The research agenda for trauma critical care

Effect of early hemostasis strategy on secondary post-traumatic sepsis in trauma hemorrhagic patients

INTRODUCTION

Fibrinogen and platelet, as the two main components of hemostatic resuscitation, are frequently administered in traumatic massive hemorrhage patients. It is reasonable to infer that they may have an impact on post-traumatic sepsis as more and more recognition of their roles in inflammation and immunity. This study aims to determine the association between the fibrinogen/platelet transfusion ratio during the first 24 h after trauma and the risk of the post- traumatic sepsis.

METHODS

We analyzed the data from the National Trauma Data Bank (NTDB). Subjects included the critically injured adult patients admitted to Level I/II trauma center from 2013 to 2017 who received fibrinogen and platelet supplementation and more than 10 units (about 4000 ml) packed red blood cells (pRBCs) during the first 24 h after trauma. Two parts of analyses were performed: (1) multivariable stepwise regression was used to determine the variables that influence the risk of post-traumatic sepsis; (2) propensity score matching (PSM), to compare the influences of different transfusion ratio between fibrinogen and platelet on the risk of sepsis and other outcomes after trauma.

RESULTS

8 features were screened out by bi-directional multivariable stepwise logistic regression to predict the post-traumatic sepsis. They are age, sex, BMI, ISSabdomen, current smoker, COPD, Fib4h/24h and Fib/PLT24h. Fib/PLT24h was negatively related to sepsis (p < 0.05). A total of 1601 patients were included in the PSM cohort and grouped by Fib/PLT24h = 0.025 according to the fitting generalized additive model (GAM) model curve. The incidence of sepsis was significantly decreased in the high Fib/PLT group [3.3 % vs 9.4 %, OR = 0.33, 95 %CI (0.17-0.60)]; the length of stay in ICU and mechanical ventilation were both shortened as well [8 (IQR 2.00,17.00) vs 9 (IQR 3.00,19.25), p = 0.006 and 4 (IQR 2.00,10.00) vs 5 (IQR 2.00,14.00), p = 0.003, respectively.

CONCLUSIONS

Early and sufficient supplementation of fibrinogen was a convenient way contribute to reduce the risk of sepsis after trauma.

The role of fibrinogen in traumatic brain injury: from molecular pathological mechanisms to clinical management

Fibrinogen is the substrate of plasma coagulation. It plays an important role in the formation of reticular network, which is crucial to the strength and stability of blood clots. In addition to directly participating in coagulation, fibrinogen also participates in the destruction of blood-brain barrier and neuroinflammation. This article reviews the pathophysiological changes of fibrinogen after traumatic brain injury. Considerable efforts have been made to understand the mechanisms by which fibrinogen damages the central nervous system. Combined with the latest research hotspots, potentially promising treatment strategies at the molecular level were discussed. We believe that understanding the role of fibrinogen-mediated damage in nerve and blood-brain barrier function will enable timely intervention in patients with nerve damage, and guide the development of novel targeted therapeutics.

Role of TREM2 in the Development of Neurodegenerative Diseases After Traumatic Brain Injury

Traumatic brain injury (TBI) has been found as the primary cause of morbidity and disability worldwide, which has posed a significant social and economic burden. The first stage of TBI produces brain edema, axonal damage, and hypoxia, thus having an effect on the blood-brain barrier function, promoting inflammatory responses, and increasing oxidative stress. Patients with TBI are more likely to develop post-traumatic epilepsy, behavioral issues, as well as mental illnesses. The long-term effects arising from TBI have aroused rising attention over the past few years. Microglia in the brain can express the triggering receptor expressed on myeloid cells 2 (TREM2), which is a single transmembrane receptor pertaining to the immunoglobulin superfamily. The receptor has been correlated with a number of neurodegenerative disorders, including Alzheimer's disease, Parkinson's disease, and other relevant diseases. In this review, it is demonstrated that TREM2 is promising to serve as a neuroprotective factor for neurodegenerative disorders following TBI by modulating the function of microglial cells. Accordingly, it has potential avenues for TREM2-related therapies to improve long-term recovery after TBI.

Automated Assessment of Cardiovascular Sufficiency Using Non-Invasive Physiological Data

For fluid resuscitation of critically ill individuals to be effective, it must be well calibrated in terms of timing and dosages of treatments. In current practice, the cardiovascular sufficiency of patients during fluid resuscitation is determined using primarily invasively measured vital signs, including Arterial Pressure and Mixed Venous Oxygen Saturation (SvO2), which may not be available in outside-of-hospital settings, particularly in the field when treating subjects injured in traffic accidents or wounded in combat where only non-invasive monitoring is available to drive care. In this paper, we propose (1) a Machine Learning (ML) approach to estimate the sufficiency utilizing features extracted from non-invasive vital signs and (2) a novel framework to address the detrimental impact of inter-patient diversity on the ability of ML models to generalize well to unseen subjects. Through comprehensive evaluation on the physiological data collected in laboratory animal experiments, we demonstrate that the proposed approaches can achieve competitive performance on new patients using only non-invasive measurements. These characteristics enable effective monitoring of fluid resuscitation in real-world acute settings with limited monitoring resources and can help facilitate broader adoption of ML in this important subfield of healthcare.

A Nomogram to Better Predict the In-Hospital Mortality of Trauma Patients with Sepsis in the Intensive Care Unit

BACKGROUND

Trauma has a high incidence and mortality worldwide, and sepsis is one of the main causes of mortality in trauma patients. Therefore, it is essential to identify the risk factors of in-hospital mortality for trauma patients with sepsis.

METHODS

Data were extracted from the Medical Information Mart for Intensive Care III database and divided into a training set and internal validation set, and another Chinese dataset was used as external validation set. Then, risk factors were estimated using univariate and multivariate logistic regression analyses in the training set. Finally, a nomogram was created to predict the probability of in-hospital mortality for trauma patients with sepsis.

RESULTS

A total of 503 patients were enrolled in our study (335 in the training set and 168 in the validation set). Multivariate logistic regression analysis revealed that age (1.047 [1.025-1.071]), respiratory rate (1.258 [1.135-1.394]), PTT (1.026 [1.008-1.044]), ventilation (6.703 [1.528-29.408]), and vasopressor use (3.682 [1.502-9.025]) were independent factors associated with in-hospital mortality. The nomogram for trauma-related sepsis predicted in-hospital mortality with AUC values of 0.8939 in the training set, 0.8200 in the internal validation set, and 0.7779 in the external validation set.

CONCLUSIONS

The new nomogram has a well predicted value for in-hospital mortality for patients with trauma and sepsis in intensive care units.

Saving the brain after mild-to-moderate traumatic injury: A report on new insights of the physiology underlying adequate maintenance of cerebral perfusion

ABSTRACT

Traumatic brain injury (TBI) is associated with increased morbidity and mortality in civilian trauma and battlefield settings. It has been classified across a continuum of dysfunctions, with as much as 80% to 90% of cases diagnosed as mild to moderate in combat casualties. In this report, a framework is presented that focuses on the potential benefits for acute noninvasive treatment of reduced cerebral perfusion associated with mild TBI by harnessing the natural transfer of negative intrathoracic pressure during inspiration. This process is known as intrathoracic pressure regulation (IPR) therapy, which can be applied by having a patient breath against a small inspiratory resistance created by an impedance threshold device. Intrathoracic pressure regulation therapy leverages two fundamental principles for improving blood flow to the brain: (1) greater negative intrathoracic pressure enhances venous return, cardiac output, and arterial blood pressure; and (2) lowering of intracranial pressure provides less resistance to cerebral blood flow. These two effects work together to produce a greater pressure gradient that results in an improvement in cerebral perfusion pressure. In this way, IPR therapy has the potential to counter hypotension and hypoxia, potentially significant contributing factors to secondary brain injury, particularly in conditions of multiple injuries that include severe hemorrhage. By implementing IPR therapy in patients with mild-to-moderate TBI, a potential exists to provide early neuroprotection at the point of injury and a bridge to more definitive care, particularly in settings of prolonged delays in evacuation such as those anticipated in future multidomain operations.

LEVEL OF EVIDENCE

Report.

Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications

Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.

Morbidity and Mortality in Critically Ill Children. II. A Qualitative Patient-Level Analysis of Pathophysiologies and Potential Therapeutic Solutions

OBJECTIVES

To describe at the individual patient level the pathophysiologic processes contributing to morbidity and mortality in PICUs and therapeutic additions and advances that could potentially prevent or reduce morbidity and mortality.

DESIGN

Qualitative content analysis of intensivists' conclusions on pathophysiologic processes and needed therapeutic advances formulated by structured medical record review.

SETTING

Eight children's hospitals affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.

PATIENTS

A randomly selected cohort of critically ill children with a new functional morbidity or mortality at hospital discharge. New morbidity was assessed using the Functional Status Scale and defined as worsening by two or more points in a single domain from preillness baseline.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 292 children, 175 (59.9%) had a new morbidity and 117 (40.1%) died. The most common pathophysiology was impaired substrate delivery (n = 158, 54.1%) manifesting as global or regional hypoxia or ischemia due to low cardiac output or cardiac arrest. Other frequent pathophysiologies were inflammation (n = 104, 35.6%) related to sepsis, respiratory failure, acute respiratory distress syndrome, or multiple organ dysfunction; and direct tissue injury (n = 64, 21.9%) including brain and spinal cord trauma. Chronic conditions were often noted (n = 156, 53.4%) as contributing to adverse outcomes. Drug therapies (n = 149, 51.0%) including chemotherapy, inotropes, vasoactive agents, and sedatives were the most frequently proposed needed therapeutic advances. Other frequently proposed therapies included cell regeneration (n = 115, 39.4%) mainly for treatment of neuronal injury, and improved immune and inflammatory modulation (n = 79, 27.1%).

CONCLUSIONS

Low cardiac output and cardiac arrest, inflammation-related organ failures, and CNS trauma were the most common pathophysiologies leading to morbidity and mortality in PICUs. A research agenda focused on better understanding and treatment of these conditions may have high potential to directly impact patient outcomes.

Temporal patterns of organ dysfunction after severe trauma

Background

Understanding temporal patterns of organ dysfunction (OD) may aid early recognition of complications after trauma and assist timing and modality of treatment strategies. Our aim was to analyse and characterise temporal patterns of OD in intensive care unit-admitted trauma patients.

Methods

We used group-based trajectory modelling to identify temporal trajectories of OD after trauma. Modelling was based on the joint development of all six subdomains comprising the sequential organ failure assessment score measured daily during the first two weeks post trauma. Further, the time for trajectories to stabilise and transition to final group assignments were evaluated.

Results

Six-hundred and sixty patients were included in the final model. Median age was 40 years, and median ISS was 26 (IQR 17–38). We identified five distinct trajectories of OD. Group 1, mild OD (n = 300), median ISS of 20 (IQR 14–27), had an early resolution of OD and a low mortality. Group 2, moderate OD (n = 135), and group 3, severe OD (n = 87), were fairly similar in admission characteristics and initial OD but differed in subsequent OD trajectories, the latter experiencing an extended course and higher mortality. In group 3, 56% of the patients developed sepsis as compared with 19% in group 2. Group 4, extreme OD (n = 40), received most blood transfusions, had the highest proportion of shock at admission and a median ISS of 41 (IQR 29–50). They experienced significant and sustained OD affecting all organ systems and a 28-day mortality of 30%. Group 5, traumatic brain injury with OD (n = 98), had the highest mortality of 35% and the shortest time to death for non-survivors, median 3.5 (IQR 2.4–4.8) days. Groups 1 and 5 reached their final group assignment early, > 80% of the patients within 48 h. In contrast, groups 2 and 3 had a prolonged time to final group assignment.

Conclusions

We identified five distinct trajectories of OD after severe trauma during the first two weeks post-trauma. Our findings underline the heterogeneous course after trauma and describe some potentially important clinical insights that are suggested by the groupings and temporal trajectories.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03586-6.

Plasma Vanin-1 as a Novel Biomarker of Sepsis for Trauma Patients: A Prospective Multicenter Cohort Study

Introduction

Vanin-1 plays a pivotal role in oxidative stress and the inflammatory response. However, its relationship with traumatic sepsis remains unknown. The aim of our study was to evaluate whether plasma vanin-1 could be used for the early prediction of traumatic sepsis.

Methods

In this three-stage prospective cohort study, severe trauma patients admitted from January 2015 to October 2018 at two hospitals were enrolled. Plasma vanin-1 levels were measured by enzyme-linked immunosorbent assay (ELISA). The associations among variables and traumatic sepsis were identified by logistic regression models and the receiver operating characteristic (ROC) curve was analyzed to evaluate the diagnostic efficiency.

Results

A total of 426 trauma patients (22 in the discovery cohort, 283 in the internal test cohort, and 121 in the external validation cohort) and 16 healthy volunteers were recruited. The plasma vanin-1 of trauma patients was significantly higher than that of healthy volunteers (P < 0.05). Patients with sepsis had higher plasma vanin-1 than patients without sepsis in the discovery trauma cohort (P < 0.05). In the internal test cohort, plasma vanin-1 at day 1 after trauma was significantly associated with the incidence of sepsis (OR = 3.92, 95% CI 2.68–5.72, P = 1.62 × 10⁻¹²). As a predictive biomarker, vanin-1 afforded a better area under the curve (AUC) (0.82, 95% CI 0.77–0.87) than C-reaction protein (CRP) (0.62, 95% CI 0.56–0.68, P < 0.0001), procalcitonin (PCT) (0.66, 95% CI 0.60–0.71, P < 0.0001), and Acute Physiology and Chronic Health Evaluation II (APACHE II) (0.71, 95% CI 0.65–0.76, P = 6.70 × 10⁻³). The relevance was further validated in the external validation cohort (OR = 4.26, 95% CI 2.22–8.17, P = 1.28 × 10⁻⁵), with an AUC of 0.83 (95% CI 0.75–0.89). Vanin-1 could also improve the diagnostic efficiency of APACHE II (AUC = 0.85).

Conclusions

Our study demonstrated that plasma vanin-1 increased among trauma patients and was independently associated with the risk of sepsis. Vanin-1 might be a potential biomarker for the early prediction of traumatic sepsis.

Trial Registration

Clinicaltrials.gov Identifier, NCT01713205.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00414-w.

Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial

PURPOSE

Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs).

METHODS

This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI).

RESULTS

Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34).

CONCLUSION

There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.

Estimating Surgical Blood Loss Volume Using Continuously Monitored Vital Signs

Background: There are currently no effective and accurate blood loss volume (BLV) estimation methods that can be implemented in operating rooms. To improve the accuracy and reliability of BLV estimation and facilitate clinical implementation, we propose a novel estimation method using continuously monitored photoplethysmography (PPG) and invasive arterial blood pressure (ABP). Methods: Forty anesthetized York Pigs (31.82 ± 3.52 kg) underwent a controlled hemorrhage at 20 mL/min until shock development was included. Machine-learning-based BLV estimation models were proposed and tested on normalized features derived by vital signs. Results: The results showed that the mean ± standard deviation (SD) for estimating BLV against the reference BLV of our proposed random-forest-derived BLV estimation models using PPG and ABP features, as well as the combination of ABP and PPG features, were 11.9 ± 156.2, 6.5 ± 161.5, and 7.0 ± 139.4 mL, respectively. Compared with traditional hematocrit computation formulas (estimation error: 102.1 ± 313.5 mL), our proposed models outperformed by nearly 200 mL in SD. Conclusion: This is the first attempt at predicting quantitative BLV from noninvasive measurements. Normalized PPG features are superior to ABP in accurately estimating early-stage BLV, and normalized invasive ABP features could enhance model performance in the event of a massive BLV.

Development of hemorrhage identification model using non-invasive vital signs

OBJECTIVE

Early detection and timely management of bleeding is critical as failure to recognize physiologically significant bleeding is associated with significant morbidity and mortality. Many such instances are detected late, even in highly monitored environments, contributing to delay in recognition and intervention. We propose a non-invasive early identification model to detect bleeding events using continuously collected photoplethysmography (PPG) and electrocardiography (ECG) waveforms.

APPROACH

Fifty-nine York pigs undergoing fixed-rate, controlled hemorrhage were involved in this study and a least absolute shrinkage and selection operator regression-based early detection model was developed and tested using PPG and ECG derived features. The output of the early detection model was a risk trajectory indicating the future probability of bleeding.

MAIN RESULTS

Our proposed models were generally accurate in predicting bleeding with an area under the curve of 0.89 (95% CI 0.87-0.92) and achieved an average time of 16.1 mins to detect 16.8% blood loss when a false alert rate of 1% was tolerated. Models developed on non-invasive data performed with similar discrimination and lead time to hemorrhage compared to models using invasive arterial blood pressure as monitoring data.

SIGNIFICANCE

A bleed detection model using only non-invasive monitoring performs as well as those using invasive arterial pressure monitoring.

[Hypovolemic and hemorrhagic shock]

The term "shock" refers to a life-threatening circulatory failure caused by an imbalance between the supply and demand of cellular oxygen. Hypovolemic shock is characterized by a reduction of intravascular volume and a subsequent reduction in preload. The body compensates the loss of volume by increasing the stroke volume, heart frequency, oxygen extraction rate, and later by an increased concentration of 2,3-diphosphoglycerate with a rightward shift of the oxygen dissociation curve. Hypovolemic hemorrhagic shock impairs the macrocirculation and microcirculation and therefore affects many organ systems (e.g. kidneys, endocrine system and endothelium). For further identification of a state of shock caused by bleeding, vital functions, coagulation tests and hematopoietic procedures are implemented. Every hospital should be in possession of a specific protocol for massive transfusions. The differentiated systemic treatment of bleeding consists of maintenance of an adequate homeostasis and the administration of blood products and coagulation factors.

Management of moderate and severe traumatic brain injury

Traumatic brain injury (TBI) is a common disorder with high morbidity and mortality, accounting for one in every three deaths due to injury. Older adults are especially vulnerable. They have the highest rates of TBI-related hospitalization and death. There are about 2.5 to 6.5 million US citizens living with TBI-related disabilities. The cost of care is very high. Aside from prevention, little can be done for the initial primary injury of neurotrauma. The tissue damage incurred directly from the inciting event, for example, a blow to the head or bullet penetration, is largely complete by the time medical care can be instituted. However, this event will give rise to secondary injury, which consists of a cascade of changes on a cellular and molecular level, including cellular swelling, loss of membrane gradients, influx of immune and inflammatory mediators, excitotoxic transmitter release, and changes in calcium dynamics. Clinicians can intercede with interventions to improve outcome in the mitigating secondary injury. The fundamental concepts in critical care management of moderate and severe TBI focus on alleviating intracranial pressure and avoiding hypotension and hypoxia. In addition to these important considerations, mechanical ventilation, appropriate transfusion of blood products, management of paroxysmal sympathetic hyperactivity, using nutrition as a therapy, and, of course, venous thromboembolism and seizure prevention are all essential in the management of moderate to severe TBI patients. These concepts will be reviewed using the recent 2016 Brain Trauma Foundation Guidelines to discuss best practices and identify future research priorities.

Making sense of gut feelings in the traumatic brain injury pathogenesis

Traumatic brain injury (TBI) is a devastating condition which often initiates a sequel of neurological disorders that can last throughout lifespan. From metabolic perspective, TBI also compromises systemic physiology including the function of body organs with subsequent malfunctions in metabolism. The emerging panorama is that the effects of TBI on the periphery strike back on the brain and exacerbate the overall TBI pathogenesis. An increasing number of clinical reports are alarming to show that metabolic dysfunction is associated with incidence of long-term neurological and psychiatric disorders. The autonomic nervous system, associated hypothalamic-pituitary axis, and the immune system are at the center of the interface between brain and body and are central to the regulation of overall homeostasis and disease. We review the strong association between mechanisms that regulate cell metabolism and inflammation which has important clinical implications for the communication between body and brain. We also discuss the integrative actions of lifestyle interventions such as diet and exercise on promoting brain and body health and cognition after TBI.

Development and validation of a novel predictive score for sepsis risk among trauma patients

Background

Patients suffering from major trauma often experience complications such as sepsis. The early recognition of patients at high risk of sepsis after trauma is critical for precision therapy. We aimed to derive and validate a novel predictive score for sepsis risk using electronic medical record (EMR) data following trauma.

Materials and methods

Clinical and laboratory variables of 684 trauma patients within 24 h after admission were collected, including 411 patients in the training cohort and 273 in the validation cohort. The least absolute shrinkage and selection operator (LASSO) technique was adopted to identify variables contributing to the early prediction of traumatic sepsis. Then, we constructed a traumatic sepsis score (TSS) using a logistic regression model based on the variables selected in the LASSO analysis. Moreover, we evaluated the discrimination and calibration of the TSS using the area under the curve (AUC) and the Hosmer-Lemeshow (H-L) goodness-of-fit test.

Results

Based on the LASSO, seven variables (injury severity score, Glasgow Coma Scale, temperature, heart rate, albumin, international normalized ratio, and C-reaction protein) were selected for construction of the TSS. Our results indicated that the incidence of sepsis after trauma increased with an increasing TSS (P_trend = 7.44 × 10⁻²¹ for the training cohort and P_trend = 1.16 × 10⁻¹³ for the validation cohort). The areas under the receiver operating characteristic (ROC) curve of TSS were 0.799 (0.757–0.837) and 0.790 (0.736–0.836) for the training and validation datasets, respectively. The discriminatory power of our model was superior to that of a single variable and the sequential organ failure assessment (SOFA) score (P < 0.001). Moreover, the TSS was well calibrated (P > 0.05).

Conclusions

We developed and validated a novel TSS with good discriminatory power and calibration for the prediction of sepsis risk in trauma patients based on the EMR data.

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0231-8) contains supplementary material, which is available to authorized users.

The role of coagulopathy on clinical outcome following traumatic brain injury in children: analysis of 66 consecutive cases in a single center institution

INTRODUCTION

Head injury is a significant economic, social, and medical problem in developing countries and remains one of the leading causes of pediatric morbidity and mortality. The association of traumatic brain injury and coagulopathy in children is linked with an increase in mortality and poor functional outcomes. However, its impact on long-term outcome has not been discussed in the literature so far.

OBJECTIVES

The aim of this paper was to investigate the effect of coagulopathy diagnosed by routine laboratory tests on neurological outcome following traumatic brain injury in children.

METHODS

A retrospective review was carried out using medical records of children with a traumatic brain injury admitted at a level I trauma center, between January 2013 and December 2016, submitted to any neurosurgical procedures. Statistical analysis was performed accordingly to identify factors predicting unfavorable or favorable outcomes at 1- and 6-month follow-ups. Data regarding age, gender, trauma mechanism, Glasgow Coma Scale at admission and at discharge, highest and lowest stable intracranial pressure, serum glucose and coagulation assessment, radiological findings, and length of stay were analyzed.

RESULTS

We identified 66 children with surgical head trauma. Mean age was 10.9 years (ranges from 3 months to 17 years), with male predominance (77.3%). Common mechanisms were road traffic accidents (66.7%), falls (19.7%), and blunt trauma (10.6%). Brain edema was detected in 68.2% of the patients, surgical fractures or intracranial bleeding in 75.8%. ICP monitoring was performed in 24.2% of the patients, and of these, 18.7% underwent consecutive decompressive craniectomy. Mean length of in-patient treatment was 16.3 ± 28.2 days. At 1- and 6-month follow-ups, favorable outcome was detected in 71.2 and 78.7% of the patients, respectively. The mortality rate was 12.1%. Routine coagulation assessments such as prothrombin time, fibrinogen levels, and thrombocyte count upon admission were potential prognostic variables identified.

CONCLUSIONS

The present study concluded that a trauma-related coagulopathy is an important predictor of unfavorable neurological outcome following TBI in pediatric patients. Initial GCS score, age, and neuroradiological findings, such as severe brain edema and different types of intracranial bleeding, correlated with GOS in the first 6 months following TBI. Sustained intracranial hypertension also predicted unfavorable outcome and death in this series.

Current strategies for hemostatic control in acute trauma hemorrhage and trauma-induced coagulopathy

Introduction: Despite advances in the treatment of severely injured patients that have resulted in overall improved outcomes, uncontrolled hemorrhage still represents the most common cause of preventable death following major injury. While addressing both endo- and exogenous factors that lead to an acute trauma-induced coagulopathy, massive transfusion plays a key role in managing bleeding trauma patients. However, the best practice for hemostatic control including massive transfusion in these patients is still under debate. Areas covered: This review summarizes the current knowledge and clinical practice for hemostatic control including massive transfusion for bleeding trauma patients. The recent literature was reviewed and extended by current guidelines and their underlying evidence was incorporated. Expert commentary: Treatment strategies for bleeding trauma patients are still an area of emerging scientific and clinical interest as advances are likely to translate into improved outcomes including survival. To date, damage control resuscitation principles with ratio-based transfusion of packed red blood cells, plasma and platelets still dominate as "gold standard" of care but goal-directed strategies guided either by conventional coagulation tests or viscoelastic assays may demonstrate a better characterization of the underlying coagulopathy thereby allowing individualized and targeted therapies.

Regional whole-course trauma care - Experiences from a county-level hospital

Fifty percent of the deaths caused by severe trauma occur within 1 h after injury. With the concepts of "golden 1 h" and "platinum 10 min", the professionals in the field of emergency trauma treatment have agreed on the necessity of establishing a rapid and efficient trauma rescue system. However, due to the size of the hospital, the population in the neighborhood, the local economic conditions and geographical features, how to establish an optimal trauma rescue system remains an issue. In this paper, we introduced our experiences in a county-level hospital located in middle-and high-income areas.

Optimizing transfusion strategies in damage control resuscitation: current insights

From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.

Concentrations of Plasma Nucleosomes but Not Cell-Free DNA Are Prognostic in Dogs Following Trauma

Trauma is common in dogs and causes significant morbidity and mortality, but it remains a challenge to assess prognosis in these patients. This study aimed to investigate the use of plasma cell-free DNA (cfDNA) and nucleosome concentrations as prognostic biomarkers in canine trauma. Using a prospective, observational case-control study design, 49 dogs with trauma were consecutively enrolled from 07/2015 to 10/2017 and followed to hospital discharge. Dogs with animal trauma triage (ATT) scores ≥3 at presentation were eligible for enrollment. Dogs <3 kg or with pre-existing coagulopathies were excluded. Thirty-three healthy control dogs were also enrolled. Illness and injury severity scores were calculated using at-presentation data. Plasma cfDNA was measured in triplicate using a benchtop fluorimeter. Plasma nucleosome concentrations were determined in duplicate by ELISA. Mann-Whitney U tests were used to compare biomarker concentrations between groups and between survivors and non-survivors. Associations between biomarkers were evaluated using Spearman's correlation coefficients. Alpha was set at 0.05. Concentrations of cfDNA and nucleosomes were significantly higher in injured dogs compared to healthy controls (P ≤ 0.0001). Nucleosomes and cfDNA concentrations were positively correlated (rs 0.475, P < 0.001). Concentrations of both cfDNA and nucleosomes were correlated with shock index (rs 0.367, P = 0.010, rs 0.358, P = 0.012 respectively), but only nucleosomes were correlated with ATT (rs 0.327, P = 0.022) and acute patient physiology and laboratory evaluation (APPLE) scores (rs 0.356, P = 0.012). Median nucleosome concentrations were significantly higher in non-survivors than in survivors [8.2 AU (3.1-26.4) vs. 1.6 AU (0.5-5.2); P = 0.01]. Among illness severity scores, only APPLE was discriminant for survival (AUROC 0.912, P < 0.001). In summary, in moderately-severely injured dogs, high nucleosome concentrations are significantly associated with non-survival.

Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis

PURPOSE

Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter (ONSD) has been suggested as a potential non-invasive ICP estimator. We performed a meta-analysis to evaluate the diagnostic accuracy of sonographic ONSD measurement for assessment of intracranial hypertension (IH) in adult patients.

METHODS

We searched on electronic databases (MEDLINE/PubMed^®, Scopus^®, Web of Science^®, ScienceDirect^®, Cochrane Library^®) until 31 May 2018 for comparative studies that evaluated the efficacy of sonographic ONSD vs. ICP measurement with IID. Data were extracted independently by two authors. We used the QUADAS-2 tool for assessing the risk of bias (RB) of each study. A diagnostic meta-analysis following the bivariate approach and random-effects model was performed.

RESULTS

Seven prospective studies (320 patients) were evaluated for IH detection (assumed with ICP > 20 mmHg or > 25 cmH₂O). The accuracy of included studies ranged from 0.811 (95% CI 0.678‒0.847) to 0.954 (95% CI 0.853‒0.983). Three studies were at high RB. No significant heterogeneity was found for the diagnostic odds ratio (DOR), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), with I² < 50% for each parameter. The pooled DOR, PLR and NLR were 67.5 (95% CI 29‒135), 5.35 (95% CI 3.76‒7.53) and 0.088 (95% CI 0.046‒0.152), respectively. The area under the hierarchical summary receiver-operating characteristic curve (AUHSROC) was 0.938. In the subset of five studies (275 patients) with IH defined for ICP > 20 mmHg, the pooled DOR, PLR and NLR were 68.10 (95% CI 26.8‒144), 5.18 (95% CI 3.59‒7.37) and 0.087 (95% CI 0.041‒0.158), respectively, while the AUHSROC was 0.932.

CONCLUSIONS

Although the wide 95% CI in our pooled DOR suggests caution, ultrasonographic ONSD may be a potentially useful approach for assessing IH when IIDs are not indicated or available (CRD42018089137, PROSPERO).

Influence of tranexamic acid on cerebral hemorrhage: A meta-analysis of randomized controlled trials

Tranexamic acid might be beneficial for cerebral hemorrhage. However, the results remained controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on cerebral hemorrhage. PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of tranexamic acid on cerebral hemorrhage were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model. Seven RCTs involving 1702 patients were included in the meta-analysis. Overall, compared with control intervention in cerebral hemorrhage, tranexamic acid could significantly reduce growth of hemorrhagic mass (RR = 0.78; 95% CI = 0.61-0.99; P = 0.04) and unfavorable outcome (RR = 0.75; 95% CI = 0.61-0.93; P = 0.008), but demonstrated no substantial influence on volume of hemorrhagic lesion (Std. MD = -0.10; 95% CI = -0.27 to 0.08; P = 0.28), neurologic deterioration (RR = 1.25; 95% CI = 0.60-2.60; P = 0.56), rebleeding (RR = 0.62; 95% CI = 0.35-1.09; P = 0.10), surgery requirement (RR = 0.78; 95% CI = 0.40-1.51; P = 0.46), and mortality (RR = 0.86; 95% CI = 0.69-1.05; P = 0.14). Compared to control intervention in cerebral hemorrhage, tranexamic acid was found to significantly decrease growth of hemorrhagic mass and unfavorable outcome, but showed no notable impact on volume of hemorrhagic lesion, neurologic deterioration, rebleeding, surgery requirement and mortality.