Massive Transfusion in Children (MATIC), we analyzed if patient sex and age were associated with differences in severity of illness, therapies, and outcomes. Primary outcomes were 24 hour mortality and weight-adjusted transfusion volume during LTH. Kruskal-Wallis, chi-square testing, and multivariable linear regression were used for adjusted analyses.

RESULTS

Of 449 children, 45% were females and 55% were males. Females were more commonly younger, white, and with less trauma as the etiology of LTH compared to males. Markers of clinical severity were similar between groups, except injury severity score (ISS) was higher in females in the trauma subgroup. In terms of resuscitative practices, females received greater weight-adjusted total transfusion volumes compared to males (76 (40-150) mL/kg vs. 53 (24-100) mL/kg), as well as increased red blood cells (RBCs), plasma, and platelets compared to males. After adjustment for confounders, female sex and age 0-11 years were independently associated with increased transfusion volume during LTH. There were no differences in mortality or adverse outcomes according to patient sex.

CONCLUSION

Patient sex and age may impact factors associated with LTH and therapies received. Studies in developmental hemostasis are needed to determine the optimal transfusion strategy for LTH according to patient sex and age.

Sex dimorphisms in coagulation: Implications in trauma-induced coagulopathy and trauma resuscitation

Trauma-induced coagulopathy (TIC) is one of the leading causes of preventable death in injured patients. Consequently, it is imperative to understand the mechanisms underlying TIC and how to mitigate this mortality. An opportunity for advancement stems from the awareness that coagulation demonstrates a strong sex-dependent effect. Females exhibit a relative hypercoagulability compared to males, which persists after injury and confers improved outcomes. The mechanisms underlying sex dimorphisms in coagulation and its protective effect after injury have yet to be elucidated. This review explores sex dimorphisms in enzymatic hemostasis, fibrinogen, platelets, and fibrinolysis, with implications for resuscitation of patients with TIC.

Sex disparities in adverse outcomes after surgically managed isolated traumatic spinal injury

BACKGROUND

Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI.

METHODS

Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting.

RESULTS

A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex.

CONCLUSION

Female sex is associated with a significantly decreased risk of in-hospital mortality as well as cardiopulmonary and venothromboembolic complications following surgical management of traumatic spinal injuries. Further studies are needed to elucidate the cause of these differences.

The impact of patient sex on survival after unintentional trauma in Korea: a retrospective, observational, case-control study

OBJECTIVE

This study aimed to describe the relationship between sex and survival in patients experiencing unintentional trauma.

METHODS

This retrospective, national population-based observational, case-control study involved a cohort of Korean trauma patients who were transferred to an emergency department by a Korean emergency medical service from January 1 to December 31, 2018. Propensity score matching was used. The primary outcome was survival until hospital discharge.

RESULTS

Of 25,743 patients with severe unintentional trauma, 17,771 were male and 7,972 were female. Prior to propensity score matching, there was no significant difference in survival among male and female patients (92.6% vs. 93.1%, P=0.105). After using propensity score matching to adjust for confounders, there was still no sex difference in survival (male, 93.6% vs. female, 93.1%; P=0.270).

CONCLUSION

Survival after severe trauma was not influenced by the sex of the patient. Further studies with patients of reproductive age and a larger study population are needed to analyze the effects of sex on survival in patients with trauma.

Age and sex differences in blood product transfusions and mortality in trauma patients at a level I trauma center

Objectives

Hemorrhage is a common complication of trauma. We evaluated age and sex differences in treatment with blood product transfusions and massive transfusions as well as in-hospital mortality following trauma at a Level 1 Trauma Center.

Methods

This cross-sectional study evaluated trauma data from a Level 1 trauma center registry from January 2013 to December 2017. The primary outcome was amount of blood products (packed red blood cells (PRBCs), plasma, platelets), and massive transfusion (MT) by biological sex and by age group: 16-24 (youth), 25-59 (middle age), and >=60 (older age) The secondary outcome was in-hospital mortality to hospital discharge.

Results

There were 13596 trauma patients in the registry, mean age was 48 years, 4589 (34%) female and 9007 (66%) male, and median ISS of 9. Male patients received significantly more PRBC transfusions than female patients within 4-hours 6.6% vs 4.4%, and 24-hours 6.7% vs 4.5% respectively. Older patients received significantly fewer PRBC transfusions within 4-hours and 24-hours than their younger counterparts, with 6.9% in the youth group, 6.8% in the middle age group, and 3.9% in the older group (p<0.001). When adjusted for injury severity, the odds of receiving a blood transfusion within 4 hours of injury was significantly lower in older females. Using multivariate analysis, predictors of mortality included (in order of significance) injury severity, older age, transfusion within 4 hours of injury, penetrating trauma, and male sex.

Conclusion

In this large trauma cohort, older female trauma patients were less likely to receive blood products compared to younger females and to their older male counterparts, even after adjusting for injury severity. Predictors of mortality included injury severity, older age, early transfusion, penetrating trauma, and male sex. Following trauma, older women appear vulnerable to undertreatment. Further study is needed to determine the reasons for these differences and their impact on patient outcomes.

What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures?

BACKGROUND

Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF.

QUESTIONS/PURPOSES

(1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure?

METHODS

The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI.

RESULTS

Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI.

CONCLUSION

One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Gender-related differences in the coagulofibrinolytic responses and long-term outcomes in patients with isolated traumatic brain injury: A 2-center retrospective study

Coagulation function differs by gender, with women being characterized as more hypercoagulable. Even in the early stages of trauma, women have been shown to be hypercoagulable. Several studies have also examined the relationship between gender and the prognosis of trauma patients, but no certain conclusions have been reached. Patients with isolated traumatic brain injury (iTBI) are known to have coagulopathy, but no previous studies have examined the gender differences in detail. This is a retrospective analysis of a prospective registry conducted at 2 centers. The study included adult patients with iTBI enrolled from April 2018 to March 2021. Coagulofibrinolytic markers were measured in each patient at 1 hour, 24 hours, 3 days, and 7 days after injury, and neurological outcomes were assessed with the Glasgow Outcome Scale Extended at 6 months. Subgroup analysis was also performed by categorizing patients into groups according to neurological prognosis or age at 50 years. Males (n = 31) and females (n = 21) were included in the analysis. In males, there was a significant difference in the levels of activated partial thromboplastin time (P = .007), fibrin/fibrinogen degradation products (P = .025), D-dimer (P = .034), α2-plasmin inhibitor (P = .030), plasmin-α2-plasmin inhibitor complex (P = .004) at 1 hour after injury between favorable and unfavorable long-term neurological outcome groups, while in females there was no significant difference in these markers between 2 groups. In the age group under 50 years, there were significant gender differences in fibrinogen (day 3: P = .018), fibrin/fibrinogen degradation products (1 hour: P = .037, day 3: P = .009, day 7: P = .037), D-dimer (day 3: P = .005, day 7: P = .010), plasminogen (day 3: P = .032, day 7: P = .032), and plasmin-α2-plasmin inhibitor complex (day 3: P = .001, day 7: P = .001), and these differences were not evident in the age group over 50 years. There were differences in coagulofibrinolytic markers depending on gender in patients with iTBI. In male patients, aggravation of coagulofibrinolytic markers immediately after traumatic brain injury may be associated with poor neurologic outcome 6 months after injury.

Syndecan-1 as a severity biomarker for patients with trauma

Tissue injury and hemorrhage induced by trauma lead to degradation of the endothelial glycocalyx, causing syndecan-1 (SDC-1) to be shed into the blood. In this study, we investigated whether serum SDC-1 is useful for evaluating trauma severity in patients. A single-center, retrospective, observational study was conducted at Gifu University Hospital. Patients transported to the emergency room for trauma and subsequently admitted to the intensive care unit from January 2019 to December 2021 were enrolled. A linear regression model was constructed to evaluate the association of serum SDC-1 with injury severity score (ISS) and probability of survival (Ps). A total of 76 trauma patients (54 men and 22 women) were analyzed. ISS was significantly associated with serum SDC-1 level in trauma patients. Among the six body regions defined in the AIS used to calculate the ISS score, “chest” and “abdominal or pelvic contents” were significantly associated with serum SDC-1 level, and “extremities or pelvic girdle” also tended to show an association with serum SDC-1 level. Moreover, increasing serum SDC-1 level was significantly correlated with decreasing Ps. Serum SDC-1 may be a useful biomarker for monitoring the severity of trauma in patients. Further large-scale studies are warranted to verify these results.

Analysis of Admission Thromboelastogram Profiles in 1369 Male and Female Trauma Patients

INTRODUCTION

Recent studies have demonstrated a hypercoagulable thromboelastrogram (TEG) in female trauma patients compared with males, conferring a possible survival advantage. We hypothesized that TEG profiles would reveal a relative hypercoagulable state in female compared with male trauma patients.

METHODS

A prospective review was conducted on all adult trauma patients admitted to the trauma service at an American College of Surgeons-verified level I trauma center from December 2019 to June 2021 who, per our institutional protocol, received a thrombelastotgraphy on their initial arrival to the trauma center if classified as a level I or II trauma activation. The thromboelastography values of male and female trauma patients were compared as the primary outcome variables of interest. The secondary outcomes investigated were hospital length of stay, surgical interventions, and ventilatory requirement.

RESULTS

A total of 1369 patients met inclusion criteria, with 878 (64.1%) male and 491 (35.9%) female. Female patients had a higher median alpha angle (74.8 versus 72.6°, P < 0.001), maximum amplitude (69.3 versus 66.2 mm, P < 0.001), and shorter median K time (1.0 versus 1.2 s, P < 0.001). Female patients had a shorter hospital length of stay (4 versus 5 d, P < 0.001), had a lower rate of surgical intervention (14.6% versus 25.5%, P < 0.001), and had lower rates of mechanical ventilation (19.3% versus 39.5%, P < 0.001).

CONCLUSIONS

Female trauma patients were found to have hypercoagulable indices on TEG at the time of initial trauma evaluation compared with males. Intrinsic differences in sex coagulation profiles should be further investigated to optimize modern resuscitation strategies.

A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias?

BACKGROUND

Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias.

METHOD

A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05.

RESULTS

A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001).

CONCLUSION

Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.

Sex discrimination after injury: is inequity in tranexamic acid administration just the tip of the iceberg?

There is emerging evidence of inequalities in healthcare provision between women and men. Trauma care is no exception with a number of studies indicating lower levels of prioritisation for injured female patients. The antifibrinolytic drug tranexamic acid, reduced trauma deaths to a similar extent in females and males in the international Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) randomised controlled trials, but in real-world practice, national registry data shows females are less likely to receive tranexamic acid than males. Inequity in the provision of tranexamic acid may extend beyond sex (and gender), and further study is required to examine the effect of age and mechanism of injury differences between men and women in the decision to treat.

Thromboelastography-Based Evaluation of Gender-Associated Hypercoagulability

BACKGROUND

Age, race, and gender differences in coagulation status of healthy volunteers have been reported in previous case series; however, rigorous multivariate analysis adjusting for these factors is lacking. We aimed to investigate the effects of age, race, and gender on baseline coagulation status in healthy volunteers.

METHODS

Thirty healthy volunteer controls with no history of bleeding or thrombotic events and no previous anticoagulant or antiplatelet use were recruited. Citrated and heparinized blood samples were drawn, and kaolin and platelet-mapping thromboelastography (TEG) assays performed.

RESULTS

Thirty participants had a mean age of 37, mean body mass index of 29 kg/m², and were 47% African-American and 70% female. Women were significantly older than men (40 ± 11 y vs 28 ± 7 y, P = .002); there were no significant differences in demographics by race. Multivariate analysis of variance for the effect of age, race, and gender across TEG parameters yielded evidence for gender differences in hypercoagulability (Pillai's trace P = .02), which appear to be driven by differences in K-time, alpha angle, maximal amplitude, and G parameter. Women were hypercoagulable compared to men, as manifested by shorter K-time, steeper alpha angle, higher maximal amplitude, and larger G parameter.

DISCUSSION

Women at baseline have relatively hypercoagulable fibrin deposition kinetics, platelet contributions to clot formation, and overall clot strength compared to men, even when adjusted for age and race. Additional research is needed to specifically detail the key patient-level factors, clinical implications, and opportunities for tailored therapy related to gender-associated hypercoagulability.

An estrogen (17α-ethinyl estradiol-3-sulfate) reduces mortality in a swine model of multiple injuries and hemorrhagic shock

BACKGROUND

Although 17α-ethinyl estradiol-3-sulfate (EES) reduces mortality in animal models of controlled hemorrhage, its role in a clinically relevant injury model is unknown. We assessed the impact of EES in a swine model of multiple injuries and hemorrhage.

METHODS

The study was performed under Good Laboratory Practice, with 30 male uncastrated swine (25-50 kg) subjected to tibial fracture, pulmonary contusion, and 30% controlled hemorrhage for an hour. Animals were randomized to one of five EES doses: 0 (control), 0.3, 1, 3, and 5 mg/kg, administered postinjury. Subjects received no resuscitation and were observed for 6 hours or until death. Survival data were analyzed using Cox-proportional hazard regression. Left ventricular pressure-volume loops were used to derive preload recruitable stroke work as a measure of cardiac inotropy. Immediate postinjury preload recruitable stroke work values were compared with values at 1 hour post-drug administration.

RESULTS

Six-hour survival for the 0, 0.3, 1, 3, and 5 mg/kg groups was 0%, 50%, 33.3%, 16.7%, and 0%, respectively. Following Cox regression, the hazard (95% confidence interval) of death was significantly reduced in the 0.3 (0.22 [0.05-0.93]) and 1 (0.24 [0.06-0.89]) mg/kg groups but not the 3 (0.49 [0.15-1.64]) and 5 (0.46 [0.14-1.47]) mg/kg groups. Mean survival time was significantly extended in the 1 mg/kg group (246 minutes) versus the 0 mg/kg group (96 minutes) (p = 0.04, t test). At 1 hour post-drug administration, inotropy was significantly higher than postinjury values in the 0.3 and 1 mg/kg groups (p = 0.003 and p < 0.001, respectively). Inotropy was unchanged in the 3 and 5 mg/kg groups but significantly depressed in the control (p = 0.022).

CONCLUSION

Administration of EES even in the absence of fluid resuscitation reduces mortality and improves cardiac inotropy in a clinically relevant swine model of multiple injuries and hemorrhage. These findings support the need for a clinical trial in human trauma patients.

Postinjury Sepsis-Associations With Risk Factors, Impact on Clinical Course, and Mortality: A Retrospective Observational Study

OBJECTIVES

Overall outcomes for trauma patients have improved over time. However, mortality for postinjury sepsis has been reported to be unchanged. Estimate incidence of and risk factors for sepsis in ICU patients after major trauma and the association between sepsis, mortality, and clinical course.

DESIGN SETTING AND PATIENTS

ICU in a large urban trauma center in Sweden with a well-developed trauma system. Retrospective cohort study of trauma patients admitted to the ICU for more than 24 hours were included.

MEASUREMENTS AND MAIN RESULTS

Primary outcome measure was 30-day mortality. Secondary outcomes were 1-year mortality and impact on clinical course. In total, 722 patients with a median Injury Severity Score of 26 (interquartile range, 18-38) were included. Incidence of sepsis was 22%. Septic patients had a four-fold increase in length of stay and need for organ supportive therapy. The overall 30-day mortality rate was 9.3%. After exclusion of early trauma-related deaths in the first 48 hours, the 30-day mortality rate was 6.7%. There was an association between sepsis and this adjusted 30-day mortality (day 3 odds ratio, 2.1 [95% CI, 1.1-3.9]; day 4 odds ratio, 3.1 [95% CI, 1.5-6.1]; day 5 odds ratio, 3.0 [95% CI, 1.4-6.2]). Septic patients had a 1-year mortality of 17.7% (nonseptic 11.0%). Development of sepsis was independently associated with age, spine and chest injury, shock, red cell transfusion, and positive blood alcohol concentration at admission. The risk of sepsis increased, in a dose-dependent manner, with the number of transfusions.

CONCLUSIONS

Postinjury sepsis was associated with a complicated clinical course and with mortality after exclusion of early, trauma-related deaths.

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage

BACKGROUND

Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage.

METHODS

A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses.

RESULTS

A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, P = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, P = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, P < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, P < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, P = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, P < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group (P > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, P = .48).

CONCLUSIONS

Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.

Hypercoagulability in pregnant trauma patients

Circulating hormones affect coagulopathy in pregnancy and after trauma. The hemostatic profile of pregnant women after injury has not been characterized. We hypothesized that injured pregnant females would present with an initial thrombelastography (TEG) reflecting a more hypercoagulable profile and a higher incidence of venous thromboembolic events (VTE) when compared with non-pregnant females and males.

Trauma-induced coagulopathy

Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.

Considering Biological Sex in Traumatic Brain Injury

Published epidemiological studies of traumatic brain injury (TBI) of all severities consistently report higher incidence in men. Recent increases in the participation of women in sports and active military service as well as increasing awareness of the very large number of women who sustain but do not report TBI as a result of intimate partner violence (IPV) suggest that the number of women with TBI is significantly larger than previously believed. Women are also grossly under-represented in clinical and natural history studies of TBI, most of which include relatively small numbers of women, ignore the role of sex- and age-related gonadal hormone levels, and report conflicting results. The emerging picture from recent studies powered to detect effects of biological sex as well as age (as a surrogate of hormonal status) suggest young (i.e., premenopausal) women are more likely to die from TBI relative to men of the same age group, but this is reversed in the 6th and 7th decades of life, coinciding with postmenopausal status in women. New data from concussion studies in young male and female athletes extend this finding to mild TBI, since female athletes who sustained mild TBI are significantly more likely to report more symptoms than males. Studies including information on gonadal hormone status at the time of injury are still too scarce and small to draw reliable conclusions, so there is an urgent need to include biological sex and gonadal hormone status in the design and analysis of future studies of TBI.

Role of gender in the survival outcome of acute phase of major trauma: A nationwide, population-based study

BACKGROUND

Animal models of trauma have shown that females have better posttraumatic survival; however, results of previous studies on the influence of gender on major trauma patients have been controversial. This study aimed to evaluate the association between gender and survival in major trauma patients.

METHODS

We retrospectively analyzed patients registered in Taiwan's National Health Insurance Research Database between 2008 and 2012 with the diagnosis codes 800-939 and 950-957 (International Classification of Diseases, ninth revision, clinical modification). Data on gender, age, catastrophic illness, and new injury severity score (NISS) ≥16 were collected for comparing patients' mortality after trauma. Propensity score matching (PSM) was performed to eliminate dissimilarities in age, comorbidities, NISS, and primary traumatic regions between the genders.

RESULTS

Among 10 012 major trauma patients included in the study cohort, 28.8% (n = 2880) were women. The PSM patient group consisted of 50% (2876 of 5752) women. Women had a higher 30-day (15.4% of women vs 13.8% of men; p < 0.05) and hospital (16.1% of women vs 14.5% of men; p < 0.05) mortality and lower incidence rates of acute respiratory dysfunction (62.5% of women vs 65.9% of men; p < 0.005) and acute hepatic dysfunction (0.8% of women vs 2.1% of men; p < 0.001). However, the analysis of PSM patient groups showed lower mortality rates in women with moderate trauma (NISS 16-24) in the acute phase within three days (1.4% of women vs 2.7% of men, p = 0.03). Analysis of patients with an NISS of 16-24 who died within three days showed a higher NISS in women than in men (19.7 ± 2.3 vs 18.0 ±1.9, respectively, p <0.05).

CONCLUSION

There is no gender difference in 30-day or hospital mortality among major trauma patients. However, women admitted for moderate major trauma had higher survival within three days of major trauma.

Neuroendocrine Modulation of the Immune Response after Trauma and Sepsis: Does It Influence Outcome?

Although the treatment of multiple-injured patients has been improved during the last decades, sepsis and multiple organ failure (MOF) still remain the major cause of death. Following trauma, profound alterations of a large number of physiological systems can be observed that may potentially contribute to the development of sepsis and MOF. This includes alterations of the neuroendocrine and the immune system. A large number of studies focused on posttraumatic changes of the immune system, but the cause of posttraumatic immune disturbance remains to be established. However, an increasing number of data indicate that the bidirectional interaction between the neuroendocrine and the immune system may be an important mechanism involved in the development of sepsis and MOF. The aim of this article is to highlight the current knowledge of the neuroendocrine modulation of the immune system during trauma and sepsis.

Predictors of new-onset atrial fibrillation in geriatric trauma patients

INTRODUCTION

Geriatric patients (age >65) comprise a growing segment of the trauma population. New-onset atrial fibrillation may occur after injury, complicating clinical management and resulting in significant morbidity and mortality. This study was undertaken to identify clinical and demographic factors associated with new-onset atrial fibrillation among geriatric trauma patients.

METHODS

In this case control study, eligible participants included admitted trauma patients age 65 and older who developed new-onset atrial fibrillation during the hospitalization. Controls were admitted trauma patients who were matched for age and injury severity score, who did not develop atrial fibrillation. We evaluated the associations between new-onset atrial fibrillation and clinical characteristics, including patient demographics, health behaviors, chronic medical conditions, and course of care.

RESULTS

Data were available for 63 cases and 25 controls. Patients who developed atrial fibrillation were more likely to be male, compared to controls (49% versus 24%; odds ratio 3.0[1.0, 8.9]). Other demographic and clinical factors were not associated with new-onset atrial fibrillation, including mechanism of injury, co-morbid medical conditions, drug or alcohol use, surgical procedures, and intravenous fluid administration.

CONCLUSIONS

Male geriatric trauma patients were at higher risk for developing new-onset atrial fibrillation. Other demographic and clinical factors were not associated with new-onset atrial fibrillation.

Impact of gender on post- traumatic intensive care and outcomes

Background

Several reports indicate gender disparities in health care provision. There is a well-documented male patient dominance in intensive care unit (ICU) admittance. It is not established if this difference reflects medical needs or is influenced by other factors. The aim of the current study was to investigate if patient gender influences the pattern of ICU admittance in a cohort of trauma patients.

Methods

Data from patients admitted to an urban trauma centre over a 10-year interval were linked to regional and national health registries to obtain data on demographics, co-comorbidities, trauma-related variables, ICU-admittance patterns and mortality. The association between gender and ICU-admission were explored using logistic regression analysis. The association between gender and short- and long-term mortality were explored using Cox regression models.

Results

In this study cohort of approximately 14,000 trauma patients, men had a higher probability of being admitted to the ICU after initial trauma resuscitation. The difference was limited to patients with less severe injuries (ISS < 15). No differences were noted in short-term survival, whereas men had a higher long-term mortality.

Conclusions

In this retrospective cohort study we found a difference between men and women in post trauma ICU admittance patterns, restricted to less injured patients, where men had a higher probability of ICU admittance. Whether this is a true gender bias or an effect of other factors not analysed in this study remains unknown. This finding warrants further studies.

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy

BACKGROUND

Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy.

MATERIALS AND METHODS

Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects.

RESULTS

Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01).

CONCLUSIONS

Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.

Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria

OBJECTIVES

The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center.

METHODS

An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center.

RESULTS

Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR] = 0.89), age ≥ 90 (OR = 0.76), and either only a Level 3 (OR = 0.3) or no trauma center (OR = 0.11) in county of residence had decreased odds of transport, while male sex (OR = 1.38), black race (OR = 2.07), Injury Severity Score (ISS) 10-15 (OR = 1.99), ISS > 15 (OR = 2.85), and Glasgow Coma Scale score < 9 (OR = 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR = 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center.

CONCLUSIONS

We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport.

Among Trauma Patients, Younger Men with Ventilator-Associated Pneumonia Have Worse Outcomes Compared to Older Men-An Exploratory Study

Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP). Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival. Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, (p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days (p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09). Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.

Female risk-adjusted survival advantage after injuries caused by falls, traffic or assault: a nationwide 11-year study

BACKGROUND

A female survival advantage after injury has been observed, and animal models of trauma have suggested either hormonal or genetic mechanisms as component causes. Our aim was to compare age and risk-adjusted sex-related mortality in hospital for the three most common mechanisms of injury in relation to hormonal effects as seen by age.

METHODS

All hospital admissions for injury in Sweden during the period 2001-2011 were retrieved from the National Patient Registry and linked to the Cause of Death Registry. The International Classification of Diseases Injury Severity Score (ICISS) was used to adjust for injury severity, and the Charlson Comorbidity Index to adjust for comorbidity. Age categories (0-14, 15-50, and ≥ 51 years) were used to represent pre-menarche, reproductive and post- menopausal women.

RESULTS

Women had overall a survival benefit (OR 0.51; 95% CI 0.50 to 0.53) after adjustment for injury severity and comorbidity. A similar pattern was seen across the age categories (0-14 years OR 0.56 (95% CI 0.25 to 1.25), 15-50 years OR 0.70 (95% CI 0.57 to 0.87), and ≥ 51 years OR 0.49 (95% CI 0.48 to 0.51)).

CONCLUSION

In this 11-year population-based study we found no support for an oestrogen-related mechanism to explain the survival advantage for females compared to males following hospitalisation for injury.

An Increasing Neutrophil-to-Lymphocyte Ratio Trajectory Predicts Organ Failure in Critically-Ill Male Trauma Patients. An Exploratory Study

Background: Although the association of neutrophil proportions with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. We sought to investigate the association of neutrophil proportions with organ failure in critically-ill trauma patients. Methods: We reviewed a randomly-selected group of trauma patients admitted to our level-1 trauma intensive care unit between July 2007 and December 2016. Data collected included demographics, injury mechanism and severity (ISS), neutrophil-to-lymphocyte ratio (NLR) at admission and at 24 and 48 hours and organ failure data. NLR patterns during the first 48 hours were divided into two trajectories identified by applying factor and cluster analysis to longitudinal measures. Logistic regression was performed for the association between NLR trajectories and any organ failure; negative binomial regression was used to model the number of organ failures and stage of kidney failure measured by KDIGO classification. Results: 207 patients had NLR data at all three time points. The average age was 44.9 years with mean ISS of 20.6. Patients were 72% male and 23% had penetrating trauma. The 74 patients (36%) with Trajectory 1 had a mean NLR at admission of 3.6, which increased to 14.7 at 48 hours. The 133 (64%) patients in Trajectory 2 had a mean NLR at admission of 8.5 which decreased to 6.6 at 48 hours. Mean NLR was different between the two groups at all three time points (all p < 0.01). There was no significant difference in ISS, age or gender between the two trajectory groups. Models adjusted for age, gender and ISS showed that relative to those with trajectory 2, patients with the trajectory 1 were more likely to have organ failure OR 2.96 (1.42⁻6.18; p < 0.01), higher number of organ failures IRR 1.50 (1.13⁻2.00, p < 0.01), and degree of AKI IRR 2.06 (1.04⁻4.06, p = 0.04). In all cases, the estimated associations were higher among men vs. women, and all were significant among men, but not women. Conclusions: Trauma patients with an increasing NLR trajectory over the first 48 hours had increased risk, number and severity of organ failures. Further research should focus on the mechanisms behind this difference in outcome.

Sex-based differences in transfusion need after severe injury: Findings of the PROPPR study

BACKGROUND

Women are underrepresented in trauma research, and aggregated results of clinical trials may mask effects that differ by sex. It is unclear whether women respond differently to severe hemorrhage compared with men. We sought to evaluate sex-based differences in outcomes after severe trauma with hemorrhage.

METHODS

We performed a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Trauma patients predicted to require massive transfusion were randomized to a 1:1:1 vs 1:1:2 plasma to platelet to red blood cell transfusion ratio. Analysis was performed according to sex, controlling for clinical characteristics and transfusion arm.

RESULTS

A total of 134 women and 546 men were analyzed. In multivariable analysis, there was no difference in mortality at 24 hours (hazard ratio for women 0.64, 95% confidence interval 0.34-1.23, P = .18) or in time to hemostasis (hazard ratio 1.10, 95% confidence interval 0.84-1.42, P = .49) by sex. We observed no difference between sexes in volume of blood products transfused during active hemorrhage. However, after anatomic hemostasis, women received lower volumes of all products, with a 38% reduction in fresh frozen plasma (mean ratio 0.62 (95% confidence interval 0.43-0.89, P = .01), 49% reduction in platelets (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01) and 49% reduction in volume of red blood cells (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01).

CONCLUSION

Mortality and time to hemostasis of trauma patients with hemorrhage did not differ by sex. Although there was no difference in transfusion requirement during active hemorrhage, once hemostasis was achieved, women received fewer units of all blood products than men. Further research is required to determine whether women exhibit differences in coagulation during and after severe traumatic hemorrhage.

Is there an association between female gender and outcome in severe trauma? A multi-center analysis in the Netherlands

INTRODUCTION

Little evidence suggest that female gender is associated with a lower risk of mortality in severely injured patients, especially in premenopausal women. Previous clinical studies have shown contradictory results regarding protective effects of gender on outcome after severe trauma. The objective of this study was to determine the association between gender and outcome (mortality and Intensive Care Unit (ICU) admission) among severely injured patients in the Netherlands.

METHODS

A retrospective multicentre study was performed including all polytrauma patients (Injury Severity Score (ISS) ≥16) admitted to the ED of three level 1 trauma centres, between January 1st, 2006 and December 31st, 2014. Data on age, gender, mechanism of injury, ISS, Abbreviated Injury Scale (AIS), prehospital intubation, Revised Trauma Score (RTS), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) upon admission at the Emergency Department was collected from three Regional Trauma Registries. To determine whether gender was an independent predictor of mortality and ICU admission, logistic regression analysis was performed.

RESULTS

Among 6865 trauma patients, male patients had a significantly higher ISS compared to female patients (26.3 ± 10.2 vs 25.3 ± 9.7, P = < 0.0001). Blunt trauma was significantly more common in the female group (95.2% vs 92.3%, P = < 0.0001). Males aged 16- to 44-years had a significant higher in-hospital mortality rate (10.4% vs 13.4%, P = 0.046). ICU admission rate was significantly lower in females (49.3% vs 54.5%, P = < 0.0001). In the overall group, logistic regression did not show gender as an independent predictor for in-hospital mortality (OR 1.020 (95% CI 0.865-1.204), P = 0.811) or mortality within 24 h (OR 1.049 (95% CI 0.829-1.327), P = 0.693). However, male gender was associated with an increased likelihood for ICU admission in the overall group (OR 1.205 (95% CI 1.046-1.388), P = 0.010).

CONCLUSION

The current study shows that in this population of severely injured patients, female sex is associated with a lower in-hospital mortality rate among those aged 16- to 44-years. Furthermore, female sex is independently associated with an overall decreased likelihood for ICU admission. More research is needed to examine the physiologic background of this protective effect of female sex in severe trauma.

Trauma Resuscitation Consideration: Sex Matters

BACKGROUND

Sex dimorphisms in coagulation have been recognized, but whole blood assessment of these dimorphisms and their relationship to outcomes in trauma have not been investigated. This study characterizes the viscoelastic hemostatic profile of severely injured patients by sex, and examines how sex-specific coagulation differences affect clinical outcomes, specifically, massive transfusion (MT) and death. We hypothesized that severely injured females are more hypercoagulable and therefore, have lower rates of MT and mortality.

STUDY DESIGN

Hemostatic profiles and clinical outcomes from all trauma activation patients from 2 level I trauma centers were examined, with sex as an experimental variable. As part of a prospective study, whole blood was collected and thrombelastography (TEG) was performed. Coagulation profiles were compared between sexes, and association with MT and mortality were examined. Poisson regression with robust standard errors was performed.

RESULTS

Overall, 464 patients (23% female) were included. By TEG, females had a more hypercoagulable profile, with a higher angle (clot propagation) and maximum amplitude (MA, clot strength). Females were less likely to present with hyperfibrinolysis or prolonged activating clotting time than males. In the setting of depressed clot strength (abnormal MA), female sex conferred a survival benefit, and hyperfibrinolysis was associated with higher case-fatality rate in males.

CONCLUSIONS

Severely injured females have a more hypercoagulable profile than males. This hypercoagulable status conferred a protective effect against mortality in the setting of diminished clot strength. The mechanism behind these dimorphisms needs to be elucidated and may have treatment implications for sex-specific trauma resuscitation.

Effects of Estrogen on Bacterial Clearance and Neutrophil Response After Combined Burn Injury and Wound Infection

Females have a higher rate of mortality following burn injury, largely due to differences in sepsis-related mortality. The present study seeks to understand the underpinnings of the estrogen's immunomodulatory effects in a murine model of burn injury and infection. Gonad-intact and ovariectomized female mice were subjected to a 15% total BSA scald injury and then inoculated with 3000 CFU of Pseudomonas aeruginosa by topical application to the wound. Animals were killed at 1, 2, or 7 days after injury. Tissue and whole blood were collected. Cultures were performed of all tissues to assess for bacteria content. Lungs were examined for histologic appearance and homogenates were analyzed for chemokines and myeloperoxidase activity. Mortality reached 95% by 3 days after injury for gonad intact mice, whereas in ovariectomized mice it was 76% at 7 days. Blood and tissue samples from gonad intact mice had significantly higher levels of P. aeruginosa compared with ovariectomized mice. Histologic assessment of lungs demonstrated a similar overall cellularity in ovariectomized mice relative to gonad intact mice 1 day after injury, but increased neutrophil count in gonad intact mice. This correlated with chemotactic signaling as lung homogenates had lower levels of KC in ovariectomized mice (128.0 ± 19.8 vs 48.3 ± 5.7 pg/mg protein). Also, myeloperoxidase was significantly lower in lung homogenates of ovariectomized mice (1.12 ± 0.34 vs 0.56 ± 0.08 units/mg protein). Ovariectomy confers an early, but brief survival advantage in female mice after burn injury and wound infection. This appears to be secondary to enhanced bacterial clearance.

The Role and Use of Estrogens Following Trauma

Several lines of evidence indicate that female sex is a protective factor in trauma and hemorrhage. In both clinical and experimental studies, proestrus females have been shown to have better chances of survival and reduced rates of posttraumatic sepsis. Estrogen receptors are expressed in a variety of tissues and exert genomic, as well as nongenomic effects. By improving cardiac, pulmonary, hepatic, and immune function, estrogens have been shown to prolong survival in animal models of hemorrhagic shock. Despite encouraging results from experimental studies, retrospective clinical studies have not clearly pointed to advantages of estrogens following trauma-hemorrhage, which may be due to insufficient study design. Therefore, this review aims to give an overview on the current evidence and emphasizes on the importance of further clinical investigation on estrogens following trauma.

Effects of Female Sex Steroids Administration on Pathophysiologic Mechanisms in Traumatic Brain Injury

Secondary brain damage following initial brain damage in traumatic brain injury (TBI) is a major cause of adverse outcomes. There are many gaps in TBI research and a lack of therapy to limit debilitating outcomes in TBI or enhance the neurogenesis, despite pre-clinical and clinical research performed in TBI. Females show harmful outcomes against brain damage including TBI less than males, independent of different TBI occurrence. A significant reduction in secondary brain damage and improvement in neurologic outcome post-TBI has been reported following the use of progesterone and estrogen in many experimental studies. Although useful features of sex steroids including progesterone have been identified in TBI clinical trials I and II, clinical trials III have been unsuccessful. This review article focuses on evidence of secondary injury mechanisms and neuroprotective effects of estrogen and progesterone in TBI. Understanding these mechanisms may enable researchers to achieve greater success in TBI clinical studies. It seems that the design of clinical studies should be revised due to translation loss of animal studies to clinical studies. The heterogeneous and complex nature of TBI, the endogenous levels of sex hormones at the time of taking these hormones, the therapeutic window of the drug, the dosage of the drug, the selection of appropriate targets in evaluation, the determination of responsive population, gender and age based on animal studies should be considered in the design of TBI human studies in future.

Is a stepdown unit safe for patients with mild traumatic intracranial hemorrhages?

PURPOSE

Traumatic brain injuries (TBIs) are a major source of disability in the United States. The ideal unit in the hospital for patients with mild traumatic intracranial hemorrhages (ICHs) has not been elucidated. We sought to investigate whether patients treated in the surgical stepdown area had worse outcomes than those treated in the surgical ICU.

METHODS

We compared patients with ICHs and a Glasgow Coma Scale (GCS) upon admission of 14 or 15 who went to the ICU to those who went to the stepdown area from April 2014 to November 2016. We compared age, gender, Injury Severity Score (ISS), admission GCS (14 or 15), operative intervention, discharge destination, hospital length of stay (HLOS), mortality, and cost between these two groups.

RESULTS

Patients admitted to the ICU had a significantly longer HLOS. Admission costs for patients admitted to ICU were also significantly higher than their stepdown area counterparts. This was true for both total charges (p = 0.0001) and for net revenue (p = 0.002) (Table 2). There was no statistically significant difference in mortality, operative intervention, or discharge destination.

CONCLUSION

A surgical stepdown unit can be a safe disposition for patients with mild traumatic ICHs and represents an effective use of hospital resources.

Estrogens as neuroprotectants: Estrogenic actions in the context of cognitive aging and brain injury

There is ample empirical evidence to support the notion that the biological impacts of estrogen extend beyond the gonads to other bodily systems, including the brain and behavior. Converging preclinical findings have indicated a neuroprotective role for estrogen in a variety of experimental models of cognitive function and brain insult. However, the surprising null or even detrimental findings of several large clinical trials evaluating the ability of estrogen-containing hormone treatments to protect against age-related brain changes and insults, including cognitive aging and brain injury, led to hesitation by both clinicians and patients in the use of exogenous estrogenic treatments for nervous system outcomes. That estrogen-containing therapies are used by tens of millions of women for a variety of health-related applications across the lifespan has made identifying conditions under which benefits with estrogen treatment will be realized an important public health issue. Here we provide a summary of the biological actions of estrogen and estrogen-containing formulations in the context of aging, cognition, stroke, and traumatic brain injury. We have devoted special attention to highlighting the notion that estrogen appears to be a conditional neuroprotectant whose efficacy is modulated by several interacting factors. By developing criteria standards for desired beneficial peripheral and neuroprotective outcomes among unique patient populations, we can optimize estrogen treatments for attenuating the consequences of, and perhaps even preventing, cognitive aging and brain injury.

Comparable impediment of cognitive function in female and male rats subsequent to daily administration of haloperidol after traumatic brain injury

Antipsychotic drugs, such as haloperidol (HAL), are prescribed in the clinic to manage traumatic brain injury (TBI)-induced agitation. While preclinical studies have consistently shown that once-daily administration of HAL hinders functional recovery after TBI in male rats, its effects in females are unknown. Hence, the objective of this study was to directly compare neurobehavioral and histological outcomes in both sexes to determine whether the reported deleterious effects of HAL extend to females. Anesthetized adult female and male rats received either a controlled cortical impact (CCI) or sham injury and then were randomly assigned to a dosing regimen of HAL (0.5mg/kg, i.p.) or vehicle (VEH; 1mL/kg, i.p.) that was initiated 24h after injury and continued once daily for 19 consecutive days. Motor function was tested using established beam-balance/walk protocols on post-operative days 1-5 and acquisition of spatial learning was assessed with a well-validated Morris water maze task on days 14-19. Cortical lesion volume was quantified at 21days. No statistical differences were revealed between the HAL and VEH-treated sham groups and thus they were pooled for each sex. HAL only impaired motor recovery in males (p<0.05), but significantly diminished spatial learning in both sexes (p<0.05). Females, regardless of treatment, exhibited smaller cortical lesions vs VEH-treated males (p<0.05). Taken together, the data show that daily HAL does not prohibit motor recovery in females, but does negatively impact cognition. These task-dependent differential effects of HAL in female vs male rats may have clinical significance as they can direct therapy.

Does sex matter? Effects on venous thromboembolism risk in screened trauma patients

BACKGROUND

Sex is associated with disparate risk of venous thromboembolism (VTE) in nontrauma patients, with increased risk seen during pregnancy and in women on hormone-containing medications. Sex effects on VTE after trauma are unclear. Some studies have demonstrated no effect whereas others have instead shown a higher incidence of VTE among men. We hypothesized that male sex would increase the risk of VTE across all age groups in trauma patients undergoing standardized duplex screening.

METHODS

All admissions to a Level I academic trauma center 2000 to 2014 were reviewed. We excluded patients for age <18 years, pregnancy, pre-admission anticoagulant use, and hospital length of stay (LOS) <72 hours. A strict venous duplex screening protocol was followed. Female patients were subcategorized into pre- and post-menopausal groups based on age (18-44 vs. ≥ 55 years). Bivariate analysis and logistic regression were used to identify variables correlating with VTE risk.

RESULTS

A total of 8,726 patients met inclusion criteria. The overall VTE rate was 5.3%. Bivariate analysis did not find a difference in VTE risk by sex (5.1% women vs. 5.4% men, p = 0.565), or between women and men within age-defined menopausal categories (pre-menopausal women 3.9% vs. men 4.7%, p = 0.293; post-menopausal women 5.9% vs. men 7.0%, p = 0.22). Logistic regression (see figure) did identify other risk factors for VTE including age ≥55 (adjusted odds ratio [AOR] 2.0), increasing ISS (AOR 1.5-2.1), penetrating mechanism of injury (AOR 2.2), lower extremity injury (AOR 1.7), need for mechanical ventilation (AOR 2.1), and increasing hospital length of stay (LOS 7-28 days, AOR 3.8; LOS > 28 days, AOR 9.1).

CONCLUSION

There was no difference in VTE rates based on patient sex, even after controlling for menopausal status. Aggressive VTE screening of over 8,700 patients did identify several other patient populations at increased risk of developing VTE. More intensive VTE prophylaxis may be appropriate in these patients.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level V.

Sex-based differences in outcomes after severe injury: an analysis of blunt trauma patients in China

BACKGROUND

Experimental research suggests that females have a higher survival rate after trauma, although this claim is controversial. This study sought to determine the role of sex on mortality among trauma patients in China.

METHODS

The study enrolled 1789 trauma patients who visited the Emergency Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University during 2015 and 2016. A retrospective data analysis was performed to determine sex-based differences after blunt trauma. Patients were stratified by age and injury severity (using the Injury Severity Score). Multiple logistic regression was used to analyze the association between sex and post-injury complications and mortality.

RESULTS

Female trauma patients experienced a significantly lower risk of mortality than males (odds ratio, 0.931; 95% confidence interval, 0.883-0.982). This survival advantage of females was particularly notable in the 'younger than 45 years' age group. Sex-based differences were also found in the occurrence of life-threatening complications after trauma.

CONCLUSION

This study demonstrated that females are more likely to survival after severe blunt trauma and also have less inpatient complications than men, suggesting an important role for sex hormones after severe traumatic injury.

Influence of gender on systemic IL-6 levels, complication rates and outcome after major trauma

BACKGROUND

While female gender was associated with lower rates of systemic inflammatory response syndrome (SIRS), sepsis and single and/or multiple organ failure (MOF), contradictory data suggest no correlation between gender and complication rates and/or outcome in trauma patients (TP). Here, we analyzed the gender influence on systemic interleukin (IL)-6 levels and outcome in TP.

PATIENTS/METHODS

343 TP with injury severity scores (ISS) ≥16 were included upon admittance to the emergency department (ED) and grouped to male (n=257) vs. female (n=86). Injury severity, vital signs, physiological parameters, length of intensive care unit (ICU) and in-hospital stay, outcome parameters including SIRS, sepsis, respiratory complications, single- and/or MOF and in-hospital mortality were analyzed. Systemic IL-6 levels during the first 10 post-injury days were determined daily.

RESULTS

Age (45.0±1.0 vs. 48.2±2.1) and ISS (27.1±0.8 vs. 24.7±1.2) were comparable between both groups. Abbreviated Injury Scale (AIS) ≥3 of chest and abdominal body regions were significantly higher in male TP (chest:51.02% vs. 36.05%, abdomen:19.84% vs. 10.47%, p<0.05). IL-6 was significantly increased in male TP on post-injury days 1 and 2 (d1:363.9±72.58 vs. 163.7±25.98; d2:194.3±31.38 vs. 114.3±17.81pg/ml, p<0.05). Multivariate analysis excluded an association of increased chest or abdominal injury occurrence with IL-6 levels. Female vs. male TP had significantly lower SIRS and sepsis occurrence (SIRS:40.70% vs. 53.31%, sepsis:6.98% vs. 19.46%, p<0.05). There were no gender-based differences regarding ICU or in-hospital stay, single and/or MOF and respiratory complications.

CONCLUSIONS

Taken together, higher systemic IL-6 levels after trauma are associated with enhanced susceptibility for SIRS and sepsis in male patients.

Unplanned intensive care unit admission following trauma

BACKGROUND

The prevalence and outcomes of trauma patients requiring an unplanned return to the intensive care unit (ICU) and those initially admitted to a step-down unit or floor and subsequently upgraded to the ICU, collectively termed unplanned ICU (UP-ICU) admission, are largely unknown.

METHODS

A retrospective review of the trauma registry of a suburban regional trauma center was conducted for adult patients who were admitted between 2007 and 2013, focusing on patients requiring ICU admission. Prehospital or emergency department intubations and patients undergoing surgery immediately after emergency room evaluation were excluded.

RESULTS

Of 5411 admissions, there were 212 UP-ICU admissions, 541 planned ICU (PL-ICU) admissions, and 4658 that were never admitted to the ICU (NO-ICU). Of the 212 UP-ICU admits, 19.8% were unplanned readmissions to the ICU. Injury Severity Score was significantly different between PL-ICU (16), UP-ICU (13), and NO-ICU (9) admits. UP-ICU patients had significantly more often major (Abbreviated Injury Score ≥ 3) head/neck injury (46.7%) and abdominal injury (9.0%) than the NO-ICU group (22.5%, 3.4%), but significantly less often head/neck (59.5%) and abdominal injuries (17.9%) than PL-ICU patients. Major chest injury in the UP-ICU group (27.8%) occurred at a statistically comparable rate to PL-ICU group (31.6%) but more often than the NO-ICU group (14.7%). UP-ICU patients also significantly more often underwent major neurosurgical (10.4% vs 0.7%), thoracic (0.9% vs 0.1%), and abdominal surgery (8.5% vs 0.4%) than NO-ICU patients. Meanwhile, the PL-ICU group had statistically comparable rates of neurosurgical (6.8%) and thoracic surgical (0.9%) procedures but lower major abdominal surgery rate (2.0%) than the UP-ICU group. UP-ICU admission occurred at a median of 2 days following admission. UP-ICU median hospital LOS (15 days), need for mechanical ventilation (50.9%), and in-hospital mortality (18.4%) were significantly higher than those in the PL-ICU (9 days, 13.9%, 5.4%) and NO-ICU (5 days, 0%, 0.5%) groups.

CONCLUSIONS

UP-ICU admission, although infrequent, was associated with significantly greater hospital length of stay, rate of major abdominal surgery, need for mechanical ventilation, and mortality rates than PL-ICU and NO-ICU admission groups.

Outcome and Predicting Factor Following Severe Traumatic Brain Injury: A Retrospective Cross-Sectional Study

INTRODUCTION

Severe traumatic brain injury (TBI) is a major and challenging problem in critical care medicine.

AIM

To assess the outcome and predicting factor following severe TBI.

MATERIALS AND METHODS

This is a retrospective and cross-sectional study. Data were collected from two sections; one section consisting of a questionnaire answered by the patients and other section from the patient records. The instruments used included the Glasgow Outcome Scale (GOS), SF-36 and the Hospital Anxiety and Depression Scale (HAD).

RESULTS

The mortality rate of the patients was 46.2%. The quality of life (QOL) of the patients in most dimension were impaired and (58%) of patients had unfavourable QOL. About (37.5%) of patients with anxiety and (27.5%) had a depression. A significant correlation was found between age, GCS arrival, length of ICU stay, mechanical ventilation, VAP & ARDS and pupil reactivity with QOL, GOS, HAD-A and HAD-D (p<0.05, p< 0.001). GCS arrival a predicate factor for QOL and GOS (p <0.001, OR: 1.75, 1.94 respectively); length of ICU stay a predicate factor for QOL and GOS (p <0.05, OR : 1.11, 1.28 respectively); mechanical ventilation a predicate factor for GOS (p <0.001, OR : 1.78); ventilation associated pneumonia (VAP) & acute respiratory distress syndrome (ARDS) and pupil reactivity a predicate factor for GOS (p <0.05, OR : 1.36; p<0.001, OR: 1.94 respectively). The GCS arrival and ICU stay a predicate factor for HAD-A (p<0.05, OR: 1.73, 1.38 respectively).

CONCLUSION

With respect to results advanced in pre hospital, medical and surgical care for the decrease in mortality rates of Head trauma (HT), the use of trauma triage tools and strict enforcement of traffic rules are necessary.

Do male and female trauma patients receive the same prehospital care?: an observational follow-up study

BACKGROUND

Trauma-related mortality can be lowered by efficient prehospital care. Less is known about whether gender influences the prehospital trauma care provided. The aim of this study was to explore gender-related differences in prehospital trauma care of severely injured trauma patients, with a special focus on triage, transportation, and interventions.

METHODS

We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County, Sweden. A total of 383 trauma patients (279 males and 104 females) > 15 years of age with an Injury Severity Score (ISS) of > 15 transported to emergency care hospitals in the Stockholm area were included.

RESULTS

Male patients had a 2.75 higher odds ratio (95 % CI, 1.2-6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. No significant difference between genders was detected regarding other aspects of the prehospital care provided.

CONCLUSIONS

This study indicated that prehospital prioritization among severely injured late adolescent and adult trauma patients differs between genders. Knowledge of a more diffuse presentation of symptoms in female trauma patients despite severe injury may help to adapt and improve prehospital trauma care for this group.

Pathogenesis of infection in surgical patients

Purpose of review

Despite the application of prophylactic antimicrobial therapy and advanced technologies, infection remains one of the most common causes of morbidity and mortality in surgical patients. Understanding the pathogenesis of surgical infection would offer new insights into the development of biomarkers to predict and stratify infection in patients, and to explore specific strategies to minimize this serious postoperative complication.

Recent findings

The acute nonspecific inflammatory response triggered by endogenous danger signals evoked by surgical insult is beneficial, while paradoxically associated with reduced resistance to infection. There is growing evidence indicating that primed inflammation by surgical insult exaggerates the dysregulation of the immune-inflammatory response to the invasion of pathogens postoperatively. Innate immune receptors, such as Toll-like receptors (TLRs), contribute to detecting both pathogen-associated molecular patterns and endogenous damage-associated molecular patterns, and to further amplifying inflammatory responses to infection. Current evidence shows the fascinating role of non-TLRs in the process of infection. Non-TLRs, such as membrane-associated triggering receptor expressed on myeloid cells family, cytosolic nucleotide-binding oligomerization domain-like receptors and nuclear receptor nuclear family 4 subgroup A receptors, are also crucial in triggering the immune responses and mounting an effective defense against surgical insults and the second hit of infection.

Summary

Understanding the pivotal role of non-TLRs in sensing exogenous and endogenous molecules, and the influence of primed systemic inflammation and depressed immune status on the defense against pathogen after surgical insult, would be helpful to fully explore the relevant sophisticated phenomena of surgical infection, and to elucidate the occurrence of heterogeneous constellations of clinical signs and symptoms among this special population.

The influence of sex on outcomes in trauma patients: a meta-analysis

BACKGROUND

This study aims to assess the influence of sex on outcomes among trauma patients, including injury severity, medical resource utility, complications, and mortality.

METHODS

A systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes between male and female injured patients.

RESULTS

Eventually, 19 studies met our inclusion criteria with 100,566 men and 39,762 women. Pooled data revealed that male sex was associated with increased risk of mortality, hospital length of stay, and higher incidence of complications. No difference was detected in injury severity between male and female patients.

CONCLUSION

Evidence of this meta-analysis strongly supports the sex dimorphism in the prognosis of trauma patients and further work should be done to decipher potential mechanism.

Increased mortality in adult patients with trauma transfused with blood components compared with whole blood

Hemorrhage is a preventable cause of death among patients with trauma, and management often includes transfusion, either whole blood or a combination of blood components (packed red blood cells, platelets, fresh frozen plasma). We used the 2009 National Trauma Data Bank data set to evaluate the relationship between transfusion type and mortality in adult patients with major trauma (n = 1745). Logistic regression analysis identified 3 independent predictors of mortality: Injury Severity Score, emergency medical system transfer time, and type of blood transfusion, whole blood or components. Transfusion of whole blood was associated with reduced mortality; thus, it may provide superior survival outcomes in this population.

Gender differences in outcome and use of resources do exist in Swedish intensive care, but to no advantage for women of premenopausal age

INTRODUCTION

Preclinical data indicate that oestrogen appears to play a beneficial role in the pathophysiology of and recovery from critical illness. In few previous epidemiologic studies, however, have researchers analysed premenopausal women as a separate group when addressing potential gender differences in critical care outcome. Our aim was to see if women of premenopausal age have a better outcome following critical care and to investigate the association between gender and use of intensive care unit (ICU) resources.

METHODS

On the basis of our analysis of 127,254 consecutive Simplified Acute Physiology Score III-scored Swedish Intensive Care Registry ICU admissions from 2008 through 2012, we determined the risk-adjusted 30-day mortality, accumulated nurse workload score and ICU length of stay. To investigate associations with sex, we used logistic regression and multivariate analyses on the entire cohort as well as on two subgroups stratified by median age for menopause (up to and including 45 years and older than 45 years) and six selected diagnostic subgroups (sepsis, multiple trauma, chronic obstructive pulmonary disease, acute respiratory distress syndrome, pneumonia and cardiac arrest).

RESULTS

There was no sex difference in risk-adjusted mortality for the cohort as a whole, and there was no sex difference in risk-adjusted mortality in the group 45 years of age and younger. For the group of patients older than 45 years of age, we found a reduced risk-adjusted mortality in men admitted for cardiac arrest. For the cohort as a whole, and for those admitted with multiple trauma, male sex was associated with a higher nurse workload score and a longer ICU stay.

CONCLUSIONS

Using information derived from a large multiple ICU register database, we found that premenopausal female sex was not associated with a survival advantage following intensive care in Sweden. When the data were adjusted for age and severity of illness, we found that men used more ICU resources per admission than women did.