The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline

A China-Based exploration of surgical timing for polytrauma with a focus on fracture reconstruction

BACKGROUND

For patients with severe polytrauma and fractures, early fracture reconstruction surgery under stable conditions can significantly reduce pulmonary and other complications. However, premature surgical intervention may heighten infection risk, adversely affecting the patient's prognosis. Consequently, determining the optimal timing of surgery is crucial for patients with multiple traumatic injuries. Given China's healthcare context, this study will assess injury severity and perform definitive fracture reconstruction at specified post-trauma intervals. Postoperative infection rates, including wound infections, other complication incidences, hospital stay duration, treatment costs, and long-term outcomes will be observed and compared to identify the optimal timing for surgical intervention. This study also aims to develop effective polytrauma management models. By applying accessible criteria and choosing suitable timing for fracture reconstruction, we can better assess patient conditions, reduce complications, and minimize the surgery's "second hit" effect, addressing an important research gap regarding optimal surgical timing for polytrauma in China.

METHODS

This study collected data on 200 patients treated at our hospital between March 2023 and March 2024, with an average age of 47.24 ± 16.56 years and an average Injury Severity Score (ISS) of 25.85 ± 13.35. A total of 250 fractures received definitive fixation in the initial surgery, including femoral fractures (n = 75), spinal fractures (n = 46), pelvic ring fractures (n = 49), tibial fractures (n = 25), acetabular fractures (n = 12), humeral fractures (n = 12), and other fractures (n = 5) (including clavicle, radius and ulna, calcaneus, and patella). Among these patients, 151 underwent single-fracture reconstruction, 42 had two fractures reconstructed, and 5 had three fractures treated during the first surgery. The study protocol excluded patients with absolute contraindications, including bacteremia and infections near the surgical site. Additional inclusion criteria required stable vital signs (temperature < 38.5 °C with a downward trend, systolic blood pressure > 100 mmHg, stable traumatic brain injury status) and blood routine (white blood cell count < 22.0 × 10⁹/L with a neutrophil percentage < 90%, both trending downward; platelet count > 50 × 10⁹/L; hemoglobin > 90 g/L). Based on these criteria, historical cohorts were identified and assigned to either an experimental group or a control group. Observed outcomes included postoperative complications, wound healing grades, inflammatory markers, changes in vital signs, length of hospital stay, costs, and long-term follow-up results.

RESULTS

Among the patients, 97 underwent surgery after meeting the specified criteria for fracture reconstruction, while 103 received surgery without meeting these criteria. Patients who met the surgical criteria demonstrated superior outcomes, with lower complication rates (including pneumonia and respiratory distress syndrome), improved surgical incision healing, faster postoperative consciousness recovery, shorter overall and ICU stays, reduced hospitalization costs, greater joint mobility at the 9-month follow-up, and higher quality of life assessments compared to those who did not meet the criteria. Among patients who met the criteria, those with spinal fractures experienced better quality of life outcomes, and those with femoral fractures showed improved fracture healing.

CONCLUSIONS

For polytrauma patients with fractures, performing surgery once surgical requirements are met results in fewer early postoperative pulmonary complications, quicker recovery of consciousness, lower wound infection rates, shorter hospital and ICU stays, reduced costs, and improved postoperative outcomes. This protocol is safe and effective for most polytrauma patients requiring fixation, particularly those with mechanically unstable femoral, pelvic, acetabular, or spinal fractures.

Thrombocytopenia in Critically Ill Children: A Review for Practicing Clinicians

Thrombocytopenia frequently occurs in patients before, during, and after admission to Pediatric Intensive Care Units (PICUs). In critically ill children, it is often due to multifactorial causes and can be a sign of significant organ dysfunction. This review summarizes the potential causes/mechanisms of thrombocytopenia in acutely ill children, their identification, and treatments, with special attention paid to septic patients. The mechanisms of thrombocytopenia include decreased production and sequestration, but the most common reason is increased destruction or consumption. This review specifically reviews and compares the presentation, pathogenesis, and treatment of disseminated intravascular coagulation (DIC) and the thrombotic microangiopathic spectrum (TMA), including thrombocytopenia-associated multiorgan failure (TAMOF), hemolytic uremic syndrome, and other diagnoses. The other etiologies discussed include HLH/MAS, immune thrombocytopenia, and dilutional thrombocytopenia. Finally, this review analyzes platelet transfusions, the various thresholds, and complications.

Multiphase photon counting detector CT data sets - Which combination of contrast phase and virtual non-contrast algorithm is best suited to replace true non-contrast series in the assessment of active bleeding?

PURPOSE

Aim of this study was to determine which virtual non-contrast (VNC) reconstruction algorithm, applied to which contrast phase of computed tomography angiography, best matches true non-contrast (TNC) images in the assessment of active bleeding.

METHOD

Patients who underwent a triphasic scan (pre-contrast, arterial, portal venous contrast) on a photon-counting detector CT (PCD-CT) (120 kV, image quality level 68) with suspected active (tumor, postoperative, spontaneous or other) bleeding were retrospectively included in this study. Conventional (VNCConv) and a calcium-preserving VNC algorithm (VNCPC) were derived from both arterial (art) and portal venous (pv) contrast scans, and analyzed quantitatively and qualitatively by two independent and blinded raters.

RESULTS

40 patients (22 female, mean age 76 years) were included. Measurements of CT values showed significant albeit small differences between TNC and VNC for most analyzed tissue regions without clear superiority of a VNC algorithm or contrast phase (e.g. ΔHU fat TNC to VNCPCpv 3.1 HU). However, qualitative analysis showed a preference to VNCPCpv in terms of image quality (on a 5-point Likert scale VNCConvart = 3.5 ± 0.8, VNCPCart = 3.7 ± 0.7, VNCConvpv = 3.7 ± 0.7, VNCPCpv = 3.8 ± 0.7) and residual calcium contrast (VNCConvart = 3.0 ± 0.8, VNCPCart = 3.5 ± 0.7, VNCConvpv = 3.6 ± 0.7, VNCPCpv = 3.9 ± 0.6).

CONCLUSIONS

When multiple post-contrast phases are available, VNCPC series based on portal venous phase are the most suitable replacement for an additional pre-contrast scan, with the prospect of a significant reduction in patient radiation dose.

Management of Coagulopathy in Bleeding Patients

Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.

The effect of tranexamic acid on blood loss in orthognathic surgery: a randomized, placebo-controlled, equivalence study

Orthognathic surgery can cause substantial bleeding. Recent meta-analyses concluded that there is a statistically significant reduction in perioperative blood loss with the preventive use of tranexamic acid (TA). However, the mean reported difference in bleeding was moderate, and the clinical relevance of this blood-sparing effect remains debated. We therefore conducted a prospective, double-blind, randomized, placebo-controlled equivalence study of the effect of TA in patients undergoing Lefort I or bimaxillary osteotomies. Our main outcome measure was total blood loss on postoperative day 1. The equivalence margin was ± 250 ml for the difference in blood loss and its 95% confidence interval. One hundred and forty-seven patients were randomized, of which 122 underwent bimaxillary osteotomies. Blood loss in the treatment group was 682 ± 323 vs. 875 ± 492 ml. The mean difference in bleeding was -132 [-243; -21] ml as per-protocol, but -193 [-329; -57] ml in intention-to-treat: the limits of this confidence interval exceeded the margin of equivalence. Similar results were obtained when analysing only patients undergoing bimaxillary osteotomy. Haemoglobin decreased by 1.8 ± 1.2 g/dl with TA, vs. 2.6 ± 1.1 g/dl with placebo (p<0.001). Our study did not demonstrate equivalence between TA and placebo on perioperative blood loss in orthognathic surgery. TA may reduce blood loss but without evidence of clinical consequences.

Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.