Adult Trauma Patients Research Articles

Epinephrine in Prehospital Traumatic Cardiac Arrest – Life Saving or False Hope?

ABSTRACT OBJECTIVES While epinephrine is widely used for medical cardiac arrests, there is a knowledge gap regarding its utility for traumatic arrests. Traumatic arrests result from hypovolemia, hypoxia, or anatomic impairment of cardiac function such that the inotropic and vasoconstrictive effects of epinephrine may be ineffective or harmful. We hypothesized that epinephrine does not improve survival among patients with traumatic cardiac arrest. METHODS This was a multicenter retrospective cohort study of trauma patients sustaining prehospital cardiac arrest who were treated at seven level I and II trauma centers over six years (2011-2017), ascertained via trauma registry data and chart abstraction. The primary outcome was survival to hospital discharge; patients treated with or without epinephrine were compared. Multivariable analyses were performed using Poisson regression. Time to event analyses were conducted using Cox proportional hazard models. RESULTS We included 1631 adult and pediatric trauma patients with prehospital cardiac arrest. Prehospital epinephrine was administered to 844 (52%). The median age was 35 years, 335 (21%) were female, 712 (44%) sustained blunt trauma, and 58 (4%) had a shockable initial rhythm. Survival to hospital discharge was significantly lower in the prehospital epinephrine cohort compared to the no epinephrine cohort in univariable analysis [43/844 (5%) vs 125/787 (16%), p < 0.001]. Among patients with blunt mechanism, survival was significantly lower in the prehospital epinephrine cohort [12/382 (3%) vs 54/330 (16%), p < 0.001]. Among patients with penetrating mechanism, survival was not statistically different [10/276 (4%) with epinephrine vs 22/374 (6%) without, p = 0.19]. In multivariable analyses adjusting for age, sex, mechanism, and initial rhythm, epinephrine was associated with lower likelihood of survival in the overall and blunt cohorts; there was no significant difference in the penetrating cohort (overall aRR 0.33, 95% CI 0.23-0.46; blunt aRR 0.20, 95% CI 0.11-0.37; penetrating aRR 0.62, 95% CI 0.30-1.28). Adjusted and unadjusted time to event analyses across each of these cohorts showed that epinephrine was associated with either statistically inferior or indistinct hazard ratios. CONCLUSIONS Epinephrine was not associated with improved survival following traumatic cardiac arrest, and in multiple subanalyses, it was associated with inferior outcomes. These results may inform prehospital traumatic arrest protocols.

Assessing the role of chest CT in minor blunt trauma: evaluation of the NEXUS decision instrument across an expanded population.

To evaluate the NEXUS Chest CT ALL decision instrument (DI) in reducing unnecessary chest CT imaging in minor blunt trauma patients while preserving high sensitivity for detecting clinically meaningful injuries. Additionally, we examined the impact of delayed presentation, chronic disease, and anticoagulation/anti-aggregation medications on trauma outcomes. This retrospective study included 853 adult minor blunt trauma patients who underwent chest CT in the emergency department (ED) of Tel-Aviv Sourasky Medical Center between 2018 and 2022. Clinically meaningful outcomes were defined as trauma-related interventions or hospital admissions. The NEXUS Chest CT DI criteria, along with three additional criteria, were analyzed using logistic regression to identify independent predictors for the primary outcome. These predictors formed a modified DI, and its performance was compared to the original NEXUS DI. Among 853 patients (median age 44.5years, 64.2% male), 230 (27.0%) had trauma-related chest CT findings, and 64 (7.5%) experienced clinically meaningful outcomes. Independent predictors included abnormal chest X-ray (aOR 6.5, p < 0.001), chronic disease (aOR 5.2, p < 0.001), sternal tenderness (aOR 4.7, p = 0.007), rapid deceleration (aOR 3.7, p < 0.001), and chest wall tenderness (aOR 3.1, p < 0.001). The NEXUS DI achieved 92.1% sensitivity, reducing imaging by 41.3%, while the modified DI increased sensitivity to 98.4% with a 34.3% imaging reduction. The NEXUS Chest CT ALL DI significantly reduces unnecessary imaging while maintaining high diagnostic precision. A modified version enhances sensitivity, refining decision-making in emergency care. Integrating such decision tools, particularly in cases of minor trauma, is highly recommended to optimize resource use and improve patient outcomes.

ELECTROCARDIOGRAPHY FINDINGS IN BLUNT CHEST TRAUMA AT TERTIARY CARE HOSPITAL PESHAWAR

Introduction: Blunt chest trauma is a significant cause of morbidity and mortality, often leading to a range of cardiac complications detectable through electrocardiogram (ECG) abnormalities. Objectives: The primary objective of this research was to identify the early onset of myocardial damage in patients with acute blunt chest injuries using ECG. The secondary objective is being to compare the ECG changes between paediatric and adult trauma patients. Methodology: This cross-sectional study was conducted in the Emergency department (ED) and patients admitted with acute blunt chest trauma were included in the current study. A total of 281 patients were included based on the following inclusion criteria: patients of all ages with blunt chest trauma. Exclusion criteria included preexisting cardiac and neurological conditions, penetrating chest injuries, pregnant women and incomplete medical records. Demographic and clinical data were collected, and a standard 12-lead ECG was performed and analyzed for abnormalities. Statistical analysis was done using SPSS version 26, where chi square test was applied to identify factors that may be associated with ECG abnormalities and assess age-related differences in ECG findings. Results: ECG findings in patients with blunt chest trauma, recorded in 30.9% of the total sample. Sinus arrhythmia's, particularly sinus tachycardia were the most common findings in both adults (6.2%) and pediatrics (8.1%). In adult’s sinus tachycardia was followed by ST segment changes and atrial fibrillation. In pediatrics, sinus tachycardia was accompanied by PVCs and supraventricluar tachycardia. Conclusion: Sinus arrhythmias were the most common findings in both group, followed by ST segment changes and atrial fibrillation in adults while in pediatrics, followed by PVCs and SVT.

Comparison of conventional coagulation tests and ROTEM in identifying trauma-induced coagulopathy for massive haemorrhage protocol activation.

Trauma-induced coagulopathy (TIC) can be fatal but preventable if recognised early. With emerging uses of rotational thromboelastometry (ROTEM) to guide transfusions in trauma, patient outcomes with TIC-defined by initial ROTEM and conventional coagulation tests (CCTs) during massive haemorrhage protocol (MHP) activations were evaluated at a primary trauma centre in British Columbia. This retrospective observational study included adult trauma patients requiring MHP from June 1, 2020, to May 31, 2022. TIC, defined by initial results including (1) ROTEM-based EXTEM A10 <40 mm, EXTEM CT >100 s, EXTEM ML30 >10%, FIBTEM A10 <10 mm; and (2) CCT-based INR ≥1.8, PTT ≥1.5 times of upper normal limit, platelets <50 x 109/L, and Clauss Fibrinogen <1.5 g/L, was assessed for its correlation with mortality. Modified Poisson regression was used to model 28-day mortality. Twenty-two of sixty-eight patients (32%) had abnormal ROTEM but normal CCTs. TIC defined by CCTs was associated with increased mortality [24 h: 5/13 (38%) vs. 5/55 (9%), p = 0.025; 28d: 8/13 (62%) vs. 11/55 (20%), p = 0.002]; compared to ROTEM, which was not [24 h: 7/35 (20%) vs. 3/33 (9%), p = 0.307; 28d: 11/35 (31%) vs. 9/33 (27%), p = 0.594], despite requiring significantly higher blood component transfusion within the first 4 and 24 h of MHP (p-values<0.05). ROTEM is more sensitive in identifying TIC. Patients with abnormal CCTs had a higher death rate, and those with abnormal ROTEM had no significantly increased mortality. A prospective study is required to assess the effects of ROTEM further.

Pre-injury narcotic drug use in isolated severe traumatic brain injury: effect on outcomes.

The aim of this study was to explore the association between pre-injury narcotic drug use (opioids, methadone, and/or oxycodone) and outcomes in isolated severe traumatic brain injury (TBI) patients. ACS TQIP study included adult trauma patients (≥ 16 years) with complete drug and alcohol screening. Isolated severe TBI was defined as head trauma with AIS 3-5 and without significant extracranial trauma. Exact matching was used to compare patients with isolated pre-injury narcotic drug use to those with no illicit drug or alcohol use. Patients were matched 1:1 based on the following matching criteria: age, gender, mechanism of injury, Injury Severity Score, systolic blood pressure, head AIS, and comorbidities. Of 1,846,630 patients, 141,058 had isolated severe head injuries with complete drug and alcohol screenings. After exact matching, 1,560 patients in each group were analyzed. There were no significant differences in hospital mortality, craniectomy rates, complication rates, or length of hospital stay. Patients that tested positive for narcotics had lower rates of mechanical ventilation (16.5% vs. 25.3%, p < 0.01) and shorter ICU stays [3 (2-4) days vs. 3 (2-6) days; p < 0.01]. Pre-injury narcotic drug use in isolated severe TBI is not associates with adverse outcomes. Further research is needed to understand the biochemical and physiological effects of narcotic drugs on TBI outcomes.

The tissue-plasminogen activator-challenged thromboelastography provides a comprehensive assessment of fibrinolysis in the severely injured.

Tissue-plasminogen activator-challenged thromboelastography (tPA-TEG) predicts massive transfusion and mortality better than conventional rapid thromboelastography (rTEG), with little concordance between their lysis values (LY30). We hypothesized that the main fibrinolytic inhibitors plasminogen activator inhibitor-1 (PAI-1) and α-2 antiplasmin (A2AP), as well as markers of fibrinolytic activation (plasmin-antiplasmin [PAP], tPA-PAI-1 complex, tPA activity), would correlate more strongly with tPA-TEG versus rTEG LY30 and may explain the recent findings of four distinct fibrinolytic phenotypes in trauma based on these two TEG methodologies. Adult trauma patients (n = 56) had tPA-TEG, rTEG, and plasma obtained on arrival to the emergency department with institutional review board approval. Plasminogen activator inhibitor-1 activity, A2AP, PAP, and tPA-PAI-1 complex as well as tPA activity were measured. Data were analyzed using Spearman's correlations and analysis of variance. The median age was 34 years, 75% were male, and the New Injury Severity Score was 14. Mortality was 25%, and 23% required a massive transfusion. There was a significant negative correlation between PAI-1 activity and A2AP with tPA-TEG LY30 (r = -0.77, p < 0.0001 and r = -0.62, p < 0.0001). There was a significant positive correlation between PAP complex and tPA-TEG LY30 (r = 0.74, p < 0.0001). There was no correlation between any fibrinolytic analyte and rTEG LY30. When stratified by phenotype, patients with hypofibrinolysis and nonpathologic fibrinolysis had higher active PAI-1 (p < 0.05) and A2AP levels (p < 0.05), lower PAP (p < 0.05), and tPA-PAI-1 complex (p < 0.05). Tissue-plasminogen activator activity was higher in hyperfibrinolysis relative to the other three groups (p < 0.05). Tissue-plasminogen activator-TEG LY30 more accurately reflects fibrinolysis phenotypes in trauma patients than conventional TEG methods. This provides an explanation for tPA-TEG's superior performance over rTEG in predicting clinical outcomes. Basic Science; N/A.

Clinical Characteristics and Mortality-Associated Factors in Trauma Patients Undergoing Permanent Versus Temporary Tracheostomy.

Objective: This study evaluated the characteristics, outcomes, and mortality-associated factors in patients who underwent tracheostomy after traumatic injury to optimize clinical decision-making and patient care in critical trauma settings. Materials and Methods: A retrospective cohort analysis was conducted using the National Trauma Data Bank (NTDB) records from 2013 to 2016. This study included 41,630 adult trauma patients who underwent tracheostomy procedures. Data analysis included descriptive statistics, univariate comparisons, and multivariate logistic regression analyses. The study protocol adhered to STROBE guidelines for observational studies. Results: Analysis of the total cohort revealed that patients with tracheostomy demonstrated high rates of severe injuries (75.2%) and a notable comorbidity burden, including cardiovascular disorders (4.0%) and blood disorders (5.8%). Multivariate analysis revealed that mortality risk was independently associated with advanced age (OR 1.018, 95% CI 1.016-1.021), higher injury severity scores (OR 1.004, CI 1.002-1.007), female sex (OR 1.187, CI 1.078-1.308), and cardiovascular surgical intervention (OR 1.487, CI 1.350-1.638). Among the study population, 7.6% underwent permanent tracheostomy procedures, with these patients showing some distinct clinical characteristics in terms of injury severity and comorbidity profiles. Conclusions: This comprehensive analysis demonstrates the complex clinical characteristics and mortality-associated factors in trauma patients requiring tracheostomy. Key factors influencing survival outcomes include age, injury severity, sex, and cardiovascular surgical intervention. These findings provide valuable insights for clinical decision-making and risk assessment in trauma patients requiring tracheostomy. The observed differences between permanent and temporary tracheostomy patients warrant further investigation with more detailed timing and indication data.

Outcomes and predictors of unplanned intensive care unit admission for pediatric trauma patients.

Unplanned intensive care unit (ICU) admission (UIA) is associated with increased morbidity in adult trauma patients, however, is not well studied in pediatric trauma patients (PTPs). We sought to identify predictors of UIA, hypothesizing PTPs with UIA have increased odds of mortality. The 2017-2019 Trauma Quality Improvement Program (TQIP) database was queried for PTPs ≤16-years-old admitted to non-ICU level of care. Patients with UIA were compared to those without UIA. Multivariable logistic regression analysis was performed to determine predictors of UIA. From 142,160 PTPs, 233 patients had UIA (<1%). The UIA group had increased acute kidney injury (2.6% vs 0%, p<0.001), length of stay (7 vs 2days, p<0.001), and mortality (1.3% vs. 0.1%, p<0.001). Independent predictors of UIA included ureteral, esophageal, and brain injury (all p<0.001). UIA for PTPs is rare but associated with increased complications and death. Significant predictors of UIA include ureteral, esophageal and brain injury.

The acute management of penetrating carotid artery injuries-A systematic review.

Penetrating carotid artery injuries (CAI) are rare with high morbidity and mortality. We aimed to perform a systematic review of the published literature to evaluate the workup and management of penetrating CAI. Studies of acute management of adult trauma patients with penetrating common or internal carotid artery injuries on MEDLINE or EMBASE from 1946 through July 2024 were included following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement methodology. Exclusion criteria was case series with <5 patients, review articles, animal studies, cadaver studies, non-English language, and age<18. Risk of bias was assessed with Oxford Level of Evidence and findings evaluated via GRADE. Our systematic review identified 4737 studies, of which 35 were included. Preoperative evaluation transitioned to screening CTA of the neck in the absence of hard signs. Management now includes endovascular and nonoperative in select cases: nonoperative for some small intraluminal injuries and stenting or embolization for surgically inaccessible lesions. Repair or revascularization was preferred in all but neurologically devastated comatose patients, in which, ligation was deemed acceptable. Temporary intravascular shunting (TIVS) with a takeback for definitive revascularization was associated with a 100% stroke or death. Postoperative antiplatelet or anticoagulation therapy and follow-up was non-standardized with a shift toward antiplatelet therapy for all injuries described more recently. Penetrating CAI remain challenging with a shift toward less invasive initial workup with CTA and management including endovascular and nonoperative in select cases. TIVS with delayed revascularization and ligation were both associated with poor outcomes. Postoperative antiplatelet therapy has become increasingly common and postoperative surveillance is not standardized.

Outcomes Associated With Airway Management of Adult Trauma Patients Admitted to Surgical Intensive Care.

Advanced airway management and ventilation of trauma patients are often needed during acute stabilization and resuscitation and later, in those admitted. In addition to endotracheal intubation for advanced airway management, tracheostomy is commonly used in critically ill patients when prolonged mechanical ventilation is required. However, the outcomes associated with airway management approaches and the timing of a tracheostomy in critically ill patients are mixed. This protocol intended to compare the effect of tracheostomy in major trauma patients vs. management with non-invasive techniques and endotracheal intubation during admission, examine complications and outcomes associated with the three types of airway management approaches, and explore the association of clinical and social determinants of health variables with complications in patients requiring advanced airway management. A total of 911 adult trauma patients admitted to a Level 1 trauma center surgical intensive care unit (SICU) were included in this retrospective, single-center, quantitative study from 2019 to 2021. Descriptive and correlational analyses were used to examine outcomes of ventilator days, length of stay, pneumonia, readmission, mortality, and associations with the airway management approach. The outcomes of ventilator days and length of stay were compared between groups with a one-way ANOVA, and differences between groups on outcomes of pneumonia, readmission, and mortality were estimated using crosstabulations and chi-square (x²) statistics. Hypothesized relationships of clinical and social determinants of health variables associated with outcomes of ventilator days, hospital length of stay, pneumonia, readmission, and mortality in patients requiring advanced airway management ≥ four days were estimated. There was no significant difference in outcomes of pneumonia and mortality between the advanced airway management groups (p=0.856 and p=0.167, respectively). There were significant differences in ventilator days, length of stay (LOS), and readmission. Between the groups: endotracheal intubation only, early (<10 days post-intubation) tracheostomy, and late (>10 days post-intubation) tracheostomy in SICU patients (p <0.001, p=0.028, and p=0.003, respectively). Specifically, patients in the early tracheostomy group had a higher readmission rate (33.3%) as compared to endotracheal tube patients (2.3%) and late tracheostomy patients (0.0%). Social determinants of health variables (smoking and functional dependence) were also significantly correlated with readmission in the early tracheostomy and endotracheal tube airway management groups (p=.047 and p=.022, respectively). Additionally, clinical variables of injury severity scores, ED arrival systolic blood pressure (SBP), and presence of pre-existing comorbidities were found to be significantly associated with complications of pneumonia, readmission, and mortality within the patients (n=229) requiring advanced airway approaches. Adult trauma patients with early tracheostomy airway management may experience a higher readmission rate related to the complexity of their injuries than patients managed with endotracheal intubation or late tracheostomy. Clinical and social determinants of health factors may be associated with complications. Further studies examining these associations in larger samples are needed to examine the validity of these findings.

Early Restrictive vs Liberal Oxygen for Trauma Patients

Early administration of supplemental oxygen for all severely injured trauma patients is recommended, but liberal oxygen treatment has been associated with increased risk of death and respiratory complications. To determine whether an early 8-hour restrictive oxygen strategy compared with a liberal oxygen strategy in adult trauma patients would reduce death and/or major respiratory complications. This randomized controlled trial enrolled adult trauma patients transferred directly to hospitals, triggering a full trauma team activation with an anticipated hospital stay of a minimum of 24 hours from December 7, 2021, to September 12, 2023. This multicenter trial was conducted at 15 prehospital bases and 5 major trauma centers in Denmark, the Netherlands, and Switzerland. The 30-day follow-up period ended on October 12, 2023. The primary outcome was assessed by medical specialists in anesthesia and intensive care medicine blinded to the randomization. In the prehospital setting or on trauma center admission, patients were randomly assigned 1:1 to a restrictive oxygen strategy (arterial oxygen saturation target of 94%) (n = 733) or liberal oxygen strategy (12-15 L of oxygen per minute or fraction of inspired oxygen of 0.6-1.0) (n = 724) for 8 hours. The primary outcome was a composite of death and/or major respiratory complications within 30 days. The 2 key secondary outcomes, death and major respiratory complications within 30 days, were assessed individually. Among 1979 randomized patients, 1508 completed the trial (median [IQR] age, 50 [31-65] years; 73% male; and median Injury Severity Score was 14 [9-22]). Death and/or major respiratory complications within 30 days occurred in 118 of 733 patients (16.1%) in the restrictive oxygen group and 121 of 724 patients (16.7%) in the liberal oxygen group (odds ratio, 1.01 [95% CI, 0.75 to 1.37]; P = .94; absolute difference, 0.56 percentage points [95% CI, -2.70 to 3.82]). No significant differences were found between groups for each component of the composite outcome. Adverse and serious adverse events were similar across groups, with the exception of atelectasis, which was less common in the restrictive oxygen group compared with the liberal oxygen group (27.6% vs 34.7%, respectively). In adult trauma patients, an early restrictive oxygen strategy compared with a liberal oxygen strategy initiated in the prehospital setting or on trauma center admission for 8 hours did not significantly reduce death and/or major respiratory complications within 30 days. ClinicalTrials.gov Identifier: NCT05146700.

Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study

Background Major trauma places substantial demand on critical care services, is a leading cause of death in under 40-year-olds and causes significant morbidity and mortality across all age groups. Various factors influence patient outcome and predefining these could allow prognostication. The aim of this study was to identify predictors of mortality from major trauma in intensive care. Methods This was a retrospective study of adult trauma patients admitted to general intensive care between January 2018 and December 2019. We assessed the impact on mortality of patient demographics, patterns of injury, injury scores (Glasgow Coma Score (GCS), Charlson’s comorbidity index (CCI), Acute Physiology and Health Evaluation II (APACHE II), Injury Severity Score (ISS) and Probability of Survival Score (Ps19)), number of surgeries and mechanism of injury using logistic regression. Results A total of 414 patients were included with a median age of 54 years (IQR 34–72). Overall mortality was 18.6%. The most common mechanism of injury was traffic collision (46%). Non-survivors were older, had higher ISS scores with lower GCS on admission and lower probability of survival scores. Factors independently predictive of mortality were age 70-80 (OR 3.267, p = 0.029), age &gt;80 (OR 27.043, p &lt; 0.001) and GCS &lt; 15 (OR 8.728, p &lt; 0.001). Ps19 was the best predictor of mortality (p &lt;0.001 for each score category), with an AUROC of 0.90. Conclusions The significant mortality predictors were age, fall from &lt;2 metres, injury of head or limbs, GCS &lt;15 and Ps19. Contrary to previous studies, CCI and APACHE II did not significantly predict mortality. Although Ps19 was found to be the best current prognostic score, trauma prognostication would benefit from a single validated scoring system incorporating both physiological variables and injury patterns.

Exploring Saudi paramedics’ experiences in managing adult trauma cases: a qualitative study

BackgroundSaudi paramedics face numerous challenges while providing care for adult trauma patients affecting their care but little is known about these specific challenges.MethodsA qualitative study was conducted using a purposive sample of Saudi paramedics from the Saudi Red Crescent Authority (SRCA) across various cities. Data were collected through online semi-structured interviews and analyzed using the framework method.ResultsA total of 20 paramedics were recruited and interviewed. They identified challenges in trauma response, including coordinating care, ensuring the accuracy and accessibility of patient information, and maintaining confidence and readiness. Participants emphasized the need for independent knowledge acquisition through courses, simulations, and peer discussions. They also highlighted the need for more paramedics, strategies to reduce burnout, and the importance of accurately assessing patient conditions. Additionally, they also stressed the importance of raising public awareness to enhance trauma care.ConclusionThis study explored Saudi paramedics' experiences in managing adult trauma patients. standardized handovers, more staff, and greater public awareness are the main key needs to improve daily practice.

Hypothermia on Admission Predicts Poor Outcomes in Adult Trauma Patients

BackgroundHypothermia is known to contribute to poor outcomes in trauma patients during acute phases. The aim of our study is to evaluate the effect of hypothermia on admission, upon in-hospital complications and mortality in adult trauma patients. MethodsWe performed a 5-year analysis of ACS-TQIP database (2017-2021). Patients with incomplete data, burns, inter-facility transfers, or documented as dead on arrival were excluded. Hypothermia (HT) was defined as a temperature of <35 degrees Celsius(°C), and Normothermia (NT) as ≥35°C to≤40°C measured at the time of patient arrival. Data were collected including demographic variables, mechanism of injury, injury severity, injury patterns, and shock index. Outcome variables were mortality, ICU length of stay (LOS), duration of mechanical ventilation, hospital LOS, and in-hospital complications. Multivariable regression analysis was performed. ResultsA total of 3,043,030 patients were included and 1% were hypothermic. HT patients were severely injured, developed in-hospital complications (17.1%vs.4.5%), had longer ICU LOS (4 (2-9) vs. 3 (2-5) days), hospital LOS (5 (2-12) vs. 4 (2-6) days), and higher mortality (23.4% vs. 2.3%). Hypothermia was independently associated with higher odds of mortality (OR:1.934 [1.858–2.013]). Subgroup analysis of patients with isolated traumatic brain injury revealed pre-hospital hypothermia to still be an independent predictor of mortality (OR: 1.728[1.600–1.867]). HT who underwent rewarming had a lower mortality, shorter hospital and ICU LOS. ConclusionPre-hospital hypothermia is independently associated with higher resource utilization, in-hospital complications, and mortality. Even in patients with isolated TBI, pre-hospital hypothermia increases the odds of mortality. Rewarming interventions can potentially improve outcomes among patients, even with mild hypothermia.

Evaluating the utility of end-tidal CO2 as a predictor of mortality in trauma victims: A systematic review and meta-analysis.

Capnography has shown to be an invaluable tool in assessing trauma victims in different setups. To elucidate this, we conducted this meta-analysis to evaluate the utility of end-tidal CO2 (ETCO2) and the arterial CO2 -ETCO2 gap (PaCO2-ETCO2) measurements on predictiveness for mortality in trauma patients. A systematic literature search was performed (01/1990-06/2023). The inclusion criteria included adult trauma patients, with mention of mortality. The primary outcome was evaluating the reliability of ETCO2 in predicting mortality. Seventeen studies were included, with total of 3445 patients. Mean age was 39.08-year, 22.3​% female. Overall mortality was 25.6​%, mostly retrospective studies. Mean ETCO2 in survivors was 31.45​mmHg, and 24.75​mmHg in deceased patients, (p​=​0.0128). Mean PaCO2-ETCO2 gap in survivors was 6.8​mmHg, and 15.0​mmHg in deceased patients, (p​<​0.001). Using receiver operator characteristic curve analysis, ETCO2 of 30.2​mmHg with high sensitivity to predict mortality. Low ETCO2 or a wide PaCO2-ETCO2 gap were significantly correlated with poor outcomes in trauma patients. This easily obtained value can help predict those who need more aggressive treatments.

Factors associated with anxiety and depression one year after trauma critical care admission: A multi-centre study.

Recovery after severe injury may be impacted by a range of psychological factors. This multi-site study investigated the prevalence and impact of anxiety and depression at one year after trauma critical care admission. Adult trauma patients admitted to four Level 1 Critical Care Units were prospectively enrolled over 18 months. Survivors were followed-up at one year post discharge using EQ-5D-5L questionnaires. Multivariable logistic regression analysis was used to evaluate factors associated with anxiety and depression at follow up. Of the 657 patients consented and alive at follow-up, 290 questionnaires were completed (44 % response rate). Two-thirds (63 %) reported anxiety or depression (AoD) at follow up, and this was associated with a worse overall health state (EQ-VAS No AoD: 80 vs. AoD: 60, p < 0.0001). Median ISS in both groups was 25 but those with AoD were younger (53 years vs. 60 years, p = 0.033), had previous psychological morbidities (16 % vs. 5 %, p = 0.0056) and longer hospital stays (32 vs. 24 days, p = 0.0027). All physical EQ-5D-5 L domains were worse in the presence of AoD and problems increased as anxiety or depression became more severe. Factors associated with anxiety and depression were younger age (OR 0.98 [95 % CI 0.96-0.99] p = 0.004), previous psychological morbidity (OR 3.30 [95 % CI 1.51-7.40] p = 0.004), penetrating injury (OR 10.10 [95 % CI 1.90 - 44.4] p = 0.007), ongoing pain (OR 1.61 [95 % CI 1.10-2.30] p = 0.003) or difficulties carrying out usual activities (OR 1.40 [95 % CI 1.02-2.29] p = 0.04). Anxiety and depression are significant longer-term impacts after severe injury. Younger age, penetrating injury and psychological comorbidities may be identifiers of longer-term anxiety and depression following trauma critical care. Pain at one-year had a strong association and represents a modifiable target to improve psychological outcomes.

Average Age of Resuscitation Blood Products Is not Associated With In-Hospital Mortality Among Trauma Patients: A Retrospective Cohort Study

ABSTRACT Introduction Transfusion of packed red blood cells (PRBC) or low-titer group O whole blood (LTOWB) has become standard practice in trauma patients with significant blood loss. As blood ages, it undergoes metabolic and structural changes. This study aimed to test the association between age of PRBC/LTOWB and mortality among adult trauma patients. Materials and Methods This is a retrospective cohort study at an academic level one trauma center. Adult trauma patients who received at least one unit of PRBC or LTOWB within the first hour of arrival to the emergency department (ED) between January 2016 and December 2019 were included. The primary outcome was in-hospital mortality. Multivariable logistic regression models were used to test the associations between the mean age of PRBC and LTOWB units transfused during the initial 24 hours and in-hospital mortality. Results Of 388 patients included, 362 received PRBC and 121 received LTOWB. In-hospital mortality occurred in 31% of patients. The median (interquartile range) mean age of transfused PRBC units was 21 (16-26) days and LTOWB units was 11 (9-12) days. Neither age of PRBC nor LTOWB were found to be associated with in-hospital mortality: PRBC adjusted odds ratio (aOR) = 0.99 (95% CI 0.95 to 1.03) and LTOWB aOR = 1.12 (95% CI 0.88 to 1.41). Conclusions The mean age of LTOWB or PRBC units transfused during the first 24 hours after presenting to the ED for a traumatic injury was not found to be associated with in-hospital mortality.

Association of endotheliopathy with coagulofibrinolytic reactions and disseminated intravascular coagulation after trauma: a retrospective observational study

We carried out a retrospective observational investigation to explore the association of endotheliopathy with coagulofibrinolytic reactions and the progression of disseminated intravascular coagulation (DIC) in adult trauma patients. We measured syndecan-1 (SDC-1), an indicator of endotheliopathy, and biomarkers of coagulofibrinolysis in 100 trauma patients immediately transferred to Ehime University Hospital. We evaluated the correlations between the coagulofibrinolytic parameters and SDC-1. We also investigated the association between SDC-1 elevations and the development of DIC, and determined the discriminators of DIC development. The median SDC-1 concentration was 82.7 (43.5–178.1) ng/mL. DIC developed in 16 patients (16.0%), and SDC-1 concentrations were significantly higher in DIC patients than in non-DIC patients (218.8 [134.5–798.2] ng/mL vs. 67.2 [39.6–114.5] ng/mL, p < 0.001). Receiver operating characteristic curve analysis revealed that the circulating SDC-1 level effectively predicted the progression of DIC, with an area under the curve of 0.862 (95% confidence interval [CI], 0.789–0.936). The optimal cut-off value was determined to be 92.5 ng/mL, yielding a sensitivity of 100.0% and a specificity of 67.8% (p < 0.001). A simple logistic regression analysis showed that a circulating SDC-1 concentration of > 92.5 ng/mL was significantly correlated with DIC progression (odds ratio [OR], 31.67; 95%CI: 3.97–252.31, p = 0.001). Many coagulofibrinolytic parameters were significantly correlated with SDC-1. Estimating the discriminators of DIC development by the least absolute shrinkage and selection operator (LASSO) and elastic-net regression analysis identified markers of coagulofibrinolytic activation, such as thrombin-antithrombin complex (TAT) and tissue plasminogen activator (tPA). A multivariate logistic regression model using TAT, tPA, and SDC-1 demonstrated that TAT and tPA, but not SDC-1, were independent factors predicting the development of DIC (TAT per 10 µg/L: OR, 1.14, 95%CI: 1.05–1.24, p = 0.003; tPA per 100pg/mL: OR, 1.03, 95%CI: 1.01–1.05, p = 0.003; SDC-1 per 10ng/mL: OR, 1.00, 95%CI: 0.99–1.01, p = 0.973). Mediation analysis showed that SDC-1 elevation was predominantly associated with the development of DIC indirectly through the increase in TAT (proportion mediated = 96.1%, p < 0.001), while there was no significant indirect effect of SDC-1 elevation on the role of TAT elevation in DIC development was observed (p = 0.340). The primary pathogenesis of DIC in the acute phase of trauma is likely driven by coagulofibrinolytic activation. Endotheliopathy, as reflected by elevated circulating levels of SDC-1, is strongly associated with coagulofibrinolytic responses. Although endotheliopathy may contribute to the early development of DIC through coagulation activation, its role appears to be limited.

Feasibility of a Web-Based and Mobile-Supported Follow-Up Treatment Pathway for Adult Patients With Orthopedic Trauma in the Netherlands: Concurrent Mixed Methods Study.

Orthopedic trauma care encounters challenges in follow-up treatment due to limited patient information provision, treatment variation, and the chaotic settings in which it is provided. Additionally, pressure on health care resources is rising worldwide. In response, digital follow-up treatment pathways were implemented for patients with orthopedic trauma, aiming to optimize health care resource use and enhance patient experiences. We aim to assess digital follow-up treatment pathway feasibility from the patient's perspective and its impact on health care resource use. A concurrent mixed methods study was conducted parallel to implementation of digital follow-up treatment pathways in an urban level-2 trauma center. Inclusion criteria were (1) minimum age of 18 years, (2) an active web-based patient portal account, (3) ability to read and write in Dutch, and (4) no cognitive or preexisting motor impairment. Data were collected via electronic patient records, and surveys at three time points: day 1-3, 4-6 weeks, and 10-12 weeks after an initial emergency department visit. Semistructured interviews were performed at 10-12 weeks post injury. Anonymous data from a pre-existing database were used to compare health care resource use between the digital treatment pathways and traditional treatment. Quantitative data were reported descriptively. A thematic analysis was used for qualitative data. All outcomes were categorized according to the Bowen feasibility parameters: acceptability, demand, implementation, integration, and limited efficacy. Sixty-six patients were included for quantitative data collection. Survey response rates were 100% (66/66) at day 1-3, 92% (61/66) at 4-6 weeks, and 79% (52/66) at 10-12 weeks. For qualitative data collection, 15 semistructured interviews were performed. Patients reported median satisfaction scores of 7 (IQR 6-8) with digital treatment pathways and 8 (IQR 7-9) for overall treatment, reflecting positive experiences regarding functionality, actual and intended use, and treatment safety. Digital treatment pathways reduced secondary health care use, with fewer follow-up appointments by phone (median 0, IQR 0-0) versus the control group (median 1, IQR 0-1; P<.001). Consequently, fewer physicians were involved in follow-up treatment for the intervention group (median 2, IQR 1-2) than for the control group (median 2, IQR 1-3; P<.001). Fewer radiographs were performed for the intervention group (median 1, IQR 0-1) than for the control group (P=.01). Qualitative data highlighted positive experiences with functionalities, intended use, and safety, but also identified areas for improvement, including managing patient expectations, platform usability, and protocol adherence. Use of digital follow-up treatment pathways is feasible, yielding satisfactory patient experiences and reducing health care resource use. Recommendations for improvement include early stakeholder involvement, integration of specialized digital tools within electronic health record systems, and hands-on training for health care professionals. These insights can guide clinicians and policy makers in effectively integrating similar tools into clinical practice.

Resuscitation of adult shocked trauma patients using major haemorrhage protocol guided by viscoelastic haemostatic assays versus formulaic approach.

The resuscitation of trauma patients with critical bleeding may follow a formulaic approach using high ratios of blood components or a viscoelastic haemostatic assay (VHA) guided approach. The aim of this study was to compare the two strategies for resuscitation of shocked trauma patients. This was a registry-based cohort study including shocked trauma patients from two trauma centres-one practising a formulaic approach, with VHA unavailable during trauma resuscitation and the other practicing a VHA-guided resuscitation strategy. The primary outcome was the total units of blood components transfused in 24 h after adjusting for differences in baseline characteristics and time to death. Between 01 Jan 2020 and 31 Dec 2022, 152 eligible patients were categorised to the formulaic group and 40 to the VHA group. Prehospital times were longer in the formulaic group (2.0 vs. 1.4 h), and more patients in the VHA group (38% vs. 17%) were transfused prehospital blood components. Formulaic resuscitation was associated with significantly more blood components transfused (adjusted incidence rate ratio 1.5; 95%CI: 1.4-1.7, p < 0.001). Using a formulaic approach, patients were administered more red blood cells, plasma and platelets, but fewer cryoprecipitate. There was no significant association of the formulaic approach with in-hospital mortality (adjusted odds ratio 2.4; 95%CI: 0.7-8.0, p = 0.17). Given the cost and potential adverse effects of blood component transfusions, VHA-guided transfusion strategies present an attractive option, particularly among centres managing high volumes of shocked patients. Further trials, enrolling the population most likely to benefit from precision transfusion strategies, are indicated.