The Diagnostic, Therapeutic and Prognostic Relevance of Neutrophil Extracellular Traps in Polytrauma

Neutrophil extracellular traps (NETs) represent a recently discovered polymorphonuclear leukocyte-associated ancient defence mechanism, and they have also been identified as part of polytrauma patients' sterile inflammatory response. This systematic review aimed to determine the clinical significance of NETs in polytrauma, focusing on potential prognostic, diagnostic and therapeutic relevance. The methodology covered all major databases and all study types, but was restricted to polytraumatised humans. Fourteen studies met the inclusion criteria, reporting on 1967 patients. Ten samples were taken from plasma and four from whole blood. There was no standardisation of methodology of NET detection among plasma studies; however, of all the papers that included a healthy control NET, proxies were increased. Polytrauma patients were consistently reported to have higher concentrations of NET markers in peripheral blood than those in healthy controls, but their diagnostic, therapeutic and prognostic utility is equivocal due to the diverse study population and methodology. After 20 years since the discovery of NETs, their natural history and potential clinical utility in polytrauma is undetermined, requiring further standardisation and research.

The Application of PiCCO-guided Fluid Resuscitation in Patients With Traumatic Shock

BACKGROUND

The aim of this study was to evaluate the application of pulse contour cardiac output (PiCCO) in patients with traumatic shock.

METHODS

Seventy-eight patients with traumatic shock were included and grouped. The control group (CG, n = 39) underwent fluid resuscitation through transthoracic echocardiography (TTE) monitoring, and the research group (RG, n = 39) received PiCCO-guided fluid resuscitation.

RESULTS

The mechanical ventilation time, duration of vasoactive drug use, and duration of stay in the intensive care unit were lower in the RG compared to the CG (P < .05). At 72 h after fluid resuscitation, the mean arterial pressure and central venous pressure in the RG were higher than those in the CG (P < .05). The stroke volume variation and distensibility index of the inferior vena cava were lower at 72 h after fluid resuscitation, but the levels of extravascular lung water, global end-diastolic volume index, and intrathoracic blood volume index were higher in the RG (P < .05). The levels of endothelial 1, nitrogen monoxide, tumor necrosis factor-α, procalcitonin, C-reactive protein, and partial pressure of carbon dioxide at 72 h after fluid resuscitation in the RG were lower than those in the CG (P < .05).

CONCLUSION

PiCCO-guided liquid resuscitation may help to accurately evaluate the volumetric parameters, alleviate symptoms of ischemia and hypoxia, regulate hemodynamics and blood gas analysis, reduce inflammatory reactions, improve endothelial functions, and effectively guide the usage of vascular active drugs.

The Clinical Significance of iNOS/NO Signaling Pathway in Traumatic Shock and the Mechanism under the Promotion on the Development of Traumatic Shock via Endoplasmic Reticulum Stress

OBJECTIVE

This study aims to clarify the clinical significance of the inducible nitric oxide synthase (iNOs)/nitric oxide (NO) signaling pathway and endoplasmic reticulum stress (ERS) in traumatic shock (TS) and the mechanism of action, so as to offer a novel direction for the emergency treatment of TS in the future.

METHODS

The clinical data of 90 patients with TS treated in our hospital between June 2019 and January 2021 were retrospectively analyzed. Patients were divided into mild (n = 30), moderate (n = 30), and severe group (n = 30) based on their disease severity. Furthermore, patients were assigned into Groups A and B for fluid resuscitation based on a pulse index continuous cardiac output (PICCO) monitor and fluid resuscitation based on monitoring results of central venous pressure (CVP) and mean arterial pressure (MAP), respectively. Additionally, the 18 purchased Sprague Dawley (SD) rats were randomized into model (TS model), control (normal rats) and intervention (TS model injected with iNOS inhibitor) groups, with 6 rats each. iNOs and NO levels were measured by colorimetry, and the concentrations of inflammatory factors were quantified using enzyme-linked immunosorbent assays (ELISAs). Polymerase chain reaction (PCR) and western blot were adopted for the quantification of ERS markers (glucose-related protein 78 (GRP78), GRP94 and C/EBP homologous protein (CHOP)), and hematoxylin-eosin (HE) staining of rat cardiac tissue was carried out to observe the pathological state of myocardial tissue.

RESULTS

The moderate group showed higher levels of iNOS, NO, GRP78, GRP94 and CHOP than the mild group and lower levels of them than the severe group (all p < 0.05). MAP, extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI), and locus control region (LCR) increased in both Groups A and B after resuscitation, with more significant increases of these parameters in Group A. The application of PICCO technique lowered the levels of iNOS, NO, inflammatory factors, GRP78, GRP94 and CHOP in TS patients. In addition, the intervention group had lower levels of iNOS, NO, inflammatory factors, GRP78, GRP94, and CHOP than the model group and higher levels of them than the control group. According to the results of HE staining of myocardial tissue, the intervention group had significantly alleviated myocardial necrosis than the model group, with slightly stained cytoplasm, visible contraction bands in most myocardium, and significantly reduced neutrophil infiltration.

CONCLUSIONS

iNOS/NO and ERS increase with the severity of TS, and PICCO can effectively lower their levels. The results of animal experiments suggest that the inhibition of iNOS/NO can relieve inflammation and ERS intensification, thus alleviating the progression of TS.

Permissive untreated pseudoaneurysm concept in damage control interventional radiology for traumatic pancreaticoduodenal artery injury

Background

Angioembolization for traumatic pancreaticoduodenal artery injury with unstable circulation, which characteristically requires a prolonged procedure time, does not yet have a standardized strategy for damage control interventional radiology.

Case Presentation

We encountered two cases of rare traumatic pancreaticoduodenal artery injury wherein the patients were saved by a multidisciplinary team with a shared goal of clinical success, rather than the procedural success of angioembolization. Both patients treated with angioembolization had residual pseudoaneurysm or faint extravasation in the pancreaticoduodenal artery arcade. We prioritized critical care with preemptive plasma transfusion and aggressive blood pressure control, and planned repeat angiography. The patients showed no clinical signs of rebleeding or pseudoaneurysm based on computed tomography during follow-up.

Conclusion

Our findings suggest that the permissive untreated pseudoaneurysm concept can be useful in developing damage control interventional radiology strategies for trauma cases with challenging time limitations, such as traumatic pancreaticoduodenal artery injury with circulatory collapse.

Provider Fatigue During Direct Manual Compression for Life-Threatening Bleeding

Introduction

Trauma is a leading cause of death throughout the world, with hemorrhage being responsible for more than 35% of pre-hospital trauma deaths and more than 40% of deaths within the first 24 hours after injury. Despite first aid having a demonstrable effect on mortality from trauma, relatively little research has compared the best methods for bleeding control in the prehospital first aid setting. The most common first-line therapy for external bleeding control in the pre-hospital first aid setting is direct manual compression (DMC). However, a prior study demonstrated that the primary cause of failure in a simulated model of life-threatening bleeding was the inability to maintain adequate direct pressure for three minutes. In this study, we evaluated the effect of fatigue on DMC for the duration of a typical urban emergency medical services (EMS) response time.

Methods

We conducted a prospective observational trial of 33 participants, 18 years of age or older to measure the pressure generated on a model of life-threatening bleeding over an eight-minute period using a “CPR posture” for applying pressure. The primary analyses were longitudinal two-level multilevel models (MLM) with repeated measures of outcome (i.e., CPR posture pressure) nesting within participants. The demographic factors of gender, age, and weight were included as moderators in the analyses and each was analyzed independently.

Results

The participants’ average age was 31 (SD = 11) and the average weight was 161 pounds (SD = 31). The sample consisted of 18 female participants (54.5%) and 15 male participants (45.5%). Applied DMC pressure declined over time, more sharply initially from the beginning to approximately 250 seconds, at which point the decrease in pressure was gradual. Of the demographic factors, gender was associated with a difference in cardiopulmonary resuscitation (CPR) posture pressure over time.

Conclusion

Rescuers should be aware that fatigue may occur and may affect the quality of direct manual compression for control of life-threatening bleeding. Further research is needed to define the external pressures needed to control life-threatening bleeding and the extent that rescuer fatigue affects this pressure.

The effect of prehospital intravenous access in traumatic shock: a Japanese nationwide cohort study

Aim

We aimed to evaluate effect of prehospital intravenous (IV) access on mortality in traumatic shock using a large nationwide dataset.

Methods

We used the Japan Trauma Data Bank to identify adults (≥18 years) with a systolic blood pressure <90 mm Hg at the trauma scene and were directly transported to the hospital between 2010 and 2019. We compared patients who had prehospital IV access (IV (+)) or not (IV (−)), using propensity score‐matched analysis, and 1:1 nearest‐neighbor matching without replacement. Standardized mean difference was used to evaluate the match balance between the two matched groups; a standardized mean difference >0.1 was considered a significant imbalance. Primary outcome was 72‐h mortality.

Results

Propensity scores matching generated 479 pairs from 5,857 patients. No significant between group differences occurred in 72‐h mortality (7.8 versus 8.8%; difference, −1.0%; 95% confidence interval [CI]: −2.5–4.5%), 28‐day mortality (11.8 versus 11.3%; 95% CI: −4.6–3.6%), blood transfusion administration within 24 h (55.3 versus 49.1%; 95% CI: −0.1–12.6%), prehospital time (56.3 versus 53.0 min; 95% CI: −1.8–8.4 min), and cardiopulmonary arrest on hospital arrival (1.3 versus 1.3%; 95% CI: −1.4–1.4%). However, significantly higher systolic blood pressure on hospital arrival was found in the IV (+) than in the IV (−) group (104.6 versus 100.1 mm Hg; 95% CI: 0.3‐8.7 mm Hg).

Conclusion

We found no significant effect of establishing IV access in the prehospital setting on survival outcomes of patients with traumatic shock.

Application value of procalcitonin, C-reactive protein and interleukin-6 in the evaluation of traumatic shock

Procalcitonin (PCT), C-reactive protein (CRP) and interleukin-6 (IL-6) were detected to explore the value of these inflammatory markers in the assessment of traumatic shock patients. The clinical data of 80 patients with traumatic shock and infections in Zhangzhou Municipal Hospital of Fujian Province from January 2014 to December 2017 were collected as the experimental group. During the same period, 80 acute trauma patients who did not suffer from traumatic shock were regarded as the control group. According to the prognosis outcomes, the experimental group was divided into 56 patients with good prognosis and 24 patients with poor prognosis. Also the PCT, CRP and IL-6 levels in serum of patients at admission (T1), 12 h after admission (T2), three days after admission (T3) and on day 7 (T4) were detected. The differences between the three inflammatory indicators, the pre-admission injury severity score (ISS score), the acute physiology and chronic psychological score (APACHE II score) were compared between the good prognosis and the poor prognosis group. The serum CRP at the T4 time period was significantly lower than both the T1 and T2 time periods (P<0.05). There were differences in serum PCT, CRP and IL-6 between the good prognosis and the poor prognosis group at the time of T1-T4 (P<0.05). The expression levels of PCT, CRP and IL-6 in the serum of patients with poor prognosis were higher than those with good prognosis (P<0.05). Pre-admission ISS scores and APACHE II scores in patients with good prognosis were lower than those with poor prognosis (P<0.05). Detection of PCT, CRP and IL-6 expression levels in serum of the patients has an important reference value for assessing the condition of patients with traumatic shock.

[Extracorporeal membrane oxygenation in severe combined trauma complicated by fat embolism]

It is presented the victim with severe combined injury complicated by fat embolism and acute respiratory failure. Veno-venous extracorporeal membrane oxygenation was successfully used to provide adequate extracorporeal gas exchange in refractory respiratory failure.

Preoperative fluid management in traumatic shock: A retrospective study for identifying optimal therapy of fluid resuscitation for aged patients

Fluid resuscitation was used on aged patients with traumatic shock in their early postoperative recovery. The present study aimed to assess whether different fluid resuscitation strategies had an influence on aged patients with traumatic shock.A total of 219 patients with traumatic shock were recruited retrospectively. Lactated Ringer and hydroxyethyl starch solution were transfused for fluid resuscitation before definite hemorrhagic surgery. Subjects were divided into 3 groups: group A: 72 patients were given aggressive fluid infusion at 20 to 30 mL/min to restore normal mean arterial pressure (MAP) of 65 to 75 mm Hg. Group B: 72 patients were slowly given restrictive hypotensive fluid infusion at 4 to 5 mL/min to maintain MAP of 50 to 65 mm Hg. Group C: 75 patients were given personalized infusion to achieve MAP of 75 to 85 mm Hg. Preoperative infusion volume, preoperative MAP, optimal initial points for surgery, postoperative shock time and mortality rates at 6 and 24 hours after surgery were determined.No significant difference in clinical characteristics was found among the 3 groups. Amount of preoperative infusion was considerably lower in the restrictive group (P < .01, compared with group A). A significant difference in preoperative infusion volume was found between the personalized and other 2 groups (P < .01, compared with groups A and B). Patients in the personalized resuscitation group achieved a higher preoperative MAP (P < .01 compared with Group B; P < .05, compared with group A) and required less prepared time for surgery (P < .01 compared with groups A and B). In addition, a lower mortality rate at 6 and 24 hours after operation was observed in the subjects with personalized therapy (P < .05, compared with group B).Personalized management of fluid resuscitation in traumatized aged patients with appropriate volume and speed of fluid transfusion, suggesting increased survival rate and less prepared time for surgery.