The predictive value of the Kampala Trauma Score (KTS) in the outcome of multi-traumatic patients compared to the estimated Injury Severity Score (eISS).

PURPOSE: The classification of trauma patients in emergency settings is a constant challenge for physicians. However, the Injury Severity Score (ISS) is widely used in developed countries, it may be difficult to perform it in low- and middle-income countries (LMIC). As a result, the ISS was calculated using an estimated methodology that has been described and validated in a high-income country previously. In addition, a simple scoring tool called the Kampala Trauma Score (KTS) was developed recently. The aim of this study was to compare the diagnostic accuracy of KTS and estimated ISS (eISS) in order to achieve a valid and efficient scoring system in our resource-limited setting. METHODS: We conducted a cross-sectional study between December 2020 and March 2021 among the multi-trauma patients who presented at the emergency department of Imam Reza hospital, Tabriz, Iran. After obtaining informed consent, all data including age, sex, mechanism of injury, GCS, KTS, eISS, final outcome (including death, morbidity, or discharge), and length of hospital stay were collected and entered into SPSS version 27.0 and analyzed. RESULTS: 381 multi-trauma patients participated in the study. The area under the curve for prediction of mortality (AUC) for KTS was 0.923 (95%CI: 0.888-0.958) and for eISS was 0.910 (95% CI: 0.877-0.944). For the mortality, comparing the AUCs by the Delong test, the difference between areas was not statistically significant (p value = 0.356). The diagnostic odds ratio (DOR) for the prediction of mortality KTS and eISS were 28.27 and 32.00, respectively. CONCLUSION: In our study population, the KTS has similar accuracy in predicting the mortality of multi-trauma patients compared to the eISS.

Diagnostic and Prognostic Potential of Exosomal Cytokines IL-6 and IL-10 in Polytrauma Patients.

Trauma remains a leading cause of morbidity and mortality. Polytraumatized patients need a precise, early diagnosis to avoid complications such as multiorgan failure or sepsis. Inflammatory cytokines, commonly used for diagnosis, have a short half-life, which limits their efficacy as a diagnostic or prognostic marker. In this study, we hypothesized that cytokines in exosomes could have a longer half-life, and therefore could be used as diagnostic and prognostic markers in polytrauma patients. Plasma samples from polytraumatized patients (ISS ≥ 16, n = 18) were collected in the emergency room (ER) 1, 2, 3 and 5 days after trauma. Plasma-exosomes were isolated via size exclusion chromatography from polytraumatized patients and healthy volunteers (n = 10). The systemic and exosomal concentrations of interleukin (IL)-6, IL-10, IL-1ß and TNF were measured using high-sensitive ELISAs. To investigate the diagnostic and prognostic potential of exosomal cytokines, data were correlated with clinical outcome parameters (injury severity, ventilation time, time in ICU and survival) documented in the patients' electronic records. Despite the use of high-sensitive ELISAs, IL-1ß and TNF alpha were not detected in exosomes. IL-6 and IL-10 were detectable in polytraumatized patient exosomes at all time points. A decrease over time of both systemic and exosomal IL-6 concentrations was observed. Furthermore, exosomal and systemic IL-6 concentrations moderately correlated (r = 0.63). Exosomal IL-6 in the ER moderately correlated with the Injury Severity Score (ISS) (mean 35.5 ± 11.5) (r = 0.45) and was associated with non-survival in polytrauma patients (p < 0.05). In contrast to IL-6, no correlation between systemic and exosomal IL-10 concentrations was found. Exosomal IL-10 concentrations remained unchanged throughout the observation time, whereas systemic IL-10 concentrations peaked in the ER and were significantly reduced after 24 h. Data from this study support our hypothesis that some cytokines (IL-10), but not all (IL-6), are detectable in exosomes significantly longer than they are in plasma. This might indicate that they are protected from degradation. Although we did not find a correlation between IL-10 exosomal concentration and patient outcome, our data confirm that exosomal cytokines are of interest as potential diagnostic and prognostic markers in polytrauma patients, and require further detailed research.

[Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]. / Okkulter und residueller Hämatothorax nach Thoraxtrauma ­ Empfehlungen der interdisziplinären Arbeitsgruppe Thoraxtrauma der Sektion NIS der Deutschen Gesellschaft für Unfallchirurgie (DGU) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT).

The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.

[Pathophysiology, Diagnostics and Therapy of Pulmonary Contusion - Recommendations of the Interdisciplinary Group on Thoracic Trauma of the Section NIS of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT)]. / Pathophysiologie, Diagnostik und Therapie der Lungenkontusion ­ Empfehlungen der interdisziplinären Arbeitsgruppe der Sektion NIS der DGU und DGT zur Thoraxtraumaversorgung.

Pulmonary contusion usually occurs in combination with other injuries and is indicative of a high level of force. Especially in multiply injured patients, pulmonary contusions are frequently detected. The injury is characterised by dynamic development, which might result in difficulties in recognising the actual extent of the injury at an early stage. Subsequently, correct classification of the extent of injury and appropriate initiation of therapeutic steps are essential to achieve the best possible outcome. The main goal of all therapeutic measures is to preserve lung function as best as possible and to avoid associated complications such as the development of pneumonia or Acute Respiratory Distress Syndrome (ARDS).The present report from the interdisciplinary working group "Chest Trauma" of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT) includes an extensive literature review on the background, diagnosis and treatment of pulmonary contusion. Without exception, papers with a low level of evidence were included due to the lack of studies with large cohorts of patients or randomised controlled studies. Thus, the recommendations given in the present article correspond to a consensus of the aforementioned interdisciplinary working group.Computed tomography (CT) of the chest is recommended for initial diagnosis; the extent of pulmonary contusion correlates with the incidence and severity of complications. A conventional chest X-ray may initially underestimate the injury, but is useful during short-term follow-up.Therapy for pulmonary contusion is multimodal and symptom-based. In particular, intensive care therapy with lung-protective ventilation and patient positioning are key factors of treatment. In addition to invasive ventilation, non-invasive ventilation should be considered if the patient's comorbidities and compliance allows this. Furthermore, depending on the extent of the lung injury and the general patient's condition, ECMO therapy may be considered as an ultima ratio. In particular, this should only be performed at specialised hospitals, which is why patient assignment or anticipation of early transfer of the patient should be anticipated at an early time during the course.

[Initial Treatment of Multiple Trauma].

Head trauma is a common neurosurgical complication. It is encountered daily at neurosurgical outpatient departments or after-hour emergency outpatient departments. In addition, most cases of patients with trauma transported by ambulance involve those with head trauma. Head trauma is a common and unavoidable neurosurgical injury. In case of a head injury, the neurosurgeon should verify the level of consciousness and perform a proper neurological examination. A head computed tomography should be performed immediately for any abnormalities. However, currently, severe trauma is often complicated by head trauma and various other injuries. When medical examinations and treatments focus only on head trauma, preventable trauma death cannot be avoided. Functional prognosis due to secondary brain injury may be exacerbated. This article presents a standardized procedure for the initial care of patients with multiple trauma and head injuries.

Predictive Values of sTREM-1, PCT and CRP for Multiple Trauma-Induced Acute Respiratory Distress Syndrome Complicated with Pulmonary Infection.

BACKGROUND: The aim is to investigate the predictive values of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), procalcitonin (PCT) and C-reactive protein (CRP) for multiple trauma-induced acute respiratory distress syndrome (ARDS) complicated with pulmonary infection. METHODS: One hundred and twelve patients with multiple trauma-induced ARDS admitted from April 2019 to April 2021 were selected and divided into infection group (n = 49) and non-infection group (n = 63). Their general data and laboratory test indicators were compared. Multivariate logistic regression analysis was utilized to identify the influencing factors for concurrent pulmonary infection. Pearson's analysis was employed to analyze the correlations of sTREM-1, PCT, and CRP with other influencing factors. The predictive values of sTREM-1, PCT, and CRP for pulmonary infection in ARDS patients were evaluated using receiver operating characteristic (ROC) curves. Based on the cutoff values, the patients were assigned to low-, medium-, and high-risk groups. Survival curves were plotted by Kaplan-Meier method to compare the 28-day survival. RESULTS: The infection group had significantly higher injury severity score (ISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, sTREM-1, PCT, CRP, and macrophage inflammatory protein (MIP)-1α, longer tracheal intubation time and intensive care unit (ICU) stay time, and lower oxygenation index than those of the non-infection group (p < 0.05). Multivariate logistic regression analysis revealed that increased ISS, APACHE II score, as well as elevated blood concentrations of sTREM-1, PCT, CRP and MIP-1α were risk factors for concurrent pulmonary infection (p < 0.05). sTREM-1, PCT, and CRP were positively correlated with ISS, APACHE II score, and MIP-1α (p < 0.05). The areas under ROC curves of sTREM-1, PCT, CRP, and their combination were 0.795, 0.784, 0.756, and 0.860, respectively (p < 0.001), indicating high predictive values. The survival rate of the high-risk group (46.43%) was significantly lower than those of the low-risk group (89.58%) and medium-risk group (75.00%) (p < 0.05). CONCLUSIONS: sTREM-1, PCT, and CRP are highly expressed in serum of patients with multiple trauma-induced ARDS complicated with pulmonary infection. The combined detection of three markers is of high predictive value.

Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®.

INTRODUCTION: Traumatic diaphragmatic rupture is a rare injury in the severely injured patient and is most commonly caused by blunt mechanisms. However, penetrating mechanisms can also dominate depending on regional and local factors. Traumatic diaphragmatic rupture is difficult to diagnose and can be missed by primary diagnostic procedures in the resuscitation room. Initially not life-threatening, diaphragmatic ruptures can cause severe sequelae in the patient's long-term course if untreated. The objective of this study was to assess the epidemiology, associated injuries, and outcome of traumatic diaphragmatic ruptures based on a multicenter registry-based analysis. MATERIAL AND METHODS: Data from all patients enrolled in the TraumaRegister DGU® between 2009 and 2018 were retrospectively analyzed. That multicenter database collects data on prehospital, intra-hospital emergency, intensive care therapy, and discharge. Included were all patients with a Maximum Abbreviated Injury Scale (MAIS) score of 3 or above and patients with a MAIS score of 2 who died or were treated in the intensive care unit, for whom standard documentation forms had been completed and who had sustained a diaphragmatic rupture (AIS score of 3 or 4). The data has been analyzed using descriptive statistics and chi-square test or Mann-Whitney U test. RESULTS: Of the 199,933 patients included in the study population, 687 patients (0.3%) had a diaphragmatic rupture. Of these, 71.9% were male. The mean patient age was 46.1 years. Blunt trauma accounted for 73.5% of the injuries. Primary diagnosis was established in the resuscitation room in 93.1% of the patients. Multislice helical computed tomography (MSCT) was performed in 82.7% of the cases. Rib fractures were detected in 60.7% of the patients with a diaphragmatic injury. Patients with diaphragmatic rupture had a higher mean Injury Severity Score (ISS) than patients without a diaphragmatic injury (32.9 vs. 18.6) and a higher mortality rate (13.2% vs. 9.0%). CONCLUSIONS: In contrast to the literature, primary diagnostic procedures in the resuscitation room detected relevant diaphragmatic ruptures (AIS ≥ 3) in more than 90% of the patients in our study population. In addition, complex associated serial rib fractures are an important diagnostic indicator.

[Implications of prehospital estimation of trauma patients for the treatment pathway-An evaluation of the TraumaRegister DGU®]. / Implikationen der prähospitalen Einschätzung des Traumapatienten auf den Behandlungsverlauf ­ Eine Auswertung aus dem TraumaRegister DGU®.

BACKGROUND: In the prehospital acute treatment phase of severely injured patients, the stabilization of the vital parameters is paramount. The rapid and precise assessment of the injuries by the emergency physician is crucial for the initial treatment and the selection of the receiving hospital. OBJECTIVE: The aim of this study was to determine whether the prehospital emergency medical assessment has an influence on prehospital and emergency room treatment. MATERIAL AND METHODS: Data from the TraumaRegister DGU® between 2015 and 2019 in Germany were evaluated. The prehospital emergency medical assessment of the injury pattern and severity was recorded using the emergency physician protocol and compared with the in-hospital documented diagnoses using the abbreviated injury scale. RESULTS: A total of 47,838 patients with an average injury severity score (ISS) of 18,7 points (SD 12.3) were included. In summary, 127,739 injured body regions were documented in the hospitals. Of these, a total of 87,921 were correctly suspected by the emergency physician Thus, 39,818 injured body regions were not properly documented. In 42,530 cases a region of the body was suspected to be injured without the suspicion being confirmed in the hospital. Traumatic brain injuries and facial injuries were mostly overdiagnosed (13.5% and 14.7%, respectively documented by an emergency physician while the diagnosis was not confirmed in-hospital). Chest injuries were underdocumented (17.3% missed by an emergency physician while the diagnosis was finally confirmed in-hospital). The total mortality of all groups was very close to the expected mortality calculated with the revised injury severity classification II(RISC II)-score (12.0% vs. 11.3%). CONCLUSION: In the prehospital care of severely injured patients, the overall injury severity is often correctly recorded by the emergency physician and correlates well with the derived treatment, the selection of the receiving hospital as well as the clinical course and the patient outcome; however, the assessment of injuries of individual body regions seems to be challenging in the prehospital setting.

[Is polytrauma treatment in deficit in the aG-DRG system?] / Ist die Polytraumaversorgung im aG-DRG-System defizitär?

BACKGROUND: The interdisciplinary care of severely injured patients is staff and resource intensive. Since the introduction of the G­DRG system in Germany in 2003, most studies have identified a financial deficit in the care of severely injured patients. The aim of this study was to analyze the effects of the new aG-DRG system introduced in 2020 on cost recovery in the treatment of severely injured patients. For the first time, the costs for organization, certification and documentation as well as the costs for non-seriously injured shock room patients were included. METHODS: All patients who were treated in the surgical shock room of the emergency department of the Leipzig University Hospital in 2017 were included. For the analysis, the cost model according to Pape et al. was extended by the module organization, documentation and certification and for the first time the costs for overtriaged patients were considered. A cost calculation was performed for the years 2017-2020 as well a comparison with the respective earnings. RESULTS: A total of 834 patients were treated in the shock room and 258 severely injured patients were divided into 3 groups: ISS 9-15 + ICU (n 72; ∅ ISS 11.9; costs per patient 14,715 €),ISS ≥ 16 (n 186; ∅ ISS 27.7; costs per patient 30,718 €) and DRG polytrauma (n 59; ∅ ISS 32.4; costs per patient 26,102 €). CONCLUSION: Polytrauma care under the aG-DRG 2020 is in deficit. Overall, in 2020 a deficit of 5858 € per severely injured patient resulted.

Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System.

Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the 'Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries' (UPPS) score for easier prediction of GUI in the emergency setting.

Utility of ETCO2 to predict hemorrhagic shock in multiple trauma patients.

BACKGROUND: For identifying hemorrhagic shock in trauma patients, some objective data are needed. The use of base excess (BE) and lactate values have been originated. In this study, it was aimed to determine the usability of end tidal carbon dioxide (ETCO2) in patients with multiple trauma for recognizing hemorrhagic shock. METHODS: Patients who were admitted to the emergency department between June 2019 and February 2020 with highenergy multiple trauma were included in the study. ETCO2 and BE values were measured. Correlation coefficients were calculated to determine correlations between ETCO2 and BE levels. RESULTS: One hundred and twenty-two patients were included in the study. Eighty-nine (73%) were men and 33 (27%) were women, and the mean age of the study population was 38.70 ± 19.18. The mortality rate was 14.8% in the study population. The correlation between ETCO2 and BE values was significant (r: 0.27) and in the same range in the Bland-Altmann analysis. ETCO2 levels above 35 were specific for stage 1 hemorrhagic shock. ETCO2 levels below 30 were sensitive for stage 2 and 3 hemorrhagic shocks and when the levels were measured below 22 it was found specific for stage 4 shock. The specificity increased to 99% at levels below 18. The sensitivity for ETCO2 values below 22 for predicting mortality was 33.33%, the specificity was 89.42%, the positive predictive value was 35.29% and the negative predictive value was 88.57%. The sensitivity for BE values below -10 for predicting mortality was 50%, the specificity was 93.27%, the positive predictive value was 56.25% and the negative predictive value was 91.51%.

[Treatment of victims with mine-explosive injuries]. / Rezul'taty lecheniya ranenykh s minno-vzryvnoi travmoi.

OBJECTIVE: To study the incidence and structure of combat gunshot surgical trauma received during the 2nd Karabakh War and to analyze the results of treatment of these victims. MATERIAL AND METHODS: We analyzed surgical treatment of 60 victims with combat gunshot surgical trauma received during the 2nd Karabakh war. In 25 (41.7%) victims, injury occurred as a result of mine-explosive trauma. These victims were divided into 3 groups depending on mechanism of mine-explosive injury. The 1st group included 7 (28%) patients who received mine-explosive injury due to indirect (propelling) effect of blast wave. The 2nd group included 14 (56%) victims in whom mine-explosive injury was caused by non-contact (distant) impact of mine fragments. The 3rd group consisted of 4 (16%) patients whose mine-explosive injuries were caused by direct impact of explosion factors on various anatomical areas. Patients were also ranked into 3 groups depending on the nature and severity of mine-explosive injury: wounded with isolated injuries (n=16, 64%), wounded with concomitant injuries (n=2.8%), wounded with combined and multiple injuries (n=7, 28%). RESULTS: Most patients underwent organ-sparing procedures. Resections were performed only in 4 cases (splenectomy - 3, nephrectomy - 1). Postoperative complications developed in 23 (38.3%) wounded (suppuration of postoperative wounds - 13, post-traumatic pleuritis - 5, clotted hemothorax - 2, subphrenic abscess - 1, phlegmon of perineum and perianal region - 2). Mortality rate was 1.7%. CONCLUSION: Timely sorting and evacuation of victims, early qualified surgical care and correct postoperative management with monitoring of vital functions can improve the results of treatment of victims with mine-explosive trauma. Autologous skin grafting for extensive defects and closure of colostomy with restoration of colon continuity were essential in rehabilitation of these patients.

Blunt Chest Trauma and Regional Anesthesia for Analgesia of Multitrauma Patients in French Intensive Care Units: A National Survey.

BACKGROUND: Chest injuries are associated with mortality among patients admitted to the intensive care unit (ICU) and require multimodal pain management strategies, including regional anesthesia (RA). We conducted a survey to determine the current practices of physicians working in ICUs regarding RA for the management of chest trauma in patients with multiple traumas. METHODS: An online questionnaire was sent to medical doctors (n = 1230) working in French ICUs, using the Société Française d'Anesthésie Réanimation (SFAR) mailing list of its members. The questionnaire addressed 3 categories: general characteristics, practical aspects of RA, and indications and contraindications. RESULTS: Among the 333 respondents (response rate = 27%), 78% and 40% of 156 respondents declared that they would consider using thoracic epidural analgesia (TEA) and thoracic paravertebral blockade (TPB), respectively. The main benefits declared for performing RA were the ability to have effective analgesia, a more effective cough, and early rehabilitation. For 70% of the respondents, trauma patients with a theoretical indication of RA did not receive TEA or TPB for the following reasons: the ICU had no experience of RA (62%), no anesthesiologist-intensivist working in the ICU (46%), contraindications (27%), ignorance of the SFAR guidelines (19%), and no RA protocol available (13%). In this survey, 95% of the respondents thought the prognosis of trauma patients could be influenced by the use of RA. CONCLUSIONS: While TEA and TPB are underused because of several limitations related to the patterns of injuries in multitrauma patients, lack of both experience and confidence in combination with the absence of available protocols appear to be the major restraining factors, even if physicians are aware that patients' outcomes could be improved by RA. These results suggest the need to strengthen initial training and provide continuing education about RA in the ICU.

Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma.

Objective: The purpose of this study was to investigate whether routine blood tests on admission and clinical characteristics can predict prognosis in patients with traumatic brain injury (TBI) combined with extracranial trauma. Methods: Clinical data of 182 patients with TBI combined with extracranial trauma from April 2018 to December 2019 were retrospectively collected and analyzed. Based on GOSE score one month after discharge, the patients were divided into a favorable group (GOSE 1-4) and unfavorable group (GOSE 5-8). Routine blood tests on admission and clinical characteristics were recorded. Results: Overall, there were 48 (26.4%) patients with unfavorable outcome and 134 (73.6%) patients with favorable outcome. Based on multivariate analysis, independent risk factors associated with unfavorable outcome were age (odds ratio [OR], 1.070; 95% confidence interval [CI], 1.018-1.124; p<0.01), admission Glasgow Coma Scale (GCS) score (OR, 0.807; 95% CI, 0.675-0.965; p<0.05), heart rate (OR, 1.035; 95% CI, 1.004-1.067; p<0.05), platelets count (OR, 0.982; 95% CI, 0.967-0.997; p<0.05), and tracheotomy (OR, 15.201; 95% CI, 4.121-56.078; p<0.001). Areas under the curve (AUC) of age, admission GCS, heart rate, tracheotomy, and platelets count were 0.678 (95% CI, 0.584-0.771), 0.799 (95% CI, 0.723-0.875), 0.652 (95% CI, 0.553-0.751), 0.776 (95% CI, 0.692-0.859), and 0.688 (95% CI, 0.606-0.770), respectively. Conclusions: Age, admission GCS score, heart rate, tracheotomy, and platelets count can be recognized as independent predictors of clinical prognosis in patients with severe TBI combined with extracranial trauma.

How Common Are Civilian Blast Injuries in the National Trauma Databank, and What Are the Most Common Mechanisms and Characteristics of Associated Injuries?

BACKGROUND: Recent military conflicts have produced substantial improvements in the care of service members who experience blast injuries. As conflicts draw down, it is important to preserve and improve skills gained in combat. It is unknown whether civilian blast injuries can serve as a surrogate for military blast trauma. To guide further research, it is crucial to understand the volume, severity, and distribution of civilian blast injury in the civilian population. QUESTIONS/PURPOSES: (1) What proportion of US trauma admissions are a result of blast injury? (2) What are the common mechanisms, and what is the demographic breakdown of civilian patients presenting to trauma centers after blast injuries? (3) What is the severity, and what are the characteristics of injuries sustained by civilian patients after blast injuries? METHODS: We queried the American College of Surgeons National Trauma Databank (NTDB), a national aggregation of trauma registry data which captures robust mechanism of injury and wounding pattern information, for any patient admitted for trauma and an initial mechanism of injury corresponding to a predefined list of ICD-9 and ICD-10 external cause of injury codes related to blast injuries and reported as a proportion of all trauma-related admissions. Mechanisms were categorized into similar groups, and data were collected regarding demographics as well as location and intentionality of blast (that is, unintentional, the result of assault, or self-inflicted). Patient injuries were characterized by ICD-9 or ICD-10 diagnosis codes and sorted according to the body area affected and severity of injury, measured via the Injury Severity Score (ISS). The ISS is a measure of trauma severity, with scores ranging from 1 to 75 points based on injury severity, which is calculated according to injury scores in six separate body domains (head or neck, face, chest, abdomen or pelvis, extremities, external). A score of 1 represents a minor trauma to one region, while a score of 75 indicates injuries deemed nonsurvivable in one or more domains. Data were limited to trauma admissions in 2016. RESULTS: Patients injured by blast mechanisms represented 0.3% (2682 of 968,843) of patients in NTDB-participating trauma centers who were treated after a blast injury in the year 2016; 86% (2315 of 2682) of these patients were men, and the mean ± SD age was 38 ± 21 years. Blast injuries most commonly occurred after detonation of fireworks (29% [773 of 2682]) or explosion of gas or pressurized containers (27% [732 of 2682]). The most commonly injured area of the body was the upper extremity (33% [894 of 2682]), followed by the face (28% [747 of 2682]), lower extremity (11% [285 of 2682]), thorax (10% [280 of 2682]), and head (10% [259 of 2682]). Fifty-eight percent (1564 of 2682) of patients had at least one burn injury. A total of 2% (51 of 2682) of the injuries were fatal, with a mean ISS score of 6 ± 8; 23% (608 of 2682) of patients presented with injuries classified as severe (ISS > 8). CONCLUSION: Civilian blast-associated injuries are not common, but they can be severe, and in many (though not all) respects they seem similar to those described in published case series of military blast victims. Key differences include age and gender (civilian injuries more commonly involve women and older patients than do those in military studies). The potential of civilian blast patient care as a surrogate for study and clinical experience for military surgeons in the interwar period-as recommended by the National Academies of Sciences, Engineering, and Medicine report-is supported by our preliminary results. Future interventions or training programs would likely need to rely on multisite or targeted partnerships to encounter appropriate numbers of patients with blast injuries. LEVEL OF EVIDENCE: Level IV, prognostic study.

Comparison of base excess, lactate and pH predicting 72-h mortality of multiple trauma.

OBJECTIVE: To compare the predictive values of base excess (BE), lactate and pH of admission arterial blood gas for 72-h mortality in patients with multiple trauma. METHODS: This was a secondary analysis based on a publicly shared trauma dataset from the Dryad database, which provided the clinical data of 3669 multiple trauma patients with ISS > = 16. The records of BE, lactate, pH and 72-h prognosis data without missing values were selected from this dataset and 2441 individuals were enrolled in the study. Logistic regression model was performed to calculate the odds ratios (ORs) of variables. Area under the curve (AUC) of receiver operating curve (ROC) was utilized to evaluate the predictive value of predictors for 72 h in-hospital mortality. Pairwise comparison of AUCs was performed using the Delong's test. RESULTS: The statistically significant correlations were observed between BE and lactate (r = - 0.5861, p < 0.05), lactate and pH (r = - 0.5039, p < 0.05), and BE and pH (r = - 0.7433, p < 0.05). The adjusted ORs of BE, lactate and pH for 72-h mortality with the adjustment for factors including gender, age, ISS category were 0.872 (95%CI: 0.854-0.890), 1.353 (95%CI: 1.296-1.413) and 0.007 (95%CI: 0.003-0.016), respectively. The AUCs of BE, lactate and pH were 0.693 (95%CI: 0.675-0.712), 0.715 (95%CI: 0.697-0.733), 0.670 (95%CI: 0.651-0.689), respectively. CONCLUSIONS: There are significant correlations between BE, lactate and pH of the admission blood gas, all of them are independent predictors of 72-h mortality for multiple trauma. Lactate may have the best predictive value, followed by BE, and finally pH.

[Road combined trauma of the urinary system organs: organization and clinical tactics in a multidisciplinary hospital].

INTRODUCTION: Damage to the organs of the urinary system (UMS) in road trauma (DT) is 4%, of which multiple and combined - over 70%. The aim of the study is to determine the main organizational and clinical directions for improving the EMC in case of trauma OMS in a trauma center of the 1st level. MATERIAL AND METHODS: For the period from 2017 to 2020. 508 injured with road polytrauma were admitted to the hospital. Of these, trauma and secondary injuries were diagnosed in 108 people (21.3%), which were divided into three groups: the first - 73 (67.6%) victims with the injury of the OMVS, the second - 25 (23.1%) with secondary damage kidney, the third - 10 (9.3%) patients with "neurogenic bladder" with spinal trauma. The assessment of the severity of damage was carried out using the ISS scales and tables of the IH P and IH C. RESULTS: It has been shown that the introduction of an interdisciplinary approach to the organization of in-hospital routing and differentiated algorithms of medical and diagnostic tactics based on the concept of traumatic disease, led to the establishment of a final diagnosis in every third victim in the early stages, as well as to a decrease in the overall mortality rate by 3.7%, the overall mortality rate was 12,2%. The key directions for improving the efficiency and quality of care in case of dominant and concomitant trauma of the urinary system have been identified, based on the tactics of programmed multistage surgical treatment (Damage Control Urological). CONCLUSION: In the FSBI "3CVKG A.A. Vishnevsky "developed, organized and implemented a system and algorithm for the provision of specialized medical care for trauma to the Ministry of Railways, including high-tech assistance to victims of road accidents, associated with the regional and federal services of disaster medicine.

Functional immune monitoring in severely injured patients-A pilot study.

After severe trauma, the resulting excessive inflammatory response is countered by compensatory anti-inflammatory mechanisms. The systemic inflammatory response to trauma enhanced by inappropriately timed surgical second hits may be detrimental for the patient. On the other hand, overwhelming anti-inflammatory mechanisms may put patients at increased risk from secondary local and systemic infections. The ensuing sepsis and organ dysfunction due to immune dysregulation remain the leading causes of death after injury. To date, there are no clinically applicable techniques to monitor the pro-/anti-inflammatory immune status of the patients and the remaining ability to react to microbial stimuli. Therefore, in the present study, we used a highly standardized and easy-to-use system to draw peripheral whole blood from polytraumatized patients (ISS ≥ 32, n = 7) and to challenge it with bacterial lipopolysaccharide. Secreted cytokines were compared with those in samples from healthy volunteers. We observed a significant decrease in the release of monocyte-derived mediators. Surprisingly, we detected stable or even increased concentrations of cytokines related to T cell maturation and function. For clinical practicability, we reduced the incubation time before supernatants were collected. Even after an abbreviated stimulation period, a stable release of almost all analysed parameters in patient blood could be detected. In conclusion, the data are indicative of a clinically well-applicable approach to monitor the immune status in severely injured patients in a short time. This may be used to optimize the timing of necessary surgical interventions to avoid a boost of proinflammation and reduce risk of secondary infections.

Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure.

BACKGROUND: Musculoskeletal injuries are common following trauma and variables that are associated with late femur fracture fixation are important to perioperative management. Furthermore, the association of late fracture fixation and multiple organ failure (MOF) is not well defined. METHODS: We performed a retrospective cohort investigation from 2 academic trauma centers. INCLUSION CRITERIA: age 18-89 years, injury severity score (ISS) >15, femoral shaft fracture requiring operative fixation, and admission to the intensive care unit >2 days. Admission physiology variables and abbreviated injury scale (AIS) scores were obtained. Lactate was collected as a marker of shock and was described as admission lactate (LacAdm) and as 24-hour time-weighted lactate (LacTW24h), which reflects an area under the curve and is considered a marker for the overall depth of shock. The primary aim was to evaluate clinical variables associated with late femur fracture fixation (defined as ≥24 hours after admission). A multivariable logistic regression model tested variables associated with late fixation and is reported by odds ratio (OR) with 95% confidence interval (CI). The secondary aim evaluated the association between late fixation and MOF, defined by the Denver MOF score. The summation of scores (on a scale from 0 to 3) from the cardiac, pulmonary, hepatic, and renal systems was calculated and MOF was confirmed if the total daily sum of the worst scores from each organ system was >3. We assessed the association between late fixation and MOF using a Cox proportional hazards model adjusted for confounding variables by inverse probability weighting (a propensity score method). A P value <.05 was considered statistically significant. RESULTS: One hundred sixty of 279 (57.3%) patients received early fixation and 119 of 279 (42.7%) received late fixation. LacTW24h (OR = 1.66 per 1 mmol/L increase, 95% CI, 1.24-2.21; P < .001) and ISS (OR = 1.07 per 1-point increase, 95% CI, 1.03-1.10; P < .001) were associated with higher odds of late fixation. Late fixation was associated with a 3-fold increase in the odds of MOF (hazard ratio [HR] = 3.21, 95% CI, 1.48-7.00; P < .01). CONCLUSIONS: In a cohort of multisystem trauma patients with femur fractures, greater injury severity and depth of shock, as measured by LacTW24h, were associated with late operative fixation. Late fixation was also associated with MOF. Strategies to reduce the burden of MOF in this population require further investigation.

Traumatic abdominal wall hernias: disruptions of the abdominal wall muscles associated to pelvic bone fractures illustrated by two case reports.

BACKGROUND: Blunt abdominal traumas are often associated with intra-abdominal injuries and pelvic fractures. Traumatic abdominal wall hernias due to disruption of the abdominal wall muscles may be overlooked. Delayed diagnosis can lead to hernia related complications. CASE PRESENTATION: We present two cases of high kinetic trauma with pelvic fractures and acute traumatic abdominal wall herniation. Both of these cases suffered from a delayed diagnosis and needed surgery to treat the symptomatic herniation. CONCLUSION: Clinical reassessment and appropriate medical imaging are mandatory in patients with high kinetic abdominal blunt traumas and associated pelvic fracture, in order to prevent delayed diagnosis and possible complications.