Incidence and etiology of mortality in polytrauma patients in a Dutch level I trauma center

Injury characteristics and mortality in an emergency department in Ethiopia: a single-center observational study

INTRODUCTION

An injury is described as any damage to the body that impairs health, and its severity can span from mild to life-threatening. On a global scale, injuries account for approximately 4.4 million deaths annually and are anticipated to become the seventh leading cause of death by 2030. In Ethiopia, injuries account for 7% of all deaths, with one of the world's highest rates of road traffic injuries. This study, undertaken at a primary trauma centre in the capital of Ethiopia, aimed to explore the characteristics of injured patients and emergency department mortality as the patient outcome. Understanding the patterns and outcomes of injuries helps to anticipate needs, prioritize patients, and allocate resources effectively.

METHODS

A retrospective single-center observational study utilised patient records from September 2020 to August 2021 at Addis Ababa Burn Emergency and Trauma Hospital, located in Ethiopia. A structured checklist facilitated the data collection. All patients arriving in the ED from September 2020 to August 2021 were eligible for the study while incomplete records (missing > 20% of wanted data elements) were excluded.

RESULT

Of the 3502 injured patients recorded during the study period, 317 were selected. The mean patient age was 30 years, with 78.5% being male. About 8% arrived the emergency department within an hour after the injury. Ambulances transported 38.8% of patients; 58.5% of these were referred from other facilities. The predominant mechanism of injury both in and outside Addis Ababa was pedestrian road traffic injuries (31.4% and 38%). The predominant injury type was fractures (33.8%). The mortality rate was 5%, of which half were pedestrian road traffic incidents.

CONCLUSION

Pedestrian road traffic injuries were the main cause of injury in and outside of Addis Ababa. A small proportion of patients arrived at the emergency department within the first hour after an injury event. A significant proportion of ambulance-transported patients were referred from other facilities rather than directly from the scene. The overall mortality rate was high, with pedestrian road traffic injury accounting for half of the proportion.

The paediatric polytrauma CT-indication (PePCI)-score-Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients

BACKGROUND

Whole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients.

METHODS

A retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients' symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model.

RESULTS

Multiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores.

CONCLUSION

With the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.

Parameters influencing health-related quality of life after severe trauma: a systematic review (part II)

INTRODUCTION

It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma.

METHODS

The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner.

RESULTS

A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability.

CONCLUSION

Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

Early correction of base deficit decreases late mortality in polytrauma

INTRODUCTION

Physiology-driven resuscitation has become the standard of care in severely injured patients. This has resulted in a decrease in acute deaths by hemorrhagic shock. With increased survival from hemorrhage, focus shifts towards death later during hospital stay. This population based cohort study investigated the association of initial physiology derangement correction and (late) mortality.

METHODS

Consecutive polytrauma patients aged > 15 years with deranged physiology who were admitted to a level-1 trauma center intensive care unit (ICU) from 2015 to 2021, and requiring surgical intervention < 24 h were included. Patients who acutely (< 48 h) died were excluded. Demographics, treatment, and outcome parameters were analyzed. Physiology was monitored by serial base deficits (BD) during the first 48 h. Correction of physiology was defined as BD return to normal values. Area under the curve (AUC) of BD in time was used as measurement for the correction of physiological derangement and related to mortality 3-6 days (early), and > 7 days (late).

RESULTS

Two hundred thirty-five patients were included with a median age of 44 years (70% male), and Injury Severity Score (ISS) of 33. Mortality rate was 16% (71% due to traumatic brain injury (TBI)). Median time to death was 11 (6-17) days; 71% died > 7 days after injury. There was no difference between the single base deficit measurements in the emergency department(ED), operating room (OR), nor ICU between patients who died and those who did not. However, patients who later died were more acidotic at 24 and 48 h after arrival, and had a higher AUC of BD in time. This was independent of time and cause of death.

CONCLUSION

Early physiological restoration based on serial BD measurements in the first 48 h after injury decreases late mortality.

Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets

INTRODUCTION

The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase.

METHODS

We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly.

RESULTS

The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively.

CONCLUSIONS

In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

Recommendations for Placement of Bleeding Control Kits in Public Spaces-A Simulation Study

OBJECTIVE

Bleeding control measures performed by members of the public can prevent trauma deaths. Equipping public spaces with bleeding control kits facilitates these actions. We modeled a mass casualty incident to investigate the effects of public bleeding control kit location strategies.

METHODS

We developed a computer simulation of a bomb exploding in a shopping mall. We used evidence and expert opinion to populate the model with parameters such as the number of casualties, the public's willingness to aid, and injury characteristics. Four alternative placement strategies of public bleeding control kits in the shopping mall were tested: co-located with automated external defibrillators (AEDs) separated by 90-second walking intervals, dispersed throughout the mall at 10 locations, located adjacent to 1 exit, located adjacent to 2 exits.

RESULTS

Placing bleeding control kits at 2 locations co-located with AEDs resulted in the most victims surviving (18.2), followed by 10 kits dispersed evenly throughout the mall (18.0). One or 2 kit locations placed at the mall's main exits resulted in the fewest surviving victims (15.9 and 16.1, respectively).

CONCLUSIONS

Co-locating bleeding control kits with AEDs at 90-second walking intervals results in the best casualty outcomes in a modeled mass casualty incident in a shopping mall.

Effect of Injury Patterns on the Development of Complications and Trauma-Induced Mortality in Patients Suffering Multiple Trauma

Patients that suffer from severe multiple trauma are highly vulnerable to the development of complications that influence their outcomes. Therefore, this study aimed to evaluate the risk factors that can facilitate an early recognition of adult patients at risk. The inclusion criteria were as follows: admission to a level 1 trauma center, injury severity score (ISS) ≥ 16 (severe injury was defined by an abbreviated injury score (AIS) ≥ 3) and ≥18 years of age. Injury- and patient-associated factors were correlated with the development of four complication clusters (surgery-related, infection, thromboembolic events and organ failure) and three mortality time points (immediate (6 h after admission), early (>6 h-72 h) and late (>72 h) mortality). Statistical analysis was performed using a Chi-square, Mann-Whitney U test, Cox hazard regression analysis and binominal logistic regression analysis. In total, 383 patients with a median ISS of 24 (interquartile range (IQR) 17-27) were included. The overall mortality rate (27.4%) peaked in the early mortality group. Lactate on admission significantly correlated with immediate and early mortality. Late mortality was significantly influenced by severe head injuries in patients with a moderate ISS (ISS 16-24). In patients with a high ISS (≥25), late mortality was influenced by a higher ISS, older age and higher rates of organ failure. Complications were observed in 47.5% of all patients, with infections being seen most often. The development of complications was significantly influenced by severe extremity injuries, the duration of mechanical ventilation and length of ICU stay. Infection remains the predominant posttraumatic complication. While immediate and early mortality is mainly influenced by the severity of the initial trauma, the rates of severe head injuries influence late mortality in moderate trauma severity, while organ failure remains a relevant factor in patients with a high injury severity.

Do Patients with Diabetes Mellitus and Polytrauma Continue to Have Worse Outcomes?

The management of patients with multiple injuries remains challenging. Patients presenting with comorbidities, such as diabetes mellitus, may have additional unpredictable outcomes with increased mortality. Therefore, we aim to investigate the impact of major trauma centres in the UK on the outcomes of polytrauma patients with diabetes. The Trauma Audit and Research Network was used to identify polytrauma patients presenting to centres in England and Wales between 2012 and 2019. In total, 32,345 patients were thereby included and divided into three groups: 2271 with diabetes, 16,319 with comorbidities other than diabetes and 13,755 who had no comorbidities. Despite an overall increase in diabetic prevalence compared to previously published data, mortality was reduced in all groups, but diabetic patient mortality remained higher than in the other groups. Interestingly, increasing Injury Severity Score (ISS) and age were associated with increasing mortality, whereas the presence of diabetes, even when taking into consideration age, ISS and Glasgow Coma Score, led to an increase in the prediction of mortality with an odds ratio of 1.36 (p < 0.0001). The prevalence of diabetes mellitus in polytrauma patients has increased, and diabetes remains an independent risk factor for mortality following polytrauma.

Incidence and predictors of mortality among adult trauma patients admitted to the intensive care units of comprehensive specialized hospitals in Northwest Ethiopia

BACKGROUND

Trauma is the leading cause of morbidity and mortality among adult population in the world. Despite many improvements in technology and care, mortality among trauma patients in the intensive care unit is still high particularly in Ethiopia. However, there is limited evidence on the incidence and predictors of mortality among trauma patients in Ethiopia. Therefore, this study aimed to assess the incidence and predictors of mortality among adult trauma patients admitted to intensive care units.

METHODS

Institutional-based retrospective follow-up study was conducted from January 9, 2019 to January 8, 2022. A total of 421 samples were chosen using simple random sampling. Data were collected with Kobo toolbox software and exported to STATA version 14.1 software for data analysis. Kaplan-Meier failure curve and log-rank test were fitted to explore the survival difference among groups. After the bivariable and multivariable Cox regression analysis, an Adjusted Hazard Ratio (AHR) with 95% Confidence Intervals (CI) was reported to declare the strength of association and statistical significance, respectively.

RESULT

The overall incidence rate of mortality was 5.47 per 100 person-day observation with a median survival time of 14 days. Did not get pre-hospital care (AHR = 2.00, 95%CI 1.13, 3.53), Glasgow Coma Scale (GCS) score < 9 (AHR = 3.89, 95%CI 1.67, 9.06), presence of complications (AHR = 3.71, 95%CI 1.29, 10.64), hypothermia at admission (AHR = 2.11, 95%CI 1.13, 3.93) and hypotension at admission (AHR = 1.93, 95%CI 1.01, 3.66) were found significant predictors of mortality among trauma patients.

CONCLUSION

The incidence rate of mortality among trauma patients in the ICU was high. Did not get pre-hospital care, GCS < 9, presence of complications, hypothermia, and hypotension at admission were significant predictors of mortality. Therefore, healthcare providers should give special attention to trauma patients with low GCS scores, complications, hypotension, and hypothermia and better to strengthen pre-hospital services to reduce the incidence of mortality.

Evidence-Based Pearls

The challenge in caring for patients who sustain traumatic chest injuries centers on their complex needs from high acuity and the potential for multisystem effects and complications. Hemorrhage and respiratory compromise are common sequela of thoracic trauma. Patients must be resuscitated and their injuries managed with the primary goals of restoring cardiopulmonary structural integrity and preventing complications. There are evolving strategies for the management of the thoracic trauma victim including damage control resuscitation and surgery, endovascular repairs, and assessments implementing severity scores to aid in planning interventions.

Pediatric Trauma in The Netherlands: Incidence, Mechanism of Injury and In-Hospital Mortality

BACKGROUND

In the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care.

METHODS

A retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009-2018, concerning all children (0-16 years) hospitalized due to injury in the Netherlands.

RESULTS

The annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0-5 years (89.2%). Severe injury (injury severity score ≥  16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%).

CONCLUSIONS

Domestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.

5-HT3 SEROTONIN RECEPTOR BLOCKERS FOR INTENSIVE THERAPY OF TRAUMATIC DISEASE IN PATIENTS WITH MULTIPLE TRAUMA

OBJECTIVE

The aim: To find the most rational choice of drugs that have anti-emetic effect in patients with polytrauma in acute and early periods.

PATIENTS AND METHODS

Materials and methods: We examined 82 patients with polytrauma, 62 men and 20 women. The age of patients ranged from 19 to 50 years. Patients were divided into the main and control group with 36 and 46 people respectively, who did not differ significantly by sex, age, anthropometric data, the nature and severity of injuries, and the time from injury to admission to hospital.

RESULTS

Results: Full antiemetic effect was achieved in 72.4% of patients, where metoclopramide was used. Сomplete antiemetic effect was achieved in 96.3% of patients, where sturgeon was used. Decrease of peristaltic activity does not increase postoperative intestinal paresis, and also prevents irritable bowel syndrome and diarrhea caused by dysbacteriosis on the background of antibiotic therapy. Anxiolytic effect without sedative effect and impairment of motor coordination, decrease of the somatic and psychopathological symptoms intensity in alcohol-toxic withdrawal syndrome contributes to the correct interpretation of the traumatic disease.

CONCLUSION

Conclusions: Use of drugs with antiemetic effect is an important part of the complex of traumatic disease treatment in patients with polytrauma. The use of osetron is rational in patients with polytrauma with cranio-abdominal injuries.

Differences in characteristics between patients ≥ 65 and < 65 years of age with orthopaedic injuries after severe trauma

Aim

Many trauma patients have associated orthopaedic injuries at admission. The existing literature regarding orthopaedic trauma often focuses on single injuries, but there is a paucity of information that gives an overview of this group of patients. Our aim was to describe the differences in characteristics between polytrauma patients ≥ 65 and < 65 years of age suffering orthopaedic injuries.

Methods

Patients registered in the Norwegian Trauma Registry (NTR) with an injury severity score (ISS) > 15 and orthopaedic injuries, who were admitted to Haukeland University Hospital in 2016–2018, were included. Data retrieved from the patients’ hospital records and NTR were analysed. The patients were divided into two groups based on age.

Results

The study comprised 175 patients, of which 128 (73%) and 47 (27%) were aged < 65 (Group 1) and ≥ 65 years (Group 2), respectively. The ISS and the new injury severity score (NISS) were similar in both groups. The dominating injury mechanism was traffic-related and thoracic injury was the most common location of main injury in both groups. The groups suffered a similar number of orthopaedic injuries. A significantly higher proportion of Group 1 underwent operative treatment for their orthopaedic injuries than in Group 2 (74% vs. 53%). The mortality in Group 2 was significantly higher than that in Group 1 (15% vs. 3%). In Group 2 most deaths were related to traffic injuries (71%). High energy falls and traffic-related incidents caused the same number of deaths in Group 1. In Group 1 abdominal injuries resulted in most deaths, while head injuries was the primary reason for deaths in Group 2.

Conclusions

Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age. The younger age group underwent more frequently surgery for orthopaedic injuries than the elderly. There may be multiple reasons for this difference, but our study does not have sufficient data to draw any conclusions. Future studies may provide a deeper understanding of what causes treatment variation between age groups, which would hopefully help to further develop strategies to improve outcome for the elderly polytrauma patient.

Predicting mortality in trauma patients - A retrospective comparison of the performance of six scoring systems applied to polytrauma patients from the emergency centre of a South African central hospital

Introduction

Over 90% of trauma-related deaths worldwide, ensue in low- and middle-income countries. Multiple useful trauma scoring systems have been devised. Although validated in high-income countries, they cannot always be replicated in resource-limited countries. This study compares six trauma scores to identify the best-suited system to use for polytrauma patients in a hospital in Pretoria, South Africa.

Methods

This is an observational retrospective analysis of polytrauma admissions from 1 July 2016 to 31 December 2016. Data collected from patients' records from the EC of Steve Biko Academic Hospital, was analysed using Stata Release 14. Outcomes were recorded as 30-day survival, ICU– and overall hospital LOS. Scores pertaining to patient mortality, were compared in terms of sensitivity, specificity, and cut-off points based on ROC curve. Finally, for LOS Pearson correlation analysis was used.

Results

At the best calculated mortality prediction cut-points for the scores, the sensitivities and specificities were respectively 87% and 68% for TRISS, 81% and 61% for ISS, RTS yielded 81% and 60%, while for REMS it was 61% and 69%. The SI and RSI (cut-points used in agreement with the literature) produced sensitivities 58% and only 48%, and specificities of 73% and 83%, respectively.

45(41,7%) patients required ICU admission. Though the ICU LOS best correlated with ISS(r = 0.2710), the ICU LOS correlation coefficient was weak for all trauma scores. None of the scores had a significant p value for hospital LOS.

Discussion

Among the scores compared, TRISS had the highest sensitivity and NPV for mortality prediction in this South African polytrauma population. ISS correlated best with ICU LOS. However, compared to developed countries, ROC analyses & predictability of these scores fare relatively worse, and no correlation was found with hospital LOS. Therefore, we conclude that further studies are needed to ascertain a more suitable system for resource-limited settings.

Characteristics of Prehospital Death in Trauma Victims

Background: Using Injury Severity Score (ISS) data, this study aimed to give an overview of trauma mechanisms, causes of death, injury patterns, and potential survivability in prehospital trauma victims. Methods: Age, gender, trauma mechanism, cause of death, and ISS data were recorded regarding forensic autopsies and whole-body postmortem CT. Characteristics were analyzed for injuries considered potentially survivable at cutoffs of (I) ISS ≤ 75 vs. ISS = 75, (II) ISS ≤ 49 vs. ISS ≥ 50, and (III) ISS < lethal dose 50% (LD50) vs. ISS > LD50 according to Bull’s probit model. Results: In n = 130 prehospital trauma victims (45.3 ± 19.5 years), median ISS was 66. Severity of injuries to the head/neck and chest was greater compared to other regions (p < 0.001). 52% died from central nervous system (CNS) injury. Increasing injury severity in head/neck region was associated with CNS-injury related death (odds ratio (OR) 2.7, confidence interval (CI) 1.8–4.4). Potentially survivable trauma was identified in (I) 56%, (II) 22%, and (III) 9%. Victims with ISS ≤ 75, ISS ≤ 49, and ISS < LD50 had lower injury severity across most ISS body regions compared to their respective counterparts (p < 0.05). Conclusion: In prehospital trauma victims, injury severity is high. Lethal injuries predominate in the head/neck and chest regions and are associated with CNS-related death. The appreciable amount (9–56%) of victims dying at presumably survivable injury severity encourages perpetual efforts for improvement in the rescue of highly traumatized patients.

Prevalence and risk factors of acute kidney injury in polytrauma patients at Muhimbili Orthopedic Institute, Tanzania

Background

Polytrauma can lead to multi-organ dysfunction in addition to the local injuries. Acute kidney injury (AKI) is one of the most common causes and contributors to the high morbidity and mortality. Prevalence of acute kidney injury in trauma patients is as reported to be as high as 40.3%. Early detection and management leads to better outcomes. The prevalence of AKI among polytrauma patients remains unknown in our setting.

Methodology

A cross-sectional study involving all adults with polytrauma who presented at the emergency department at Muhimbili Orthopedic Institute (MOI) was designed. A score of ≥18 on the New Injury Severity Score (NISS) screening tool was used to identify polytrauma patients. The Kidney Disease Improving Global Outcomes (KDIGO) criteria was used to identify patient with polytrauma who developed acute kidney injury. Descriptive statistics were then obtained followed by hypothesis testing between variables with the chi squared test. Logistic regression models were used to determine factors associated with acute kidney injury.

Results

More than half (56.4%) of the patients were between 26 and 40 years and 92.3% of the polytrauma patients were males. Almost 2/5th (38.5%) of the polytrauma patients had acute kidney injury – half of these had stage 1 AKI, 33.3% had stage 2 AKI and the remaining 16.7% had stage 3 AKI. On multivariate logistic regression, it was found that patients who were older than 45 years (OR 8.53, CI 1.65–43.89, p = 0.01) and those patients with Systemic Inflammatory Response Syndrome (SIRS) (OR 21.83, CI 1.66–286.2, p = 0.019) had higher risk of acute kidney injury.

Conclusion

There is high prevalence of AKI among polytrauma patients. Elderly patients and those with SIRS were seen to have higher likelihood of AKI.

Neglected No More: Emerging Cellular Therapies in Traumatic Injury

Traumatic injuries are a leading cause of death and disability in both military and civilian populations. Given the complexity and diversity of traumatic injuries, novel and individualized treatment strategies are required to optimize outcomes. Cellular therapies have potential benefit for the treatment of acute or chronic injuries, and various cell-based pharmaceuticals are currently being tested in preclinical studies or in clinical trials. Cellular therapeutics may have the ability to complement existing therapies, especially in restoring organ function lost due to tissue disruption, prolonged hypoxia or inflammatory damage. In this article we highlight the current status and discuss future directions of cellular therapies for the treatment of traumatic injury. Both published research and ongoing clinical trials are discussed here.

Polytrauma Is Associated with Increased Three- and Six-Month Disability after Traumatic Brain Injury: A TRACK-TBI Pilot Study

Polytrauma and traumatic brain injury (TBI) frequently co-occur and outcomes are routinely measured by the Glasgow Outcome Scale-Extended (GOSE). Polytrauma may confound GOSE measurement of TBI-specific outcomes. Adult patients with TBI from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study had presented to a Level 1 trauma center after injury, received head computed tomography (CT) within 24 h, and completed the GOSE at 3 months and 6 months post-injury. Polytrauma was defined as an Abbreviated Injury Score (AIS) ≥3 in any extracranial region.

Univariate regressions were performed using known GOSE clinical cutoffs. Multi-variable regressions were performed for the 3- and 6-month GOSE, controlling for known demographic and injury predictors. Of 361 subjects (age 44.9 ± 18.9 years, 69.8% male), 69 (19.1%) suffered polytrauma. By Glasgow Coma Scale (GCS) assessment, 80.1% had mild, 5.8% moderate, and 14.1% severe TBI. On univariate logistic regression, polytrauma was associated with increased odds of moderate disability or worse (GOSE ≤6; 3 month odds ratio [OR] = 2.57 [95% confidence interval (CI): 1.50-4.41; 6 month OR = 1.70 [95% CI: 1.01-2.88]) and death/severe disability (GOSE ≤4; 3 month OR = 3.80 [95% CI: 2.03-7.11]; 6 month OR = 3.33 [95% CI: 1.71-6.46]). Compared with patients with isolated TBI, more polytrauma patients experienced a decline in GOSE from 3 to 6 months (37.7 vs. 24.7%), and fewer improved (11.6 vs. 22.6%). Polytrauma was associated with greater univariate ordinal odds for poorer GOSE (3 month OR = 2.79 [95% CI: 1.73-4.49]; 6 month OR = 1.73 [95% CI: 1.07-2.79]), which was conserved on multi-variable ordinal regression (3 month OR = 3.05 [95% CI: 1.76-5.26]; 6 month OR = 2.04 [95% CI: 1.18-3.42]). Patients with TBI with polytrauma are at greater risk for 3- and 6-month disability compared with those with isolated TBI. Methodological improvements in assessing TBI-specific disability, versus disability attributable to all systemic injuries, will generate better TBI outcomes assessment tools.

Predictors of Acute Mortality After Open Pelvic Fracture: Experience From 37 Patients From A Level I Trauma Center

BACKGROUND

Open pelvic fractures are caused by high-energy traumas and are accompanied by organ injuries. Despite improvements in pre-hospital care, the acute mortality rate following open pelvic fractures remains high. This study aimed to report experiences in managing open pelvic fractures, identify potential independent predictors that contribute to acute mortality in such patients, and generate a scoring formula to predict mortality rate.

METHODS

Open pelvic fracture patients managed during a 42-month period were retrospectively studied. Logistic regression analysis was used to determine predictors of acute mortality. Using the Youden index, threshold values of predictors were selected. Significant predictors were weighted to create a scoring formula. The area under the curve (AUC) was tested in this specific group.

RESULTS

The incidence of open pelvic fractures in all pelvic fractures was 4.9% (37/772), and the overall mortality rate was 21.6% (8/37). All the successfully resuscitated patients entered the reconstruction stage survived and underwent the complete treatment course. Univariate and multivariate logistic regression analyses revealed that the revised trauma score (RTS) was the single independent predictor of acute mortality. A scoring formula was generated following the statistical analysis. The probability of mortality was 0% and 100% when the score was above and below -2, respectively. This model predicted mortality with an AUC of 0.948 (95% confidence interval 0.881-1.000, P < 0.01).

CONCLUSION

The RTS may be a potential predictor of acute mortality in open pelvic fracture patients. Further work would be required to validate the clinical efficacy of the generated scoring formula.

Risk factors affecting post-traumatic acute respiratory distress syndrome development in thoracic trauma patients

Background

This study aims to investigate the risk factors affecting post-traumatic acute respiratory distress syndrome development in thoracic trauma patients.

Methods

This two-centered, retrospective study included 3,080 thoracic trauma patients (2,562 males, 518 females; mean age 33.9±19.4 years; range, 2 months to 91 years) treated between January 2005 and January 2019. Demographic characteristics, mechanisms of injury, traumatic injuries, injury severity score and new injury severity score results, treatments, comorbidities, complications, morbidity and mortality rates, and durations of hospital stay were collected. Data were used to predict the risk factors for development of post-traumatic acute respiratory distress syndrome by univariate and multivariate statistical analysis.

Results

Acute respiratory distress syndrome was detected in 81 patients. In multivariate logistic regression analysis; age, pulmonary contusion, intracranial hemorrhage, rib fracture (unilateral and four-five pieces), femur and tibia fracture, diabetes mellitus, chronic obstructive pulmonary disease, blood transfusion (≥3 units), high white blood cell count at admission, sepsis, and hepatic injury were detected as independent risk factors (p<0.05). Optimal cutoff points (sensitivity/specificity ratios) for acute respiratory distress syndrome development risk were ≥16 (79%/68%) for injury severity score, ≥27 (90%/68.7%) for new injury severity score, and ≥16,000 (75.3%/71.6%) for admission white blood cell count. New injury severity score was superior than injury severity score to predict the development of acute respiratory distress syndrome.

Conclusion

Acute respiratory distress syndrome causes significant mortality and morbidity in trauma patients. In addition to the well-known risk factors, diabetes mellitus and chronic obstructive pulmonary disease were independent risk factors. We defined a cutoff value for new injury severity score to predict post-traumatic acute respiratory distress syndrome.

The influence of arm positions on abdominal image quality of whole-body computed tomography in trauma: systematic review

PURPOSE

Whole-body computed tomography (WBCT) is the standard diagnostic method for evaluating polytrauma patients. When patients are unable to elevate their arms, the arms are placed along the body, which affects the image quality negatively. Aim of this systematic review is to evaluate the influence of below the shoulder arm positions on image quality of WBCT.

METHODS

Literature in PubMed and Scopus databases was systematically searched. Results of the papers were stratified into 4 categories: arms elevated, 1 arm up 1 arm down, arms ventrally supported, arms along the body. A qualitative analysis was performed on subjective image quality and a quantitative analysis on objective quality (image noise).

RESULTS

Eight studies were included with 1421 participants. Various studies reported significantly higher quality scores with arms elevated, compared to arms along the body. Significant differences in objective image quality were found between the arms elevated and the arms ventrally on support group. The arms ventrally supported group had a significantly higher image quality than the arms along the body group. A statistically significant difference was found in objective image quality between the 1 arm up 1 arm down and arms along the body group. No preferential below the shoulders position could be identified.

CONCLUSION

Positioning the arms alongside the body results in a poor image quality. Placing the arms on a pillow ventrally to the chest improves image quality. Interestingly, asymmetrical arm positioning has potential to improve the image quality for patients that are unable to elevate the arms.

Older polytrauma: Mortality and complications

INTRODUCTION

Older adults enduring a polytrauma have an increased mortality risk. Apart from age, the role of other predisposing factors on mortality are mainly described for the total polytrauma population. This study aimed to describe the mortality pattern of older polytrauma patients, its associated risk factors, and the role and etiology of in-hospital complications.

METHODS

An eight-year retrospective cohort was constructed from 380 polytrauma patients aged ≥65 in a Dutch level 1 trauma center and linked to the national trauma database (DTR). Demographics, injury characteristics, comorbidity, clinical characteristics, in-hospital mortality, mortality etiology and complications scored according to the Clavien-Dindo classification were analyzed. Primary outcome was the identification of risk factors associated with in-hospital mortality, followed by identification of in-hospital complications and their nature.

RESULTS

Overall in-hospital mortality was 36.3%, rising significantly with age. For patients aged ≥85 in-hospital mortality was 60.8%. Polytrauma patients aged ≥75 showed a peak of late-onset deaths one week following trauma. Age, a Glasgow coma score ≤8, coagulopathy, acidosis, injury severity score and the presence of a large subdural hematoma were significant risk factors influencing in-hospital mortality. Respiratory failure was the most prevalent severe and fatal complication. The proportion of fatal complications grew significantly with age (p < 0.01).

CONCLUSIONS

Age is strongly associated with in-hospital mortality in polytraumatized elderly. Coagulopathy, acidosis, a low Glasgow coma score, presence of a large subdural hematoma and injury severity score were independently of age associated with an increased mortality. Patients older than 75 years showed a unique trimodal distribution of mortality with a late onset one week following the initial trauma. Elderly were more susceptible for fatal complications. Respiratory failure was the most prevalent severe and fatal complication. Aggressive monitoring and treatment of the pulmonary status is therefore of utmost importance.

Severe blunt trauma in Finland and Estonia: comparison of two regional trauma repositories

Purpose

Evolving trauma system of Estonia has undergone several reforms; however, performance and outcome indicators have not been benchmarked previously. Thus, we initiated a baseline study to compare demographics, management and outcomes of severely injured patients between Southern Finland and Northern Estonia utilizing regional trauma repositories.

Methods

A comparison of data fields of the Helsinki University Hospital trauma registry (HTR) and trauma registry at the North Estonia Medical Centre in Tallinn (TTR) between 1/1/2015 and 31/12/2016 was performed. The inclusion criterion was Injury Severity Score > 15. Transferred patients, patients with penetrating injuries, and pediatric patients were excluded. The data for comparison included demographics, Trauma Score-Injury Severity Score (TRISS), mortality, and standardized mortality ratio (SMR). Primary outcome was mortality and SMR per TRISS methodology.

Results

During the 2-year study period, 324 patients from the HTR and 152 from the TTR were included. Demographic profile was similar between the repositories with the exception of severe abdominal injuries being more prevalent at the TTR (25.0% vs. 13.3%, p = 0.002). Predominant injury mechanism was non-ground level fall in both repositories. Mortality was similar at 14.5% and 13.6% at the TTR and HTR, respectively (adj. p = 0.762; OR 1.13, 95% CI 0.64–1.99). SMR was lower at the HTR compared to the TTR (0.65 vs. 0.77, p > 0.05), however, the difference did not reach statistical significance.

Conclusion

Benchmarking trauma repositories at a national level provides opportunities for quality and performance improvements. We observed comparable demographic profile and outcome indicators in the compared regional trauma systems.

Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea

Objective

To investigate the effects of trauma center establishment on the clinical characteristics and outcomes of trauma patients with traumatic brain injury (TBI).

Methods

We enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.

Results

Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICU) admissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.

Conclusion

We confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary.

Organ donation in trauma victims: A systematic review and meta-analysis

BACKGROUND

Although trauma patients represent a large pool of potential organ donors (PODs), the donor conversion rates (DCRs) in this population are unclear. Our primary objective was to synthesize published evidence on DCRs in trauma patients. As a secondary objective, we investigated factors that affect organ donation (OD) in the trauma population.

METHODS

We searched four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) and gray literature for articles on OD in trauma patients (PROSPERO 2017: CRD42017070388). Articles were excluded if it was not possible to calculate the DCR (actual organ donors divided by PODs). We pooled DCRs and performed subgroups analysis by trauma subpopulation, patients' age, and study publication date.

RESULTS

We identified 27 articles with a total of 123,142 participants. Cohorts ranged in size from 28 to 120,512 patients (median, 132), with most studies performed in the United States. Conversion rates among individual studies ranged from 14.0% to 75.2% (median, 49.3%). All 27 studies were included in the meta-analysis. We found a pooled DCR of 48.1% using the random effects model. There was a high level of heterogeneity between studies (I = 97.4%). Upon subgroup analysis, we found DCRs were higher in head trauma patients compared with traumatic cardiac arrest patients (45.3% vs 20.9%, p < 0.001), in pediatric patients compared with adults (61.0% vs 38.0%, p = 0.018), and in studies published after 2007 compared with those published before (50.8% vs 43.9%, p < 0.001). Few studies assessed for factors associated with OD in trauma patients.

CONCLUSIONS

We found variation in DCRs among trauma patients (range, 14.0-75.2%) and estimated a pooled DCR of 48.1%. Our results are limited by heterogeneity across studies, which may be attributable to differences in study design and population, definitions of a POD, and in the institutional criteria and processes regarding OD.

LEVEL OF EVIDENCE

Systematic reviews and meta-analyses level III.

A Novel Approach to Identify Polytraumatized Patients in Extremis

Introduction

Due to the fact that early objective identification of polytraumatized patients in extremis is crucial for carrying out immediate life-saving measures, our objectives were to provide and scrutinize a definition that results in a particularly high mortality rate and to identify predictors of mortality in this group.

Materials and Methods

A polytraumatized patient (ISS ≥ 16) was classified “in extremis” if five out of seven parameters (arterial paCO₂ > 50 mmHg, hemoglobin < 9.5 g/dl, pH value < 7.2, lactate level > 4 mmol/l, base excess < −6 mmol/l, shock index > 1, and Horowitz index < 300) were met. By applying this definition, polytraumatized patients (age ≥ 18 years), admitted to our level I trauma center within a time period of three years, were retrospectively allocated to the “in extremis” group and to an age-, gender-, and ISS-matched “non-in extremis” group for comparison.

Results

Out of 64 polytraumatized patients (mean ISS, 43.6), who formed the “in extremis” group, 36 patients (56.3%) died, thus revealing a threefold higher mortality rate than in the matched group (18.9%). Within the “in extremis” group, age and ISS were identified as predictors of mortality.

Conclusion

Our definition might serve as a valuable early warning score or at least an impetus for defining polytraumatized patients in extremis in clinical practice.

Murine Models of Sepsis and Trauma: Can We Bridge the Gap?

Sepsis and trauma are both leading causes of death in the United States and represent major public health challenges. Murine models have largely been used in sepsis and trauma research to better understand the pathophysiological changes that occur after an insult and to develop potential life-saving therapeutic agents. Mice are favorable subjects for this type of research given the variety of readily available strains including inbred, outbred, and transgenic strains. In addition, they are relatively easy to maintain and have a high fecundity. However, pharmacological therapies demonstrating promise in preclinical mouse models of sepsis and trauma often fail to demonstrate similar efficacy in human clinical trials, prompting considerable criticism surrounding the capacity of murine models to recapitulate complex human diseases like sepsis and traumatic injury. Fundamental differences between the two species include, but are not limited to, the divergence of the transcriptomic response, the mismatch of temporal response patterns, differences in both innate and adaptive immunity, and heterogeneity within the human population in comparison to the homogeneity of highly inbred mouse strains. Given the ongoing controversy, this narrative review aims to not only highlight the historical importance of the mouse as an animal research model but also highlight the current benefits and limitations of the model as it pertains to sepsis and trauma. Lastly, this review will propose future directions that may promote further use of the model.

[Polytrauma and concomitant traumatic brain injury : The role of the trauma surgeon]

BACKGROUND

Concomitant traumatic brain injury (TBI) increases mortality and reduces quality of life of polytrauma patients. These facts demand effective treatment strategies while the growing specialization of medicine is questioning the role of the trauma surgeon in the management of these patients.

OBJECTIVES

Which factors influence outcome of polytrauma with concomitant TBI? Who should be responsible for the management of these patients and what is the limit of management?

MATERIALS AND METHODS

A literature search using Medline via PubMed was performed with Medical Subject Headings and text word search.

RESULTS

The crucial factors for outcome are absence of hypotension, adherence to pre- and in-hospital standards like fast transportation to appropriate centers, priority-based diagnostic and therapeutic strategies and strict adherence to principles of damage control surgery. Patients with polytrauma and TBI are treated by different specialties around the world based on the trauma system, geographic circumstances and resources. Investigations of operative and conservative management by different medical specialties showed comparable outcomes.

CONCLUSIONS

In an age of standardization and a high degree of specialization in the field of medicine, the trauma surgeon still seems to be able to ensure an optimal treatment of polytrauma and concomitant TBI by focusing on priority-based diagnostic and therapeutic strategies and adhering to principles of damage control surgery.