Physiology dictated treatment after severe trauma: timing is everything

Early vs Late Fixation of Extremity Fractures Among Adults With Traumatic Brain Injury

Importance

The optimal timing for fixation of extremity fractures after traumatic brain injury (TBI) remains controversial.

Objective

To investigate whether patients who underwent extremity fixation within 24 hours of TBI experienced worse outcomes than those who had the procedure 24 hours or more after TBI.

Design, Setting, and Participants

This cohort study used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Patients 16 years or older with TBI who underwent internal extremity fixation met inclusion criteria. To compare outcomes, patients who underwent the procedure within 24 hours were propensity score matched with those who underwent it 24 hours or later. Patients were treated from December 9, 2014, to December 17, 2017. Data analysis was conducted between August 1, 2022, and December 25, 2023.

Main Outcomes and Measures

The primary outcome was an unfavorable functional status at 6 months (Glasgow Outcome Scale-Extended [GOSE] score ≤4).

Results

A total of 253 patients were included in this study. The median age was 41 (IQR, 27-57) years, and 184 patients (72.7%) were male. The median Injury Severity Score (ISS) was 41 (IQR, 27-49). Approximately half of the patients (122 [48.2%]) had a mild TBI while 120 (47.4%) had moderate to severe TBI. Seventy-four patients (29.2%) underwent an internal extremity fixation within 24 hours, while 179 (70.8%) had the procedure 24 hours or later. At 6 months, 86 patients (34.0%) had an unfavorable functional outcome. After propensity score matching, there were no statistically significant differences in unfavorable functional outcomes at 6 months (odds ratio [OR], 1.12 [95% CI, 0.51-1.99]; P = .77) in patients with TBI of any severity. Similar results were observed in patients with mild TBI (OR, 0.71 [95% CI, 0.22-2.29]; P = .56) and moderate to severe TBI (OR, 1.08 [95% CI, 0.32-3.70]; P = .90).

Conclusions and Relevance

The outcomes of extremity fracture fixation performed within 24 hours after TBI appear not to be worse than those of procedures performed 24 hours or later. This finding suggests that early fixation after TBI could be considered in patients with mild head injuries.

Early correction of base deficit decreases late mortality in polytrauma

INTRODUCTION

Physiology-driven resuscitation has become the standard of care in severely injured patients. This has resulted in a decrease in acute deaths by hemorrhagic shock. With increased survival from hemorrhage, focus shifts towards death later during hospital stay. This population based cohort study investigated the association of initial physiology derangement correction and (late) mortality.

METHODS

Consecutive polytrauma patients aged > 15 years with deranged physiology who were admitted to a level-1 trauma center intensive care unit (ICU) from 2015 to 2021, and requiring surgical intervention < 24 h were included. Patients who acutely (< 48 h) died were excluded. Demographics, treatment, and outcome parameters were analyzed. Physiology was monitored by serial base deficits (BD) during the first 48 h. Correction of physiology was defined as BD return to normal values. Area under the curve (AUC) of BD in time was used as measurement for the correction of physiological derangement and related to mortality 3-6 days (early), and > 7 days (late).

RESULTS

Two hundred thirty-five patients were included with a median age of 44 years (70% male), and Injury Severity Score (ISS) of 33. Mortality rate was 16% (71% due to traumatic brain injury (TBI)). Median time to death was 11 (6-17) days; 71% died > 7 days after injury. There was no difference between the single base deficit measurements in the emergency department(ED), operating room (OR), nor ICU between patients who died and those who did not. However, patients who later died were more acidotic at 24 and 48 h after arrival, and had a higher AUC of BD in time. This was independent of time and cause of death.

CONCLUSION

Early physiological restoration based on serial BD measurements in the first 48 h after injury decreases late mortality.

[Application of artificial intelligence systems in the emergency room : Do the communication patterns give indications for possible starting points? An observational study]

BACKGROUND

High expectations are currently attached to the application of artificial intelligence (AI) in the resuscitation room treatment of trauma patients with respect to the development of decision support systems. No data are available regarding possible starting points for AI-controlled interventions in resuscitation room treatment.

OBJECTIVE

Do information request behavior and quality of communication indicate possible starting points for AI applications in the emergency room?

MATERIAL AND METHODS

A 2‑stage qualitative observational study: 1. Development of an observation sheet based on expert interviews that depicts the following six relevant topics: situational factors (course of accident, environment), vital parameters, treatment-specific Information (treatment carried out). trauma-specific factors (injury patterns), medication, special features of the patient (anamnesis, etc.) 2. Observational study Which topics were inquired about during emergency room treatment? Was the exchange of information complete?

RESULTS

There were 40 consecutive observations in the emergency room. A total of 130 questions: 57/130 inquiries about medication/treatment-specific Information and vital parameters, 19/28 of which were inquiries about medication. Questions about injury-related parameters 31/130 with 18/31 regarding injury patterns, course of accident (8/31) and type of accident (5/31). Questions about medical or demographic background 42/130. Within this group, pre-existing illnesses (14/42) and demographic background (10/42) were the most frequently asked questions. Incomplete exchange of information was found in all six subject areas.

CONCLUSION

Questioning behavior and incomplete communication indicate a cognitive overload. Assistance systems that prevent cognitive overload can maintain decision-making abilities and communication skills. Which AI methods can be used requires further research.

Release of exosomes in polytraumatized patients: The injury pattern is reflected by the surface epitopes

Background

Trauma is still a leading cause of morbidity and mortality, especially in the younger population. Trauma patients need a precise, early diagnostic to avoid complications like multiorgan failure and sepsis. Exosomes were described as markers and mediators in trauma. The aim of the present study was to analyze, whether the surface epitopes of plasma-exosomes can reflect the injury pattern in polytrauma.

Material and Methods

Polytraumatized patients (Injury Severity Score = ISS ≥16, n = 38) were subdivided according to the predominant injury in either abdominal trauma, chest trauma or traumatic brain injury (TBI). Plasma exosomes were isolated via size exclusion chromatography. The concentration and size distribution of the plasma exosomes from emergency room samples were measured by nanoparticle tracking analysis. The exosomal surface antigens were investigated by bead-based multiplex flow cytometry and compared with healthy controls (n=10).

Results

In contrast to other studies, we did not observe an increase in the total amount of plasma exosomes in polytrauma patients (1,15x109 vs. 1,13x109 particles/ml), but found changes in the exosomal surface epitopes. We found a significant reduction of CD42a+ (platelet-derived) exosomes in polytrauma patients, CD209+ (dendritic cell-derived) exosomes in the patients with predominant abdominal trauma, and CD11+ (monocyte-derived) exosomes in the patients with chest trauma. The group of patients with TBI was characterized in contrast by an increase of CD62p+ (endothelial/platelet-derived) exosomes (*p&lt;0.05).

Conclusion

Our data showed that the polytrauma injury pattern might be reflected by the cellular origin/surface epitopes of plasma-released exosomes immediately after trauma. The observed reduction of CD42+ exosomes in polytrauma patients was not associated with a reduction of total platelets in polytrauma patients.

Longitudinal assessment of the inflammatory response: The next step in personalized medicine after severe trauma

Infections in trauma patients are an increasing and substantial cause of morbidity, contributing to a mortality rate of 5-8% after trauma. With increased early survival rates, up to 30-50% of multitrauma patients develop an infectious complication. Trauma leads to a complex inflammatory cascade, in which neutrophils play a key role. Understanding the functions and characteristics of these cells is important for the understanding of their involvement in the development of infectious complications. Recently, analysis of neutrophil phenotype and function as complex biomarkers, has become accessible for point-of-care decision making after trauma. There is an intriguing relation between the neutrophil functional phenotype on admission, and the clinical course (e.g., infectious complications) of trauma patients. Potential neutrophil based cellular diagnostics include subsets based on neutrophil receptor expression, responsiveness of neutrophils to formyl-peptides and FcγRI (CD64) expression representing the infectious state of a patient. It is now possible to recognize patients at risk for infectious complications when presented at the trauma bay. These patients display increased numbers of neutrophil subsets, decreased responsiveness to fMLF and/or increased CD64 expression. The next step is to measure these biomarkers over time in trauma patients at risk for infectious complications, to guide decision making regarding timing and extent of surgery and administration of (preventive) antibiotics.