Patterns and Effects of Admission Hyperglycemia and Inflammatory Response in Trauma Patients: A Prospective Clinical Study.

BACKGROUND: The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients. METHODS: A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups [non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)]. The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson's correlation test and logistic regression analysis were also performed. RESULTS: During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p = 0.005), lower Trauma Injury Severity Score (p = 0.01) and lower GCS (p = 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%; p = 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39-33.68) points was found more in hyperglycemia than normoglycemia group (p = 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (r = 0.40, p = 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076-5.447, p = 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion. CONCLUSIONS: In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment. TRIAL REGISTRATION: This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016. https://clinicaltrials.gov/ct2/show/NCT02999386 .

Occult Pneumothorax in Patients Presenting with Blunt Chest Trauma: An Observational Analysis.

Background: We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Methods: Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Results: Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Conclusions: Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.

Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes.

BACKGROUND: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. METHODS: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12-24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). RESULTS: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). CONCLUSION: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.

Patterns, Management, and Outcome of Traumatic Femur Fracture: Exploring the Experience of the Only Level 1 Trauma Center in Qatar.

BACKGROUND: Femur is the most fractured long bone in the body that often necessitates surgical fixation; however, data on the impact of the mechanism of injury (MOI), age, and timing of intervention are lacking in our region of the Arab Middle East. We aimed to describe the patterns, management, and outcome of traumatic femoral shaft fractures. METHODS: A retrospective descriptive observational study was conducted for all trauma patients admitted with femoral shaft fractures between January 2012 and December 2015 at the only level 1 trauma center and tertiary hospital in the country. Data were analyzed and compared according to the time to intervention (intramedullary nailing; IMN), MOI, and age groups. Main outcomes included in-hospital complications and mortality. RESULTS: A total of 605 hospitalized cases with femur fractures were reviewed. The mean age was 30.7 ± 16.2 years. The majority of fractures were unilateral (96.7%) and 91% were closed fractures. Three-fourths of fractures were treated by reamed intramedullary nailing (rIMN), antegrade in 80%. The pyriform fossa nails were used in 71.6% while trochanteric entry nails were used in 28.4%. Forty-five (8.9%) fractures were treated with an external fixator, 37 (6.1%) had conservative management. Traffic-related injuries occurred more in patients aged 14-30 years, whereas fall-related injuries were significantly higher in patients aged 31-59. Thirty-one patients (7.8%) had rIMN in less than 6 h post-injury, 106 (25.5%) had rIMN after 6-12 h and 267 (66.8%) had rIMN after more than 12 h. The implant type, duration of surgery, DVT prophylaxis, in-hospital complications, and mortality were comparable among the three treatment groups. CONCLUSIONS: In our center, the frequency of femoral fracture was 11%, and it mainly affected severely injured young males due to traffic-related collisions or falls. Further multicenter studies are needed to set a consensus for an appropriate management of femur fracture based on the MOI, location, and timing of injury.

Postoperative complications of intestinal anastomosis after blunt abdominal trauma.

BACKGROUND: Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma. METHOD: We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications. RESULTS: A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications. CONCLUSION: Repair of traumatic blunt bowel injury remains a surgical challenge.