European Journal of Trauma and Emergency Surgery最新文献

Purpose: Hemorrhage is a significant cause of trauma-related death. Low-titer O-positive whole blood (LTOWB) is an alternative to component therapy (CT) [packed red blood cells (PRBC) and fresh frozen plasma (FFP)]. We evaluated if LTOWB reduces transfusion requirement or mortality.

Methods: Adult male trauma activations requiring uncrossmatched transfusion in the emergency department underwent nonblinded 24-hour block randomization to receive uncrossmatched LTOWB or CT in the emergency department (ED). Female patients, children, and known prisoners were excluded. If LTOWB was not available, CT was used. Primary outcome was transfusion requirement in patients surviving ≥ 24 h, with a subset analysis for patients undergoing hemorrhage control interventions (HCI). Dichotomous variables were evaluated with Chi-Square testing and continuous outcomes with Student's T-test.

Results: Overall, 199 patients were randomized (52 LTOWB, 147 CT); 36 patients (12 LTOWB, 24 CT) were excluded post-randomization for mortality within 24 h. The remaining 40 LTOWB and 123 CT patient cohorts had similar age, Glasgow Coma Scale, Injury Severity Score, heart rate, systolic blood pressure, and temperature. LTOWB patients received 1.4 ± 0.75 LTOWB units. LTOWB patients trended toward less transfusion (PRBC [3.8 ± 5.6 vs. 5.7 ± 6.2 units, p = 0.077], FFP [2.3 ± 3.8 vs. 3.5 ± 4.3 units, p = 0.088], and CRYO [0.13 ± 0.34 vs. 0.28 ± 0.68 units, p = 0.061]). Mortality was similar (LTOWB:10.2% [4/39] vs. CT:10.5% [13/123], p = 0.956). LTOWB patients undergoing HCI had less transfusion than CT patients (PRBC [3.9 ± 5.1 vs. 7.4 ± 7.2 units, p = 0.013]; in the HCI cohort the differences were even more pronounced when severe traumatic brain injury (TBI) deaths were excluded (PRBC [3.0 ± 3.6 vs. 7.4 ± 7.2 units, p < 0.001], FFP [2.1 ± 2.3 vs. 4.5 ± 5.2 units, p = 0.005]).

Conclusion: LTOWB is associated with reduced PRBC transfusion in patients undergoing HCI, and a trend toward decreased PRBC, FFP, and CRYO transfusion in all patients.

Trial registration: ClinicalTrials.gov (NCT05081063), posted 10/18/2021.

Background: This study developed a temperature-controlled transport preservation box for severed limb tissues using phase change material (PCM) as the main source to solve the problem of inconvenient preservation of trauma and severed tissues under emergency conditions. The goal of this study is to extend the time window for treatment of severed limb casualties and reduce the rate of disability and teratogenicity.

Methods: In this study, after successfully establishing an animal model of severed limb injury in rats, the rats were divided into experimental and control groups. The rats in the control group were given emergency bandaging of the severed limbs and then reimplanted, while the rats in the experimental group were placed in the PCM preservation box at 4℃, 8℃, 12℃, and 16℃, and then the limbs were reimplanted. The PCM was subjected to temperature control test, thermal conductivity test, and DSC test at the four test temperatures. The biochemical indices, histological HE and PTAH staining, and ultrastructural observation by transmission electron microscopy were performed at the four test temperatures to evaluate the damage and degeneration of the severed limb tissues.

Results and conclusions: The PCM had good material and thermal properties at the four test temperatures. The control group was more damaged than the test group in terms of biochemical factor expression, histologic degeneration, and ultrastructural changes. Considering the material and thermal properties, cell structure changes, and cell physiological status, the 8℃ test group shows excellent potential for clinical application and lays a solid foundation for further clinical application in the future.

Background: Management of the pleural space during and after SSRF is a matter of debate. Tube thoracostomy (TT), intra-operative pleural lavage (PL) and video assisted thoracoscopic surgery (VATS) use varies between surgeons. The purpose of this study is to describe differences in practice patterns of pleural space management (TT, PL, VATS) after SSRF at institutions with extensive experience in chest wall reconstruction.

Methods: Prospective data from adult SSRF patients at eight U.S. trauma centers between January 1, 2020 and September 1, 2022 was collected. Patients were managed according to institutional protocols. Outcome measures included hospital and ICU length of stay, 30-day readmission rate, infectious complications, and incidence of procedural re-intervention. Discrete variables are reported as median (IQR). P-values for continuous variables were obtained using Kruskal-Wallis, and for categorical variables using Chi-square.

Results: 273 patients from 8 centers were included. Median age was 60 (46-68), 70% were male, and 99% suffered blunt trauma. ISS was 17 (13-26), ranging from a low of 14 (10-19) to 26 (18-35) (p = 0.002). Median operative time was 2.5 (1.9-3.3) hours, with 5 (4-6) plates placed. VATS ranged from 2 to 78% at each center and PL ranged from 25 to 100% (p < 0.001). Almost all patients received TT. TT remained in place for 3 (2-4) days, few (2%) had any complication related to the TT, nor did they require drain replacement (7%) or reoperation (2%). ICU and hospital lengths of stay were 3 (2-6) and 8 (6-13) days (P < 0.001). Readmission rates were low (4%), and did not differ between centers.

Conclusion: At centers experienced in SSRF, there is variation in management of the pleural space. While ICU and hospital lengths of stay are different between centers, rates of reoperation and readmission are similar. Further study is needed to delineate optimal management of the pleural space after SSRF.

Introduction: Upper limb arterial trauma is associated with significant morbidity and functional impairment. Despite the critical role of timely intervention, we often encounter delayed presentations due to poor access to vascular surgery services and long travel times to the hospital. We analyzed the patterns of vascular injury encountered in our experience and gauged the impact of time delay and the nature of injury on our post-surgical outcomes.

Methods: We conducted a retrospective observational study of patients undergoing intervention for upper extremity arterial injuries at our vascular surgery department from 2020-2021. Patients presenting with a primary traumatic amputation or a non-salvageable ischemic hand defined according to the Rutherford classification of acute limb ischemia Grade III were excluded. Data regarding their demography, presentation, surgical interventions, and outcomes were gathered.

Results: 69 cases of upper extremity vascular trauma were included. The limb salvage rate was 94%, and the mortality rate was 0%. Higher Rutherford ischemia classes and more excellent MESS scores are associated with more excellent limb loss rates. Associated soft tissue injury also led to a higher rate of limb loss; while coexisting fractures or neurological injuries had no significant impact on salvage rates. Limb salvage was comparable to ligation and revascularization in brachial and radial injuries.

Conclusion: Upper-limb arterial injuries have a good prognosis if presented early to a vascular surgery centre. Our experience has yielded promising results with repair via native venous graft. Ligation of distal arteries is also possible owing to good collateral circulation.

Background: Proximal femoral nailing (PFN) is a preferred treatment for intertrochanteric femoral fractures in elderly patients due to its minimally invasive nature and early mobilisation benefits. However, mechanical complications such as implant failure, cutout, and reduction collapse remain significant challenges. This study introduces the targeted surgical score (TSS), a novel scoring system designed to predict and mitigate mechanical complications by evaluating modifiable surgical factors.

Methods: A retrospective analysis of 586 patients aged 65 and older treated with PFN between 2015 and 2022 was conducted. Data on demographic characteristics, fracture classifications, and surgical parameters were collected. Radiographic assessments included tip-apex distance (TAD) and lag screw positioning for implant placement quality, medial and anterior cortical support (MCS and ACS), and fracture alignment in both AP and lateral planes for reduction quality. Each parameter was scored, resulting in a cumulative TSS ranging from 0 to 8. Logistic regression and ROC curve analysis were performed to evaluate the predictive capacity of TSS.

Results: The average TSS was 4.06 ± 2.22 in the complication group and 6.14 ± 1.56 in the non-complication group (p < 0.001). A one-point increase in TSS was associated with a 44.9% reduction in complication risk (OR 0.551; p < 0.001). Independent risk factors included lag screw placement (non-central superior quadrants), inadequate cortical support in AP and lateral planes (MCS and ACS), and TAD (≥ 25 mm). The TSS demonstrated relatively good discriminative ability with an AUC of 0.768.

Conclusion: TSS may aid in predicting and mitigating mechanical complications while potentially guiding surgical applications in PFN, but further prospective multicentre validation is required. While certain parameters of TSS could be considered intraoperatively, its full implementation may be more practical for postoperative risk assessment.

Introduction: Considerable heterogeneity exists in the configuration and implementation maturity of trauma systems across European healthcare settings, and the opportunities for guideline-informed high-quality care varies considerably. Therefore, the European Society of Trauma and Emergency Surgery (ESTES), with its constituent national societies, has developed comprehensive consensus recommendations for care-context appropriate treatment of polytrauma patients in Europe, from the pre-hospital setting to the first surgical phase.

Methods: Adhering to the RAND/UCLA Appropriateness Method (RAM), ESTES conducted a three-round modified Delphi consensus. National society expert delegates assessed Grade of Recommendation (GoR) A and Good Clinical Practice Points (GPP) elements of the German Society of Trauma Surgery (DGU) "S3 guidelines for polytrauma/severe injury management" for appropriateness and implementability within their respective healthcare systems.

Results: In the first consensus round, 82 GoR A and 57 GPP recommendations were analysed. Of these, seven GPP were rephrased for clarity and four were removed due to redundancy or conflicting content. Consequently, 135 recommendations (82 GoR A and 53 GPP) remained, with 128 (77 GoR A and 51 GPP) deemed appropriate and necessary, and seven as uncertain due to expert disagreement.

Conclusion: These ESTES recommendations constitute the first cohesive Europe-wide framework for managing the polytrauma patient from the prehospital setting to the end of the first surgical phase. They serve as a foundational tool for the development of national guidelines, particularly in regions with evolving trauma systems, and promote alignment towards a uniform standard-of-care across Europe.

Purpose: Polytrauma patients in intensive care units (ICUs) face significant risks of morbidity and mortality, with nutrition playing a crucial role in mitigating energy deficits and complications such as multi-organ failure (MOF). This study aimed to evaluate adherence to enteral nutrition (EN) guidelines in ventilated polytrauma patients and explored correlations between EN timing and clinical outcomes.

Methods: A four-year retrospective (2019-2022) analysis of ventilated polytrauma patients (abbreviated injury scale > 2 in ≥ 2 body regions) admitted to a level 1 trauma centre. Collected data included demographics, injury characteristics and EN patterns. Early EN was defined as started withing 24 h. Statistical analysis assessed associations between EN, injury severity, and outcomes such as ICU length of stay (LOS), mortality, and MOF.

Results: Of 182 patients (median age 41, male 77%, median ISS 34), 41 did not receive EN and were excluded. Of the remaining 141, 64% received early EN, with a median time to EN of 17.8 h. Early EN was associated with reduced ICU LOS (p = 0.016). Delaying EN initiation correlated with higher injury severity (p = 0.008). Each one-hour delay to EN increased MOF odds by 1.47% (OR: 1.0147, p = 0.07). EN interruptions (> 6 h) occurred 354 times.

Conclusion: Investigations into current EN standards in polytrauma patients demonstrated an average of 2.5 interruptions in EN exceeding 6 h per patient, with 40% not fed within 24 h. Combined with inconsistent dietician input, this offers room for improvement as early EN is associated with better outcomes, with a reduced ICU LOS established through this study.

This letter to the Editor is a comment to the report by Kahana N et al. evaluating the diagnostic properties of the Alvarado and AIR score in pregnant women. The AIR score is not correctly described. This has important implications for the interpretation of the study results.

Background: The aim of this research is to access the expression of adenosine A3 receptor (ADORA3) and nitric oxide synthase 3 (NOS3) genes and serum levels of ADORA3 and NOS3 in patients with multiple trauma with hemorrhagic shock.

Materials and methods: The study was performed at Erciyes University between November 2022 and March 2024, in a prospective and controlled manner. Patients diagnosed with traumatic hemorrhagic shock and requiring transfusion in the emergency department were selected as the patients group. Gene expressions were analyzed using quantitative real-time PCR analysis in total RNA samples and serum levels of NOS3 and ADORA3 were detected using ELISA measurements.

Results: In patients with multiple trauma, adenosine A3 receptor (ADORA3) gene expression showed a significant increase at discharge when compared to healthy controls (P < 0.05). However, serum levels of ADORA3 showed significant decreases at all stages (i.e. at admission, at 24 h, and at discharge) of patients. Although no significant changes were detected in NOS3 gene expression, marked decreases in serum NOS3 levels were observed at admission and at 24 h in multiple trauma patients (P < 0.05). ADORA3 and NOS3 gene expressions were found to be significantly diminished in nonsurvivors.

Conclusion: The study emphasizes the importance of ADORA3 and NOS3 gene expressions in influencing shock progression in multiple trauma patients. The increase in ADORA3 gene expression may play a role in restoring vascular reactivity after traumatic shock. Decreased serum NOS3 and ADORA3 levels can contribute to the shock progression in the pathophysiology of multiple trauma.