European Journal of Trauma and Emergency Surgery最新文献

Purpose: One of the important causes of morbidity and mortality in the world is traumatic brain injury (TBI), which is a process that triggers damaging mechanisms such as inflammation, oxidative stress, and apoptosis. The results of current pharmaceutical methods are not enough, and researches into new therapy modalities are needed. This study aimed to evaluate the neuroprotective effects of Urapidil (Ura), which is an alpha-1 adrenergic receptor antagonist with serotonergic activity, in a TBI model and investigating signaling pathways like high mobility group box 1 (HMGB1), BCL2-interacting protein 3-like (BNIP3L), and hypoxia-inducible factor-1 alpha (HIF1α).

Methods: Thirty-two rats were divided into four groups: control, TBI, TBI + Ura_0.5 (0.5 mg/kg), TBI + Ura₅ (5 mg/kg) groups. Tissue integrity and expressions of tumor necrosis factor-alpha (TNF-α), caspase-3 (Cas-3), tyrosine hydroxylase (TH), HIF1α, BNIP3L, and HMGB1 were assessed. Ura's biochemical oxidative stress indicators were also assessed.

Results: Ura treatment at both doses, significantly decreased histopathological findings, BNIP3L, HMGB1, and HIF1α expressions, TNF-α, Cas-3, TH immunexpressions, and TOS and OSI levels, and elevated TAS levels compared to TBI group. These results show that Ura regulates molecular pathways related to TBI, including neuroinflammation, mitochondrial dysfunction, and hypoxia.

Conclusion: Ura shows promising tissue-protective effects in TBI by targeting inflammation, oxidative stress, and apoptosis. This study provides a new perspective on the need for further development of Ura for therapeutic use.

Introduction: Neuromonitoring plays an integral part of neurocritical care decision making in patients with acute brain injury, as it facilitates detection of physiological changes with the goal to mitigate further neurological deterioration and prevent secondary brain injury. There are increasing efforts being made to understand how the care of neurocritical patients is delivered globally, but there is little information about the use of neuroimaging and neuromonitoring in Lower Middle-Income Country. We aimed to investigate the availability of different neuromonitoring tools in intensive care units in Mexico.

Methods: This was a prospective observational survey focused on gathering current neuroimaging and neuromonitoring practices in Mexico. We used a web-based survey using Google Forms (©2024 Google) to query practicing intensive care physicians in all states in Mexico. The questionnaire consisted of two sections with 27 questions.

Results: A total of 66 responses were included in the final analysis, that represent 65% of the states in Mexico (21 out of 32 states). Most ICUs reported not having access to a neurointensivist (79%, 52/66). Computed Tomography (CT) was available around the clock in 97% of ICUs (64/66), while CT angiography (CTA) was available 24/7 in 20% of ICUs (13/66) with only daytime availability in 35% (23/66) of ICUs. The most available invasive monitor in Mexico was the jugular bulb oximetry, which was available in 62% of ICUs (41/66). One third of ICUs (34%, 29/66) reported the use of invasive ICP monitoring. Of those, ventriculostomy was the most commonly use type of catheter, followed by the intraparenchymal ICP monitor, epidural and subdural ICP monitors. Brain tissue oxygen monitor (pbtO₂₎ was only available in less than third of ICUs, 14% (5/66). Only 62% percent (41/66) of hospitals had 24/7 access to a neurosurgeon.

Conclusion: The availability of neuroimaging and neuromonitoring is limited in ICUs in Mexico, despite a sizeable proportion of neurocritical care patients. This may be in part driven by resources constraints, as well as lack of neurocritical care and neurosurgical access in many centers. There is an unmet need for recruiting and training in neurocritical care and neurosurgery.

Research in trauma care is indispensable for advancing the field of trauma surgery and healthcare delivery. The outcomes of such research have the potential to save lives, reduce disability, and optimise healthcare resource allocation. This chapters summarises key types of research in trauma care, highlights funding opportunities, and outlines future research priorities in Europe.

Purpose: Geriatric patients with a hip fracture are at risk for adverse outcomes after surgery. A pilot study showed the feasibility of assessing of systemic inflammation in these patients through neutrophil analysis. The aim of this study was to correlate neutrophil categories to clinical outcomes in a larger cohort.

Methods: In this prospective cohort study, blood samples were taken from geriatric patients with a hip fracture directly after trauma and healthy older people serving as controls. Neutrophil phenotypes were categorized (0-6 from no inflammation to severe inflammation) and correlated to clinical outcomes.

Results: In total, 289 patients (median age 82) and 45 age matched controls were included. Severe infections occurred in 8% of the patients and 9% died within 30 days. Patients displayed all neutrophil categories (0-6), while controls showed categories 0,1,3. A newly identified neutrophil category had higher leukocyte counts and CRP, with trends toward increased infections and mortality. Among patients receiving palliative care, 30-day mortality was 50% in categories 0-1 and 83% in higher categories.

Conclusion: Neutrophil categories offer a feasible method to assess systemic inflammation and may assist in shared decision-making for palliative care. The data are consistent with the hypothesis that patients in category 0-1 are deemed fit for surgery, when other risk factors are absent. However, further research should investigate the quality-of-life of patients still alive after 30 days in order to determine whether immune profiling is of added clinical value in decision making regarding traumatic hip fractures in geriatric patients.

Purpose: The anterior interosseous nerve (AIN) is susceptible to injury during forearm surgery, particularly open reduction and internal fixation (ORIF) of radius fractures. This study aimed to analyze the anatomical relationships between the AIN and the radius to identify regions most vulnerable to iatrogenic injury.

Methods: A cadaveric study was conducted on ten fresh, non-embalmed forearms. Standardized dissections were performed to assess the course of the AIN, its motor branches, and their proximity to bony landmarks. Measurements were taken using a graduated ruler, with reference to the radius, the bi-epicondylar and bi-styloid lines.

Results: The AIN originated, on average, 13 mm from the radius, initially separated from the bone by the flexor digitorum profundus and flexor pollicis longus. The first branch to the flexor pollicis longus emerged at an average of 8 mm from the radius, marking the start of the nerve's close contact with the bone. The highest risk zone for AIN injury was identified at the junction of the proximal and middle thirds of the forearm.

Conclusion: The AIN and its motor branches exhibit significant anatomical variability but consistently demonstrate proximity to the radius at the proximal-middle third junction. To minimize iatrogenic injury, care should be taken when exposing the anterior radius, particularly by avoiding excessive traction or deep retractor placement in this region.

Purpose: Lymphopenia is associated with adverse clinical outcome in trauma, but no immunomonitoring method is established to identify patients at risk. Absolute lymphocyte count (ALC) represents a promising biomarker and may support clinical decision-making in the intensive care unit (ICU). This study examined the temporal patterns of ALC in severely injured patients and their correlation with clinical outcomes.

Methods: 38 severely injured patients with an Injury Severity Score (ISS) of 18 and greater were enrolled. Blood samples were collected on admission and after 8, 24 and 48 h and 5 and 10 days. 38 healthy volunteers served as controls. Patients were classified into four groups after 48 h based on their dynamic ALC: persistent lymphopenia (PL), rapidly decreasing (RD), slowly rising (SR) and normal fluctuation (NF). The groups were compared regarding physical performative outcome - defined as unfavorable when patients died or new functional disability necessitated long term care, in-hospital mortality, ICU length of stay (LOS), and incidence of multi-organ dysfunction syndrome (MODS).

Results: A significant reduction in ALC was observed in all patients over 10 days when compared to healthy volunteers, with all patients trending towards a recovery of their ALC after 10 days. PL and RD were associated with an unfavorable physical performative outcome, increased in-hospital mortality, ICU LOS and incidence of MODS.

Conclusion: The dynamic course of ALC represents a cheap and clinically implementable approach for immunomonitoring within 48 h in severely injured patients. The ALC dynamic may early identify severely injured patients at risk, thus facilitating more informed clinical decision-making.

Introduction: Correction of a prolonged CK-TEG R-time requires the administration of fresh frozen plasma (FFP). However, the relationship between the volume required to normalize the R-time and the patient's plasma volume (PV_i) has not been investigated. This study investigated the impact of the PV_i on the amount of FFP needed to normalize the R-time.

Methods: 30 patients receiving FFP to normalize their R-times were analyzed from the standpoint of sex distribution and R-time response to the administration of FFP. PV_i was calculated as blood volume minus hematocrit (Hct). Data included age, sex, height, weight, Hct, changes in PV_i (ΔPV) and ΔR-time within 24 h of administration of FFP. Responders were divided in high and low based on a decrease in R-time > 5 min after the administration of FFP. Data presented as mean ± SD and median with interquartile range were analyzed with parametric and non-parametric tests as applicable.

Results: Females had a smaller PV_i (2.6 ± 0.4 vs. 3.7 ± 0.6; p < 0.05), yielding a larger ΔPV (14.0 ± 7.0% vs. 10.6 ± 5.4% from 353 ± 141 vs. 381 ± 174 ml of FFP, respectively; p > 0.05). They required less FFP for a ΔR-time of one minute (80 ± 59 vs. 116 ± 64 ml; p > 0.05). There was a significant difference in the number of high responders between females and males (7/11 vs. 5/19; p < 0.05). The R-time response did not differ with respect to age, and the PV_i before transfusions but it was affected by the amount FFP and the resulting ΔPV (483 ± 173 vs. 296 ± 99 and 17.0% ± 6.6% vs. 8.6% ± 3.0%; p < 0.05).

Conclusions: We conclude that: 1) The amount of FFP required to normalize the R-time is lower than the recommended dose of 10-20 ml/kg: 2) 6.8 ml/kg of FFP, corresponding to an initial administration of two units of FFP (~ 500 ml) will provide an increase of 15.6% in the concentration of coagulation factors sufficient to normalize the R-time: 3) The assessment of PV_i is the key element required to estimate the volume of FFP needed to correct a prolonged R-time.

One of the most common manifestations of cardiac injury because of trauma is myocardial contusion. Today, the blurred definition and wide range of nonspecific clinical presentations led to absence in consensus of diagnostic pathways and criteria. Currently, the marker of cardiac injury measured at clinical level is troponin and instrumental diagnostic tool is ECG. The patients with elevated troponin level after the chest trauma should be suspected to have myocardial contusion as cardiogenic shock or arrhythmia might take place as a complication. The release of DAMPs after the trauma has been observed as a part of inflammatory response to it. HMGB1 protein and histone levels were found to be elevated in patients with trauma and associated to recruit the inflammation. In this review the potential of these molecules to be used as diagnostic markers of myocardial contusion is discussed. Moreover, the obstacles for implementing DAMPS to clinical protocols and future research directions are included.

Introduction: Low-profile dual plating techniques have gained popularity for diaphyseal clavicula fractures due to their potential to reduce soft tissue irritation. Intramedullary nailing is also an established surgical option for treatment of diaphyseal clavicle fractures. The present study therefore aimed to evaluate whether a 2 × 2.0 mm dual plating system can achieve biomechanical performance comparable to intramedullary nailing while reducing implant-related complications.

Methodology: Twelve paired human cadaveric clavicles with simulated unstable diaphyseal shaft fractures AO/OTA 15.2 C were stabilized via elastic nailing (Group 1) or dual plating using a superior and an anterior 2.0 mm plate (Group 2). Specimens underwent biomechanical testing with initial quasistatic superior-inferior and anterior-posterior bending, followed by cyclic superior-inferior loading to failure. Interfragmentary movements were monitored by optical motion tracking.

Results: Dual plating demonstrated significantly higher initial construct stiffness in all bending directions and a reduced neutral zone compared to intramedullary nailing (p ≤ 0.016). In addition, fracture displacement amplitudes over all cycles were significantly higher in Group 1 versus Group 2 (p = 0.002). The number of cycles required to reach the test endpoint at a 45 mm displacement did not differ significantly between the groups (p = 0.160), with Group 1 averaging 24,420 cycles (SD ± 3,615) and Group 2 averaging 28,232 cycles (SD ± 5,417).

Conclusion: Low-profile dual plating may offer improved initial stability of midshaft clavicle fractures without compromising their long-term performance, making it a promising alternative to elastic nailing. In selected patients with simpler unstable midshaft clavicle fractures, 2 × 2.0 mm dual plating may offer effective biomechanical stability.

Purpose: Rib fractures, common in blunt chest trauma, affect 10% of trauma patients and are linked to increased pulmonary morbidity and mortality. This study applies machine learning to identify predictors of complications in conservatively managed rib fracture patients.

Methods: Data from the 2013-2021 American College of Surgeons' Trauma Quality Improvement Program included adults (≥ 18 years) with isolated thoracic injury from blunt trauma and conservatively managed rib fractures. Variables included demographics, comorbidities, injury severity, injury patterns, admission vitals, and complications. The permutation importance method identified top predictors of in-hospital complications.

Results: Of 321,355 rib fracture patients, 183,303 (57.0%) had isolated rib fractures. The five primary predictors of complications in all rib fracture patients were age, Glasgow Coma Scale (GCS) on admission, Revised Cardiac Risk Index (RCRI), chronic obstructive pulmonary disease (COPD), and alcohol use disorder. For isolated rib fracture patients, the same predictors applied but in the order: age, RCRI, GCS, COPD, and alcohol use disorder. A logistic regression model using these predictors showed acceptable discriminative capacity for complications in the full cohort [AUC (95% CI): 0.72 (0.71-0.72)] and isolated rib fracture patients [AUC (95% CI): 0.72 (0.71-0.73)].

Conclusion: Cardiovascular risk, age, and level of consciousness on admission are key predictors of complications in conservatively managed rib fracture patients. Though complication rates remain low overall, elderly patients with multiple cardiovascular risk factors face a heightened risk of deterioration.