Base excess determined within one hour of admission predicts mortality in patients with severe pelvic fractures and severe hemorrhagic shock

Abstract : Background: : Unstable pelvic ring fractures with exsanguinating hemorrhages are rare but potentially lifethreatening injuries. The aim of this retrospective study was to evaluate whether early changes in acid- base parameters predict mortality of patients with severe pelvic trauma and hemorrhagic shock. Methods: : Data for 50 patients with pelvic ring disruption and severe hemorrhage were analyzed retrospectively. In all patients, the pelvic ring was temporarily stabilized by C-clamp. Patients with ongoing bleeding underwent laparotomy with extra and/or intraperitoneal pelvic packing, as required. Base excess, lactate, and pH were measured upon admission and at 1, 2, 3, 4, 6, 8, and 12 h postadmission. Patients were categorized as early survivors (surviving the first 12 h after admission) and nonsurvivors. Statistical analysis was performed by Mann-Whitney test; significance was assumed at p < 0.05. Receiver operating characteristic curves were generated for early mortality from each acid-base variable. Results: : Sixteen patients (32%) were nonsurvivors due to hemorrhagic shock (n = 13) or severe traumatic brain injury (n = 3). Thirty-four patients were early survivors. Base excess, lactate, and pH significantly discriminated between early survivors and nonsurvivors. Base excess determined 1 h after admission discriminated most strongly, with an area under the receiver operating characteristic curve of 0.915 (95% confidence interval, 0.836-0.993; p < 0.001). Conclusion: : Base excess, lactate, and pH discriminate early survivors from nonsurvivors suffering from severe pelvic trauma and hemorrhagic shock. Base excess measured 1 h after admission best predicted early mortality following pelvic trauma with concomitant hemorrhag

Settlement Is at the End-Common Trauma Scores Require a Critical Reassessment Due to the Possible Dynamics of Traumatic Brain Injuries in Patients' Clinical Course.

Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIShead (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis

Implementing Peace Agreements: Supporting the Transition from the Negotiation Table to Reality

To date, conversations on best practice in mediation support and peace promotion have tended to focus primarily on efforts to bring about the signing of a peace agreement. Yet the challenges in realizing the often ambitious provisions of a peace agreement are considerable. Implementation begins at the negotiating table, when the parties discuss how to ensure the realization of their commitments, and remains a challenge years after the signing of a peace agreement. This paper aims to make a modest contribution to the discussion on how mediation support actors and peacebuilders can contribute to quality implementation. Doing so, it draws from the discussions during the Mediation Support Network (MSN) meetings 2018 in London and 2019 in Bogota where participants and guests discussed the dynamics of implementation, identifying opportunities and challenges, and explored how third parties can play a constructive role in promoting effective implementation.Bis heute tendieren Diskussionen über bewährte Methoden in der Mediationsunterstützung und der Friedensförderung dazu, sich auf Bemühungen zu fokussieren, welche auf das Unterzeichnen eines Friedensabkommens abzielen. Dennoch lohnt es sich auch, die Herausforderungen der Umsetzung von oftmals ambitionierten Bestimmungen eines Friedensabkommens näher zu betrachten. Die Implementierung beginnt am Verhandlungstisch, wo die Parteien diskutieren, wie die Umsetzung ihrer Zusicherungen sichergestellt werden kann. Die damit verbundene Herausforderung bleibt auch Jahre nach der Unterzeichnung des Friedensabkommens bestehen. Diese Publikation zielt darauf ab, einen bescheidenen Beitrag dazu zu leisten, wie Akteure der Mediationsunterstützung und Peacebuilder zu einer qualitativen Umsetzung beitragen können. Sie basiert sich dabei auf Diskussionen, die während den Mediation Support Network (MSN) Sitzungen 2018 in London und 2019 in Bogota stattgefunden haben, wo Teilnehmende und Gäste die Dynamiken der Implementierung diskutiert, Chancen und Herausforderungen identifiziert und zudem untersucht haben, wie Drittparteien eine konstruktive Rolle in der Förderung effektiver Implementierung spielen können.ISSN:2413-202

Beyond the Tracks? Reflections on Multitrack Approaches to Peace Processes

This report presents insights and analyses on peace processes that involve multiple societal levels or “tracks” ranging from high-level diplomatic negotiations to community-based peacebuilding. It presents the insights from a retreat with practitioners involved in dialogue, negotiation or mediation initiatives in Colombia, Myanmar, Syria, Ukraine and Zimbabwe, as well as representatives from the Folke Bernadotte Academy, swisspeace, the Centre for Humanitarian Dialogue and the CSS. The report aims to frame existing debates around multitrack approaches and serves as practical guidance for contemporary peace processes and practitioners.Dieser Bericht enthält Erkenntnisse und Analysen zu Friedensprozessen, die mehrere gesellschaftliche Ebenen oder „Tracks“ betreffen. Diese können von hochrangigen diplomatischen Verhandlungen bis hin zu lokalen Friedensinitiativen reichen. Der Bericht beruht auf Erkenntnissen eines Retreats mit Praktikern, die an Dialog -, Verhandlungs - oder Mediationsinitiativen in Kolumbien, Myanmar, Syrien, der Ukraine und Simbabwe beteiligt sind, sowie Vertretern der Folke Bernadotte Academy, von swisspeace, des Centre for Humanitarian Dialogue und des CSS. Der Bericht zielt darauf ab, bestehende Debatten auf multi-track Ansätze auszurichten und dient als praktische Anleitung für bestehende Friedensprozesse und Praktiker

C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption

BACKGROUND: Exsanguinating hemorrhage is the major cause of death in patients with pelvic ring disruption. AIMS: The aim of this study was to document outcomes after the stabilization of pelvic ring injuries by a C-clamp and control of hemorrhage by pelvic packing. Physiological parameters were tested as prognostic factors. SETTING AND DESIGN: This was a retrospective study at a level I trauma center. The study period was from January 1996 to December 2007. MATERIALS AND METHODS: Fifty patients with pelvic ring disruption and hemorrhagic shock were analyzed. The pelvic rings were fixed by a C-clamp, and patients with ongoing hemorrhage underwent laparotomy and extra- and/or intra-peritoneal pelvic packing. Clinical parameters (heart rate, mean arterial pressure) and physiological parameters (lactate levels, hemoglobin, hematocrit) were documented at admission and at different time points during the initial treatment (1, 2, 3, 4, 6, 8, and 12h after admission). RESULTS: Within 12 h of admission, 16 patients died (nonsurvivors) due to hemorrhagic shock (n=13) or head injuries (n=3). In this group, 12 patients underwent laparotomy with pelvic packing. Thirty-four patients survived the first 12 h (early survivors) after fixation by a C-clamp and additional packing in 23 patients. Four of these patients died 12.3±7.1 days later due to multiple organ failure (n=3) or severe head injury (n=1). The blood lactate level at admission was significantly higher in the group of nonsurvivors (7.2±0.8 mmol/L) compared to the early survivors (4.3±0.5 mmol/L, P<0.05). While hemoglobin values improved within the first 2 h in nonsurvivors, lactate levels continued to increase. CONCLUSION: Pelvic packing in addition to the C-clamp fixation effectively controls severe hemorrhage in patients with pelvic ring disruption. Early sequential measurements of blood lactate levels can be used to estimate the severity of shock and the response to the shock treatment

Secondary angio-embolization after emergent pelvic stabilization and pelvic packing is a safe option for patients with persistent hemorrhage from unstable pelvic ring injuries

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated. Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization. Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury. Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm