Severe Multiple Trauma Research Articles

Development and validation of a machine learning-based model to assess probability of systemic inflammatory response syndrome in patients with severe multiple traumas

BackgroundSystemic inflammatory response syndrome (SIRS) is a predictor of serious infectious complications, organ failure, and death in patients with severe polytrauma and is one of the reasons for delaying early total surgical treatment. To determine the risk of SIRS within 24 h after hospitalization, we developed six machine learning models.Materials and methodsUsing retrospective data about the patient, the nature of the injury, the results of general and standard biochemical blood tests, and coagulation tests, six models were developed: decision tree, random forest, logistic regression, support vector and gradient boosting classifiers, logistic regressor, and neural network. The effectiveness of the models was assessed through internal and external validation.ResultsAmong the 439 selected patients with severe polytrauma in 230 (52.4%), SIRS was diagnosed within the first 24 h of hospitalization. The SIRS group was more strongly associated with class II bleeding (39.5% vs. 60.5%; OR 1.81 [95% CI: 1.23–2.65]; P = 0.0023), long-term vasopressor use (68.4% vs. 31.6%; OR 5.51 [95% CI: 2.37–5.23]; P < 0.0001), risk of acute coagulopathy (67.8% vs. 32.2%; OR 2.4 [95% CI: 1.55–3.77]; P < 0.0001), and greater risk of pneumonia (59.5% vs. 40.5%; OR 1.74 [95% CI: 1.19–2.54]; P = 0.0042), longer ICU length of stay (5 ± 6.3 vs. 2.7 ± 4.3 days; P < 0.0001) and mortality rate (64.5% vs. 35.5%; OR 10.87 [95% CI: 6.3–19.89]; P = 0.0391). Of all the models, the random forest classifier showed the best predictive ability in the internal (AUROC 0.89; 95% CI: 0.83–0.96) and external validation (AUROC 0.83; 95% CI: 0.75–0.91) datasets.ConclusionsThe developed model made it possible to accurately predict the risk of developing SIRS in the early period after injury, allowing clinical specialists to predict patient management tactics and calculate medication and staffing needs for the patient.Level of evidenceLevel 3.Trial registrationThe study was retrospectively registered in the ClinicalTrials.gov database of the National Library of Medicine (NCT06323096).

Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report

BackgroundFiberoptic-guided intubation is considered as “gold standard” of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist.Case presentationA man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient’s recovery was uneventful, and he was discharged from the hospital one month after the surgery.ConclusionsAwake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

Effect of Injury Patterns on the Development of Complications and Trauma-Induced Mortality in Patients Suffering Multiple Trauma.

Patients that suffer from severe multiple trauma are highly vulnerable to the development of complications that influence their outcomes. Therefore, this study aimed to evaluate the risk factors that can facilitate an early recognition of adult patients at risk. The inclusion criteria were as follows: admission to a level 1 trauma center, injury severity score (ISS) ≥ 16 (severe injury was defined by an abbreviated injury score (AIS) ≥ 3) and ≥18 years of age. Injury- and patient-associated factors were correlated with the development of four complication clusters (surgery-related, infection, thromboembolic events and organ failure) and three mortality time points (immediate (6 h after admission), early (>6 h-72 h) and late (>72 h) mortality). Statistical analysis was performed using a Chi-square, Mann-Whitney U test, Cox hazard regression analysis and binominal logistic regression analysis. In total, 383 patients with a median ISS of 24 (interquartile range (IQR) 17-27) were included. The overall mortality rate (27.4%) peaked in the early mortality group. Lactate on admission significantly correlated with immediate and early mortality. Late mortality was significantly influenced by severe head injuries in patients with a moderate ISS (ISS 16-24). In patients with a high ISS (≥25), late mortality was influenced by a higher ISS, older age and higher rates of organ failure. Complications were observed in 47.5% of all patients, with infections being seen most often. The development of complications was significantly influenced by severe extremity injuries, the duration of mechanical ventilation and length of ICU stay. Infection remains the predominant posttraumatic complication. While immediate and early mortality is mainly influenced by the severity of the initial trauma, the rates of severe head injuries influence late mortality in moderate trauma severity, while organ failure remains a relevant factor in patients with a high injury severity.

Preclinical care of children with multiple trauma

Severe multiple trauma in children is rare with approximately 380-550cases per year in Germany. In addition to the S3 guideline "Polytrauma", which was published more than a decade ago, the S2Kguideline "Severe multiple trauma care in childhood" was published in 2020. Accidents and especially the resulting traumatic brain injuries still represent the most frequent cause of death in children. While prehospital treatment according to Prehospital Trauma Life Support (PHTLS®) is basically analogous to that in adults which is based on the ABCDE concept (airway, breathing, circulation, disability, exposure), knowledge of age-dependent anatomical-physiological characteristics is essential. For simplification, various tools and dosing aids, such as the pediatric emergency ruler and specific emergency tables, are available. Further treatment after initial preclinical care should take place in an interdisciplinary manner in designated pediatric trauma centers.

Effect of ionized calcium level on short-term prognosis in severe multiple trauma patients: a clinical study

BackgroundHypocalcemia has been reported as an independent predictor of trauma mortality. We investigated the relationship between temporal variations in blood ionized calcium concentration (iCa) and prognosis in severe trauma patients...

C-reactive Protein/Albumin Ratio as a Prognostic Indicator in Posttraumatic Shock and Outcome of Multiple Trauma Patients.

C-reactive protein (CRP)/albumin ratio (CAR) is a new inflammation-based index for predicting the prognosis of various diseases. The CAR determined on admission may help to predict the prognostic value of multiple trauma patients. A total of 264 adult patients with severe multiple trauma were included for the present retrospective study, together with the collection of relevant clinical and laboratory data. CAR, CRP, albumin, shock index and ISS were incorporated into the prognostic model, and the receiver operating characteristic (ROC) curve was drawn. Then, the shock index for patients with different levels of CAR was analyzed. Finally, univariate and multivariate logistic regression analyses were performed to identify the independent risk factors for the 28-day mortality of multiple trauma patients. A total of 36 patients had poor survival outcomes, and the mortality rate reached 13.6%. Furthermore, after analyzing the shock index for patients with different levels of CAR, it was revealed that the shock index was significantly higher when CAR was ≥4, when compared to CAR <2 and 2≤ CAR <4, in multiple trauma patients. The multivariate logistic analysis helped to identify the independent association between the variables CAR (P=0.029) and shock index (P=0.019), and the 28-day mortality of multiple trauma patients. CAR is higher in patients with severe multiple trauma. Furthermore, CAR serves as a risk factor for independently predicting the 28-day mortality of multiple trauma patients. The shock index was significantly higher when CAR was ≥4 in multiple trauma patients.

Cell-Free DNA in Plasma and Serum Indicates Disease Severity and Prognosis in Blunt Trauma Patients

Background: Trauma is still a major cause of mortality in people < 50 years of age. Biomarkers are needed to estimate the severity of the condition and the patient outcome. Methods: Cell-free DNA (cfDNA) and further laboratory markers were determined in plasma and serum of 164 patients at time of admission to the emergency room. Among them were 64 patients with severe trauma (Injury Severity Score (ISS) ≥ 16), 51 patients with moderate trauma (ISS < 16) and 49 patients with single fractures (24 femur neck and 25 ankle fractures). Disease severity was objectified by ISS and Glasgow Coma Scale (GCS). Results: cfDNA levels in plasma and serum were significantly higher in patients with severe multiple trauma (SMT) than in those with moderate trauma (p = 0.002, p = 0.003, respectively) or with single fractures (each p < 0.001). CfDNA in plasma and serum correlated very strongly with each other (R = 0.91; p < 0.001). The AUC in ROC curves for identification of SMT patients was 0.76 and 0.74 for cfDNA in plasma and serum, respectively-this was further increased to 0.84 by the combination of cfDNA and hemoglobin. Within the group of multiple trauma patients, cfDNA levels were significantly higher in more severely injured patients and patients with severe traumatic brain injury (GCS ≤ 8 versus GCS > 8). Thirteen (20.3%) of the multiple trauma patients died during the first week after trauma. Levels of cfDNA were significantly higher in non-surviving patients than in survivors (p < 0.001), reaching an AUC of 0.81 for cfDNA in both, plasma and serum, which was further increased by the combination with hemoglobin and leukocytes. Conclusions: cfDNA is valuable for estimation of trauma severity and prognosis of trauma patients.

Clinical effect of emergency orthopedic surgery for multiple trauma

This paper focuses on the clinical control strategies for multiple injuries in bone surgery. Fifty patients with severe orthopaedic multiple trauma admitted to our hospital from January 2023 to April 2023 were selected. All patients were treated with the principle of injury control osteology. Clinical diagnosis and treatment data of the patients were retrospectively analyzed. The average time and intraoperative blood loss of the first stage operation were (55.3±17.7) and 18nL, respectively. The results were significantly different from those of the second stage surgery (P<0.05). Two patients (4.0%) died, and the complication rate was 10.0% (5/50). Follow-up of the patients showed that there were no long-term complications and the fracture healed satisfactorily. The principle of injury control in the treatment of severe multiple trauma in orthopedics can reduce the risk of early surgical treatment, improve the clinical treatment effect and promote the rehabilitation of patients, which is worthy of clinical promotion and application.

Association Between Neutrophil Density and Survival in Trauma Patients Admitted to the Intensive Care Unit; a Retrospective Cohort Study.

Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immune responses to trauma. This study aimed to evaluate the association of neutrophil changes with patients' survival in severe multiple trauma cases. The current retrospective cohort study was conducted using data from patients admitted in the intensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into three groups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and the association of neutrophil count with in-hospital mortality was analyzed. 2176 patients with the mean age of 37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in this series was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia (n = 14). There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p = 0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groups were 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank test showed a statistically significant difference between the three groups adjustment for ISS (p ≤ 0.001). For each unit increase in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also, in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients. In general, the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment was higher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was 15 times higher than the normal group.

Editorial Comment on the Article by Belenkiy I.G. et al. “Strategies of Osteosynthesis: Problems and Perspectives”

The commentary critically analyzes the strategy proposed by the authors of the article for performing osteosynthesis and describes the system of care for patients with fractures in Moscow. Operating rooms are divided into planned and emergency. And they, in turn, are divided into conventional and hybrid, in which it is simultaneously possible to perform endoscopic, endovascular, and open surgery. Surgeries are performed in order of priority. Highest priority: extra-focal fixation of limb bones and/or pelvis with ex-fix devices; surgery on extremities with impaired blood supply in the distal parts; decompressive fasciotomies with simultaneous external fixation of fragments in ex-fix devices with suspected formation of compartment syndrome; surgeries performed in patients with severe combined or multiple trauma. High priority: open fractures of type 3A and 3B according to the Gustillo classification, requiring primary surgical treatment of wounds and external fixation; closed unstable fractures.

The effect of mechanical skin damage on manifestations of endotoxicosis and immune response under the influence of skeletal trauma complicated by acute blood loss and PRP-therapy effectiveness

Summary. The frequency of emergencies in both peacetime and wartime conditions has significantly increased in recent years. Under those circumstances, severe multiple and combined traumas, caused by skeletal trauma, acute blood loss and massive soft-tissue and skin damage, predominate among the various kinds of injuries. The role of mechanical skin damage in the course of severe trauma is insufficiently presented in the existing studies and literature. There are no data on the effectiveness of platelet-rich plasma grafts (PRP-therapy) under those conditions, which can greatly accelerate the regeneration of damaged soft tissues and skin, and thus inhibit the manifestations of systemic disorders, in particular endotoxicosis and immune responses. The aim of the study – to establish the effect of mechanical skin damage on the dynamics of indicators of endogenous intoxication and immune responses under the influence of skeletal trauma complicated by acute blood loss and evaluate the PRP-therapy effectiveness. Materials and Methods. The experimental studies were performed on 186 nonlinear white male rats weighing 180–200 g. In the first experimental group, the animals were simulated a mechanical damage of skin (a skin flap of 2×2 cm on the back of the animal was cut). The animals of the second experimental group were subjected to a skeletal trauma complicated by acute blood loss. In the third experimental group, these lesions were combined. In the fourth experimental group, the animals with combined trauma were administered an intradermal injection of 0.1 ml of platelet-rich plasma in wound edges. After 3, 7, 14, 21 and 28 days of trauma infliction, the animals were removed from the experiment. Contents of middle molecular weight (MMW280) fraction and circulation immune complexes (CICs) were measured in serum. The control group consisted of intact animals. Results. The research findings have shown that the infliction of isolated damage to skin is accompanied by the accumulation of the MMW280fraction and CICs in serum, the contents were higher than control values at all experimental periods reaching their maximum after 7 days and starting to increase again after 21 days. The pattern of the dynamics of the studied indicators in conditions of skeletal trauma complicated by acute blood loss was similar, but with greater amplitude. A combined trauma model resulted in an even greater increase in the intensity of endogenous intoxication and immune responses at all experimental time points. The administration of the PRP-therapy led to the decrease in the contents of MMW280 fraction and CICs in serum of rats with the combined trauma model starting from 7thday and 21st day of the experiment, respectively, as compared to the animals with the trauma model without correction. Conclusions. The infliction of damage to skin provokes the significant increase in the contents of MMW280 fraction and CICs in serum and can enhance the endogenous intoxication and immune responses in the presence of skeletal trauma complicated by acute blood loss. Intradermal administration of allogeneic platelet-rich plasma injection under these conditions leads to the decrease in the contents of MMW280 fraction and CICs as compared to the untreated animals with trauma model

Glial fibrillary acidic protein level on admission can predict severe traumatic brain injury in patients with severe multiple trauma: A single-center retrospective observational study.

This study aimed to clarify whether the glial fibrillary acidic protein (GFAP) and soluble protein-100β (S100β) can predict severe traumatic brain injury (TBI) in patients with severe multiple trauma. This is a single-center retrospective observational study of 179 patients with severe multiple trauma. The GFAP and S100β were measured upon patient arrival at the hospital. We divided the patients into the severe TBI group (with a Traumatic Coma Data Bank classification of ≥III), the non-severe TBI group (non-TBI group [absence of abnormality on the computed tomography scan and extracranial injury], and the mild to moderate TBI group [TCDB classification I and II]). We compared biomarker levels between the two groups and then evaluated the accuracy of predicting severe TBI using a receiver operating characteristic curve. A total of 41 patients had severe TBI, and 138 had non-severe TBI. Mean GFAP levels were significantly higher in the severe TBI group (median, 6000pg/mL; interquartile range [IQR], 651-15,548pg/mL) than in the non-severe TBI group (median, 149pg/mL; IQR, 0-695pg/mL) (p<0.0001). In contrast, there was no significant difference in S100β levels between the severe TBI group (median, 64pg/mL; IQR, 0-536pg/mL) and non-severe TBI group (median, 117pg/mL; IQR, 0-403pg/mL) (p=0.637). The area under the receiver operating characteristic curve was 0.810 (p<0.0001) for GFAP and 0.476 (p=0.908) for S100β. For the GFAP, the optimal cutoff value for detecting severe TBI was 947pg/mL (sensitivity, 75.6%; specificity, 78.3%). In patients with severe multiple trauma, the GFAP level at hospital arrival could predict severe TBI, whereas the S100β level was not a useful predictor.

Early changes in white blood cell, C-reactive protein and procalcitonin levels in children with severe multiple trauma

To analyze early changes in white blood cells (WBCs), C-reactive protein (CRP) and procalcitonin (PCT) in children with multiple trauma, before secondary inflammation develops. This single-center retrospective study collected data from patients with blunt traumatic injury admitted to the pediatric intensive care unit (PICU). According to the prognostic outcome of 28 d after admission to the PICU, patients were divided into survival group (n=141) and non-survival group (n=36). Characteristics between the two groups were compared. Receiver operation characteristic (ROC) curve analysis was conducted to evaluate the capacity of different biomarkers as predictors of mortality. The percentages of children with elevated WBC, CRP, and PCT levels were 81.36%, 31.07%, and 95.48%, respectively. Patients in the non-survival group presented a statistically significantly higher injury severity score (ISS) than those in the survival group: 37.17±16.11 vs. 22.23±11.24 (t=6.47, P<0.01). WBCs were also higher in non-survival group than in the survival group ([18.70±8.42]×109/L vs. [15.89±6.98] ×109/L, t=2.065, P=0.040). There was no significant difference between the survival and non-survival groups in PCT or CRP. The areas under the ROC curves of PCT, WBC and ISS for predicting 28-day mortality were 0.548 (P=0.376), 0.607 (P=0.047) and 0.799 (P<0.01), respectively. Secondary to multiple trauma, PCT levels increased in more patients, even if their WBC and CRP levels remained unchanged. However, early rising WBC and ISS were superior to PCT at predicting the mortality of multiple trauma patients in the PICU.

Effects of Damage Control Resuscitation Combined with Alanyl Glutamine on Complications and Survival in Sufferers with Severe Multiple Trauma

To explore the clinical value of damage control resuscitation combined with alanyl glutamine in the treatment of severe multiple trauma sufferers is the main objective of the study. A total of 120 sufferers with injury severity score≥16 points of severe multiple trauma who were admitted to our hospital from November 2019 to February 2022 were selected and separated into blank group and intervention group (group J and group M) according to random grouping method with 40 people in each group. The general information, clinical indicators, thromboelastography indicators, complications and survival rate of the sufferers were recorded. The operation time, coagulation function time, hospitalization time, body temperature recovery time, prothrombin time, activated partial thromboplastin time, blood loss, total fluid input and mortality of the study subjects were statistically significant. The coagulation indexes of the three groups of research subjects before blood transfusion were not statistically significant and the coagulation indexes of the intervention group (J and M groups) after blood transfusion were statistically significant compared with the blank group. Damage control resuscitation combined with alanyl glutamine significantly reduces complication rates in sufferers with severe polytrauma, thereby improving the survival rate of sufferers after surgery.

Life expectancy of severe multiple trauma with orthopedic injury at our center

Life expectancy of severe multiple trauma with orthopedic injury at our center

Predicting factors associated with in-hospital mortality in severe multiple-trauma patients

Background and Objectives: Traumatic injuries have become a health problem worldwide, especially in low- to middle-income countries. Therefore, this study was conducted to identify predicting factors of death in adult severe multiple trauma patients. Methods: This retrospective cross-sectional study was performed on 1397 adult multiple trauma patients referred to the emergency department (ED) of Poursina Hospital between June 2019 and August 2021. The demographic characteristics, on admission clinical parameters, laboratory tests, the need for packed red blood cell transfusion, and the need for endotracheal intubation were recorded. The revised trauma score (RTS) was calculated according to the physiological variables collected on admission to ED. The primary outcome was 1-day mortality after admission. Results: The mean age of subjects was 37.12 ± 13.61 (18–60) years, and 1250 (89.5%) subjects were male. The 1-day mortality was 339 patients (24.3%). Initial RTS score and the mean Glasgow coma scale (GCS) scores were significantly higher in the survived group than in the nonsurvived group (6.6 ± 1.2 vs. 4.9 ± 1.0, 10.2 ± 3.7 vs. 4.9 ± 2.4, P < 0.001). The multivariate analysis resulted in low GCS (odds ratio [OR] = 1.527, 95%CI 1.434–1625, P < 0.001), low O2 saturation (OR = 1.023, 95%CI 1.003–1.043, P = 0.022), and need for intubation in the ED (OR = 0.696, 95%CI 0.488–0.993, P = 0.046) as predictors of 1-day mortality. The area under the curves receiver operating characteristics of RTS and GCS scores to predict mortality were 0.853 (95% CI: 0.831–0.874) and 0.866 (95% CI: 0.846–0.887), respectively. Conclusion: Multiple factors associated with 1-day mortality were reduced GCS score, decreased oxygen saturation, and need for intubation in the ED. The RTS and GCS scores are good predictors of mortality survival in multiple trauma patients.

Динамика сывороточных уровней метаболитов оксида азота и сульфида водорода как маркеров развития органной дисфункции в остром периоде политравмы

Актуальность. У пациентов с сочетанными травмами отмечается высокий уровне риска развития шока, осложнений и смерти. В наше время существуют системы оценки, которые позволяют установить степень тяжести политравмы и определяют прогноз заболевания, но их чувствительность значительно ограничена тем, что они являються субъективными. В последние годы большое внимание уделяется газовым трансмиттерам, к которым относятся оксид азота (NO), монооксид углерода (СО) и сульфид водорода (H2S). Поскольку производство газовых трансмиттеров многими типами клеток повышается при повреждении ткани, допускают, что их концентрация, а также концентрация продуктов их окисления в сыворотке крови представляют собой маркер политравмы, коррелирующий с прогнозом. Цель: определить степень нарушения эндотелиальной дисфункции и патогенетическую роль газотрансмиттеров как маркеров развития органной дисфункции в остром периоде политравмы. Материалы и методы. В работе приведены данные клинического обследования и лечения 28 больных с политравмой. Средний возраст пострадавших — 48,4 ± 5,2 года. В зависимости от тяжести пациентов при поступлении проведена стратификации по шкале APACHE II: 1-я группа (n = 22) — среднетяжелая политравма; 2-я группа (n = 6) — тяжелая поли­травма. Результаты. Происходило значительное уменьшение уровня нитроксида уже при госпитализации у пациентов 1-й и 2-й групп по сравнению с нормой — 0,49 ± 0,06 мкмоль/л, р = 0,001. Спустя сутки интенсивной терапии у пациентов обеих групп уровень NO крови возрастал до 0,43 ± 0,03 мкмоль/л и 0,45 ± 0,03 мкмоль/л соотвественно. При поступлении у пациентов межгрупповые отличия среднего уровня NOx крови были достоверными (р = 0,003). После проведения интенсивной терапии у пациентов обеих групп уровень NO2 + NO3 продолжал увеличиваться (р = 0,001 по сравнению с предыдущим этапом, а между группами статистически значимых отличий не было (р = 0,475). Средний уровень H2S в крови при поступлении пациентов 1-й и 2-й групп был достоверно выше нормы (р = 0,025). Отличия между группами были недостоверными (р = 0,117). Проведение интенсивной терапии сопровождалось норма­лизацией уровня H2S. Выводы. У больных с политравмой в остром периоде наблюдается развитие эндотелиальной ­дисфункции, которая подтверждается статистически значимыми изменениями уровня газо­трансмиттеров в сыворотке крови. Концентрации NO и продуктов его окисления (NOx) в сыворотке крови, определенные при госпитализации, являются чувствительными маркерами тяжести политравмы. Низкий уровень NOx у больных с крайне тяжелой травмой при госпитализации может прогнозировать не­благоприятный исход острого периода травматической болезни.

Раннее энтеральное питание с расширенным белково-калорийным обеспечением в комплексе интенсивной терапии пациентов с тяжелой политравмой как средство профилактики полиорганной недостаточности

Актуальность. Необходимость идентифицировать, лечить, предупреждать тяжелые нарушения нутритивного баланса у пациентов с политравмой остается одним из основных компонентов интенсивной терапии. Правильный выбор времени и метода нутритивной терапии, состава и энергетической ценности пищевых смесей призван способствовать снижению частоты трудно корректируемых осложнений, в том числе синдрома полиорганной недостаточности. Цель: оценить эффективность раннего энтерального питания с расширенным белково-калорийным обеспечением согласно протоколу Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically III Patients (PEP uP) в комплексе интенсивной терапии пациентов с тяжелой политравмой. Материалы и методы. Обследованы 40 больных с тяжелой политравмой, доставленных в отделение анестезии и интенсивной терапии (ОАИТ) в среднем через 0,5 часа после травмы. Средний возраст пострадавших — 41,9 ± 2,4 года. Основная группа (группа А) — 15 пациентов, которым проводилась нутритивная терапия по протоколу PEP uP. Группу сравнения (группа Б) составили 25 больных, у которых нутритивная поддержка проводилась согласно Европейским рекомендациям по клиническому питанию пациентов в ОАИТ с применением стандартных полимерных смесей. С целью оценки риска полиорганной недостаточности применяли шкалу Sequential Organ Failure Assessment (SOFA) при поступлении, на 2-е, 3-и и 5-е сутки лечения. Определяли в динамике уровень общего белка и альбумина сыворотки крови. Результаты. Тяжесть органной дисфункции по шкале SOFA в обеих группах при поступлении была соизмеримой. В группе Б со вторых суток отмечено развитие устойчивой гипопротеинемии, чего в группе А не наблюдалось. На 5-е сутки лечения в группе А отмечен достоверно более высокий уровень альбумина, чем в группе Б. На третий день лечения в группе Б выросла доля пациентов с проявлениями повреждения почек: 31,8 % — 0 баллов, 54,5 % — 1 балл, 13,7 % — 2 балла по шкале SOFA. В группе А оценки в 2 балла по шкале SOFA не наблюдалось, 84,6 % имели 1 балл, 15,4 % — 0 баллов. В течение первых трех суток отмечено уменьшение проявлений повреждения легких в обеих группах. Влияние ранней нутритивной поддержки на динамику индекса оксигенации остается, по нашему мнению, неопределенным. Выводы. Достигнуто сокращение срока пребывания пациентов с тяжелой политравмой в ОАИТ в среднем на трое суток (в группе А — 16,9 ± 1,4 суток, в группе Б — 19,9 ± 1,2 суток). Первые 3–5 суток интенсивной терапии с использованием протокола PEP uP позволяют снизить риски развития полиорганной недостаточности, что следует из низшего в данный термин суммарного балла по шкале SOFA в группе А (1–4 балла) по сравнению с группой Б (4–7 баллов). Нутритивная терапия методом раннего энтерального питания с расширенным белково-калорийным обеспечением позволяет улучшить адекватность покрытия белково-энергетических потребностей у пациентов в остром периоде политравмы, что может положительно влиять на уменьшение частоты развития осложнений, продолжительность пребывания пациентов в ОАИТ.

Thermomechanical Combination Injuries: A Rare But Life-Threatening Entity.

Thermomechanical combination injuries (TMCIs) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple trauma. There remains a significant lack of standardized algorithms for diagnostics and therapy of this rare entity. The objective of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCIs were extracted from our burn database of a level 1 burn and trauma center. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including injury severity score and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI, comprising 4% of all burn injuries during the period. The average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6-37.1) with 2215 ml volume of resuscitation fluids (range: 500-8000) administered preclinically in total. The mean injury severity score was 16. The overall mortality rate was 22%. TMCIs are rare and life-threatening events that require highly qualified management in combined level 1 trauma and burn centers to address both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care-specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCIs in ABLS®, ATLS®, and PHTLS® programs.

Retrospective study of thoracic endovascular aortic repair as a first-line treatment for traumatic blunt thoracic aortic injury.

This study sought to confirm if thoracic endovascular aortic repair (TEVAR) was an appropriate therapeutic strategy for blunt thoracic aortic injury (BTAI). Between 3/2005 and 12/2020, 104 patients with BTAI were brought to our hospital. The severity of each trauma case was evaluated using the Injury Severity Score (ISS); aortic injuries were classified as type I to IV according to Society for Vascular Surgery guidelines. Initial treatment was categorized into four groups: nonoperative management (NOM), open aortic repair (OAR), TEVAR, or emergency room thoracotomy/cardiopulmonary resuscitation (ERT/CPR). The patients' mean age and ISS were 56.7 ± 20.9years and 48.3 ± 20.4, respectively. Type III or IV aortic injury were diagnosed in 82 patients. The breakdown of initial treatments was as follows: NOM for 28 patients, OAR for four, TEVAR for 47, and ERT/CPR for 25. The overall early mortality rate was 32.7%. Logistic regression analysis confirmed ISS > 50 and shock on admission as risk factors for early mortality. The cumulative survival rate of all patients was 61.2% at 5years after treatment. After initial treatment, eight patients receiving TEVAR required OAR. The cumulative rate of freedom from reintervention using TEVAR at 5years was higher in approved devices than in custom-made devices (96.0 vs. 56.3%, p = 0.011). Using TEVAR as an initial treatment for patients with BTAI is a reasonable approach. Patients with severe multiple traumas and shock on admission had poor early outcomes, and those treated with custom-made devices required significant rates of reintervention.