Critical Care for the Patient With Multiple Trauma

VX-765 Alleviates Circadian Rhythm Disorder in a Rodent Model of Traumatic Brain Injury Plus Hemorrhagic Shock and Resuscitation

Severe traumatic brain injury (TBI) can result in persistent complications, including circadian rhythm disorder, that substantially affect not only the injured people, but also the mood and social interactions with the family and the community. Pyroptosis in GFAP-positive astrocytes plays a vital role in inflammatory changes post-TBI. We determined whether VX-765, a low molecular weight caspase-1 inhibitor, has potential therapeutic value against astrocytic inflammation and pyroptosis in a rodent model of TBI plus hemorrhagic shock and resuscitation (HSR). A weight-drop plus bleeding and refusion model was used to establish traumatic exposure in rats. VX-765 (50 mg/kg) was injected via the femoral vein after resuscitation. Wheel-running activity was assessed, brain magnetic resonance images were evaluated, the expression of pyroptosis-associated molecules including cleaved caspase-1, gasdermin D (GSDMD), and interleukin-18 (IL-18) in astrocytes in the region of anterior hypothalamus, were explored 30 days post-trauma. VX-765-treated rats had significant improvement in circadian rhythm disorder, decreased mean diffusivity (MD) and mean kurtosis (MK), increased fractional anisotropy (FA), an elevated number and branches of astrocytes, and lower cleaved caspase-1, GSDMD, and IL-18 expression in astrocytes than TBI + HSR-treated rats. These results demonstrated that inhibition of pyroptosis-associated astrocytic activations in the anterior hypothalamus using VX-765 may ameliorate circadian rhythm disorder after trauma. In conclusion, we suggest that interventions targeting caspase-1-induced astrocytic pyroptosis by VX-765 are promising strategies to alleviate circadian rhythm disorder post-TBI.

Chest CT Findings and SARS-CoV-2 Infection in Trauma Patients-Is There a Prediction towards Higher Complication Rates?

Background: Polytrauma patients with SARS-CoV-2 infections may be associated with an increased complication rate. The main goal of this study was to analyze the clinical course of trauma patients with COVID infection and a positive CT finding. Methods: This was a retrospective in-hospital study. Polytrauma patients diagnosed with SARS-CoV-2 infections were included in our analysis. The outcome parameters were pulmonary complication during admission, pulmonary embolism, pleural effusion, pneumonia, mortality, length of stay and readmission < 30 days. Results: 48 patients were included in the study. Trauma patients in the age-adjusted matched-pair analysis with typical changes in SARS-CoV-2 infection in CT findings showed significantly more pulmonary complications in general and significantly more cases of pneumonia (complications: 56% vs. 11%, p = 0.046; pneumonia 44% vs. 0%, p = 0.023). In addition, the clinical course of polytrauma patients with SARS-CoV-2 infection showed a high rate of pulmonary complications in the inpatient course (53%). Conclusion: The results of our study show that the changes in the CT findings of trauma patients with SARS-CoV-2 infection are a good indicator of further inpatient outcomes. Similarly, polytrauma patients with a SARS-CoV-2 infection and positive CT findings are shown to have increased risk for pulmonary complications.

The burden of facial trauma on mortality in patients with multiple injuries: A single-center analysis of 1862 motorcycle accidents

The study aims to assess the influence on mortality of motorcycle road accidents, caused by injuries to the head, chest, abdomen, face, skin, pelvis and extremities. Road motorcycle accidents consecutively admitted to Level I Trauma Center were retrospectively analyzed. Each body site involvement was classified through Abbreviated Injury Score (AIS-98), and Comprehensive Facial Injury (CFI) score; Injury Severity Score (ISS) was also calculated. The data collected were subjected to a descriptive analysis and inferential statistic, with uni- and multivariate analysis; mortality was the main outcome examined. 1862 patients were studied. Limbs (53.9%) and Head (53.8%) are the most involved body site, facial trauma regards 19.4% of the sample. Only 4.4% of Facial injuries occurred as isolated, 71.6% were associated to Head involvement. The overall mortality was 4.6% and 80.0% of dead patients were affected by Head injury. Multivariate analysis shows that head (OR=3.06, p <0.0001), thoracic (OR=1.82, p <0.0001) and abdominal trauma (OR=1.41, p =0.019) are predicting the risk of death. Facial trauma does not directly influence mortality and, however severe and distracting it may be, becomes secondary to the management of frequently associated brain injuries. Severity scores targeted to the risk of death, such as AIS and AIS-derived, are ineffective in describing the true characteristics of facial injuries. The CFI score has been shown to predict the weight of surgical treatment and the outcome of the hospital stay, therefore its use is recommended.

Prediction of mortality in severely injured patients with facial bone fractures

PURPOSE

Identify the most common concomitant injuries associated with facial trauma, and compare the efficacy of various scoring systems in estimation of mortality risks in this category of patients.

METHODS

The study evaluated patients with facial and concomitant injuries, who received the multidisciplinary treatment in a specialized trauma hospital. Values of New Injury Severity Score, Glasgow Coma Scale, Facial Injury Severity Scale, age, and length of hospital stay were statistically analysed to determine presence of relationships between these indicators and define factors that significantly associated with lethal outcome.

RESULTS

During 6-year observation period, 719 patients were treated with multiple or combined maxillofacial trauma, brain injuries and polytrauma. Mainly with isolated midface bones (49.7%), pan-facial (34.6%), mandible (12.9%), and frontal bone and walls (2.8%) fractures. Mortality was (2.2%). The mortality rates in patients with severe pan-facial fractures were higher (p = 0.008) than in single anatomical area (6% vs 1.5%). Age, GCS, and NISS were the most reliable indicator of lethal outcome.

CONCLUSION

Age, Glasgow Coma Scale and New Injury Severity Score main factors, that predicts lethal outcome with high accuracy. New Injury Severity Score value ≥ 41 is a critical level for survival prognosis and should be considered in treatment planning and management of this category of patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Persistent Inflammation, Immunosuppression and Catabolism Syndrome (PICS) after Polytrauma: A Rare Syndrome with Major Consequences

Nowadays, more trauma patients develop chronic critical illness (CCI), a state characterized by prolonged intensive care. Some of these CCI patients have disproportional difficulties to recover and suffer from recurrent infections, a syndrome described as the persistent inflammation, immunosuppression and catabolism syndrome (PICS). A total of 78 trauma patients with an ICU stay of ≥14 days (CCI patients) between 2007 and 2017 were retrospectively included. Within this group, PICS patients were identified through two ways: (1) their clinical course (≥3 infectious complications) and (2) by laboratory markers suggested in the literature (C-reactive protein (CRP) and lymphocytes), both in combination with evidence of increased catabolism. The incidence of PICS was 4.7 per 1000 multitrauma patients. The sensitivity and specificity of the laboratory markers was 44% and 73%, respectively. PICS patients had a longer hospital stay (median 83 vs. 40, p < 0.001) and required significantly more surgical interventions (median 13 vs. 3, p = 0.003) than other CCI patients. Thirteen PICS patients developed sepsis (72%) and 12 (67%) were readmitted at least once due to an infection. In conclusion, patients who develop PICS experience recurrent infectious complications that lead to prolonged hospitalization, many surgical procedures and frequent readmissions. Therefore, PICS forms a substantial burden on the patient and the hospital, despite its low incidence.