Geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone

Purpose: Age in severely injured patients has been increasing for decades. Older age is associated with increasing mortality. However, morbidity and mortality could possibly be reduced when accurate and aggressive treatment is provided. This study investigated age-related morbidity and mortality in polytrauma including age-related decisions in initial injury management and withdrawal of life-sustaining therapy (WLST). Methods: A 6.5-year prospective cohort study included consecutive severely injured trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, data on physiology, resuscitation, MODS/ARDS, and infectious complications were prospectively collected. Patients were divided into age subgroups (< 25, 25–49, 50–69, and ≥ 70 years) to make clinically relevant comparisons. Results: 391 patients (70% males) were included with median ISS of 29 (22–36), 95% sustained blunt injuries. There was no difference in injury severity, resuscitation, urgent surgeries, nor in ventilator days, ICU-LOS, and H-LOS between age groups. Adjusted odds of MODS, ARDS and infectious complications were similar between age groups. 47% of patients ≥ 70 years died, compared to 10–16% in other age groups (P < 0.001). WLST increased with older age, contributing to more than half of deaths ≥ 70 years. TBI was the most common cause of death and decision for treatment withdrawal in all age groups. Conclusions: Patients ≥ 70 years had higher mortality risk even though injury severity and complication rates were similar to other age groups. WLST increased with age with the vast majority due to brain injury. More than half of patients ≥ 70 years survived suggesting geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone

Physiology dictated treatment after severe trauma: timing is everything

INTRODUCTION: Damage control strategies in resuscitation and (fracture) surgery have become standard of care in the treatment of severely injured patients. It is suggested that damage control improves survival and decreases the incidence of organ failure. However, these strategies can possibly increase the risk of complications such as infections. Indication for damage control procedures is guided by physiological parameters, type of injury, and the surgeon's experience. We analyzed outcomes of severely injured patients who underwent emergency surgery. METHODS: Severely injured patients, admitted to a level-1 trauma center ICU from 2016 to 2020 who were in need of ventilator support and required immediate surgical intervention ( ≤24 h) were included. Demographics, treatment, and outcome parameters were analyzed. RESULTS: Hundred ninety-five patients were identified with a median ISS of 33 (IQR 25-38). Ninety-seven patients underwent immediate definitive surgery (ETC group), while 98 patients were first treated according to damage control principles with abbreviated surgery (DCS group). Although ISS was similar in both groups, DCS patients were younger, suffered from more severe truncal injuries, were more frequently in shock with more severe acidosis and coagulopathy, and received more blood products. ETC patients with traumatic brain injury needed more often a craniotomy. Seventy-four percent of DCS patients received definitive surgery in the second surgical procedure. There was no difference in mortality, nor any other outcome including organ failure and infections. CONCLUSIONS: When in severely injured patients treatment is dictated by physiology into either early definitive surgery or damage control with multiple shorter procedures stretched over several days combined with aggressive resuscitation with blood products, outcome is comparable in terms of complications

Demographic patterns and outcomes of patients in level I trauma centers in three international trauma systems

Introduction: Trauma systems were developed to improve the care for the injured. The designation and elements comprising these systems vary across countries. In this study, we have compared the demographic patterns and patient outcomes of Level I trauma centers in three international trauma systems. Methods: International multicenter prospective trauma registry-based study, performed in the University Medical Center Utrecht (UMCU), Utrecht, the Netherlands, John Hunter Hospital (JHH), Newcastle, Australia, and Harborview Medical Center (HMC), Seattle, the United States. Inclusion: patients =18 years, admitted in 2012, registered in the institutional trauma registry. Results: In UMCU, JHH, and HMC, respectively, 955, 1146, and 4049 patients met the inclusion criteria of which 300, 412, and 1375 patients with Injury Severity Score (ISS) > 15. Mean ISS was higher in JHH (13.5; p < 0.001) and HMC (13.4; p < 0.001) compared to UMCU (11.7). Unadjusted mortality: UMCU = 6.5 %, JHH = 3.6 %, and HMC = 4.8 %. Adjusted odds of death: JHH = 0.498 [95 % confidence interval (CI) 0.303-0.818] and HMC = 0.473 (95 % CI 0.325-0.690) compared to UMCU. HMC compared to JHH was 1.002 (95 % CI 0.664-1.514). Odds of death patients ISS > 15: JHH = 0.507 (95 % CI 0.300-0.857) and HMC = 0.451 (95 % CI 0.297-0.683) compared to UMCU. HMC = 0.931 (95 % CI 0.608-1.425) compared to JHH. TRISS analysis: UMCU: Ws = 0.787, Z = 1.31, M = 0.87; JHH, Ws = 3.583, Z = 6.7, M = 0.89; HMC, Ws = 3.902, Z = 14.6, M = 0.84. Conclusion: This study demonstrated substantial differences across centers in patient characteristics and mortality, mainly of neurological cause. Future research must investigate whether the outcome differences remain with nonfatal and long-term outcomes. Furthermore, we must focus on the development of a more valid method to compare systems

Inter-rater reliability of the Abbreviated Injury Scale scores in patients with severe head injury shows good inter-rater agreement but variability between countries. An inter-country comparison study

Introduction: Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers. Methods: A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC). Results: The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC. Conclusion: The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions

Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol

PURPOSE: To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. METHODS: All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality. RESULTS: A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]). CONCLUSION: Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury

Visualization of the inflammatory response to injury by neutrophil phenotype categories: Neutrophil phenotypes after trauma

PURPOSE: The risk of infectious complications after trauma is determined by the amount of injury-related tissue damage and the resulting inflammatory response. Recently, it became possible to measure the neutrophil phenotype in a point-of-care setting. The primary goal of this study was to investigate if immunophenotype categories based on visual recognition of neutrophil subsets are applicable to interpret the inflammatory response to trauma. The secondary goal was to correlate these immunophenotype categories with patient characteristics, injury severity and risk of complications. METHODS: A cohort study was conducted with patients presented at a level 1 trauma center with injuries of any severity, who routinely underwent neutrophil phenotyping. Data generated by automated point-of-care flow cytometry were prospectively gathered. Neutrophil phenotypes categories were defined by visual assessment of two-dimensional CD16/CD62L dot plots. All patients were categorized in one of the immunophenotype categories. Thereafter, the categories were validated by multidimensional analysis of neutrophil populations, using FlowSOM. All clinical parameters and endpoints were extracted from the trauma registry. RESULTS: The study population consisted of 380 patients. Seven distinct immunophenotype Categories (0-6) were defined, that consisted of different neutrophil populations as validated by FlowSOM. Injury severity scores and risk of infectious complications increased with ascending immunophenotype Categories 3-6. Injury severity was similarly low in Categories 0-2. CONCLUSION: The distribution of neutrophil subsets that were described in phenotype categories is easily recognizable for clinicians at the bedside. Even more, multidimensional analysis demonstrated these categories to be distinct subsets of neutrophils. Identification of trauma patients at risk for infectious complications by monitoring the immunophenotype category is a further improvement of personalized and point-of-care decision-making in trauma care

New automated analysis to monitor neutrophil function point-of-care in the intensive care unit after trauma

BACKGROUND: Patients often develop infectious complications after severe trauma. No biomarkers exist that enable early identification of patients who are at risk. Neutrophils are important immune cells that combat these infections by phagocytosis and killing of pathogens. Analysis of neutrophil function used to be laborious and was therefore not applicable in routine diagnostics. Hence, we developed a quick and point-of-care method to assess a critical part of neutrophil function, neutrophil phagosomal acidification. The aim of this study was to investigate whether this method was able to analyze neutrophil functionality in severely injured patients and whether a relation with the development of infectious complications was present. RESULTS: Fifteen severely injured patients (median ISS of 33) were included, of whom 6 developed an infection between day 4 and day 9 after trauma. The injury severity score did not significantly differ between patients who developed an infection and patients who did not (p = 0.529). Patients who developed an infection showed increased acidification immediately after trauma (p = 0.006) and after 3 days (p = 0.026) and a decrease in the days thereafter to levels in the lower normal range. In contrast, patients who did not develop infectious complications showed high-normal acidification within the first days and increased tasset to identify patients at risk for infections after trauma and to monitor the inflammatory state of these trauma patients. CONCLUSION: Neutrophil function can be measured in the ICU setting by rapid point-of-care analysis of phagosomal acidification. This analysis differed between trauma patients who developed infectious complications and trauma patients who did not. Therefore, this assay might prove a valuable asset to identify patients at risk for infections after trauma and to monitor the inflammatory state of these trauma patients. TRIAL REGISTRATION: Central Committee on Research Involving Human Subjects, NL43279.041.13. Registered 14 February 2014. https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm

Incidence of acute respiratory distress syndrome and associated mortality in a polytrauma population

Background: The incidence of acute respiratory distress syndrome (ARDS) has decreased in the last decade by improvement in trauma and critical care. However, it still remains a major cause of morbidity and mortality. This study investigated the current incidence and mortality of ARDS in polytrauma patients. Methods: A 4.5-year prospective study included consecutive trauma patients admitted to a level 1 trauma center intensive care unit (ICU). Isolated head injuries, drowning, asphyxiation, burns, and deaths <48 hours were excluded. Demographics, Injury Severity Score (ISS), physiologic parameters, resuscitation parameters, Denver Multiple Organ Failure scores, and ARDS data according to Berlin criteria were prospectively collected. Data are presented as median (IQR), and p<0.05 was considered significant. Results: 241 patients were included. The median age was 45 (27-59) years, 178 (74%) were male, the ISS was 29 (22-36), and 232 (96%) patients had blunt injuries. Thirty-one patients (13%) died. Fifteen patients (6%) developed ARDS. The median time to ARDS onset was 3 (2-5) days after injury. The median duration of ARDS was 2.5 (1-3.5) days. All patients with ARDS were male compared with 61% of non-ARDS patients (p=0.003). Patients who developed ARDS had higher ISS (30 vs. 25, p=0.01), lower Partial Pressure of Oxygen in arterial blood (PaO2) both in the emergency department and ICU, and higher Partial Pressure of Carbon Dioxide in arterial blood (PaCo2) in the ICU. Patients with ARDS needed more crystalloids <24 hours (8.7 vs. 6.8 L, p=0.03), received more fresh frozen plasma <24 hours (3 vs. 0 U, p=0.04), and more platelet <8 hours and <24 hours. Further, they stayed longer on the ventilator (11 vs. 2 days, p<0.001), longer in the ICU (12 vs. 3 days, p<0.001), and in the hospital (33 vs. 15 days, p=0.004). Patients with ARDS developed more often multiple organ dysfunction syndrome (40% vs. 3%, p<0.001) and died more often (20% vs. 3%, p=0.01). Only one patient with ARDS (7%) died of ARDS. Discussion: In this polytrauma population mortality was predominantly caused by brain injury. The incidence of ARDS was low; its presentation was only early onset, during a short time period, and accompanied by low mortality. Level of evidence: Level III

The association of patient and trauma characteristics with the health-related quality of life in a Dutch trauma population

BACKGROUND: It is suggested in literature to use the Health Related Quality of Life (HRQoL) as an outcome indicator for evaluating trauma centre performances. In order to predict HRQoL, characteristics that could be of influence on a predictive model should be identified. This study identifies patient and injury characteristics associated with the HRQoL in a general trauma population. METHODS: Retrospective study of trauma patients admitted from 1st January 2007 through 31th December 2012. Patients were aged ≥18 years and discharged alive from the level I trauma centre. A combined health survey (SF-36 and EQ-5D) was sent to all traceable patients. The subdomain outcomes and EQ-5D index value (EQ-5Di) were compared with the reference population. A linear regression analysis was performed to identify parameters associated parameters with the HRQoL outcome. RESULTS: A total of 1870 patients were included for analyses. Compared to the eligible population, included patients were significantly older, more severely injured, more often admitted in the ICU and had a longer admission duration. The SF-36 and EQ-5Di were significantly lower compared to the Dutch reference population. The variables age, Injury Severity Score, hospital length of stay, ICU length of stay, Revised Trauma Score, probability of survival, and severe injury to the head and extremities were associated with the HRQoL in the majority of the subdomains. DISCUSSION: In order to use HRQoL as an indicator for trauma centre performances, there should be a consensus of the ideal timing for the measurement of HRQoL post-injury and the appropriate HRQoL instrument. Furthermore, standardised HRQoL outcomes must be developed. CONCLUSION: This study revealed eight factors (described above) which could be used to predict the HRQoL in trauma patients