bims-heshmo 2021-05-09 papers

Am J Emerg Med. 2021 Apr 30. pii: S0735-6757(21)00369-7. [Epub ahead of print]48 170-176

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome.

Reynold Henry, Cameron Ghafil, Alice Piccinini, Panagiotis K Liasidis, Kazuhide Matsushima, Adam Golden, Meghan Lewis, Kenji Inaba, Aaron Strumwasser.

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management.
METHODS: The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared.
RESULTS: Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation.
CONCLUSION: Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.

Keywords: Acute respiratory distress syndrome; Extracorporeal membrane oxygenation; Trauma; Trauma quality improvement project

DOI: https://doi.org/10.1016/j.ajem.2021.04.083

Sci Rep. 2021 May 06. 11(1): 9703

A putative "chemokine switch" that regulates systemic acute inflammation in humans.

Nabil Azhar, Rami A Namas, Khalid Almahmoud, Akram Zaaqoq, Othman A Malak, Derek Barclay, Jinling Yin, Fayten El-Dehaibi, Andrew Abboud, Richard L Simmons, Ruben Zamora, Timothy R Billiar, Yoram Vodovotz.

Systemic inflammation is complex and likely drives clinical outcomes in critical illness such as that which ensues following severe injury. We obtained time course data on multiple inflammatory mediators in the blood of blunt trauma patients. Using dynamic network analyses, we inferred a novel control architecture for systemic inflammation: a three-way switch comprising the chemokines MCP-1/CCL2, MIG/CXCL9, and IP-10/CXCL10. To test this hypothesis, we created a logical model comprising this putative architecture. This model predicted key qualitative features of systemic inflammation in patient sub-groups, as well as the different patterns of hospital discharge of moderately vs. severely injured patients. Thus, a rational transition from data to data-driven models to mechanistic models suggests a novel, chemokine-based mechanism for control of acute inflammation in humans and points to the potential utility of this workflow in defining novel features in other complex diseases.

DOI: https://doi.org/10.1038/s41598-021-88936-8

Crit Care. 2021 05 05. 25(1): 165

Temporal patterns of organ dysfunction after severe trauma.

Jesper Eriksson, David Nelson, Anders Holst, Elisabeth Hellgren, Ola Friman, Anders Oldner.

BACKGROUND: Understanding temporal patterns of organ dysfunction (OD) may aid early recognition of complications after trauma and assist timing and modality of treatment strategies. Our aim was to analyse and characterise temporal patterns of OD in intensive care unit-admitted trauma patients.
METHODS: We used group-based trajectory modelling to identify temporal trajectories of OD after trauma. Modelling was based on the joint development of all six subdomains comprising the sequential organ failure assessment score measured daily during the first two weeks post trauma. Further, the time for trajectories to stabilise and transition to final group assignments were evaluated.
RESULTS: Six-hundred and sixty patients were included in the final model. Median age was 40 years, and median ISS was 26 (IQR 17-38). We identified five distinct trajectories of OD. Group 1, mild OD (n = 300), median ISS of 20 (IQR 14-27), had an early resolution of OD and a low mortality. Group 2, moderate OD (n = 135), and group 3, severe OD (n = 87), were fairly similar in admission characteristics and initial OD but differed in subsequent OD trajectories, the latter experiencing an extended course and higher mortality. In group 3, 56% of the patients developed sepsis as compared with 19% in group 2. Group 4, extreme OD (n = 40), received most blood transfusions, had the highest proportion of shock at admission and a median ISS of 41 (IQR 29-50). They experienced significant and sustained OD affecting all organ systems and a 28-day mortality of 30%. Group 5, traumatic brain injury with OD (n = 98), had the highest mortality of 35% and the shortest time to death for non-survivors, median 3.5 (IQR 2.4-4.8) days. Groups 1 and 5 reached their final group assignment early, > 80% of the patients within 48 h. In contrast, groups 2 and 3 had a prolonged time to final group assignment.
CONCLUSIONS: We identified five distinct trajectories of OD after severe trauma during the first two weeks post-trauma. Our findings underline the heterogeneous course after trauma and describe some potentially important clinical insights that are suggested by the groupings and temporal trajectories.

Keywords: Clustering; Critical care; Data modelling; Multiple organ dysfunction; Trauma

DOI: https://doi.org/10.1186/s13054-021-03586-6

OTA Int. 2021 Mar;4(1): e116

Polytrauma: update on basic science and clinical evidence.

Aaron Nauth, Frank Hildebrand, Heather Vallier, Timothy Moore, Luke Leenen, Todd Mckinley, Hans-Christoph Pape.

The management of multiply injured or severely injured patients is a complex and dynamic process. Timely and safe fracture fixation is a critical component of the multidisciplinary care that these patients require. Effective management of these patients, and their orthopaedic injuries, requires a strong understanding of the pathophysiology of the response to trauma and indicators of patient status, as well as an appreciation for the dynamic nature of these parameters. Substantial progress in both clinical and basic science research in this area has advanced our understanding of these concepts and our approach to management of the polytraumatized patient. This article summarizes a symposium on this topic that was presented by an international panel of experts at the 2020 Virtual Annual Meeting of the Orthopaedic Trauma Association.

Keywords: damage control surgery; early appropriate care; inflammation; neutrophil; polytrauma

DOI: https://doi.org/10.1097/OI9.0000000000000116

J Surg Res. 2021 Apr 30. pii: S0022-4804(21)00203-1. [Epub ahead of print]265 180-186

Prehospital blood pressure and lactate are early predictors of acute kidney injury after trauma.

Toru Nasu, Kentaro Ueda, Shuji Kawashima, Yuko Okishio, Kosei Kunitatsu, Yasuhiro Iwasaki, Seiya Kato.

BACKGROUND: The purpose of this study is to report the prevalence of acute kidney injury (AKI) after trauma in our center, describe the risk factors associated with AKI, and determine whether these risk factors help avoid AKI.
MATERIALS AND METHODS: We retrospectively analyzed the data which were prospectively collected from a single center trauma registry from January 2017 to December 2018. Patients who were <16 years of age, patients with burns, and patients with chronic kidney disease were excluded from the present study. AKI was defined according to the risk, injury, failure, loss of the kidney function, and end-stage kidney disease (RIFLE) classification from serum creatinine alone. A logistic regression analysis was performed to identify prehospital and early hospital risk factors for AKI.
RESULTS: There were 806 trauma patients recorded in the database. One hundred thirty cases were excluded based on the abovementioned exclusion criteria. Six hundred seventy-six patients were included in the analysis. The prevalence of AKI in the overall population was 14.5% including 10.5% of patients with stage R, 3.0% of patients with stage I and 1.0% with stage F. The incidence of AKI increased to 36.3%, 12.1% and 3.3% in the subgroup of patients with hemorrhagic shock. The multivariate analysis revealed that the minimum prehospital systolic blood pressure and arterial lactate level were independent predictors of AKI. The model showed good discrimination with an area under the receiver operating characteristic curve (AUC-ROC) of 0.867 and 0.852 in the prediction of AKI stage I or F. The cutoff values were ≤126 mmHg and ≥2.5 mmol/L, respectively.
CONCLUSION: These parameters showed good performance in the early prediction of AKI after trauma. They are associated with the early onset of AKI after trauma and may be an early predictor of the effects of treatment to prevent AKI.

Keywords: Acute kidney injury; Renal failure; Risk factors; Trauma

DOI: https://doi.org/10.1016/j.jss.2021.03.037

Prehosp Disaster Med. 2021 May 06. 1-7

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.

Nazlı Ozcan Yazlamaz, Engin Ozakin, Betül T Bastug, Evvah Karakilic, Filiz Baloglu Kaya, Nurdan Acar, Rusengul Koruk.

INTRODUCTION: Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose.
METHODS: This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded.
RESULTS: Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05).
CONCLUSION: The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

Keywords: computed tomography; flatness index of inferior vena cava; hypovolemic shock; multi-trauma

DOI: https://doi.org/10.1017/S1049023X21000418