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van Eerten FJC, de Fraiture EJ, Duebel LV, Vrisekoop N, van Wessem KJP, Koenderman L, Hietbrink F. Limited impact of traumatic brain injury on the post-traumatic inflammatory cellular response. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02574-z. [PMID: 38980396 DOI: 10.1007/s00068-024-02574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/10/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Trauma triggers a systemic inflammatory cellular response due to tissue damage, potentially leading to a secondary immune deficiency. Trauma severity is quantified by the Injury Severity Score (ISS). Severe Traumatic Brain Injury (TBI) is associated with high ISSs due to high lethality, despite limited tissue damage. Therefore, ISS might overestimate the post-traumatic inflammatory cellular response. This study investigated the effect of TBI on the occurrence of different systemic neutrophil phenotypes as alternative read-out for systemic inflammation. METHODS A single-center retrospective cohort study was conducted at a level-1 trauma center. Patients aged ≥ 18 years, admitted between 01-03-2021-01-11-2022 and providing a diagnostic blood sample were included. Four groups were created: isolated TBI, isolated non-TBI, multitrauma TBI and multitrauma non-TBI. Primary outcome was occurrence of different neutrophil phenotypes determined by automated flow cytometry. Secondary outcome was infectious complications. RESULTS In total, 404 patients were included. TBI and non-TBI patients demonstrated similar occurrences of different neutrophil phenotypes. However, isolated TBI patients had higher ISSs than their isolated non-TBI controls who suffered similar post-traumatic inflammatory cellular responses. Regardless of the type of injury, patients exhibiting higher systemic inflammation had a high infection risk. CONCLUSION When TBI is involved, ISS tends to be higher compared to similar patients in the absence of TBI. However, TBI patients did not demonstrate an increased inflammatory cellular response compared to non-TBI patients. Therefore, TBI does not add much to the inflammatory cellular response in trauma patients. The degree of the inflammatory response was related to the incidence of infectious complications.
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Affiliation(s)
- F J C van Eerten
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands.
| | - E J de Fraiture
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - L V Duebel
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
- CTI Center Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - N Vrisekoop
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, Netherlands
- CTI Center Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - K J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - L Koenderman
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, Netherlands
- CTI Center Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - F Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Giles T, King K, Meakes S, Weaver N, Balogh ZJ. Traumatic rhabdomyolysis: rare but morbid, potentially lethal, and inconsistently monitored. Eur J Trauma Emerg Surg 2024; 50:1063-1071. [PMID: 38536468 DOI: 10.1007/s00068-023-02420-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/04/2023] [Indexed: 07/16/2024]
Abstract
PURPOSE Although traumatic rhabdomyolysis (TR) is shown to be associated with acute kidney injury (AKI), there are no large prospective epidemiological studies, interventional trials, official guidelines outlining the appropriate investigation, monitoring, and treatment on this poorly understood condition. We aimed to establish the contemporary epidemiology and describe current practices for TR to power future higher quality studies. We hypothesised that investigation and monitoring occur in an ad hoc fashion. MATERIAL AND METHODS We conducted a 1-year retrospective cohort study of all patients > 16 years of age, with an ISS > 12 and, admitted to a level 1 trauma centre. Demographics, initial vital signs, admission laboratory values, and daily creatinine kinase (CK) values were collected. The primary outcome was TR (defined by CK > 5000 IU), secondary outcomes included AKI (KDIGO criteria), mortality, multiple organ failure, length of stay, and need for renal replacement therapy (RRT). RESULTS 586 patients met inclusion criteria and 15 patients (2.56%) developed TR. CK testing occurred in 78 (13.1%) patients with 29 (37.7%) of these having values followed until downtrending. AKI occurred in 63 (10.8%) patients within the entire study population. Among those with TR, nine (60%) patients developed AKI. Patients with TR had higher ISS (median 29 vs 18) and mortality (26.7% vs 8.9%). DISCUSSION Whilst TR appears rare without liberal screening, it is strongly associated with AKI. Given the poor outcomes, standardised monitoring, and liberal testing of CK could be justified in trauma patients with higher injury severity. This epidemiological data can help to define study populations and power future multicentre prospective studies on this infrequent yet morbid condition.
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Affiliation(s)
- Thomas Giles
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Kate King
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Simone Meakes
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Natasha Weaver
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia.
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia.
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Hardy BM, King KL, Enninghorst N, Balogh ZJ. Trends in polytrauma incidence among major trauma admissions. Eur J Trauma Emerg Surg 2024; 50:623-626. [PMID: 36536173 DOI: 10.1007/s00068-022-02200-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Polytrauma is increasingly recognized as a disease beyond anatomical injuries. Due to population growth, centralization, and slow uptake of preventive measures, major trauma presentations in most trauma systems show a slow but steady increase. The proportional contribution of polytrauma patients to this increase is unknown. METHODS A 13-year retrospective analysis ending 31/12/2021 of all major trauma admissions (ISS > 15) to a level-1 trauma center were included. Polytrauma was classified using the Newcastle definition. Linear regression analysis was used to compare the rates of patient presentation over time. Logistic regression was used to measure for change in proportion of polytrauma. Data are presented as median (IQR), with odds ratios and 95% confidence intervals as appropriate. RESULTS 5897 (age: 49 ± 43 years, sex: 71.3% male, ISS: 20 ± 9, mortality: 10.7%) major trauma presentations were included, 1,616 (27%) were polytrauma (age: 45 ± 37 years, 72.0% male, ISS: 29 ± 14, mortality: 12.7%). Major trauma presentations increased significantly over the study period (+ 8 patients per year (3-14), p < 0.01), aged significantly (0.42 years/year (0.25-0.59, p < 0.001). The number of polytrauma presentations per year did not change significantly (+ 1 patients/year (- 1 to 4, p > 0.2). Overall unadjusted mortality did not change (OR 0.99 (0.97-1.02). Polytrauma mortality fell significantly (OR 0.96 (0.92-0.99)) over the study period. CONCLUSIONS Polytrauma patients represent about 25% of the major trauma admissions, with higher injury severity, static incidence and higher but improving mortality in comparison to all major trauma patients. Separate reporting and focused research on this group are warranted as monitoring the entire major trauma cohort does not identify these specifics of this high acuity subgroup.
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Affiliation(s)
- Benjamin Maurice Hardy
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, 2310, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | - Kate Louise King
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, 2310, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | | | - Zsolt Janos Balogh
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, 2310, Australia.
- University of Newcastle, Newcastle, NSW, Australia.
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Bihari A, McClure JA, Inculet C, Del Balso C, Vinden C, Schemitsch E, Sanders D, Lawendy AR. Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study. OTA Int 2024; 7:e333. [PMID: 38623265 PMCID: PMC11013697 DOI: 10.1097/oi9.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 12/13/2023] [Accepted: 02/16/2024] [Indexed: 04/17/2024]
Abstract
Objectives Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Design Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Setting Canadian province of Ontario. Participants Patients with tibial fracture, aged 14 years and older. Interventions Fasciotomy after tibial fracture. Main Outcomes and Measures The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. Results We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Conclusions Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.
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Affiliation(s)
- Aurelia Bihari
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | | | - Clayton Inculet
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Christopher Del Balso
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | | | - Emil Schemitsch
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - David Sanders
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Abdel-Rahman Lawendy
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
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Woo J, Choi HZ, Kang J. Intentionally self-injured patients have lower mortality when treated at trauma centers versus non-trauma centers in South Korea. Trauma Surg Acute Care Open 2024; 9:e001258. [PMID: 38779365 PMCID: PMC11110604 DOI: 10.1136/tsaco-2023-001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 04/09/2024] [Indexed: 05/25/2024] Open
Abstract
Objective This study investigated the characteristics and survival rates of patients with intentional severe trauma (self-harm or suicide) who were transported to either a regional trauma center (TC) or a non-TC facility. Methods This retrospective, national, population-based, observational, case-control study included patients who sustained intentional severe trauma and had an abnormal Revised Trauma Score at the injury site between January 2018 and December 2019. The data were a community-based severe trauma survey based on data collected from severe injury and multiple casualty patients transported by 119 emergency medical services (EMS), distributed by the Korea Disease Control and Prevention Agency. The treatment hospitals were divided into two types, TC and non-TCs, and several variables, including in-hospital mortality, were compared. Propensity score matching (PSM) was used to mitigate the influence of confounding variables on the survival outcomes. Results Among the 3864 patients, 872 and 2992 visited TC and non-TC facilities, respectively. The injury severity did not differ significantly between patients treated at TCs and non-TCs (TC, 9; non-TC, 9; p=0.104). However, compared with those treated at non-TCs, patients treated at TCs had a higher rate of surgery or transcatheter arterial embolization (14.2% vs 38.4%; p<0.001) and a higher admission rate to the emergency department (34.4% vs 60.6%; p<0.001). After PSM, 872 patients from both groups were analyzed. Patients treated at TCs exhibited a higher overall survival rate than those treated at non-TCs (76.1% vs 66.9%; p<0.001), and multiple variable logistic regression analysis demonstrated that the causes of injury and transport to the TC were significantly associated. Conclusion Using Korean EMS data, the results of this study revealed that initial transport to TCs was associated with reduced mortality rates. However, considering the limitations of using data from only 2 years and the retrospective design, further research is warranted. Study type Retrospective national, population-based observational case-control study. Level of evidence Level III.
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Affiliation(s)
- Jin Woo
- Department of Emergency Medicine, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Korea (the Republic of)
| | - Han Zo Choi
- Department of Emergency Medicine, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Korea (the Republic of)
| | - Jongkyeong Kang
- Department of Information Statistics, Kangwon National University, Chuncheon, Korea (the Republic of)
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Doran J, Salih M, Bell A, Kinsella A, Joyce D, Burke F, Moran P, Cosgrave D, Bates J, Meshkat B, Collins C, Walsh S, Soo A, Devitt A, Clarkson K, McNicholas B, Laffey J, Hussey A, Hanley C. Major trauma patients and their outcomes - A retrospective observational study of critical care trauma admissions to a trauma unit with special services. Injury 2024; 55:111622. [PMID: 38905903 DOI: 10.1016/j.injury.2024.111622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION International data describes a changing pattern to trauma over the last decade, with an increasingly comorbid population presenting challenges to trauma management and resources. In Ireland, resource provision and management of trauma is being transformed to deliver a trauma network, in line with international best practice. Our hospital plays a crucial role within this network and is designated a Trauma Unit with Specialist Services (TUSS) to distinguish it from standard trauma units. METHODS This study aims to describe the characteristics of patients and injuries and assess trends in mortality rates. It is a retrospective observational study of adult ICU trauma admissions from August 2010 to July 2021. Primary outcome was all-cause mortality at 30-days, 90-days, and 1 year. Secondary outcomes included length of stay, disposition, and complications. Patients were categorised by age, injury severity score (ISS), and mechanism of injury. RESULTS In all, 709 patients were identified for final analysis. Annual admissions doubled since 2010/11, with a trough of 41 admissions, increasing to peak at 95 admissions in 2017/18. Blunt trauma accounted for 97.6% of cases. Falls <2 m (45.4%) and RTAs (29.2%) were the main mechanisms of injury. Polytrauma comprised 41.9% of admissions. Traumatic brain injury accounted for 30.2% of cases; 18.8% of these patients were transferred to a neurosurgical centre. The majority of patients, 58.1%, were severely injured (ISS ≥ 16). Patients ≥ 65 years of age accounted for 45.7% of admissions, with falls <2 m their primary mechanism of injury. The primary outcome of all-cause mortality reduced with an absolute risk reduction (ARR) of 8.0% (95% CI: -8.37%, 24.36%), 12.9% (95% CI: -4.19%, 29.94%) and 8.2% (95% CI: -9.64%, 26.09%) for 30-day, 90-day and 1-year respectively. Regression analysis demonstrated a significant reduction in mortality for 30-days and 90-days post presentation to hospital (P-values of 0.018, 0.033 and 0.152 for 30-day, 90-day and 1-year respectively). CONCLUSION The burden of major trauma in our hospital is considerable and increasing over time. Substantial changes in demographics, injury mechanism and mortality were seen, with outcomes improving over time. This is consistent with international data where trauma systems have been adopted.
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Affiliation(s)
- Jonathan Doran
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Mohammed Salih
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Alison Bell
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Anna Kinsella
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - Diarmaid Joyce
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Fiona Burke
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Peter Moran
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - David Cosgrave
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - John Bates
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Babak Meshkat
- Department of Upper Gastrointestinal Surgery, Galway University Hospital, Galway, Ireland
| | - Chris Collins
- Department of Upper Gastrointestinal Surgery, Galway University Hospital, Galway, Ireland
| | - Stewart Walsh
- Department of Vascular and Endovascular Surgery, Galway University Hospital, Galway, Ireland
| | - Alan Soo
- Department of Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
| | - Aiden Devitt
- Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Kevin Clarkson
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland
| | - John Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland; Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland
| | - Alan Hussey
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - Ciara Hanley
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Galway, Ireland.
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Muldowney M, Liu Z, Stansbury LG, Vavilala MS, Hess JR. Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011-2021. Anesth Analg 2023; 136:927-933. [PMID: 37058729 DOI: 10.1213/ane.0000000000006388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation. METHODS We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant. RESULTS Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death. CONCLUSIONS One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.
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Affiliation(s)
- Maeve Muldowney
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Zhinan Liu
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Lynn G Stansbury
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Monica S Vavilala
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - John R Hess
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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Robertson GAJ, Marsh AG, Gill SL, Martin D, Lowe DJ, Jamal B. The influence of heatwave temperatures on fracture patient presentation to hospital. Injury 2022; 53:3163-3171. [PMID: 35810044 DOI: 10.1016/j.injury.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 06/07/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION As global warming continues at its current rate, heatwaves are likely to become an increasing phenomenon. At present, knowledge of the influence of heatwave temperatures on fracture patient presentation to hospital remains limited. METHODS This was a retrospective descriptive epidemiology study performed through hospital database review, linked to meteorological data. Emergency Department and Fracture Patient Presentation Data was obtained for the adult (16+) South Glasgow population (population count - 525,839) and the adult (16+) population covered by the West of Scotland Major Trauma Centre (population count - 2,218,326) from May 2021 to August 2021. This was combined with maximum temperature data, along with humidity and humidex data. Humidex is a measure which quantifies the temperature experienced by the patient, through a combined score incorporating both maximum temperature and humidity RESULTS: During the study period, there was one temperature heatwave (19th to 25th July), and four humidex heatwaves (27th June to 3rd July, 15th to 17th July, 19th to 27th July, 22nd to 26th August). During the temperature heatwave, there was a significantly higher incidence of orthopaedic polytrauma patient presentation (IRR 2.37: p < 0.027), as well as ED patient presentation (IRR 1.07: p < 0.036). The humidex heatwaves were associated with a significantly higher incidence of orthopaedic polytrauma patient presentation (IRR 2.31: p < 0.002) and overall fracture patient presentation (IRR 1.18: p < 0.002). Positive correlations were found between orthopaedic polytrauma patient presentation vs temperature (R=0.217: p < 0.016), ED patient presentation vs temperature (R=0.427: p < 0.001), fracture patient presentation vs temperature (R=0.394: p < 0.001), and distal radius fracture patient presentation vs temperature (R=0.246: p < 0.006). CONCLUSION This study finds that heatwave temperatures result in a significantly increased number of orthopaedic polytrauma patients presenting to a Major Trauma Centre. Given the significant resources these patients require for care, Major Trauma Centres should be aware of such findings, and consider staff and resources profiles in response.
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Affiliation(s)
- Greg A J Robertson
- Department of Orthopaedic Major Trauma Surgery, Orthopaedic post CCT Fellow, Queen Elizabeth University Hospital, 5/6 Gladstone Terrace, Glasgow, Edinburgh EH9 1LX, United Kingdom.
| | - Andrew G Marsh
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Sarah L Gill
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David Martin
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David J Lowe
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bilal Jamal
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Gebregiorgis HT, Hasan RA, Liu Z, Phuong J, Stansbury LG, Khan J, Tsang HC, Vavilala MS, Hess JR. Drivers of blood use in paediatric trauma: A retrospective cohort study. Transfus Med 2022; 32:383-393. [DOI: 10.1111/tme.12901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/29/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Hermela T. Gebregiorgis
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- University of Washington (UW) School of Pharmacy Seattle Washington USA
| | - Rida A. Hasan
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
- Department of Pediatrics UW SOM Seattle Washington USA
| | - Zhinan Liu
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
| | - Jim Phuong
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
| | - Lynn G. Stansbury
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- Department of Pediatrics UW SOM Seattle Washington USA
- Department of Anesthesiology and Pain Medicine UW SOM Seattle Washington USA
| | - Jenna Khan
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
- Transfusion Medicine Service Dartmouth Hitchcock Medical Centre Hanover New Hampshire USA
| | - Hamilton C. Tsang
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- Department of Pediatrics UW SOM Seattle Washington USA
- Department of Anesthesiology and Pain Medicine UW SOM Seattle Washington USA
| | - John R. Hess
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
- Transfusion Medicine Service Harborview Medical Centre Seattle Washington USA
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Lyons VH, Haviland MJ, Zhang IY, Whiteside LK, Arbabi S, Vavilala MS, Curatolo M, Rivara FP, Rowhani-Rahbar A. Long-Term Prescription Opioid Use After Injury in Washington State 2015-2018. J Emerg Med 2022; 63:178-191. [PMID: 36038434 DOI: 10.1016/j.jemermed.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/01/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients with injury may be at high risk of long-term opioid use due to the specific features of injury (e.g., injury severity), as well as patient, treatment, and provider characteristics that may influence their injury-related pain management. OBJECTIVES Inform prescribing practices and identify high-risk populations through studying chronic prescription opioid use in the trauma population. METHODS Using the Washington State All-Payer Claims Database (WA-APCD) data, we included adults aged 18-65 years with an incident injury from October 1, 2015-December 31, 2017. We compared patient, injury, treatment, and provider characteristics by whether or not the patients had long-term (≥ 90 days continuous prescription opioid use), or no opioid use after injury. RESULTS We identified 191,130 patients who met eligibility criteria and were included in our cohort; 5822 met criteria for long-term use. Most had minor injuries, with a median Injury Severity Score = 1, with no difference between groups. Almost all patients with long-term opioid use had filled an opioid prescription in the year prior to their injury (95.3%), vs. 31.3% in the no-use group (p < 0.001). Comorbidities associated with chronic pain, mental health, and substance use conditions were more common in the long-term than the no-use group. CONCLUSION Across this large cohort of multiple, mostly minor, injury types, long-term opioid use was relatively uncommon, but almost all patients with chronic use post injury had preinjury opioid use. Long-term opioid use after injury may be more closely tied to preinjury chronic pain and pain management than acute care pain management.
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Affiliation(s)
- Vivian H Lyons
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan; Firearm Injury & Policy Research Program, Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington
| | - Miriam J Haviland
- Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington
| | - Irene Y Zhang
- Department of Surgery, School of Public Health, University of Washington, Seattle, Washington; Surgical Outcomes Research Center, School of Public Health, University of Washington, Seattle, Washington
| | - Lauren K Whiteside
- Department of Emergency Medicine, School of Public Health, University of Washington, Seattle, Washington
| | - Saman Arbabi
- Department of Surgery, School of Public Health, University of Washington, Seattle, Washington
| | - Monica S Vavilala
- Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, School of Public Health, University of Washington, Seattle, Washington
| | - Michele Curatolo
- Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, School of Public Health, University of Washington, Seattle, Washington
| | - Frederick P Rivara
- Firearm Injury & Policy Research Program, Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington; Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington; Department of Pediatrics, School of Public Health, University of Washington, Seattle, Washington; Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Ali Rowhani-Rahbar
- Firearm Injury & Policy Research Program, Harborview Injury Prevention & Research Center, School of Public Health, University of Washington, Seattle, Washington; Department of Pediatrics, School of Public Health, University of Washington, Seattle, Washington; Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
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11
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Rau CS, Wu SC, Tsai CH, Chou SE, Su WT, Hsu SY, Hsieh CH. Association of White Blood Cell Subtypes and Derived Ratios with a Mortality Outcome in Adult Patients with Polytrauma. Healthcare (Basel) 2022; 10:healthcare10081384. [PMID: 35893206 PMCID: PMC9332442 DOI: 10.3390/healthcare10081384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background. After trauma, the subtypes of white blood cells (WBCs) in circulation and the derived neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) may undergo relative changes and reflect the patients’ immune-inflammatory status and outcome. This retrospective study was designed to investigate the relationship between these variables and the mortality outcomes in adult patients with polytrauma, which is defined as an abbreviated injury scale (AIS) score ≥ 3 in two or more different body regions. Methods. A comparison of the expression of subtypes of WBCs, NLR, MLR, and PLR upon arrival to the emergency department was performed in selected propensity score-matched patient cohorts created from 479 adult patients with polytrauma between 1 January 2015 and 31 December 2019. A multivariate logistic regression analysis was used to identify the independent risk factors for mortality. Results. There were no significant differences in monocyte, neutrophil, and platelet counts, as well as in MLR, NLR, and PLR, between deceased (n = 118) and surviving (n = 361) patients. In the propensity score-matched patient cohorts, which showed no significant differences in sex, age, comorbidities, and injury severity, deceased patients had significantly higher lymphocyte counts than survivors (2214 ± 1372 vs. 1807 ± 1162 [106/L], respectively, p = 0.036). In addition, the multivariate logistic regression analysis revealed that the lymphocyte count (OR, 1.0; 95% confidence interval [CI], 1.00–1.06; p = 0.043) was a significant independent risk factor for mortality in these patients. Conclusions. This study revealed that there was no significant difference in the counts of monocytes, neutrophils, and platelets, as well as in MLR, NLR, and PLR, between deceased and surviving patients with polytrauma. However, a significantly higher lymphocyte count may be associated with a worse mortality.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Ching-Hua Tsai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Ching-Hua Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
- Correspondence: ; Tel.: +886-7-7327476
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12
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13
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Polytrauma in the Geriatric Population: Analysis of Outcomes for Surgically Treated Multiple Fractures with a Minimum 2 Years of Follow-Up. Adv Ther 2022; 39:2139-2150. [PMID: 35294739 DOI: 10.1007/s12325-022-02109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/01/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION This study analyzed the clinical and radiological outcomes of geriatric polytrauma patients who had multiple fractures surgically treated and a minimum of 2 years of follow-up. METHODS Eighty-six geriatric patients with polytrauma and multiple fractures which were surgically treated in orthopedics and who had a minimum of 2 years of follow-up were retrospectively analyzed. Patients' demographic characteristics, comorbidities, and follow-up time were recorded. The mechanism of injury, fracture type and location, Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, duration of hospital stay, complications, and 1-year mortality were also recorded. Fracture union, implant failure, and refractures/misalignment were analyzed from radiographs. RESULTS There were 34 (39.5%) male and 52 (60.5%) female patients. Mean age was 73.5 years with an average follow-up time of 32.9 months. Patients had more low-energy traumas and more lower extremity, comminuted fractures. On the contrary, high-energy traumas and femur/pelvic fracture surgeries had higher associated mortality. The mean ISS score was 26.3. The most common ASA score was ASA 3 (75.8%). The most common clinical and radiological complications were prolonged wound drainage and implant failure. The total 1-year mortality rate was 22.1%. Patients with high ASA scores and patients with lower extremity fractures (femoral/pelvic fractures) also had significantly increased mortality rates. No significant relation was detected between mortality and ISS, fracture type, number of fractures, and duration of hospital stay. CONCLUSION Orthopedic surgeons must be alert about the possible complications of femoral fractures and comminuted fractures including pelvic girdle. Surgically treated, multifractured patients with high-energy trauma, advanced age, and high ASA scores are also at risk for mortality regardless of the ISS, comorbidities, and duration of hospital stay. Pulmonary thromboemboli must be kept in mind as a significant complication for mortality.
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14
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Alghnam S, Alghamdi M, Alzahrani S, Alzomai S, Alghannam A, Albabtain I, Alsheikh K, Bajowaiber M, Alghamdi A, Alibrahim F, Aldibasi O. The prevalence of long-term rehabilitation following motor-vehicle crashes in Saudi Arabia: a multicenter study. BMC Musculoskelet Disord 2022; 23:202. [PMID: 35241048 PMCID: PMC8895876 DOI: 10.1186/s12891-022-05153-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/23/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction In Saudi Arabia, motor-vehicle crashes (MVC) are the leading cause of disability-adjusted life years (DALYs). There is limited information locally on the magnitude and need for rehabilitation following MVC. This study examined the prevalence of MVC patients requiring long-term rehabilitation and the epidemiology of associated injuries. Methods A retrospective study was conducted at four hospitals of the National Guard Hospitals Affairs from January 2016 to March 2019. The study used data from an institutional trauma registry of all MVC admissions. Chi-square tests, bivariate and multivariate analyses were conducted to compare patients requiring long-term and short-term rehabilitation. Results The study included 506 patients. The study population was relatively young, with an average age was 32.8 ± 15.5 years, and the majority were males. Over two-thirds (71.3%) of patients required long-term rehabilitation. Half the patients sustained multiple fractures, and 17.0% sustained traumatic brain injuries. Overall, 53.1 and 61.8% of patients required occupational and physiotherapy, respectively. Those admitted to the intensive care unit were four times more likely to need long-term rehabilitation. Conclusions We found a significant burden of long-term rehabilitation following MVC. Patients were relatively young, thus posing a significant burden on future healthcare utilization. Policymakers should use these findings to guide primary, secondary, and tertiary prevention to improve health outcomes.
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Affiliation(s)
- Suliman Alghnam
- Population Health Department, King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Mashael Alghamdi
- Population Health Department, King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sarah Alzahrani
- Population Health Department, King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sufyan Alzomai
- Population Health Department, King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulah Alghannam
- Lifestyle and Health Research Center, Health Sciences Research Center , Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ibrahim Albabtain
- Department of Surgery, King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid Alsheikh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Orthopedics, King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia
| | - Miasem Bajowaiber
- National Center for Road Safety, Ministry of Transportation, Riyadh, Saudi Arabia
| | - Ali Alghamdi
- National Center for Road Safety, Ministry of Transportation, Riyadh, Saudi Arabia
| | | | - Omar Aldibasi
- Biostatistics Department, King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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15
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Liu Z, Ayyagari RC, Martinez Monegro EY, Stansbury LG, Arbabi S, Bulger EM, Vavilala MS, Hess JR. Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region. Transfusion 2021; 61:3139-3149. [PMID: 34632587 DOI: 10.1111/trf.16679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/09/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Advanced trauma care demands the timely availability of hemostatic blood products, posing special challenges for regional systems in geographically diverse areas. We describe acute trauma blood use by transfer status and injury characteristics at a large regional Level 1 trauma center. STUDY DESIGN AND METHODS We reviewed Harborview Medical Center (HMC) Trauma Registry, Transfusion Service, and electronic medical records on acute trauma patients for demographics, injury patterns, blood use, and in-hospital mortality, 2011-2019. RESULTS Among 47,471 patients (mean age 45.2 ± 23.0 years; 68.3% male; Injury Severity Score 12.6 ± 11.1), 4.7% died and 8547 (18%) received at least one blood component through HMC. Firearms injuries were the most often transfused (690/2596, 26.6%) and the most urgently (39.9% ≥3 units in <1 h; 40.6% ≥5 units in <4 h), and had the highest mortality (case-fatality, 12.2%) (all p < .001). From-scene patients were younger than transfers (42.9 ± 21.0 vs. 47.2 ± 24.4), predominated among firearms injuries (68.2% from-scene vs. 31.8% transfers), were more likely to receive blood (18.5% vs. 17.6%) more urgently (≥3 units first hour, 24.4% vs. 7.7%; ≥5 units first 4 h: 25.6% vs. 8.2%), were more likely to die of hemorrhage (15.5% vs. 4.3%) and from firearms injuries (310/1360, 22.8%) (all p < .001). DISCUSSION Early blood use, firearms injuries, and mortality were all greater among from-scene patients, and firearms injuries had worse outcomes despite greater and more urgent blood use, but the role of survivor bias for transfer patients must be clarified. Future research must identify strategies for providing local hemostatic transfusion support, particularly for firearms injuries.
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Affiliation(s)
- Zhinan Liu
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Rajiv C Ayyagari
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Edison Y Martinez Monegro
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,San Juan Bautista School of Medicine, Cauguas, Puerto Rico
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.,Harborview Medical Center Transfusion Medicine Service, Harborview Transfusion Medicine Service, Seattle, Washington, USA
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16
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Complications and Soft-Tissue Coverage After Complete Articular, Open Tibial Plafond Fractures. J Orthop Trauma 2021; 35:e371-e376. [PMID: 33675626 DOI: 10.1097/bot.0000000000002074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the incidence of nonunion and wound complications after open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates. DESIGN Retrospective case series. SETTING Three Academic Level 1 Trauma Centers. PATIENTS One hundred sixty-one patients with open OTA/AO type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002 and 2018. The mean (SD) age was 46 (14) years, 70% male, with median (interquartile range) follow-up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures. INTERVENTION Fracture fixation: acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Soft-tissue coverage: rotational or free flap. MAIN OUTCOME MEASUREMENT Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft-tissue coverage and reoperation. RESULTS Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with men (33% vs. 16%, P = 0.029), smoking (38% vs. 23%, P = 0.047), and type 3B fractures (39% vs. 25%, P = 0.046). Acute fixation of type 3A fractures demonstrated a higher rate of infection (38% vs. 20% P = 0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (<1 week) demonstrated a lower rate of infection (18% vs. 53%, P = 0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (P = 0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, P < 0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (interquartile range) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in the rate of secondary union between septic and aseptic nonunions (85% vs. 86%, P = 1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), irrigation and debridement (15%), and removal of implants (11%). CONCLUSIONS Complete articular, open pilon fractures are associated with a high rate of complications after ORIF. Early fixation carries a high risk of deep infection; however, early flap coverage for 3B fractures seems to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft-tissue cover combined with definitive fixation during single procedure if possible. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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17
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Thompson L, Hill M, Lecky F, Shaw G. Defining major trauma: a Delphi study. Scand J Trauma Resusc Emerg Med 2021; 29:63. [PMID: 33971922 PMCID: PMC8108467 DOI: 10.1186/s13049-021-00870-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/31/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Retrospective trauma scores are often used to categorise trauma, however, they have little utility in the prehospital or hyper-acute setting and do not define major trauma to non-specialists. This study employed a Delphi process in order to gauge degrees of consensus/disagreement amongst expert panel members to define major trauma. Method A two round modified Delphi technique was used to explore subject-expert consensus and identify variables to define major trauma through systematically collating questionnaire responses. After initial descriptive analysis of variables, Kruskal-Wallis tests were used to determine statistically significant differences (p < 0.05) in response to the Delphi statements between professional groups. A hierarchical cluster analysis was undertaken to identify patterns of similarity/difference of response. A grounded theory approach to qualitative analysis of data allowed for potentially multiple iterations of the Delphi process to be influenced by identified themes. Results Of 55 expert panel members invited to participate, round 1 had 43 participants (Doctor n = 20, Paramedic n = 20, Nurse n = 5, other n = 2). No consistent patterns of opinion emerged with regards to professional group. Cluster analysis identified three patterns of similar responses and coded as trauma minimisers, the middle ground and the risk averse. Round 2 had 35 respondents with minimum change in opinion between rounds. Consensus of > 70% was achieved on many variables which included the identification of life/limb threatening injuries, deranged physiology, need for intensive care interventions and that extremes of age need special consideration. It was also acknowledged that retrospective injury severity scoring has a role to play but is not the only method of defining major trauma. Various factors had a majority of agreement/disagreement but did not meet the pre-set criteria of 70% agreement. These included the topics of burns, spinal immobilisation and whether a major trauma centre is the only place where major trauma can be managed. Conclusion Based upon the output of this Delphi study, major trauma may be defined as: “Significant injury or injuries that have potential to be life-threatening or life-changing sustained from either high energy mechanisms or low energy mechanisms in those rendered vulnerable by extremes of age”. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00870-w.
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Affiliation(s)
- Lee Thompson
- North East Ambulance Service NHS Foundation Trust, Ambulance HQ, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, England. .,Northumbria University, Coach Lane Campus, Coach Lane, Newcastle Upon Tyne, NE7 7TR, England.
| | - Michael Hill
- Northumbria University, Coach Lane Campus, Coach Lane, Newcastle Upon Tyne, NE7 7TR, England
| | - Fiona Lecky
- University of Sheffield, Western Bank, Sheffield, S10 2TN, England.,University of Manchester, Oxford Rd, Manchester, M13 9PL, England.,Salford Royal Hospitals NHS Foundation Trust, Stott Lane, Salford, M6 8HD, England.,Trauma Audit and Research Network, Summerfield House, 544 Eccles New Road, Salford, M5 5AP, England
| | - Gary Shaw
- North East Ambulance Service NHS Foundation Trust, Ambulance HQ, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, England
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18
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Frailty and length of stay in older adults with blunt injury in a national multicentre prospective cohort study. PLoS One 2021; 16:e0250803. [PMID: 33930058 PMCID: PMC8087011 DOI: 10.1371/journal.pone.0250803] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
Background Patients suffering moderate or severe injury after low falls have higher readmission and long-term mortality rates compared to patients injured by high-velocity mechanisms such as motor vehicle accidents. We hypothesize that this is due to higher pre-injury frailty in low-fall patients, and present baseline patient and frailty demographics of a prospective cohort of moderate and severely injured older patients. Our second hypothesis was that frailty was associated with longer length of stay (LOS) at index admission. Methods This is a prospective, nation-wide, multi-center cohort study of Singaporean residents aged ≥55 years admitted for ≥48 hours after blunt injury with an injury severity score or new injury severity score ≥10, or an Organ Injury Scale ≥3, in public hospitals from 2016–2018. Demographics, mechanism of injury and frailty were recorded and analysed by Chi-square, or Kruskal-Wallis as appropriate. Results 218 participants met criteria and survived the index admission. Low fall patients had the highest proportion of frailty (44, 27.3%), followed by higher level fallers (3, 21.4%) and motor vehicle accidents (1, 2.3%) (p < .01). Injury severity, extreme age, and surgery were independently associated with longer LOS. Frail patients were paradoxically noted to have shorter LOS (p < .05). Conclusion Patients sustaining moderate or severe injury after low falls are more likely to be frail compared to patients injured after higher-velocity mechanisms. However, this did not translate into longer adjusted LOS in hospital at index admission.
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19
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Weber B, Lackner I, Braun CK, Kalbitz M, Huber-Lang M, Pressmar J. Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research. Front Pediatr 2021; 9:622753. [PMID: 33816396 PMCID: PMC8010656 DOI: 10.3389/fped.2021.622753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
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20
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Pape H, Leenen L. Polytrauma management - What is new and what is true in 2020 ? J Clin Orthop Trauma 2021; 12:88-95. [PMID: 33716433 PMCID: PMC7920197 DOI: 10.1016/j.jcot.2020.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 12/11/2022] Open
Abstract
This is a review of changes in the practice of treating polytrauma managemtent within the years prior to 2020. It focuses on five different topics, 1. The development of an evidence based definition of Polytrauma, 2. Resuscitation Associated Coagulopathy (RAC), 3. neutrophil guided initial resuscitation, 4. perioperative Scoring to evaluate patients at risk, and 5. evolution of fracture fixation strategies according to protocols1,2 (Early total care, ETC, damage control orthopedics, DCO, early appropriate care, EAC, safe definitive surgery, SDS).
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Affiliation(s)
- H.C. Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland,Corresponding author.
| | - L. Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585, GA, Utrecht, the Netherlands
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Ochiai H, Abe T, Okuyama H, Nagamine Y, Morisada S, Kanemaru K. Factors associated with the progression of traumatic intracranial hematoma during interventional radiology to establish hemostasis of extracranial hemorrhagic injury in severe multiple trauma patients. Acute Med Surg 2020; 7:e580. [PMID: 33133615 PMCID: PMC7590586 DOI: 10.1002/ams2.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
Aim To identify factors affecting the progression of traumatic intracranial hemorrhagic injury (t‐ICH) during interventional radiology (IVR) for the hemostasis of extracranial hemorrhagic injury. Methods This was a retrospective comparative study. Fifty‐two patients with t‐ICH who underwent hemostasis using IVR for extracranial trauma at our institute were included. Clinical and computed tomography scan data were collected to investigate factors associated with t‐ICH progression. Results Fifty‐two subjects (36 men/16 women) with a mean age of 70.9 ± 19.2 years were analyzed. The mean Injury Severity Score was 34.9 ± 11.2. In 29 patients (55.7%), t‐ICH progressed during IVR. Hematoma progression frequently occurred in patients with acute subdural hematoma (56.2%) and traumatic intracerebral hematoma/hemorrhagic brain contusion (66.6%). Factors associated with t‐ICH progression included age (P = 0.029), consciousness level at admission (P = 0.001), Revised Trauma Scale (P = 0.036), probability of survival (P = 0.043), platelet count (P = 0.005), fibrinogen level (P = 0.016), hemoglobin level (P = 0.003), D‐dimer level (P = 0.046), and red blood cell transfusion volume (P = 0.023). Conclusion Aggressive correction of anemia, thrombocytopenia, and low fibrinogen levels in severe consciousness disturbance patients with acute subdural hematoma and traumatic intracerebral hematoma/hemorrhagic brain contusion could improve the prognosis after IVR for hemostasis of extracranial hemorrhagic injuries.
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Affiliation(s)
- Hidenobu Ochiai
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Tomohiro Abe
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Hironobu Okuyama
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Yasuhiro Nagamine
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Sunao Morisada
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Katsuhiro Kanemaru
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
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Janák D, Novotný K, Fiala R, Pádr R, Roček M, Rohn V. Endovascular Treatment of a Life-threatening Blunt Thoracic Aortic Injury in Polytraumatized Patients - A Single Center Experience. Prague Med Rep 2020; 121:142-152. [PMID: 33030143 DOI: 10.14712/23362936.2020.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
A retrospective analysis of our group of patients, efficacy, safety and the results of endovascular treatment of descending thoracic aorta by using stentgraft implantation in polytraumatized patients. In the period between 6/2006 and 2/2020, in the processing of data, we analysed retrospectively patients with polytrauma diagnosed with thoracic aortic rupture or transection (TAT) and treated with multiple injuries. Clinical characteristics, complications, pathological features, and hospital follow-up data were retrieved from our group. In our group of 28 polytraumatized patients referred to our Trauma Centre with current TAT, all 28 patients with such a thoracic aortic injury were treated by using thoracic stentgraft implantation. In our group of patients, the average Injury Severity Score (ISS) was 22 for women (min 19, max 27) and 26 for men (min 17, max 41), respectively. We reached 100% technical implantation success rate with our patients. In our group, we had 30-day mortality of 10.7% (3 patients) and the in-hospital mortality was 17.8% (5 patients). Surviving patients had calculated ISS score of 25 (min 17, max 41); dead patients had an ISS score of 28 (min 19, max 34) - p≤0.05. Endovascular treatment of TAT, as a minimally invasive and effective procedure with rapid bleeding control, may increase survival chances for severely compromised polytraumatized patients in the context of multiple-organ damage and the need for a major cardio-vascular surgery.
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Affiliation(s)
- David Janák
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic.
| | - Karel Novotný
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Radovan Fiala
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Radek Pádr
- Department of Radiology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Miloslav Roček
- Department of Radiology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Vilém Rohn
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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Halgas B, Bay C, Neagoe A, Richey K, Hofmann L, Foster K. Associationbetween hyperoxia and mortality in severely burned patients. Burns 2020; 46:1297-1301. [PMID: 32600936 DOI: 10.1016/j.burns.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 11/30/2019] [Accepted: 12/06/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The use of oxygen is a key component of acute burn resuscitation, particularly when there is concern for carbon monoxide toxicity or inhalation injury. Prior studies of critically-ill patients have shown an association between early hyperoxia and increased mortality. There are no studies to date evaluating outcomes related to excessive oxygen administration in burn patients. METHODS We conducted a retrospective analysis of 219 severely burned patients to quantify the average amount of oxygen given during initial resuscitation, the level of carbon monoxide exposure, and to determine if early exposure to supratherapeutic oxygen was associated with increased hospital mortality or ventilator-associated pneumonia (VAP). The models were adjusted for inhalation injury and total body surface area (TBSA) burned. RESULTS Early hyperoxia in severely burn patients is common and possibly associated with increased overall mortality, although the results were inconclusive and after adjusting for burn-specific scoring systems, we found a negative correlation between hyperoxia and mortality. Confirmed carbon monoxide poisoning was relatively uncommon, but also associated with increased mortality. Patients with elevated carboxyhemoglobin did not receive more oxygen compared to others within the cohort. CONCLUSIONS Burn patients are exposed to higher concentrations of pure oxygen compared to other critically-ill patients, presumably for empiric treatment of carbon monoxide poisoning. Our data showed a liberal use of oxygen therapy across all patients. Considering the potentially negative effects of hyperoxia, this study exposes either a gap in clinical research or need for clearer indications.
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Affiliation(s)
- B Halgas
- William Beaumont Army Medical Center, 5005 N Piedras St, El Paso, TX, 79920, United States.
| | - C Bay
- A.T. Still University, 5850 E Still Cir, Mesa, AZ 85206, United States
| | - A Neagoe
- Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ 85008, United States
| | - K Richey
- Arizona Burn Center, 2601 E Roosevelt St, Phoenix, AZ 85008, United States
| | - L Hofmann
- San Antonio Military Medical Center 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - K Foster
- Arizona Burn Center 2601 E Roosevelt St, Phoenix, AZ 85008, United States
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Incidence and Effect of Diabetes Insipidus in the Acute Care of Patients with Severe Traumatic Brain Injury. Neurocrit Care 2020; 33:718-724. [PMID: 32207035 DOI: 10.1007/s12028-020-00955-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Literature on diabetes insipidus (DI) after severe traumatic brain injury (TBI) is scarce. Some studies have reported varying frequencies of DI and have showed its association with increased mortality, suggesting it as a marker of poor outcome. This knowledge gap in the acute care consequences of DI in severe TBI patients led us to conceive this study, aimed at identifying risk factors and quantifying the effect of DI on short-term functional outcomes and mortality. METHODS We assembled a historic cohort of adult patients with severe TBI (Glasgow Coma Scale ≤ 8) admitted to the intensive care unit (ICU) of a tertiary-care university hospital over a 6-year period. Basic demographic characteristics, clinical information, imaging findings, and laboratory results were collected. We used logistic regression models to assess potential risk factors for the development of DI, and the association of this condition with death and unfavorable functional outcomes [modified Rankin scale (mRS)] at hospital discharge. RESULTS A total of 317 patients were included in the study. The frequency of DI was 14.82%, and it presented at a median of 2 days (IQR 1-3) after ICU admission. Severity according to the Abbreviated Injury Scale (AIS) score of the head, intracerebral hemorrhage, subdural hematoma, and skull base fracture was suggested as risk factors for DI. Diagnosis of DI was independently associated death (OR 4.34, CI 95% 1.92-10.11, p = 0.0005) and unfavorable outcome (modified Rankin Scale = 4-6) at discharge (OR 7.38; CI 95% 2.15-37.21, p = 0.0047). CONCLUSIONS Diabetes insipidus is a frequent and early complication in patients with severe TBI in the ICU and is strongly associated with increased mortality and poor short-term outcomes. We provide clinically useful risk factors that will help detect DI early to improve prognosis and therapy of patients with severe TBI.
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Bågenholm A, Dehli T, Eggen Hermansen S, Bartnes K, Larsen M, Ingebrigtsen T. Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times. Scand J Trauma Resusc Emerg Med 2020; 28:2. [PMID: 31924242 PMCID: PMC6954603 DOI: 10.1186/s13049-019-0692-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/26/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The International Commission on Radiological Protection's (ICRP) justification principles state that an examination is justified if the potential benefit outweighs the risk for radiation harm. Computer tomography (CT) contributes 50% of the radiation dose from medical imaging, and in trauma patients, the use of standardized whole body CT (SWBCT) increases. Guidelines are lacking, and reviews conclude conflictingly regarding the benefit. We aimed to study the degree of adherence to ICRP's level three justification, the individual dose limitation principle, in our institution. METHODS This is a retrospective clinical audit. We included all 144 patients admitted with trauma team activation to our regional Level 1 trauma centre in 2015. Injuries were categorized according to the Abbreviated Injury Scale (AIS) codes. Time variables, vital parameters and interventions were registered. We categorized patients into trauma admission SWBCT, selective CT or no CT examination strategy groups. We used descriptive statistics and regression analysis of predictors for CT examination strategy. RESULTS The 144 patients (114 (79.2%) males) had a median age of 31 (range 0-91) years. 105 (72.9%) had at least one AIS ≥ 2 injury, 26 (18.1%) in more than two body regions. During trauma admission, at least one vital parameter was abnormal in 46 (32.4%) patients, and 73 (50.7%) underwent SWBCT, 43 (29.9%) selective CT and 28 (19.4%) no CT examination. No or only minor injuries were identified in 17 (23.3%) in the SWBCT group. Two (4.6%) in the selective group were examined with a complement CT, with no new injuries identified. A significantly (p < 0.001) lower proportion of children (61.5%) than adults (89.8%) underwent CT examination despite similar injury grades and use of interventions. In adjusted regression analysis, patients with a high-energy trauma mechanism had significantly (p = 0.028) increased odds (odds ratio = 4.390, 95% confidence interval 1.174-16.413) for undergoing a SWBCT. CONCLUSION The high proportion of patients with no or only minor injuries detected in the SWBCT group and the significantly lower use of CT among children, indicate that use of a selective CT examination strategy in a higher proportion of our patients would have approximated the ICRP's justification level three, the individual dose limitation principle, better.
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Affiliation(s)
- Anna Bågenholm
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Radiology, University Hospital of North Norway, Sykehusveien 38, PO box 103, N-9038 Tromsø, Norway
| | - Trond Dehli
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Gastrointestinal Surgery, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Stig Eggen Hermansen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Kristian Bartnes
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Marthe Larsen
- Centre for Quality Improvements and Development, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Tor Ingebrigtsen
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Neurosurgery, ENT and Ophthalmology, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
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Zivkovic AR, Schmidt K, Stein T, Münzberg M, Brenner T, Weigand MA, Kleinschmidt S, Hofer S. Bedside-measurement of serum cholinesterase activity predicts patient morbidity and length of the intensive care unit stay following major traumatic injury. Sci Rep 2019; 9:10437. [PMID: 31320703 PMCID: PMC6639389 DOI: 10.1038/s41598-019-46995-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/04/2019] [Indexed: 01/08/2023] Open
Abstract
Major traumatic injury (MTI), a life-threatening condition requiring prompt medical intervention, is associated with an extensive inflammatory response often resulting in multiple organ dysfunction. Early stratification of trauma severity and the corresponding inflammation may help optimize resources at the intensive care unit (ICU). The cholinergic system counters inflammation by quickly modulating the immune response. Serum cholinesterase (butyrylcholinesterase, BChE) is an enzyme that hydrolyses acetylcholine. We tested whether a change in the BChE activity correlates with the morbidity and the length of ICU stay. Blood samples from 10 healthy volunteers and 44 patients with MTI were gathered at hospital admission, followed by measurements 12, 24 and 48 hours later. Point-of-care approach was used to determine the BChE activity. Disease severity was assessed by clinical scoring performed within 24 hours following hospital admission. BChE activity, measured at hospital admission, showed a significant and sustained reduction and correlated with disease severity scores obtained 24 hours following admission. BChE activity, obtained at hospital admission, correlated with the length of ICU stay. Bedside measurement of BChE activity, as a complementary addition to established procedures, might prove useful in the primary assessment of the disease severity and might therefore optimize therapy in the ICU.
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Affiliation(s)
| | - Karsten Schmidt
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Stein
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, BG Trauma Center Ludwigshafen/Rhine, Ludwigshafen, Germany
| | - Matthias Münzberg
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen/Rhine, Ludwigshafen, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Kleinschmidt
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, BG Trauma Center Ludwigshafen/Rhine, Ludwigshafen, Germany
| | - Stefan Hofer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany.,Clinic for Anesthesiology, Intensive Care, Emergency Medicine I and Pain Therapy, Westpfalz Hospital, Kaiserslautern, Germany
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Hsieh CH, Chen YC, Hsu SY, Hsieh HY, Chien PC. Defining polytrauma by abbreviated injury scale ≥ 3 for a least two body regions is insufficient in terms of short-term outcome: A cross-sectional study at a level I trauma center. Biomed J 2018; 41:321-327. [PMID: 30580796 PMCID: PMC6306305 DOI: 10.1016/j.bj.2018.08.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022] Open
Abstract
Background Patients with polytrauma are expected to have a higher risk of mortality than the summation of expected mortality for their individual injuries. This study was designed to investigate the outcome of polytrauma patients, diagnosed by abbreviated injury scale (AIS) ≥ 3 for at least two body regions, at a level I trauma center. Methods Detailed data of 694 polytrauma patients and 2104 non-polytrauma patients with an overall Injury Severity Score (ISS) ≥ 16 and hospitalized between January 1, 2009, and December 31, 2014 for treatment of all traumatic injuries, were retrieved from the Trauma Registry System. Two-sided Fisher exact or Pearson chi-square tests were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann–Whitney U-test was used to compare non-normally distributed data. Propensity-score matching in a 1:1 ratio was performed using NCSS software with logistic regression to evaluate the effect of polytrauma on in-hospital mortality. Results There was no significant difference in short-term mortality between polytrauma and non-polytrauma patients, regardless of whether the comparison was made among the total patients (11.4% vs. 11.0%, respectively; p = 0.795) or among the selected propensity score-matched groups of patients following controlled covariates including sex, age, systolic blood pressure, co-morbidities, Glasgow Coma Scale scores, injury region based on AIS. Conclusions Polytrauma defined by AIS ≥3 for at least two body regions failed to recognize a significant difference in short-term mortality among trauma patients.
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Affiliation(s)
- Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| | - Yi-Chun Chen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Shiun-Yuan Hsu
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
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Chen LK, Sullivan BT, Sponseller PD. Submuscular plates versus flexible nails in preadolescent diaphyseal femur fractures. J Child Orthop 2018; 12:488-492. [PMID: 30294373 PMCID: PMC6169557 DOI: 10.1302/1863-2548.12.180036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To compare patient characteristics, operative time, estimated blood loss (EBL), postoperative length of hospital stay (LOS) and complications after insertion and removal of submuscular plates (SMPs) versus flexible nails (FNs) for paediatric diaphyseal femur fractures. METHODS We reviewed records of 58 children (mean age, 7.7 years SD 2.0) with diaphyseal femur fractures who underwent treatment with SMPs (n = 30) or FNs (n = 28) from 2005 to 2017 (mean follow-up, 22 months SD 28). Patients with pathological fractures or musculoskeletal comorbidities were excluded. Alpha = 0.05. RESULTS Insertion of FNs was associated with shorter operative time (ß = -24 mins) and less EBL (ß = -38 mL) (both, p < 0.001) compared with insertion of SMPs, after adjusting for fracture type and time from beginning of study period. Removal of FNs was also associated with shorter operative time (ß = -15 min) compared with removal of SMPs (p < 0.001). EBL during removal was similar between groups (p = 0.080). The FN group had a shorter LOS after insertion (ß = -0.2 d) compared with the SMP group (p = 0.032). Four patients treated with SMPs and three treated with FNs developed surgical site infections. Two patients treated with SMPs and seven treated with FNs experienced implant irritation that resolved with removal. No other complications occurred. CONCLUSION Compared with SMPs, FNs were associated with shorter operative time (for insertion and removal), less EBL (for insertion) and shorter post-insertion LOS in patients with diaphyseal femur fractures. LEVEL OF EVIDENCE III.
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Affiliation(s)
- L.-K. Chen
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - B. T. Sullivan
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - P. D. Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA, Correspondence should be sent to P. D. Sponseller, Johns Hopkins Children’s Center, 1800 Orleans Street, 7359A, Baltimore, Maryland 21287, United States. E-mail:
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Parreira JG, Rondini GZ, Below C, Tanaka GO, Pelluchi JN, Arantes-Perlingeiro J, Soldá SC, Assef JC. Trauma mechanism predicts the frequency and the severity of injuries in blunt trauma patients. ACTA ACUST UNITED AC 2018; 44:340-347. [PMID: 29019536 DOI: 10.1590/0100-69912017004007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/11/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE to study the correlation of trauma mechanism with frequency and severity of injuries in blunt trauma patients. METHODS retrospective analysis of trauma registry in a 15-month period was carried out. Trauma mechanism was classified into six types: occupants of four-wheeled vehicles involved in road traffic accidents (AUTO), pedestrians struck by road vehicles (PED), motorcyclists involved in road traffic accidents (MOTO), falls from height (FALL), physical assault with blunt instruments (ASSA) and falls on same level (FSL). Injuries with AIS>2 were considered severe. One-way ANOVA, Students t and Chi-square tests were used for statistical analysis, considering p<0.05 significant. RESULTS trauma mechanism was classified by group for 3639 cases, comprising 337 (9.3%) AUTO, 855 (23.5%) PED, 924 (25.4%) MOTO, 455 (12.5%) FALL, 424 (11.7%) ASSA and 644 (17.7%) FSL. There was significant difference among groups when comparing the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) of the head, thorax, abdomen and extremities (p<0.001). Severe injuries in the head and in the extremities were more frequent in PED patients (p<0.001). Severe injuries to the chest were more frequent in AUTO (p<0.001). Abdominal injuries were less frequent in FSL (p=0.004). Complex fractures of the pelvis and spine were more frequent in FALL (p<0.001). Lethality was greater in PED, followed by FALL and AUTO (p<0.001). CONCLUSION trauma mechanism analysis predicted frequency and severity of injuries in blunt trauma patients.
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Affiliation(s)
- José Gustavo Parreira
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
| | | | - Cristiano Below
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Curso de Medicina, São Paulo, SP, Brasil
| | - Giuliana Olivi Tanaka
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Curso de Medicina, São Paulo, SP, Brasil
| | - Julia Nunes Pelluchi
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Curso de Medicina, São Paulo, SP, Brasil
| | - Jacqueline Arantes-Perlingeiro
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
| | - Silvia Cristine Soldá
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
| | - José César Assef
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
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30
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To the Editor. J Orthop Trauma 2018; 32:e242-e244. [PMID: 29762433 DOI: 10.1097/bot.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Polytrauma Defined by the New Berlin Definition: A Validation Test Based on Propensity-Score Matching Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14091045. [PMID: 28891977 PMCID: PMC5615582 DOI: 10.3390/ijerph14091045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/06/2017] [Accepted: 09/09/2017] [Indexed: 02/08/2023]
Abstract
Background: Polytrauma patients are expected to have a higher risk of mortality than that obtained by the summation of expected mortality owing to their individual injuries. This study was designed to investigate the outcome of patients with polytrauma, which was defined using the new Berlin definition, as cases with an Abbreviated Injury Scale (AIS) ≥ 3 for two or more different body regions and one or more additional variables from five physiologic parameters (hypotension [systolic blood pressure ≤ 90 mmHg], unconsciousness [Glasgow Coma Scale score ≤ 8], acidosis [base excess ≤ -6.0], coagulopathy [partial thromboplastin time ≥ 40 s or international normalized ratio ≥ 1.4], and age [≥70 years]). Methods: We retrieved detailed data on 369 polytrauma patients and 1260 non-polytrauma patients with an overall Injury Severity Score (ISS) ≥ 18 who were hospitalized between 1 January 2009 and 31 December 2015 for the treatment of all traumatic injuries, from the Trauma Registry System at a level I trauma center. Patients with burn injury or incomplete registered data were excluded. Categorical data were compared with two-sided Fisher exact or Pearson chi-square tests. The unpaired Student t-test and the Mann-Whitney U-test was used to analyze normally distributed continuous data and non-normally distributed data, respectively. Propensity-score matched cohort in a 1:1 ratio was allocated using the NCSS software with logistic regression to evaluate the effect of polytrauma on patient outcomes. Results: The polytrauma patients had a significantly higher ISS than non-polytrauma patients (median (interquartile range Q1-Q3), 29 (22-36) vs. 24 (20-25), respectively; p < 0.001). Polytrauma patients had a 1.9-fold higher odds of mortality than non-polytrauma patients (95% CI 1.38-2.49; p < 0.001). Compared to non-polytrauma patients, polytrauma patients had a substantially longer hospital length of stay (LOS). In addition, a higher proportion of polytrauma patients were admitted to the intensive care unit (ICU), spent longer LOS in the ICU, and had significantly higher total medical expenses. Among 201 selected propensity score-matched pairs of polytrauma and non-polytrauma patients who showed no significant difference in sex, age, co-morbidity, AIS ≥ 3, and Injury Severity Score (ISS), the polytrauma patients had a significantly higher mortality rate (OR 17.5, 95% CI 4.21-72.76; p < 0.001), and a higher proportion of patients admitted to the ICU (84.1% vs. 74.1%, respectively; p = 0.013) with longer stays in the ICU (10.3 days vs. 7.5 days, respectively; p = 0.003). The total medical expenses for polytrauma patients were 35.1% higher than those of non-polytrauma patients. However, there was no significant difference in the LOS between polytrauma and non-polytrauma patients (21.1 days vs. 19.8 days, respectively; p = 0.399). Conclusions: The findings of this propensity-score matching study suggest that the new Berlin definition of polytrauma is feasible and applicable for trauma patients.
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Polytrauma-induced hepatic stress response and the development of liver insulin resistance. Biochim Biophys Acta Mol Basis Dis 2017; 1863:2672-2679. [PMID: 28501568 DOI: 10.1016/j.bbadis.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/27/2017] [Accepted: 05/07/2017] [Indexed: 01/04/2023]
Abstract
Insulin resistance and metabolic dysfunction are common following injury. Polytrauma is defined as combined injuries to more than one body part or organ system, and is common in modern warfare, as well as automobile and industrial accidents. Polytrauma can include any combination of burn injury, fracture, hemorrhage, trauma to the extremities, and blunt or penetrating trauma. Multiple minor injuries are often more deleterious than a more severe single injury. To investigate the mechanisms of development of insulin resistance following injury, we have developed a rat model of polytrauma which combined soft tissue trauma with burn injury and penetrating gastrointestinal (GI) trauma. Male Sprague-Dawley rats were subjected to a laparotomy plus either a 15-18% total body surface area scald burn or a single puncture of the cecum (CLP) with a G30 needle, or the combination of both burn and CLP injuries (polytrauma). We examined the effects of polytrauma which increased markers of hepatic endoplasmic reticulum (ER) stress, and increased hepatic Trib3 mRNA levels coincident with reduced insulin-inducible insulin signaling. Phosphorylation/activation of the insulin receptor (IR) and AKT were decreased at 24, but not 6h following polytrauma. These results demonstrate a complex, time-dependent development of hepatic ER-stress and a diminished response to insulin, which were among the pathological sequelae following polytrauma.
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Abstract
Neurologic complications in polytrauma can be classified by etiology and clinical manifestations: neurovascular, delirium, and spinal or neuromuscular problems. Neurovascular complications include ischemic strokes, intracranial hemorrhage, or the development of traumatic arteriovenous fistulae. Delirium and encephalopathy have a reported incidence of 67-92% in mechanically ventilated polytrauma patients. Causes include sedation, analgesia/pain, medications, sleep deprivation, postoperative state, toxic ingestions, withdrawal syndromes, organ system dysfunction, electrolyte/metabolic abnormalities, and infections. Rapid identification and treatment of the underlying cause are imperative. Benzodiazepines increase the risk of delirium, and alternative agents are preferred sedatives. Pharmacologic treatment of agitated delirium can be achieved with antipsychotics. Nonconvulsive seizures and status epilepticus are not uncommon in surgical/trauma intensive care unit (ICU) patients, require electroencephalography for diagnosis, and need timely management. Spinal cord ischemia is a known complication in patients with traumatic aortic dissections or blunt aortic injury requiring surgery. Thoracic endovascular aortic repair has reduced the paralysis rate. Neuromuscular complications include nerve and plexus injuries, and ICU-acquired weakness. In polytrauma, the neurologic examination is often confounded by pain, sedation, mechanical ventilation, and distracting injuries. Regular sedation pauses for examination and maintaining a high index of suspicion for neurologic complications are warranted, particularly because early diagnosis and management can improve outcomes.
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Heinänen M, Brinck T, Handolin L, Mattila VM, Söderlund T. Accuracy and Coverage of Diagnosis and Procedural Coding of Severely Injured Patients in the Finnish Hospital Discharge Register: Comparison to Patient Files and the Helsinki Trauma Registry. Scand J Surg 2017; 106:269-277. [DOI: 10.1177/1457496916685236] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aims: The Finnish Hospital Discharge Register data are frequently used for research purposes. The Finnish Hospital Discharge Register has shown excellent validity in single injuries or disease groups, but no studies have assessed patients with multiple trauma diagnoses. We aimed to evaluate the accuracy and coverage of the Finnish Hospital Discharge Register but at the same time validate the data of the trauma registry of the Helsinki University Hospital’s Trauma Unit. Materials and Methods: We assessed the accuracy and coverage of the Finnish Hospital Discharge Register data by comparing them to the original patient files and trauma registry files from the trauma registry of the Helsinki University Hospital’s Trauma Unit. We identified a baseline cohort of patients with severe thorax injury from the trauma registry of the Helsinki University Hospital’s Trauma Unit of 2013 (sample of 107 patients). We hypothesized that the Finnish Hospital Discharge Register would lack valuable information about these patients. Results: Using patient files, we identified 965 trauma diagnoses in these 107 patients. From the Finnish Hospital Discharge Register, we identified 632 (65.5%) diagnoses and from the trauma registry of the Helsinki University Hospital’s Trauma Unit, 924 (95.8%) diagnoses. A total of 170 (17.6%) trauma diagnoses were missing from the Finnish Hospital Discharge Register data and 41 (4.2%) from the trauma registry of the Helsinki University Hospital’s Trauma Unit data. The coverage and accuracy of diagnoses in the Finnish Hospital Discharge Register were 65.5% (95% confidence interval: 62.5%–68.5%) and 73.8% (95% confidence interval: 70.4%–77.2%), respectively, and for the trauma registry of the Helsinki University Hospital’s Trauma Unit, 95.8% (95% confidence interval: 94.5%–97.0%) and 97.6% (95% confidence interval: 96.7%–98.6%), respectively. According to patient records, these patients were subjects in 249 operations. We identified 40 (16.1%) missing operation codes from the Finnish Hospital Discharge Register and 19 (7.6%) from the trauma registry of the Helsinki University Hospital’s Trauma Unit. Conclusion: The validity of the Finnish Hospital Discharge Register data is unsatisfactory in terms of the accuracy and coverage of diagnoses in patients with multiple trauma diagnoses. Procedural codes provide greater accuracy. We found the coverage and accuracy of the trauma registry of the Helsinki University Hospital’s Trauma Unit to be excellent. Therefore, a special trauma registry, such as the trauma registry of the Helsinki University Hospital’s Trauma Unit, provides much more accurate data and should be the preferred registry when extracting data for research or for administrative use, such as resource prioritizing.
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Affiliation(s)
- M. Heinänen
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - T. Brinck
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - L. Handolin
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - V. M. Mattila
- Department of Orthopedics, Tampere University Hospital, Tampere, Finland
| | - T. Söderlund
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
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Chio CC, Hsu CC, Tian YF, Wang CH, Lin MT, Chang CP, Lin HJ. Combined Hemorrhagic Shock and Unilateral Common Carotid Occlusion Induces Neurological Injury in Adult Male Rats. Int J Med Sci 2017; 14:1327-1334. [PMID: 29200946 PMCID: PMC5707749 DOI: 10.7150/ijms.21022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/21/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Clinical assessment reveals that patients after surgery of cardiopulmonary bypass or coronary bypass experience postoperative cognitive dysfunction. This study aimed to investigate whether resuscitation after a hemorrhagic shock (HS) and/or mild cerebral ischemia caused by a unilateral common carotid artery occlusion (UCCAO) can cause brain injury and concomitant neurological dysfunction, and explore the potential mechanisms. Methods: Blood withdrawal (6 mL/100 g body weight) for 60 min through the right jugular vein catheter-induced an HS. Immediately after the termination of HS, we reinfused the initially shed blood volumes to restore and maintain the mean arterial blood pressure (MABP) to the original value during the 30-min resuscitation. A cooling water blanket used to induce whole body cooling for 30 min after the end of resuscitation. Results: An UCCAO caused a slight cerebral ischemia (cerebral blood flow [CBF] 70%) without hypotension (MABP 85 mmHg), systemic inflammation, multiple organs injuries, or neurological injury. An HS caused a moderate cerebral ischemia (52% of the original CBF levels), a moderate hypotension (MABP downed to 22 mmHg), systemic inflammation, and peripheral organs injuries. However, combined an UCCAO and an HS caused a severe cerebral ischemia (18% of the original CBF levels), a moderate hypotension (MABP downed to 17 mmHg), systemic inflammation, peripheral organs damage, and neurological injury, which can be attenuated by whole body cooling. Conclusions: When combined with an HS, an UCCAO is associated with ischemic neuronal injury in the ipsilateral hemisphere of adult rat brain, which can be attenuated by therapeutic hypothermia. A resuscitation from an HS regards as a reperfusion insult which may induce neurological injury in patients with an UCCAO disease.
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Affiliation(s)
- Chung-Ching Chio
- Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Tainan 710, Taiwan
| | - Chien-Chin Hsu
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 710, Taiwan.,Department of Emergency Medicine, Chi Mei Medical Center, Tainan 710, Taiwan
| | - Yu-Feng Tian
- Division of General Surgery, Department of Surgery, Chi Mei Medical Center, Tainan 710, Taiwan.,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
| | - Chung-Han Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan 710, Taiwan
| | - Mao-Tsun Lin
- Department of Medical Research, Chi Mei Medical Center, Tainan 710, Taiwan
| | - Ching-Ping Chang
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 710, Taiwan.,Department of Medical Research, Chi Mei Medical Center, Tainan 710, Taiwan.,The Ph.D. Program for Neural Regenerative Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Hung-Jung Lin
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 710, Taiwan.,Department of Emergency Medicine, Chi Mei Medical Center, Tainan 710, Taiwan
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Wynell-Mayow W, Guevel B, Quansah B, O'Leary R, Carrothers AD. Cambridge Polytrauma Pathway: Are we making appropriately guided decisions? Injury 2016; 47:2117-2121. [PMID: 27496722 DOI: 10.1016/j.injury.2016.05.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 05/29/2016] [Indexed: 02/02/2023]
Abstract
Addenbrooke's Hospital, the Major Trauma Centre for the East of England Trauma Network, received 1070 major trauma patients between 1st January and 31st December 2014. In order to improve care, an audit was performed of 59 patients meeting our own selection criteria for orthopaedic polytrauma between 1st January 2013 and 31st December 2013. The Cambridge Polytrauma Pathway was devised through NCEPOD guidelines, literature review, internal and external discussion. It facilitates provision of best practice Early Appropriate Care, encompassing - multidisciplinary consultant decisions around the patient in our Neurological and Trauma Critical Care Unit, early full body trauma CT scans, serial measurements of lactate and fibrinogen levels, and out-of-hours orthopaedic theatre reserved for life-and-limb threatening injuries. Re-audit was conducted of 15 patients meeting selection criteria, admitted between 1st October 2014 and 31st March 2015. Significant improvements in recording of lactate and fibrinogen were demonstrated, both on admission (lactate - p<0.000, fibrinogen - p=0.015), and preoperatively (lactate - p=0.003, fibrinogen - p=0.030). Time to trauma CT was unchanged (p=0.536) with a median time to CT of 0.53h at re-audit (IQR 0.48-0.75). The number of patients receiving definitive orthopaedic intervention out-of-hours reduced from 8 to zero (p=0.195). The approach of facilitating management decisions to be made at early daytime MDT meetings has been adopted. It is anticipated that this pathway will improve outcomes in orthopaedic polytrauma patients and it is recommended that either the GOS-E, or the EQ-5D scoring systems be introduced to assess this.
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Affiliation(s)
- William Wynell-Mayow
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Borna Guevel
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Benjamin Quansah
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Andrew D Carrothers
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK.
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Miu J, Curtis K, Balogh ZJ. Profile of fall injury in the New South Wales older adult population. ACTA ACUST UNITED AC 2016; 19:179-185. [PMID: 27474070 DOI: 10.1016/j.aenj.2016.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/01/2016] [Accepted: 07/08/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND A previous report from the New South Wales (NSW) Trauma Registry identified falls and increasing age of severely injured patients as highly prevalent, but detailed injury and demographic profiles, outcomes and their predictors are poorly reported. This study describes the fall-injury profile in the older adult major trauma patient in NSW. METHODS A retrospective registry based study between 2010 and 2014 on patients aged 55 years and over who sustained a moderate to critical injury from a fall, examining mortality and length of stay using regression analyses. RESULTS There were 4263 major trauma falls between 2010 and 2014, most occurring at home (55.4%), on the same level (46.7%) and resulting in head injury (63.2%). Significant predictors for mortality following a fall were increased age, male gender, falls in residential care institutions, isolated head injuries and injury classified as critical (ISS 41-75). CONCLUSIONS The outcomes of falls in the older adult are very poor and a focused prospective study is required to identify areas for intervention and prevention. The predictors of mortality following a fall identified in this study can be used with existing research to develop tools and design care pathways for implementation in the emergency context to improve patient care and outcomes.
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Affiliation(s)
- Jenny Miu
- NSW Institute of Trauma and Injury Management, Agency for Clinical Innovation, Australia
| | - Kate Curtis
- Sydney Nursing School, University of Sydney, Australia; Trauma Service, St. George Hospital, University of NSW, Australia.
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
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Wong TH, Krishnaswamy G, Nadkarni NV, Nguyen HV, Lim GH, Bautista DCT, Chiu MT, Chow KY, Ong MEH. Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2016; 24:25. [PMID: 26955863 PMCID: PMC4784376 DOI: 10.1186/s13049-016-0215-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/27/2016] [Indexed: 11/21/2022] Open
Abstract
Background Anatomy-based injury severity scores are commonly used with physiological scores for reporting severity of injury in a standardized manner. However, there is lack of consensus on choice of scoring system, with the commonly used injury severity score (ISS) performing poorly for certain sub-groups, eg head-injured patients. We hypothesized that adding a dichotomous variable for polytrauma (yes/no for Abbreviated Injury Scale (AIS) scores of 3 or more in at least two body regions) to the New Injury Severity Score (NISS) would improve the prediction of in-hospital mortality in injured patients, including head-injured patients—a subgroup that has a disproportionately high mortality. Our secondary hypothesis was that the ISS over-estimates the risk of death in polytrauma patients, while the NISS under-estimates it. Methods Univariate and multivariable analysis was performed on retrospective cohort data of blunt injured patients aged 18 and over with an ISS over 9 from the Singapore National Trauma Registry from 2011–2013. Model diagnostics were tested using discrimination (c-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit statistic). All models included age, gender, and comorbidities. Results Our results showed that the polytrauma and NISS model outperformed the other models (polytrauma and ISS, NISS alone or ISS alone) in predicting 30-day and in-hospital mortality. The NISS underestimated the risk of death for patients with polytrauma, while the ISS overestimated the risk of death for these patients. When used together with the NISS and polytrauma, categorical variables for deranged physiology (systolic blood pressure of 90 mmHg or less, GCS of 8 or less) outperformed the traditional ‘ISS and RTS (Revised Trauma Score)’ model, with a c-statistic of greater than 0.90. This could be useful in cases when the RTS cannot be scored due to missing respiratory rate. Discussion The NISS and polytrauma model is superior to current scores for prediction of 30-day and in-hospital mortality. We propose that this score replace the ISS or NISS in institutions using AIS-based scores. Conclusions Adding polytrauma to the NISS or ISS improves prediction of 30-day mortality. The superiority of the NISS or ISS depends on the proportion of polytrauma and head-injured patients in the study population.
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Affiliation(s)
- Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Republic of Singapore. .,Duke-National University of Singapore, Singapore, Singapore.
| | | | | | - Hai V Nguyen
- Duke-National University of Singapore, Singapore, Singapore.
| | | | | | | | | | - Marcus Eng Hock Ong
- Duke-National University of Singapore, Singapore, Singapore. .,Department of Emergency medicine, Singapore General Hospital, Singapore, Singapore.
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Guerado E, Bertrand ML, Valdes L, Cruz E, Cano JR. Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding. Open Orthop J 2015; 9:283-95. [PMID: 26312112 PMCID: PMC4541450 DOI: 10.2174/1874325001509010283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/26/2015] [Accepted: 05/18/2015] [Indexed: 12/12/2022] Open
Abstract
The term ‘severely injured patient’ is often synonymous of polytrauma patient, multiply-injured patient or, in some settings, polyfractured patient. Together with brain trauma, copious bleeding is the most severe complication of polytrauma. Consequently hypotension develop. Then, the perfusion of organs may be compromised, with the risk of organ failure. Treatment of chest bleeding after trauma is essential and is mainly addressed via surgical manoeuvres. As in the case of lesions to the pelvis, abdomen or extremities, this approach demonstrates the application of damage control (DC). The introduction of sonography has dramatically changed the diagnosis and prognosis of abdominal bleeding. In stable patients, a contrast CT-scan should be performed before any x-ray projection, because, in an emergency situation, spinal or pelvic fractures be missed by conventional radiological studies. Fractures or dislocation of the pelvis causing enlargement of the pelvic cavity, provoked by an anteroposterior trauma, and in particular cases presenting vertical instability, are the most severe types and require fast stabilisation by closing the pelvic ring diameter to normal dimensions and by stabilising the vertical shear. Controversy still exists about whether angiography or packing should be used as the first choice to address active bleeding after pelvic ring closure. Pelvic angiography plays a significant complementary role to pelvic packing for final haemorrhage control. Apart from pelvic trauma, fracture of the femur is the only fracture provoking acute life-threatening bleeding. If possible, femur fractures should be immobilised immediately, either by external fixation or by a sheet wrap around both extremities.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Spain
| | - Maria Luisa Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Spain
| | - Luis Valdes
- Department of Anaesthesiology, Hospital Costa del Sol, Spain
| | - Encarnacion Cruz
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Spain
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Spain
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