The Severity of Injury and the Extent of Hemorrhagic Shock Predict the Incidence of Infectious Complications in Trauma Patients

Abstract : Background: : Trauma patients are at high risk of developing systemic inflammatory response syndrome (SIRS) and infections. The aim of this study was to evaluate the influence of the severity of injury and the extent of hemorrhagic shock at admission on the incidence of SIRS, infection and septic complications. Methods: : A total of 972 patients who had an injury severity score (ISS) of ≥ 17, survived more than 72 h, and were admitted to a level I trauma center within 24 h after trauma were included in this retrospective analysis. SIRS, sepsis and infection rates were measured in patientswith different severities of injury as assessed by ISS, or with various degrees of hemorrhagic shock according to ATLS® guidelines, andwere compared using both uni- and multivariate analysis. Results: : Infection rates and septic complications increase significantly (p < 0.001) with higher ISS. Severe hemorrhagic shock on admission is associated with a higher rate of infection (72.8%) and septic complications (43.2%) compared to mild hemorrhagic shock (43.4%, p < 0.001 and 21.7%, p < 0.001, respectively). Conclusion: : The severity of injury and the severity of hemorrhagic shock are risk factors for infectious and septic complications. Early diagnostic and adequate therapeutic work up with planned early "second look" interventions in such high-risk patients may help to reduce these common posttraumatic complication

The Targon®-PH Nail, an intramedullary fixator for unstable capital humeral fractures in the elderly patient: a retrospective study of 39 patients

The proximal humeral fracture occurs very often especially in elderly patients suffering from osteoporosis. Minimally invasive internal fixation with the Targon®-PH proximal humeral nail may lead to quick recovery. Thirty-nine patients with unstable humeral head fractures with two or four fragments were included into this study. The application of the humeral nail was achieved by deltoid split technique. Patients were followed-up clinically and radiologically including a Constant Score. The mean age was 72.9±3.3years of the male and 74.9±1.8years of the female patients. The subjective parameters of the Constant-Murley Score were significantly lowered in both the female and the male sample compared with the healthy side (female 30.0±1.1 vs. 33.7±0.7; P<0.05; and male 30.3±1.4 vs. 34.0±0.7; P<0.05). The objective parameters were significantly lowered also in both the female and the male sample compared with the non-operated side (female 34.5±2.0 vs. 45.2±1.1; P<0.001; and male 37.7±5.4 vs. 50.6±1.7; P<0.05). Even under lowered functionality, the subjective satisfaction was high; therefore, nailing of proximal humeral head fractures may represent a method for early functional recovery in elderly patient

Rare Cause of Dysphagy: Giant Polypoid Esophageal Well-Differentiated Liposarcoma

Liposarcoma represents one of the most frequent (10–20%) malignant mesenchymal tumors in the adult, affecting mostly the soft tissue of extremities, the trunk or the retroperitoneum. This tumor type occurs exceptionally rarely in the gastrointestinal tract with only few cases described in the literature. In this case we present a 73-year-old male patient who was admitted due to loss of weight, anorexia and postprandial emesis with dysphagy. Gastrographin esophagography failed to make precise diagnostics. CT scan of the upper gastrointestinal tract revealed a large esophageal tumor filling out the whole length of the esophagus. The tumor was removed by parasternocleidomastoidal approach with a stapler. Histopathological examination revealed a well-differentiated liposarcoma (grade I). Well-differentiated liposarcomas are characterised by amplified material of the 12q13-15 chromosomal region, present in the form of giant or ring chromosomes and leading to the overexpression of MDM2 and CDK4 genes. MDM2 and CDK4 proteins can be detected immunhistochemically, which was the case in the reported tumor. Overexpression of these proteins leads to suppression of tumor suppressor genes, leading to increased cell survival

The Time-related role of early pH, Base excess and Lactate for the Development in Sepsis in Polytrauma patients. An analysis using the IBM Watson Trauma Pathway Explorer

Triaging is essential for treating polytrauma patients. The Watson Trauma Pathway Explorer® represents an outcome prediction tool that prognosticates adverse events being Systemic Inflammatory Respiratory Syndrome and sepsis within 21 days and death within 72 h. We intended to compare the time- dependent role of pH, base excess (BE) and lactate for sepsis development in these patients. Retrospective data from 3653 patients were used. According to sepsis development, two groups were formed. pH, BE and lactate values were measured until up to 48 h after admission to our trauma bay. Differences in these three factors were analyzed between the two groups. Each factor (pH 2 or 4 mmol/L) was tested regarding its predictive quality, adjusted for ISS, age and gender. Threshold values at each timepoint were calculated. Between the two groups, differences in pH existed within the first 4 h, and for BE within the first six hours. Lactate values differed from the second hour onwards. pH ( 4 mmol/L; p = 0.006) at 4 h as well as BE at 6 h (< - 2 mmol/L; p = 0.022) were independent predictors for sepsis. Threshold values for pH were acidic for the first two hours, compared to BE within the first six hours. The insights indicating a time window of avoiding sepsis may allow referencing and promote timely measures while minimizing complications. Analysis of further surrogative parameters is required to warrant a more precise prediction

Sepsis in Polytrauma Patients: A Comparative Analysis of Damage Control versus Early Total Care regarding the Injury Severity Score using IBM Watson Pathway Explorer®

Sepsis presents a challenge in polytrauma patients care, where timing of procedures is crucial. The University Hospital of Zurich and IBM developed IBM Watson Trauma Pathway Explorer for predicting polytrauma complications such as SIRS, Sepsis, and early death within 72 hours. We intended to investigate the association of surgical treatment (Damage Control, DCS and Early Total Care, ETC) and injury severity (Injury Severity Score, ISS) with the development of sepsis. Data from 3653 patients was included. Patients were divided into two groups based on the type of surgical management (DCS, ETC) and injury severity (ISS ≤ 30, ISS > 30). The groups were assessed for the development of sepsis. Totally, 1242 patients had an ISS > 30 (34.6%), while 2374 had an ISS ≤ 30 (65.4%). DCS was conducted in 66.3% of cases versus 33.7% for ETC. DCS was performed in 73.5% of patients with an ISS > 30 and in 62.5% of patients with an ISS ≤ 30. ETC was performed in 26.5% for ISS > 30 and 37.5% for ISS ≤ 30. Sepsis was detected in 15% of the patients. 50.8% of sepsis cases had an initial ISS > 30. Regarding ETC, sepsis occurred in 9.6% of cases with ISS ≤ 30 and in 18.5% of cases with an ISS > 30. Regarding DCS, sepsis was detected in 12.3% with ISS ≤ 30 and in 23.4% with ISS > 30. Development of sepsis was associated with ISS > 30 (OR 2.21, p < 0.001) and DCS treatment (OR 1.45, p< 0.001). The findings confirm the association of sepsis development in polytrauma patients with a higher injury severity (ISS < 30). On the other hand, DCS does not generally imply a lower risk for this complication

Early Serum Procalcitonin, Interleukin-6, and 24-Hour Lactate Clearance: Useful Indicators of Septic Infections in Severely Traumatized Patients

Background: Elevated lactate and interleukin-6 (IL-6) levels were shown to correlate with mortality and multiple organ dysfunction in severely traumatized patients. The purpose of this study was to test whether an association exists between 24-hour lactate clearance, IL-6 and procalcitonin (PCT) levels, and the development of infectious complications in trauma patients. Methods: A total of 1757 consecutive trauma patients with an Injury Severity Score (ISS)>16 admitted over a 10-year period were retrospectively analyzed over a 21-day period. Exclusion criteria included death within 72h of admission (24.5%), late admission>12h after injury (16%), and age3days) was 10%. Patients with insufficient 24-hour lactate clearance had a high rate of overall mortality and infections. Elevated early serum procalcitonin on days 1 to 5 after trauma was strongly associated with the subsequent development of sepsis (p<0.01) but not with nonseptic infections. The kinetics of IL-6 were similar to those of PCT but did differentiate between infected and noninfected patients after day 5. Conclusions: This study demonstrates that elevated early procalcitonin and IL-6 levels and inadequate 24-hour lactate clearance help identify trauma patients who develop septic and nonseptic infectious complications. Definition of specific cutoff values and early monitoring of these parameters may help direct early surgical and antibiotic therapy and reduce infectious mortalit

Avulsion of the Hamstring Muscle Group: A Follow-Up of 6 Adult Non-Athletes with Early Operative Treatment: A Brief Report

Background: Complete proximal avulsions of the hamstring muscle group may cause significant morbidity and loss of function. These pelvis-near musculoskeletal injuries are mostly acquired during sports activities in a hip flexion and knee extension. Here we present a study group of 6 middle-aged to elderly patients suffering a complete proximal hamstring avulsion and following early surgical refixation. Early surgical refixation leads to complete resumption of the activities of daily life without loss of function. Materials and methods: The 6 patients (3 men and 3 women) included in this study had an average age of 59.07±4.47years at the time of injury. All of them suffered a complete avulsion of the hamstring muscle group. Surgical refixation was accomplished with the corkscrew anchor refixation system (Arthrex Manufacturing, Inc., Naples, FL). The cases were retrospectively analyzed using a hip joint evaluation system, the Harris Hip Score, and radiological follow-up by magnetic resonance imaging (MRI). Data are given as mean±SEM. Student's t-test was used for normal distribution of the data. Results: The mean follow-up time was 31.83±18.9months (range: 10-118months). All patients were rated not to have a significant difference in function compared with the uninjured side. None of the patients suffered any handicaps resulting from surgery or the injury. A complete consolidation in all patients was observed in the follow-up MRI. Conclusions: Early surgical intervention and subsequent therapy in a complete hamstring avulsion injury may prevent loss of hip-joint stability and prevent the sequalae of degradative hip or vertebral event

Anatomical Injury Clusters in Polytrauma Patients

Polytrauma is a major cause of death in young adults. The trial was to identify clusters of interlinked anatomical regions to improve strategical operational planning in the acute situation. A total of 2219 polytrauma patients with an ISS (Injury Severity Score) ≥ 16 and an age ≥ 16 years was included into this retrospective cohort study. Pearson’s correlation was performed amongst the AIS (Abbreviated Injury Scale) groups. The predictive quality was tested by ROC (Receiver Operating Curve) and their area under the curve. Independency was tested by the binary logistic regression , AIS ≥3 was taken as a significant injury. The analysis was conducted using IBM SPSS® 24.0. The highest predictive value was reached in the combination of thorax, abdomen, pelvis and spine injuries (ROC: abdomen for thorax 0.647, thorax for abdomen 0.621, pelvis for thorax 0.608, pelvis for abdomen 0.651, spine for thorax 0.617). The binary logistic regression revealed the anatomical regions thorax, abdomen pelvis and spine as per-mutative independent predictors for each other when a particular injury exceeded the AIS ≥3. The documented clusters of injuries in truncal trauma are crucial to define priorities in the polytrauma management

The Role of Lactate for Sepsis in Polytrauma Patients, a Time related Analysis using the IBM Watson Trauma Pathway Explorer®

The Watson Trauma Pathway Explorer® is an outcome prediction tool invented by the University Hospital of Zurich in collaboration with IBM®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis within 21 days and death within 72 h. The hypothesis was how lactate values woud be associated with the incidence of sepsis. Data from 3653 patients in an internal database, with ongoing implementation, served for analysis. Patients were split in two groups according to sepsis presence, and lactate values were measured at formerly defined time points from admission until 21 days after admission for both groups. Differences between groups were analyzed; time points with lactate as independent predictor for sepsis were identified. The predictive quality of lactate at 2 and 12 h after admission was evaluated. Threshold values between groups at all timepoints were calculated. Lactate levels differed from less than 2 h after admission until the end of the observation period (21 d). Lactate represented an independent predictor for sepsis from 12 to 48 h and 14 d to 21 d after admission relative to ISS levels. AUROC was poor at 2 and 12 h after admission with a slight improvement at the 12 h mark. Lactate levels decreased over time at a range of 2 [mmol/L] for 6-8 h after admission. These insights may allow for time-dependent referencing of lactate levels and anticipation of subsequent sepsis, although further parameters must be considered for a higher predictability