Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study

Background: Early hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality. Methods: A 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation and outcomes were prospectively collected. Results: Four hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified. Conclusions: Despite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED

Dilemma of crystalloid resuscitation in non-exsanguinating polytrauma: What is too much?

Background: Aggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes. Methods: A 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0-5, 5-10, 10-15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value 5 L compared with the group 0-5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3-4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03). Discussion: Polytrauma patients received large amounts of crystalloids with few FFPs 15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs. Level of evidence: Level 3. Study type: Population-based cohort study

Rapid accelerations of Antarctic Peninsula outlet glaciers driven by surface melt

Atmospheric warming is increasing surface melting across the Antarctic Peninsula, with unknown impacts upon glacier dynamics at the ice-bed interface. Using high-resolution satellite-derived ice velocity data, optical satellite imagery and regional climate modelling, we show that drainage of surface meltwater to the bed of outlet glaciers on the Antarctic Peninsula occurs and triggers rapid ice flow accelerations (up to 100% greater than the annual mean). This provides a mechanism for this sector of the Antarctic Ice Sheet to respond rapidly to atmospheric warming. We infer that delivery of water to the bed transiently increases basal water pressure, enhancing basal motion, but efficient evacuation subsequently reduces water pressure causing ice deceleration. Currently, melt events are sporadic, so efficient subglacial drainage cannot be maintained, resulting in multiple short-lived (< 6 day) ice flow perturbations. Future increases in meltwater could induce a shift in glacier dynamic regime, characterised by seasonal-scale ice flow variations

Українська піснетворчість північно-західного Надкубання

Folk singing tradition of the Kuban especially its Ukrainian folk archive create one of the most representative spheres of the musical art of the Russian Federation. We made special expeditions in1990-1996 in order to collect Ukrainian folk songs of various genres in the historical living og Ukrainians in ex-Chornomorya lend. The collected materials can be divided into three types: epic, lyric, ritual. Among those types we figure out such genres: narratives, quazi-narratives, ritual songs of the calendar cycle, ritual songs of the family cycle, lyrical songs. All the collected texts are described in this article with the goal to show that they are functioning as a part of Ukrainian folk tradition within Russian cultural territory. The choir and individual singing are described as a sing of the state of singing performing tradition in contemporary Chornomorya. Authors give a detailed description of the particular performers, their styles and repertoire. Such deep research of the singing tradition of the Ukrainians living in Kuban gives the chance to look at these materials not only as cultural event but also like at the event social and historical meaning

Early correction of base deficit decreases late mortality in polytrauma

Introduction: Physiology-driven resuscitation has become the standard of care in severely injured patients. This has resulted in a decrease in acute deaths by hemorrhagic shock. With increased survival from hemorrhage, focus shifts towards death later during hospital stay. This population based cohort study investigated the association of initial physiology derangement correction and (late) mortality. Methods: Consecutive polytrauma patients aged > 15 years with deranged physiology who were admitted to a level-1 trauma center intensive care unit (ICU) from 2015 to 2021, and requiring surgical intervention 7 days (late). Results: Two hundred thirty-five patients were included with a median age of 44 years (70% male), and Injury Severity Score (ISS) of 33. Mortality rate was 16% (71% due to traumatic brain injury (TBI)). Median time to death was 11 (6–17) days; 71% died > 7 days after injury. There was no difference between the single base deficit measurements in the emergency department(ED), operating room (OR), nor ICU between patients who died and those who did not. However, patients who later died were more acidotic at 24 and 48 h after arrival, and had a higher AUC of BD in time. This was independent of time and cause of death. Conclusion: Early physiological restoration based on serial BD measurements in the first 48 h after injury decreases late mortality

Attenuation of MODS-related and ARDS-related mortality makes infectious complications a remaining challenge in the severely injured

Introduction: The recent decrease in multiple organ dysfunction syndrome (MODS)-associated and adult respiratory distress syndrome (ARDS)-associated mortality could be considered a success of improvements in trauma care. However, the incidence of infections remains high in patients with polytrauma, with high morbidity and hospital resources usage. Infectious complications might be a residual effect of the decrease in MODS-related/ARDS-related mortality. This study investigated the current incidence of infectious complications in polytrauma. Methods: A 5.5-year prospective population-based cohort study included consecutive severely injured patients (age >15) admitted to a (Level-1) trauma center intensive care unit (ICU) who survived >48 hours. Demographics, physiologic and resuscitation parameters, multiple organ failure and ARDS scores, and infectious complications (pneumonia, fracture-related infection, meningitis, infections related to blood, wound, and urinary tract) were prospectively collected. Data are presented as median (IQR), p<0.05 was considered significant. Results: 297 patients (216 (73%) men) were included with median age of 46 (27-60) years, median Injury Severity Score was 29 (22-35), 96% sustained blunt injuries. 44 patients (15%) died. One patient (2%) died of MODS and 1 died of ARDS. 134 patients (45%) developed 201 infectious complications. Pneumonia was the most common complication (50%). There was no difference in physiologic parameters on arrival in emergency department and ICU between patients with and without infectious complications. Patients who later developed infections underwent more often a laparotomy (32% vs 18%, p=0.009), had more often pelvic fractures (38% vs 25%, p=0.02), and received more blood products <8 hours. They had more often MODS (25% vs 13%, p=0.005), stayed longer on the ventilator (10 (5-15) vs 5 (2-8) days, p<0.001), longer in ICU (11 (6-17) vs 6 (3-10) days, p<0.001), and in hospital (30 (20-44) vs 16 (10-24) days, p<0.001). There was however no difference in mortality (12% vs 17%, p=0.41) between both groups. Conclusion: 45% of patients developed infectious complications. These patients had similar mortality rates, but used more hospital resources. With low MODS-related and ARDS-related mortality, infections might be a residual effect, and are one of the remaining challenges in the treatment of patients with polytrauma. Level of evidence: Level 3. Study type: Population-based cohort study

Is chest imaging relevant in diagnosing acute respiratory distress syndrome in polytrauma patients? A population-based cohort study

PURPOSE: The definition of acute respiratory distress syndrome (ARDS) has often been modified with Berlin criteria being the most recent. ARDS is divided into three categories based on the degree of hypoxemia using PaO 2/FiO 2 ratio. Radiological findings are standardized with bilateral diffuse pulmonary infiltrates present on chest imaging. This study investigated whether chest imaging is relevant in diagnosing ARDS in polytrauma patients. METHODS: The 5-year prospective study included consecutive trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, ISS, physiologic parameters, resuscitation parameters, and ARDS data were prospectively collected. Acute hypoxic respiratory failure (AHRF) was categorized as Berlin criteria without bilateral diffuse pulmonary infiltrates on imaging. Data are presented as median (IQR), p < 0.05 was considered significant. RESULTS: 267 patients were included. Median age was 45 (26-59) years, 199 (75%) males, ISS was 29 (22-35), 258 (97%) patients had blunt injuries. Thirty-five (13%) patients died. 192 (72%) patients developed AHRF. AHRF patients were older, more often male, had higher ISS, needed more crystalloids and blood products than patients without AHRF. They developed more pulmonary complications, stayed longer on the ventilator, in ICU and in hospital, and died more often. Fifteen (6%) patients developed ARDS. There was no difference in outcome between ARDS and AHRF patients. CONCLUSIONS: Many patients developed AHRF and only a few ARDS. Patients with similar hypoxemia without bilateral diffuse pulmonary infiltrates had comparable outcome as ARDS patients. Chest imaging did not influence the outcome. Large-scale multicenter validation of ARDS criteria is warranted to investigate whether diffuse bilateral pulmonary infiltrates on chest imaging could be omitted as a mandatory part of the definition of ARDS in polytrauma patients

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