Pathophysiology in patients with polytrauma

The effectiveness of phytosomal curcumin on clinical and laboratory parameters of patients with multiple trauma admitted to the intensive care unit: a double-blind randomized placebo-controlled trial

BACKGROUND

Multiple trauma has serious complications, which increases the risk of morbidity and mortality in the patients. This study aimed to evaluate the impact of supplementation with phytosomal curcumin on clinical and laboratory factors in critically ill patients with multiple trauma.

METHODS

In this double-blind trial, 53 patients with multiple trauma, who were admitted to the intensive care unit (ICU) were randomized to receive either 2 capsules, each capsule containing 250 mg phytosomal (a total of 500 mg daily) as an intervention group or 2 identical capsules (placebo capsules), each containing 250 mg maltodextrin for 7 days. Clinical and laboratory were parameters assessed before and after the intervention.

RESULTS

After seven days of intervention, the mean increase from baseline in the Glasgow coma scale (GCS) score was significantly higher in the curcumin compared with the placebo group (P-value: 0.028), while the reduction in the APACHE-II score in the curcumin group was greater than that the placebo group in a marginally non-significant fashion (P-value: 0.055). Serum total bilirubin (P-value: 0.036) and quantitative C-reactive protein (CRP) (P-value: 0.044) levels significantly decreased while potassium (P-value: 0.01) significantly increased in the curcumin compared with the placebo group. Moreover, supplementation with phytosomal curcumin significantly increased platelet count (P-value: 0.024) as compared with placebo. The 28-day mortality rate was 7.7% (n: 2 patients) and 3.7% (n: 1 patients) in the placebo and curcumin groups, respectively (P-value > 0.05).

CONCLUSION

Phytosomal curcumin had beneficial effects on several clinical and laboratory factors including GCS, APACHEII, serum total bilirubin, CRP, and platelet count in ICU-admitted patients with multiple trauma.

TRIAL REGISTRATION

IRCT20090306001747N1, Available on: https://www.irct.ir/trial/52692 . The first registration date was 12/01/2021.

Hybrid-3D robotic suite in spine and trauma surgery - experiences in 210 patients

BACKGROUND

In modern Hybrid ORs, the synergies of navigation and robotics are assumed to contribute to the optimisation of the treatment in trauma, orthopaedic and spine surgery. Despite promising evidence in the area of navigation and robotics, previous publications have not definitively proven the potential benefits. Therefore, the aim of this retrospective study was to evaluate the potential benefit and clinical outcome of patients treated in a fully equipped 3D-Navigation Hybrid OR.

METHODS

Prospective data was collected (March 2022- March 2024) after implementation of a fully equipped 3D-Navigation Hybrid OR ("Robotic Suite") in the authors level 1 trauma centre. The OR includes a navigation unit, a cone beam CT (CBCT), a robotic arm and mixed reality glasses. Surgeries with different indications of the spine, the pelvis (pelvic ring and acetabulum) and the extremities were performed. Spinal and non-spinal screws were inserted. The collected data was analysed retrospectively. Pedicle screw accuracy was graded according to the Gertzbein and Robbins (GR) classification.

RESULTS

A total of n = 210 patients (118 m:92f) were treated in our 3D-Navigation Hybrid OR, with 1171 screws inserted. Among these patients, 23 patients (11.0%) arrived at the hospital via the trauma room with an average Injury Severity Score (ISS) of 25.7. There were 1035 (88.4%) spinal screws inserted at an accuracy rate of 98.7% (CI95%: 98.1-99.4%; 911 GR-A & 111 GR-B screws). The number of non-spinal screws were 136 (11.6%) with an accuracy rate of 99.3% (CI95%: 97.8-100.0%; 135 correctly placed screws). This resulted in an overall accuracy rate of 98.8% (CI95%: 98.2-99.4%). The robotic arm was used in 152 cases (72.4%), minimally invasive surgery (MIS) was performed in 139 cases (66.2%) and wound infection occurred in 4 cases (1,9%). Overall, no revisions were needed.

CONCLUSION

By extending the scope of application, this study showed that interventions in a fully equipped 3D-Navigation Hybrid OR can be successfully performed not only on the spine, but also on the pelvis and extremities. In trauma, orthopaedics and spinal surgery, navigation and robotics can be used to perform operations with a high degree of precision, increased safety, reduced radiation exposure for the OR-team and a very low complication rate.

Suppressing upregulation of fibrinogen after polytrauma mitigates thrombosis in mice

BACKGROUND

Polytrauma results in systemic inflammation and increased circulating fibrinogen, which increases the risk of microvascular and macrovascular thrombosis that contributes to secondary organ damage and venous thromboembolism (VTE). There are no clinically approved agents to prevent hyperfibrinogenemia after polytrauma. We hypothesized that preventing the increase in fibrinogen levels after polytrauma would suppress thrombosis.

METHODS

Small-interfering ribonucleic acid (siRNA) against fibrinogen was encapsulated in lipid nanoparticles (siFibrinogen). Mice underwent a model of polytrauma and were then given varying doses of siFibrinogen, control siRNA, or no treatment. Fibrinogen was measured for 1 week via enxyme-linked immunosorbent assay (ELISA). To model postinjury VTE, the inferior vena cava was ligated 2 days after polytrauma in a portion of the mice. Thrombus weight was measured 48 hours after the inferior vena cava was ligated.

RESULTS

Treatment with siFibrinogen prevented hyperfibrinogenemia after trauma without exacerbating the hypofibrinogenemic state that occurs in the acute injury period (1 hour). In treated groups, fibrinogen was significantly lower from 6 hours postinjury through the 7-day monitoring period. Maximal fibrinogen reduction was observed at 72 hours. Here, mice that received 2.0 mg/kg of siFibrinogen had 1% of normal values relative to untreated mice, and mice that received 1.0 or 0.5 mg/kg had 4%. Mice treated with siFibrinogen that underwent the postinjury VTE model had significantly reduced thrombus weight compared with control siRNA-treated animals. More notably, among all siFibrinogen treated mice, 12 of 18 were completely protected from thrombosis, compared with 0 of 9 displaying protection in the control group.

CONCLUSION

The rise of fibrinogen and the size of thrombi after polytrauma can be mitigated via the administration of siRNA against fibrinogen. siFibrinogen represents a promising novel target for VTE prophylaxis posttrauma.

Orthoplastic Management of Lower Limb Traumas: A Retrospective Study on Polytraumas Versus Isolated Injuries

BACKGROUND

Open fractures of the lower limb represent a common challenge for trauma centers. Even where national guidelines are available, these standards are frequently missing. Our study evaluates the influence of polytrauma on the adherence to the timing and management required in an orthoplastic approach.

PATIENTS AND METHODS

A retrospective review was performed on 36 patients affected by a Gustilo-Anderson grade IIIA, IIIB, or IIIC fracture of the lower limb between 2018 and 2022. Data related to patient management were analyzed: time to the first evaluation by a plastic surgeon, time to soft tissue coverage, time to definitive osteosynthesis, days in intensive care unit (ICU), days of hospitalization, and total cost of hospital stay. Patient satisfaction was evaluated through the administration of 2 questionnaires: the Enneking and the Foot Function Index (FFI).

RESULTS

In 23 patients (63.9%), a soft tissue reconstruction was required. Of these, 13 were polytraumas (PT) (56.5%) and 10 were affected by an isolated lower limb fracture (ILLF) (43.5%). The median time to wound excision was 7.0 days (IQR, 0-16.0) in the PT group and 12.5 days (IQR, 1-41.0) in the ILLF group, whereas the mean time to soft tissue coverage was 15.0 days (IQR, 4.0-17.0) in the PT group and 38.0 days (IQR, 25.0-65.0) in the ILLF group. Mean time to definitive fixation was 33.0 days (IQR, 6.5-70.0) in the PT group and 16.5 days (IQR, 3.0-26.0) in the ILLF group. Statistically significant difference was reported on mean time to soft tissue coverage, whereas not relevant differences were reported on mean time to plastic surgeon involvement, first debridement, definitive fixation, days of hospitalization, costs, and Enneking and FFI score.

CONCLUSION

This is the first study comparing the effectiveness of the orthoplastic approach between isolated lower limb fractures and polytraumas. According to our study, open lower limb fracture management is paradoxically more effective in polytraumas rather than in isolated injuries because a multidisciplinary approach is mandatory in severely injured and compromised patients.

Mitochondrial dysfunction in platelets from severe trauma patients - A prospective case-control study

INTRODUCTION

Trauma-induced coagulopathy (TIC) refers to an abnormal coagulation process, an imbalance between coagulation and fibrinolysis due to several pathological factors, such as haemorrhage and tissue injury. Platelet activation and subsequent clot formation are associated with mitochondrial activity, suggesting a possible role for mitochondria in TIC. Comprehensive studies of mitochondrial dysfunction in platelets from severe trauma patients have not yet been performed.

METHODS

In this prospective case-control study, patients with severe trauma (ISS≥16) had venous blood samples taken at arrival to the Emergency Unit of a Level 1 Trauma Centre. Mitochondrial functional measurements (Oxygraph-2k, Oroboros) were performed to determine oxygen consumption in different respiratory states, the H2O2 production and extramitochondrial Ca2+ movements. In addition, standard laboratory and coagulation tests, viscoelastometry (ClotPro) and aggregometry (Multiplate) were performed. Measurements data were compared with age and sex matched healthy control patients.

RESULTS

Severe trauma patients (n = 113) with a median age of 38 years (IQR, 20-51), a median ISS of 28 (IQR, 20-48) met our inclusion criteria. Oxidative phosphorylation in platelet mitochondria from severe trauma patients significantly decreased compared to controls (34.7 ± 8.8 pmol/s/mL vs. 48.0 ± 19.7 pmol/s/mL). The mitochondrial H2O2 production significantly increased and greater endogenous Ca2+ release was found in the polytrauma group. Consistent with these results, clotting time (CT) increased while maximum clot firmness (MCF) decreased with the EX-test and FIB-test in severe trauma samples. Multiplate aggregometry showed significantly decreased ADP-test (38 ± 12 AUC vs. 112 ± 14 AUC) and ASPI test (78 ± 22 AUC vs. 84 ± 28 AUC) also tended to decrease in mitochondria of polytrauma patients as compared with controls. Significant strong correlation has been demonstrated between mitochondrial OxPhos and MCF while it was negatively correlated with ISS (R2=0.448, P˂0.05), INR, CT and lactate level of patients.

CONCLUSIONS

The present study revealed that severe trauma is associated with platelet mitochondrial dysfunction resulting in reduced ATP synthesis and impaired extramitochondrial Ca2+ movement. These factors are required for platelet activation, recruitment and clot stability likely thus, platelet mitochondrial dysfunction contributes to the development of TIC.

Pulmonary miRNA expression after polytrauma depends on the surgical invasiveness and displays an anti-inflammatory pattern by the combined inhibition of C5 and CD14

Background

Respiratory failure can be a severe complication after polytrauma. Extensive systemic inflammation due to surgical interventions, as well as exacerbated post-traumatic immune responses influence the occurrence and progression of respiratory failure. This study investigated the effect of different surgical treatment modalities as well as combined inhibition of the complement component C5 and the toll-like receptor molecule CD14 (C5/CD14 inhibition) on the pulmonary microRNA (miRNA) signature after polytrauma, using a translational porcine polytrauma model.

Methods

After induction of general anesthesia, animals were subjected to polytrauma, consisting of blunt chest trauma, bilateral femur fractures, hemorrhagic shock, and liver laceration. One sham group (n=6) and three treatment groups were defined; Early Total Care (ETC, n=8), Damage Control Orthopedics (DCO, n=8), and ETC + C5/CD14 inhibition (n=4). Animals were medically and operatively stabilized, and treated in an ICU setting for 72 h. Lung tissue was sampled, miRNAs were isolated, transcribed, and pooled for qPCR array analyses, followed by validation in the individual animal population. Lastly, mRNA target prediction was performed followed by functional enrichment analyses.

Results

The miRNA arrays identified six significantly deregulated miRNAs in lung tissue. In the DCO group, miR-129, miR-192, miR-194, miR-382, and miR-503 were significantly upregulated compared to the ETC group. The miRNA expression profiles in the ETC + C5/CD14 inhibition group approximated those of the DCO group. Bioinformatic analysis revealed mRNA targets and signaling pathways related to alveolar edema, pulmonary fibrosis, inflammation response, and leukocytes recruitment. Collectively, the DCO group, as well as the ETC + C5/CD14 inhibition group, revealed more anti-inflammatory and regenerative miRNA expression profiles.

Conclusion

This study showed that reduced surgical invasiveness and combining ETC with C5/CD14 inhibition can contribute to the reduction of pulmonary complications.

Systemic acylcarnitine levels are affected in response to multiple injuries and hemorrhagic shock: An analysis of lipidomic changes in a standardized porcine model

INTRODUCTION

Along with recent advances in analytical technologies, tricarboxylic acid-cycle intermediates are increasingly identified as promising makers for cellular ischemia and mitochondrial dysfunction during hemorrhagic shock. For traumatized patients, the knowledge of the role of lipid oxidation substrates is sparse. In this study, we aimed to analyze the dynamics of systemic acylcarnitine (AcCa) release in a standardized polytrauma model with hemorrhagic shock.

METHODS

Fifty-two male pigs (50 ± 5 kg) were randomized into two groups: group isolated fracture was subject to a standardized femur shaft fracture, and group polytrauma was subject to a femur fracture, followed by blunt chest trauma, liver laceration, and a pressure-controlled hemorrhagic shock for 60 minutes. Resuscitation was performed with crystalloids. Fractures were stabilized by intramedullary nailing. Venous samples were collected at six time points (baseline, trauma, resuscitation, 2 hours, 4 hours, and 6 hours). Lipidomic analysis was performed via liquid chromatography coupled mass spectrometry. Measurements were collated with clinical markers and near-infrared spectrometry measurements of tissue perfusion. Longitudinal analyses were performed with linear mixed models, and Spearman's correlations were calculated. A p value of 0.05 was defined as threshold for statistical significance.

RESULTS

From a total of 303 distinct lipids, we identified two species of long-chain AcCas. Both showed a highly significant ( p < 0.001) twofold increase after hemorrhagic shock in group polytrauma that promptly normalized after resuscitation. This increase was associated with a significant decrease of the base excess ( p = 0.005), but recovery after resuscitation was faster. For both AcCas, there were significant correlations with decreased muscle tissue oxygen delivery ( p = 0.008, p = 0.003) and significant time-lagged correlations with the increase of creatine kinase ( p < 0.001, p < 0.001).

CONCLUSION

Our results point to plasma AcCas as a possible indicator for mitochondrial dysfunction and cellular ischemia in hemorrhagic shock. The more rapid normalization after resuscitation in comparison with acid base changes may warrant further investigation.

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review

BACKGROUND

The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.

METHODS

This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.

RESULTS

A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).

CONCLUSION

A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.

LEVEL OF EVIDENCE

Delphi-Consensus/Systematic Review; Level IV.

Identifying the key characteristics, trends, and seasonality of pedestrian traffic injury at a major trauma center in Saudi Arabia: a registry-based retrospective cohort study, 2017-2022

BACKGROUND

Pedestrian traffic injuries are a rising public health concern worldwide. In rapidly urbanizing countries like Saudi Arabia, these injuries account for a considerable proportion of trauma cases and represent a challenge for healthcare systems. The study aims to analyze the key characteristics, seasonality, and outcomes of pedestrian traffic injuries in Riyadh, Saudi Arabia.

METHODS

This study was a retrospective cohort analysis of all pedestrian traffic injuries presented to King Saud Medical City, Riyadh, and included in the Saudi Trauma Registry (STAR) database between August 1, 2017, and December 31, 2022. The analysis of metric and nominal variables was reported as mean (standard deviation, SD) or median (interquartile range, IQR) and frequencies (%), respectively. A logistic regression analysis was performed to examine the influence of patients' pre-hospital vitals and key characteristics on arrival at the ED on the need for mechanical ventilation and in-hospital mortality.

RESULTS

During the study period, 1062 pedestrian-injured patients were included in the analysis, mostly males (89.45%) with a mean (SD) age of 33.44 (17.92) years. One-third (35.88%) of the patients were Saudi nationals. Two-thirds (67.04%) of the injuries occurred from 6 p.m. until 6 a.m. Compared to other years, a smaller % of injury events (13.28%) were noticed during the COVID-19 pandemic (2020). Half (50.19%) of the patients were transported to the emergency department by the Red Crescent ambulance, and 19.68% required intubation and mechanical ventilation. Most of the patients (87.85%) were discharged home after completion of treatment, and our cohort had a 4.89% overall mortality. The logistic regression analysis showed the influence of patients' pre-hospital vitals and key characteristics on arrival at the ED on the need for mechanical ventilation (Chi2 = 161.95, p < 0.001) and in-hospital mortality (Chi2 = 63.78, p < 0.001) as a whole significant.

CONCLUSION

This study details the demographic, temporal, and clinical trends of pedestrian traffic injuries at a major Saudi trauma center. Identifying high-risk individuals and injury timing is crucial for resource allocation, targeting road safety interventions like public awareness campaigns and regulatory reforms, and improving prehospital care and patient outcomes.

Beyond Trauma-Induced Coagulopathy: Detection of Auto-Heparinization as a Marker of Endotheliopathy Using Rotational Thromboelastometry

Background/Objectives: The complexity of trauma-induced coagulopathy (TIC) is a result of the unique interactions between the patient, trauma, and resuscitation-related causes. The main objective of trauma resuscitation is to create the optimal milieu for both the development of immediate reparatory mechanisms and the prevention of further secondary injuries. Endotheliopathy represents one of the hallmarks of trauma-induced coagulopathy, and comprises endothelial dysfunction, abnormal coagulation, and inflammation, all of which arise after severe trauma and hemorrhagic shock. Methods: We retrospectively and descriptively evaluated 217 patients admitted to the Bucharest Clinical Emergency Hospital who met the Berlin criteria for the diagnosis of multiple trauma. Patients with high suspicion of auto-heparinization were identified according to the dynamic clinical and para-clinical evolution and subsequently tested using rotational thromboelastometry (ROTEM). The ratio between the clot formation time (CT) was used, obtained on the two channels of interest (INTEM/HEPTEM). Results: Among the 217 patients with a mean age of 43.43 ± 15.45 years and a mean injury severity score (ISS) of 36.98 ± 1.875, 42 patients had a reasonable clinical and para-clinical suspicion of auto-heparinization, which was later confirmed by the INTEM/HEPTEM clotting time ratio in 28 cases (12.9% from the entire study population). A multiple linear regression analysis highlighted that serum lactate (estimated 0.02, p = 0.0098) and noradrenaline requirement (estimated 0.03, p = 0.0053) influenced the CT (INTEM/HEPTEM) ratio. Conclusions: There is a subset of multiple trauma patients in which the CT (INTEM/HEPTEM) ratio was influenced only by serum lactate levels and patients' need for vasopressor use, reinforcing the relationship between shock, hypoperfusion, and clotting derangements. This emphasizes the unique response that each patient has to trauma.

Calcium supplementation during trauma resuscitation: a propensity score-matched analysis from the TraumaRegister DGU®

BACKGROUND

In major trauma patients, hypocalcemia is associated with increased mortality. Despite the absence of strong evidence on causality, early calcium supplementation has been recommended. This study investigates whether calcium supplementation during trauma resuscitation provides a survival benefit.

METHODS

We conducted a retrospective analysis using data from the TraumaRegister DGU® (2015-2019), applying propensity score matching to balance demographics, injury severity, and management between major trauma patients with and without calcium supplementation. 6 h mortality, 24 h mortality, and in-hospital mortality were considered as primary outcome parameters.

RESULTS

Within a cohort of 28,323 directly admitted adult major trauma patients at a European trauma center, 1593 (5.6%) received calcium supplementation. Using multivariable logistic regression to generate propensity scores, two comparable groups of 1447 patients could be matched. No significant difference in early mortality (6 h and 24 h) was observed, while in-hospital mortality appeared higher in those with calcium supplementation (28.3% vs. 24.5%, P = 0.020), although this was not significant when adjusted for predicted mortality (P = 0.244).

CONCLUSION

In this matched cohort, no evidence was found for or against a survival benefit from calcium supplementation during trauma resuscitation. Further research should focus on understanding the dynamics and kinetics of ionized calcium levels in major trauma patients and identify if specific conditions or subgroups could benefit from calcium supplementation.

The role of big data management, data registries, and machine learning algorithms for optimizing safe definitive surgery in trauma: a review

Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer.

A nomogram for predicting hemorrhagic shock in pediatric patients with multiple trauma

The timely detection and management of hemorrhagic shock hold paramount importance in clinical practice. This study was designed to establish a nomogram that may facilitate early identification of hemorrhagic shock in pediatric patients with multiple-trauma. A retrospective study was conducted utilizing a cohort comprising 325 pediatric patients diagnosed with multiple-trauma, who received treatment at the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China. For external validation, an additional cohort of 144 patients from a children's hospital in Taizhou was included. The model's predictor selection was optimized through the application of the Least Absolute  Shrinkage and Selection Operator (LASSO) regression. Subsequently, a prediction nomogram was constructed using multivariable logistic regression analysis. The performance and clinical utility of the developed model were comprehensively assessed utilizing various statistical metrics, including Harrell's Concordance Index (C-index), receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis (DCA). Multivariate logistic regression analysis identified systolic blood pressure (ΔSBP), platelet count, activated partial thromboplastin time (APTT), and injury severity score (ISS) as independent predictors for hemorrhagic shock. The nomogram constructed using these predictors demonstrated robust predictive capabilities, as evidenced by an impressive area under the curve (AUC) value of 0.963. The model's goodness-of-fit was assessed using the Hosmer-Lemeshow test (χ2 = 10.023, P = 0.209). Furthermore, decision curve analysis revealed significantly improved net benefits with the model. External validation further confirmed the reliability of the proposed predictive nomogram. This study successfully developed a nomogram for predicting the occurrence of hemorrhagic shock in pediatric patients with multiple trauma. This nomogram may serve as an accurate and effective tool for timely and efficient management of children with multiple trauma.

Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES

PURPOSE

Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology.

METHODS

A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades.

RESULTS

4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000.

CONCLUSION

Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

BACKGROUND

The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies.

METHODS

In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics.

RESULTS

Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4).

CONCLUSION

Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

The pathophysiology of pelvic ring injuries: a review

Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.

Fracture haematoma proteomics

Aims

The aim of this study was to determine the fracture haematoma (fxH) proteome after multiple trauma using label-free proteomics, comparing two different fracture treatment strategies.

Methods

A porcine multiple trauma model was used in which two fracture treatment strategies were compared: early total care (ETC) and damage control orthopaedics (DCO). fxH was harvested and analyzed using liquid chromatography-tandem mass spectrometry. Per group, discriminating proteins were identified and protein interaction analyses were performed to further elucidate key biomolecular pathways in the early fracture healing phase.

Results

The early fxH proteome was characterized by immunomodulatory and osteogenic proteins, and proteins involved in the coagulation cascade. Treatment-specific proteome alterations were observed. The fxH proteome of the ETC group showed increased expression of pro-inflammatory proteins related to, among others, activation of the complement system, neutrophil functioning, and macrophage activation, while showing decreased expression of proteins related to osteogenesis and tissue remodelling. Conversely, the fxH proteome of the DCO group contained various upregulated or exclusively detected proteins related to tissue regeneration and remodelling, and proteins related to anti-inflammatory and osteogenic processes.

Conclusion

The early fxH proteome of the ETC group was characterized by the expression of immunomodulatory, mainly pro-inflammatory, proteins, whereas the early fxH proteome of the DCO group was more regenerative and osteogenic in nature. These findings match clinical observations, in which enhanced surgical trauma after multiple trauma causes dysbalanced inflammation, potentially leading to reduced tissue regeneration, and gained insights into regulatory mechanisms of fracture healing after severe trauma.

Promoting bone callus formation by taking advantage of the time-dependent fracture gap strain modulation

Delayed union and non-union of fractures continue to be a major problem in trauma and orthopedic surgery. These cases are challenging for the surgeon. In addition, these patients suffer from multiple surgeries, pain and disability. Furthermore, these cases are a major burden on healthcare systems. The scientific community widely agrees that the stability of fixation plays a crucial role in determining the outcome of osteosynthesis. The extent of stabilization affects factors like fracture gap strain and fluid flow, which, in turn, influence the regenerative processes positively or negatively. Nonetheless, a growing body of literature suggests that during the fracture healing process, there exists a critical time frame where intervention can stimulate the bone's return to its original form and function. This article provides a summary of existing evidence in the literature regarding the impact of different levels of fixation stability on the strain experienced by newly forming tissues. We will also discuss the timing and nature of this "window of opportunity" and explore how current knowledge is driving the development of new technologies with design enhancements rooted in mechanobiological principles.

Alterations in the immune landscape characterized by inflammatory activation and immune escape within 12 h after trauma

BACKGROUND

Trauma is statistically a significant cause of mortality among patients across countries. Nevertheless, the precise correlation between genetic diagnostic markers and the intricate mechanism of trauma remains indistinct.

METHODS

Our study exclusively centered on trauma patients and selected three trauma-related datasets from the Gene Expression Omnibus (GEO) database, all of which had blood samples collected within post-traumatic 12 h. Differential gene screening, the WGCNA and Cytoscape software were employed to analyze the two datasets, with a particular emphasis on the top 100 genes selected based on MCC algorithm scores. A logistic diagnostic model was constructed by analyzing the intersection genes in the third dataset, leading to the identification of diagnostic biomarkers with high efficiency. The global immune landscape of these patients was extensively investigated using a multidimensional approach. Meanwhile, the underlying pathological and physiological mechanisms associated with early trauma status are summarized by integrating existing literature.

RESULTS

Out of these two GEO datasets, 21 overlapping genes were identified and incorporated into in the logistic diagnostic model constructed in the GSE36809 dataset. A panel of 9 genes was uncovered as a diagnostic biomarker, and their expression and correlation were subsequently verified. Additionally, by virtue of various algorithms, the findings revealed an upregulation of neutrophil expression and a downregulation of CD8+ T cell expression, indicating characteristic early trauma-induced inflammation activation and immune suppression. The correlation observed between the feature genes and immune cells serves to validate the exceptional diagnostic capability of these 9 genes in identifying trauma status and their promising potential for patients who could benefit from targeted immune interventions. Drawing from these findings, the discussion section offers insights into the underlying pathological and physiological mechanisms at play.

CONCLUSION

Our research has discovered a novel diagnostic biomarker and unveiled its association with post-traumatic immune alterations. This breakthrough enables accurate and timely diagnosis of early trauma, facilitating the implementation of appropriate healthcare interventions.

Fracture fixation in polytraumatized patients-From an interdisciplinary early total/appropriate care to the safe definitive surgery concept

The strategies for the timing of fracture fixation in polytrauma patients have changed with improvements in resuscitation and patient assessment. Specifically, the criteria for damage control have been formulated, and more precise parameters have been found to determine those patients who can safely undergo primary definitive fixation of major fractures. Our current recommendations are supported by objective and data-based criteria and development groups. Those were validated and compared to existing scores. This review article introduces the concept of "safe definitive surgery" and provides an update on the parameters used to clear patients for timely fixation of major fractures.

Serum levels of matrix metalloproteinases 1, 2, and 7, and their tissue inhibitors 1, 2, 3, and 4 in polytraumatized patients: Time trajectories, correlations, and their ability to predict mortality

There has been limited research on assessing metalloproteinases (MMPs) 1, 2, and 7, as well as their tissue inhibitors (TIMPs) 1, 2, 3, and 4 in the context of polytrauma. These proteins play crucial roles in various physiological and pathological processes and could be a reliable tool in polytrauma care. We aimed to determine their clinical relevance. We assessed 24 blunt polytrauma survivors and 12 fatalities (mean age, 44.2 years, mean ISS, 45) who were directly admitted to our Level I trauma center and spent at least one night in the intensive care unit. We measured serum levels of the selected proteins on admission (day 0) and days 1, 3, 5, 7, and 10. The serum levels of the seven proteins varied considerably among individuals, resulting in similar median trend curves for TIMP1 and TIMP4 and for MMP1, MMP2, TIMP2, and TIMP3. We also found a significant interrelationship between the MMP2, TIMP2, and TIMP3 levels at the same measurement points. Furthermore, we calculated significant cross-correlations between MMP7 and MMP1, TIMP1 and MMP7, TIMP3 and MMP1, TIMP3 and MMP2, and TIMP4 and TIMP3 and an almost significant correlation between MMP7 and TIMP1 for a two-day-lag. The autocorrelation coefficient reached statistical significance for MMP1 and TIMP3. Finally, lower TIMP1 serum levels were associated with in-hospital mortality upon admission. The causal effects and interrelationships between selected proteins might provide new insights into the interactions of MMPs and TIMPs. Identifying the underlying causes might help develop personalized therapies for patients with multiple injuries. Administering recombinant TIMP1 or increasing endogenous production could improve outcomes for those with multiple injuries. However, before justifying further investigations into basic research and clinical relevance, our findings must be validated in a multicenter study using independent cohorts to account for clinical and biological variability.

Experimental study of a novel mouse model of tibial shaft fracture combined with blunt chest trauma

BACKGROUD

Thoracic Trauma and Limb Fractures Are the Two most Common Injuries in Multiple Trauma. However, there Is Still a Lack of Mouse Models of Trauma Combining Tibial Shaft Fracture (TSF) and Thoracic Trauma. In this Study, we Attempted to Develop a Novel Mouse Model of TSF Combined with Blunt Chest Trauma (BCT).

METHODS

A total of 84 C57BL/6J male mice were used as the multiple trauma model. BCT was induced by hitting the chests of mice with heavy objects, and TSF was induced by hitting the tibia of mice with heavy objects after intramedullary fixation. Serum specimens of mice were received by cardiac puncture at defined time points of 0, 6, 12, 24, 48, and 72 h.

RESULTS

Body weight and body temperature tended to decrease within 24 h after multiple trauma. Hemoglobin analyses revealed a decrease during the first 24 h after multiple trauma. Some animals died by cardiac puncture immediately after chest trauma. These animals exhibited the most severe pulmonary contusion and hemorrhage. The level of lung damage varied in diverse mice but was apparent in all animals. Classic hematoxylin and eosin (H&E)-stained paraffin pulmonary sections of mice with multiple trauma displayed hemorrhage and an immunoinflammatory reaction. Bronchoalveolar lavage fluid (BALF) and serum samples of mice with multiple trauma showed an upregulation of interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-1α (TNF-1α) compared with the control group. Microimaging confirmed the presence of a tibia fracture and pulmonary contusion.

CONCLUSIONS

The novel mouse multiple trauma model established in this study is a common trauma model that shows similar pathological mechanisms and imaging characteristics in patients with multiple injuries. This study is useful for determining whether blockade or intervention of the cytokine response is beneficial for the treatment of patients with multiple trauma. Further research is needed in the future.

Traumatic inflammatory response: pathophysiological role and clinical value of cytokines

Severe trauma is an intractable problem in healthcare. Patients have a widespread immune system response that is complex and vital to survival. Excessive inflammatory response is the main cause of poor prognosis and poor therapeutic effect of medications in trauma patients. Cytokines are signaling proteins that play critical roles in the body's response to injuries, which could amplify or suppress immune responses. Studies have demonstrated that cytokines are closely related to the severity of injuries and prognosis of trauma patients and help present cytokine-based diagnosis and treatment plans for trauma patients. In this review, we introduce the pathophysiological mechanisms of a traumatic inflammatory response and the role of cytokines in trauma patients. Furthermore, we discuss the potential of cytokine-based diagnosis and therapy for post-traumatic inflammatory response, although further clarification to elucidate the underlying mechanisms of cytokines following trauma is warranted.

Circulating miRNA expression in extracellular vesicles is associated with specific injuries after multiple trauma and surgical invasiveness

Introduction

Two trauma treatment principles are Early Total Care (ETC), and Damage Control Orthopedics (DCO). Cellular mechanisms that underlie the connection between treatment type, its systemic effects, and tissue regeneration are not fully known. Therefore, this study aimed to: 1) profile microRNA (miRNA) expression in plasma derived Extracellular Vesicles (EVs) from a porcine multiple trauma model at different timepoints, comparing two surgical treatments; and 2) determine and validate the miRNA's messengerRNA (mRNA) targets.

Methods

The porcine multiple trauma model consisted of blunt chest trauma, liver laceration, bilateral femur fractures, and controlled haemorrhagic shock. Two treatment groups were defined, ETC (n=8), and DCO (n=8). Animals were monitored under Intensive Care Unit-standards, blood was sampled at 1.5, 2.5, 24, and 72 hours after trauma, and EVs were harvested from plasma. MiRNAs were analysed using quantitative Polymerase Chain Reaction arrays. MRNA targets were identified in silico and validated in vivo in lung and liver tissue.

Results

The arrays showed distinct treatment specific miRNA expression patterns throughout all timepoints, and miRNAs related to the multiple trauma and its individual injuries. EV-packed miRNA expression in the ETC group was more pro-inflammatory, indicating potentially decreased tissue regenerative capacities in the acute post-traumatic phase. In silico target prediction revealed several overlapping mRNA targets among the identified miRNAs, related to inflammation, (pulmonary) fibrosis, and Wnt-signalling. These were, among others, A Disintegrin and Metalloproteinase domain-containing protein 10, Collagen Type 1 Alpha 1 Chain, Catenin Beta Interacting Protein 1, and Signal Transducers and Activators of Transcription 3. Validation of these mRNA targets in the lung showed significant, treatment specific deregulations which matched the expression of their upstream miRNAs. No significant mRNA deregulations were observed in the liver.

Discussion

This study showed treatment specific, EV-packed miRNA expression patterns after trauma that correlated with mRNA expressions in the lungs, target organs over distance. A systemic response to the increased surgical trauma in the ETC group was identified, with various miRNAs associated with injuries from the trauma model, and involved in (systemic) inflammation, tissue regeneration. EV-transported miRNAs demonstrated a clear role in multiple trauma, warranting further research into tissue-tissue talk and therapeutic applications of EVs after trauma.

Simultaneous ipsilateral floating hip and knee: the double floating extremity-a systematic review and proposal of a treatment algorithm

PURPOSE

To systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications.

METHODS

Data sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted.

STUDY SELECTION

All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included.

DATA EXTRACTION

Basic information and specific injury-related information were collected.

RESULTS

Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies.

CONCLUSION

The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries.

Advancing polytrauma care: developing and validating machine learning models for early mortality prediction

BACKGROUND

Rapid identification of high-risk polytrauma patients is crucial for early intervention and improved outcomes. This study aimed to develop and validate machine learning models for predicting 72 h mortality in adult polytrauma patients using readily available clinical parameters.

METHODS

A retrospective analysis was conducted on polytrauma patients from the Dryad database and our institution. Missing values pertinent to eligible individuals within the Dryad database were compensated for through the k-nearest neighbor algorithm, subsequently randomizing them into training and internal validation factions on a 7:3 ratio. The patients of our institution functioned as external validation cohorts. The predictive efficacy of random forest (RF), neural network, and XGBoost models was assessed through an exhaustive suite of performance indicators. The SHapley Additive exPlanations (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) methods were engaged to explain the supreme-performing model. Conclusively, restricted cubic spline analysis and multivariate logistic regression were employed as sensitivity analyses to verify the robustness of the findings.

RESULTS

Parameters including age, body mass index, Glasgow Coma Scale, Injury Severity Score, pH, base excess, and lactate emerged as pivotal predictors of 72 h mortality. The RF model exhibited unparalleled performance, boasting an area under the receiver operating characteristic curve (AUROC) of 0.87 (95% confidence interval [CI] 0.84-0.89), an area under the precision-recall curve (AUPRC) of 0.67 (95% CI 0.61-0.73), and an accuracy of 0.83 (95% CI 0.81-0.86) in the internal validation cohort, paralleled by an AUROC of 0.98 (95% CI 0.97-0.99), an AUPRC of 0.88 (95% CI 0.83-0.93), and an accuracy of 0.97 (95% CI 0.96-0.98) in the external validation cohort. It provided the highest net benefit in the decision curve analysis in relation to the other models. The outcomes of the sensitivity examinations were congruent with those inferred from SHAP and LIME.

CONCLUSIONS

The RF model exhibited the best performance in predicting 72 h mortality in adult polytrauma patients and has the potential to aid clinicians in identifying high-risk patients and guiding clinical decision-making.

Urinary peptides provide information about the risk of mortality across a spectrum of diseases and scenarios

BACKGROUND

There is evidence of pre-established vulnerability in individuals that increases the risk of their progression to severe disease or death, although the mechanisms causing this are still not fully understood. Previous research has demonstrated that a urinary peptide classifier (COV50) predicts disease progression and death from SARS-CoV-2 at an early stage, indicating that the outcome prediction may be partly due to vulnerabilities that are already present. The aim of this study is to examine the ability of COV50 to predict future non-COVID-19-related mortality, and evaluate whether the pre-established vulnerability can be generic and explained on a molecular level by urinary peptides.

METHODS

Urinary proteomic data from 9193 patients (1719 patients sampled at intensive care unit (ICU) admission and 7474 patients with other diseases (non-ICU)) were extracted from the Human Urinary Proteome Database. The previously developed COV50 classifier, a urinary proteomics biomarker panel consisting of 50 peptides, was applied to all datasets. The association of COV50 scoring with mortality was evaluated.

RESULTS

In the ICU group, an increase in the COV50 score of one unit resulted in a 20% higher relative risk of death [adjusted HR 1.2 (95% CI 1.17-1.24)]. The same increase in COV50 in non-ICU patients resulted in a higher relative risk of 61% [adjusted HR 1.61 (95% CI 1.47-1.76)], consistent with adjusted meta-analytic HR estimate of 1.55 [95% CI 1.39-1.73]. The most notable and significant changes associated with future fatal events were reductions of specific collagen fragments, most of collagen alpha I (I).

CONCLUSION

The COV50 classifier is predictive of death in the absence of SARS-CoV-2 infection, suggesting that it detects pre-existing vulnerability. This prediction is mainly based on collagen fragments, possibly reflecting disturbances in the integrity of the extracellular matrix. These data may serve as a basis for proteomics-guided intervention aiming towards manipulating/ improving collagen turnover, thereby reducing the risk of death.

Conservative management of multi-trauma induced peritonitis: Experience, outcomes, and indications

BACKGROUND

The concept of mandatory laparotomy in treating traumatic peritonitis has been increasingly questioned recently.

AIM

To summarize and share the experience of conservative treatment of patients with multi-trauma induced peritonitis.

METHODS

A retrospective review was performed on patients with multiple injury induced traumatic peritonitis.

RESULTS

A total of 184 patients with multiple injury induced traumatic peritonitis were reviewed. 46 of them underwent conservative treatment. None of the 46 patients with conservative treatment switched to surgical treatment, and all of them were cured and discharged after successful conservative treatment. No significant abnormal findings were observed at regular follow-up after discharge.

CONCLUSION

Conservative management is safe, effective, feasible, and beneficial in hemodynamically stable patients with traumatic peritonitis if there is no definite evidence of severe abdominal visceral organ injury.

Systemic inflammation induced from remote extremity trauma is a critical driver of secondary brain injury

Blast exposure, commonly experienced by military personnel, can cause devastating life-threatening polysystem trauma. Despite considerable research efforts, the impact of the systemic inflammatory response after major trauma on secondary brain injury-inflammation is largely unknown. The aim of this study was to identify markers underlying the susceptibility and early onset of neuroinflammation in three rat trauma models: (1) blast overpressure exposure (BOP), (2) complex extremity trauma (CET) involving femur fracture, crush injury, tourniquet-induced ischemia, and transfemoral amputation through the fracture site, and (3) BOP+CET. Six hours post-injury, intact brains were harvested and dissected to obtain biopsies from the prefrontal cortex, striatum, neocortex, hippocampus, amygdala, thalamus, hypothalamus, and cerebellum. Custom low-density microarray datasets were used to identify, interpret and visualize genes significant (p < 0.05 for differential expression [DEGs]; 86 neuroinflammation-associated) using a custom python-based computer program, principal component analysis, heatmaps and volcano plots. Gene set and pathway enrichment analyses of the DEGs was performed using R and STRING for protein-protein interaction (PPI) to identify and explore key genes and signaling networks. Transcript profiles were similar across all regions in naïve brains with similar expression levels involving neurotransmission and transcription functions and undetectable to low-levels of inflammation-related mediators. Trauma-induced neuroinflammation across all anatomical brain regions correlated with injury severity (BOP+CET > CET > BOP). The most pronounced differences in neuroinflammatory-neurodegenerative gene regulation were between blast-associated trauma (BOP, BOP+CET) and CET. Following BOP, there were few DEGs detected amongst all 8 brain regions, most were related to cytokines/chemokines and chemokine receptors, where PPI analysis revealed Il1b as a potential central hub gene. In contrast, CET led to a more excessive and diverse pro-neuroinflammatory reaction in which Il6 was identified as the central hub gene. Analysis of the of the BOP+CET dataset, revealed a more global heightened response (Cxcr2, Il1b, and Il6) as well as the expression of additional functional regulatory networks/hub genes (Ccl2, Ccl3, and Ccl4) which are known to play a critical role in the rapid recruitment and activation of immune cells via chemokine/cytokine signaling. These findings provide a foundation for discerning pathophysiological consequences of acute extremity injury and systemic inflammation following various forms of trauma in the brain.

Advances in trauma care to save lives from traumatic injury: A narrative review

ABSTRACT

Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.

Experimental Models of Traumatic Injuries: Do They Capture the Coagulopathy and Underlying Endotheliopathy Induced by Human Trauma?

Trauma-induced coagulopathy (TIC) is a major cause of morbidity and mortality in patients with traumatic injury. It describes the spectrum of coagulation abnormalities that occur because of the trauma itself and the body's response to the trauma. These coagulation abnormalities range from hypocoagulability and hyperfibrinolysis, resulting in potentially fatal bleeding, in the early stages of trauma to hypercoagulability, leading to widespread clot formation, in the later stages. Pathological changes in the vascular endothelium and its regulation of haemostasis, a phenomenon known as the endotheliopathy of trauma (EoT), are thought to underlie TIC. Our understanding of EoT and its contribution to TIC remains in its infancy largely due to the scarcity of experimental research. This review discusses the mechanisms employed by the vascular endothelium to regulate haemostasis and their dysregulation following traumatic injury before providing an overview of the available experimental in vitro and in vivo models of trauma and their applicability for the study of the EoT and its contribution to TIC.

Surgical load in major fractures - results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

PURPOSE

It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions.

METHODS

A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between "1," defined as the surgical load equivalent to external (monolateral) fixator application, and "5," defined as the maximal surgical load possible in that specific anatomic region.

RESULTS

This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load.

CONCLUSION

This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient's physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

Severe Trauma-Induced Coagulopathy: Molecular Mechanisms Underlying Critical Illness

Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of coagulopathy in trauma patients is multifactorial and related to the kind of injury and nature of resuscitation. Trauma-induced coagulopathy (TIC) is a biochemical response involving dysregulated coagulation, altered fibrinolysis, systemic endothelial dysfunction, platelet dysfunction, and inflammatory responses due to trauma. The aim of this review is to report the pathophysiology, early diagnosis and treatment of TIC. A literature search was performed using different databases to identify relevant studies in indexed scientific journals. We reviewed the main pathophysiological mechanisms involved in the early development of TIC. Diagnostic methods have also been reported which allow early targeted therapy with pharmaceutical hemostatic agents such as TEG-based goal-directed resuscitation and fibrinolysis management. TIC is a result of a complex interaction between different pathophysiological processes. New evidence in the field of trauma immunology can, in part, help explain the intricacy of the processes that occur after trauma. However, although our knowledge of TIC has grown, improving outcomes for trauma patients, many questions still need to be answered by ongoing studies.

Growth hormone-releasing hormone antagonists protect against hydrochloric acid-induced endothelial injury in vitro

Growth hormone-releasing hormone (GHRH) regulates the synthesis of growth hormone from the anterior pituitary gland, and it is involved in inflammatory responses. On the other hand, GHRH antagonists (GHRHAnt) exhibit the opposite effects, resulting in endothelial barrier enhancement. Exposure to hydrochloric acid (HCL) is associated with acute and chronic lung injury. In this study, we investigate the effects of GHRHAnt in HCL-induced endothelial barrier dysfunction, utilizing commercially available bovine pulmonary artery endothelial cells (BPAEC). Cell viability was measured by utilizing 3-(4,5-dimethylthiazol2-yl)- 2,5-diphenyltetrazolium bromide (MTT) assay. Moreover, fluorescein isothiocyanate (FITC)-dextran was used to assess barrier function. Our observations suggest that GHRHAnt exert protective effects against HCL-induced endothelial breakdown, since those peptides counteract HCL-triggered paracellular hyperpermeability. Based on those findings, we propose that GHRHAnt represent a new therapeutic approach towards HCL-induced endothelial injury.

Continuous improvement in optimizing the timing of axial, hip, and femoral fracture fixation

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature

INTRODUCTION

Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation.

METHODS

Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained.

RESULTS

The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma.

CONCLUSION

In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.