Global changes in mortality rates in polytrauma patients admitted to the ICU-a systematic review

Background Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients admitted to the intensive care unit (ICU). Moreover, changes in trauma mechanism over time and differences between continents were analyzed. Main body A systematic review of literature on all-cause mortality in polytrauma patients admitted to ICU was conducted. All-cause and cause-specific mortality rates were extracted as well as trauma mechanism of each patient. Poisson regression analysis was used to model time trends in all-cause and cause-specific mortality. Thirty studies, which reported mortality rates for 82,272 patients, were included and showed a decrease of 1.8% (95% CI 1.6-2.0%) in all-cause mortality per year since 1966. The relative contribution of brain injury-related death has increased over the years, whereas the relative contribution of death due to multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, and sepsis decreased. MODS was the most common cause of death in North America, and brain-related death was the most common in Asia, South America, and Europe. Penetrating trauma was most often reported in North America and Asia. Conclusions All-cause mortality in polytrauma patients admitted to the ICU has decreased over the last decades. A shift from MODS to brain-related death was observed. Geographical differences in cause-specific mortality were present, which may provide region-specific learning possibilities resulting in improvement of global trauma care

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Clinical treatment strategies and experimental studies in polytrauma

This thesis describes the clinical treatment of polytrauma patients and the underlying pathophysiological mechanisms causing injury-induced inflammatory response. Even though the treatment of polytrauma patients has improved over the years, trauma is still the leading cause of death worldwide.Classically, the epidemiology of traumatic deaths was described as a trimodal distribution (immediate deaths, early hospital deaths, late deaths). With improved trauma care, we have revaluated this and discovered that the classical trimodal death distribution nowadays is much more skewed towards early deaths. Death by exsanguination has become as frequent as lethal head injuries, but the incidence of fatal multiple organ failure is lower than reported earlier. Although the introduction of the damage control surgery strategy in the 1990s has decreased the mortality of trauma patients, morbidity rates have increased, leading to new challenges such as abdominal compartment syndrome (ACS). Recognition, treatment and prevention have decreased the incidence of ACS in the last decade. Further, attenuation of the deadly ACS to a less deleterious intra-abdominal hypertension is considered a success of the last decade in trauma and critical care. The increased popularity of damage control surgery and increased ACS recognition has led to a raised incidence of abdomens left open after surgery. Even though opening an abdomen in ACS is life-saving, morbidity rates are high. Several techniques have been described for temporary closure of an open abdomen. To date, however, there is no perfect method to cover an open abdomen. A special group of polytrauma patients are those with open pelvic fractures. Up to half of them die due to pelvic injuries (acute hemorrhage and late sepsis).The open nature of the injury increases the chances of significant fracture site uncontrolled bleeding and pelvic contamination. Historically, faecal diversion has been regarded as an obligatory procedure to minimize infectious complications. With novel wound management techniques available we suggest that a diverting stoma is only warranted in patients with transmural rectal lacerations and/or extensive soft tissue injuries in the perineum. Trauma leads to immune activation after which immune mediators and inflammatory cells are released. This immune response promotes wound healing and increases the protection against bacteria. Sometimes, however, the immune system will become hyperactive, inducing (extra) tissue damage leading to organ failure.In the second part of this thesis experimental studies are described investigating the role of neutrophils (white blood cell important for the immune response) on the development of an inflammatory response after several types of trauma (hemorrhagic shock (HS), mechanical ventilation, septic shock). It was noted that HS alone had minimal effect on the development of systemic inflammation. Mechanical ventilation (alone or in combination with HS) is the determining factor in inducing an inflammatory response. These results emphasize the importance of local (pulmonary) ventilation-induced damage in the development of systemic inflammation. Further, experiments have shown that HS and septic shock show different neutrophil phenotypes in the circulation, suggesting theyinduce an inflammatory response via at least a partially different pathwa

Diagnosis and treatment of talar dislocation fractures illustrated by 3 case reports and review of literature

Introduction: Talar fractures are a rare type of fractures (less than 1%). They are difficult to treat and outcome is often complicated by arthritis and avascular necrosis. In this article three cases are presented with different types of dislocated talar neck fractures. Anatomy of the talus, treatment, outcome and follow up of these fractures are discussed. Further, review of literature and guidelines for treatment and follow up for dislocated talar neck fractures are discussed. Discussion: The risk of developing arthritis or avascular necrosis of the talus after dislocated talar neck fractures depends on the initial trauma with vascular compromise due to dislocation of the talus. The modified Hawkins classification gives an insight in the risk of developing avascular necrosis. During follow up the Hawkins sign can be an indication of a vital talus. To diagnose avascular necrosis MRI is the only suitable diagnostic tool. Conclusion: Reduction of a dislocated talar fracture is a medical emergency in an effort to reduce the vascular compromise of the talus. Definitive fixation can be delayed but should be performed by an experienced surgeon to achieve an optimal reconstruction of the talar surface. Long-term follow up is important to evaluate signs of arthritis and avascular necrosis

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

PurposeTo 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.MethodsAll 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.ResultsA 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]).ConclusionApproximately 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

Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Purpose The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I-2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.Clinical epidemiolog

Long-term follow-up after rib fixation for flail chest and multiple rib fractures

Purpose Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures. Methods All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone. Results Of the 864 patients admitted with >= 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal. Conclusions We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.Clinical epidemiolog

Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial

Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between Mar