Extracellular RNA Sensing Mediates Inflammation and Organ Injury in a Murine Model of Polytrauma.

Severe traumatic injury leads to marked systemic inflammation and multiorgan injury. Endogenous drivers such as extracellular nucleic acid may play a role in mediating innate immune response and the downstream pathogenesis. Here, we explored the role of plasma extracellular RNA (exRNA) and its sensing mechanism in inflammation and organ injury in a murine model of polytrauma. We found that severe polytrauma-bone fracture, muscle crush injury, and bowel ischemia-induced a marked increase in plasma exRNA, systemic inflammation, and multiorgan injury in mice. Plasma RNA profiling with RNA sequencing in mice and humans revealed a dominant presence of miRNAs and marked differential expression of numerous miRNAs after severe trauma. Plasma exRNA isolated from trauma mice induced a dose-dependent cytokine production in macrophages, which was almost abolished in TLR7-deficient cells but unchanged in TLR3-deficient cells. Moreover, RNase or specific miRNA inhibitors against the selected proinflammatory miRNAs (i.e., miR-7a-5p, miR-142, let-7j, miR-802, and miR-146a-5p) abolished or attenuated trauma plasma exRNA-induced cytokine production, respectively. Bioinformatic analyses of a group of miRNAs based on cytokine readouts revealed that high uridine abundance (>40%) is a reliable predictor in miRNA mimic-induced cytokine and complement production. Finally, compared with the wild-type, TLR7-knockout mice had attenuated plasma cytokine storm and reduced lung and hepatic injury after polytrauma. These data suggest that endogenous plasma exRNA of severely injured mice and ex-miRNAs with high uridine abundance prove to be highly proinflammatory. TLR7 sensing of plasma exRNA and ex-miRNAs activates innate immune responses and plays a role in inflammation and organ injury after trauma.

Multiomics Signatures of Coagulopathy in a Polytrauma Swine Model Contrasted with Severe Multisystem Injured Patients.

Trauma-induced coagulopathy (TIC) is a leading contributor to preventable mortality in severely injured patients. Understanding the molecular drivers of TIC is an essential step in identifying novel therapeutics to reduce morbidity and mortality. This study investigated multiomics and viscoelastic responses to polytrauma using our novel swine model and compared these findings with severely injured patients. Molecular signatures of TIC were significantly associated with perturbed coagulation and inflammation systems as well as extensive hemolysis. These results were consistent with patterns observed in trauma patients who had multisystem injuries. Here, intervention using resuscitative endovascular balloon occlusion of the aorta following polytrauma in our swine model revealed distinct multiomics alterations as a function of placement location. Aortic balloon placement in zone-1 worsened ischemic damage and mitochondrial dysfunction, patterns that continued throughout the monitored time course. While placement in zone-III showed a beneficial effect on TIC, it showed an improvement in effective coagulation. Taken together, this study highlights the translational relevance of our polytrauma swine model for investigating therapeutic interventions to correct TIC in patients.

Tranexamic acid in trauma: After 3 hours from injury, when is it safe and effective to use again?

Tranexamic acid (TXA) has proven mortality benefit if used early after traumatic injury, likely related to a combination of bleeding reduction and other non-bleeding effects. If TXA is given more than 3 h after traumatic injury, there is a significant and paradoxical increased risk of death due to bleeding. TXA has level 1 evidence for use as a bleeding reduction agent in isolated orthopedic operations, but in polytrauma patients undergoing orthopedic operations, it is not clear if and when TXA is safe or effective once outside the 3-h window of proven trauma efficacy.

Multicompartmental Trauma Induces Persistent Inflammation and Organ Injury.

INTRODUCTION: Previous preclinical models of multicompartmental injury have investigated its effects for durations of less than 72 h and the long-term effects have not been defined. We hypothesized that a model of multicompartmental injury would result in systemic inflammation and multiorgan dysfunction that persists at 1 wk. METHODS: Male and proestrus female Sprague-Dawley rats (n = 16/group) underwent polytrauma (PT) (unilateral right lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofractures) and were compared to naive controls. Weight, hemoglobin, plasma neutrophil gelatinase-associated lipocalin, and plasma toll-like receptor 4 were evaluated on days two and seven. Bilateral lungs were sectioned, stained and assessed for injury at day seven. Comparisons were performed in Graphpad with significance defined as ∗P <0.05. RESULTS: Rats who underwent PT had significant weight loss and anemia at day 2 (P = 0.001) compared to naïve rats which persisted at day 7 (P = 0.001). PT rats had elevated plasma neutrophil gelatinase-associated lipocalin at day 2 compared to naïve (P <0.0001) which remained elevated at day 7 (P <0.0001). Plasma toll-like receptor 4 was elevated in PT compared to naïve at day 2 (P = 0.03) and day 7 (P = 0.01). Bilateral lungs showed significant injury in PT cohorts at day 7 compared to naïve (P <0.0004). PT males had worse renal function at day seven compared to females (P = 0.02). CONCLUSIONS: Multicompartmental trauma induces systemic inflammation and multiorgan dysfunction without recovery by day seven. However, females demonstrate improved renal recovery compared to males. Long-term assessment of preclinical PT models are crucial to better understand and evaluate future therapeutic immunomodulatory and anti-inflammatory treatments.

Multiple Casualty Incidents at a Level I Trauma Center: A 15-year Analysis.

INTRODUCTION: Limited evidence regarding multiple casualty outcomes exists. Given resource strain with increasing patient load, we hypothesized that patients involved in a multiple casualty incident have worse outcomes compared to standard trauma patients. METHODS: Multiple casualty victims from 2006 to 2021 at our institution were identified; admission data and trauma outcomes were then compared to standard trauma patients. Chi-square tests and Mann-Whitney U-tests were performed for categorical and non-normal continuous data, respectively. Logistic regression was performed to evaluate associations with mortality and intensive care unit (ICU) admission. RESULTS: We identified 39,924 patients, of which 612 were multiple casualty patients (1.5%). Multiple casualty involvement was associated with younger age (29 y versus 44 y, P < 0.001) and higher rates of penetrating trauma (26.1% versus 21.4%; P < 0.001). Multiple casualty involvement was associated with higher injury severity score (ISS) (11.6 versus 7.9, P < 0.001), mortality (2.4% versus 1.5% P < 0.005), and ICU admission (17% versus 13%, P < 0.005). On logistic regression analysis, age, ISS, shock index, presence of the COVID-19 pandemic, and mechanism all independently predicted mortality (P ≤ 0.003), while multiple casualty involvement did not (P = 0.302). CONCLUSIONS: Although multiple casualty incidents are associated with patient factors that increase hospital resource strain, when controlling for age, ISS, shock index, presence of the COVID-19 pandemic, and trauma mechanism, involvement in multiple casualty incident was not independently associated with ICU admission or mortality. Improved understanding of the impact of high-volume trauma may allow us to improve our care of this at-risk population.

Multiple nail gun injuries: suicide or homicide?

Nail gun injuries are a forensic problem; it can be difficult to distinguish self-inflicted injuries from accident and homicide instances. This kind of injuries shares some characteristics with both gunshot and puncture wounds. We describe a peculiar case of a man who committed suicide driving nails into his skull using a pneumatic nail gun. Entrance wounds were found on both temporal regions of the head. Reviewing scientific literature, this is the first case in Italy reporting the macroscopic data of bilateral head and brain nail gun injuries during an autopsy. Circumstantial elements were not sufficient to clarify if these lesions were self-inflicted, inflicted by accident, or else. Radiological examination can be helpful to show the exact location of the nails, but it has also its own limitations. We firmly believe that autopsy, especially the head section, is crucial to identify the nature and the extension of these lesions, thus giving us much more information about the mechanism of death and the circumstances in which it occurred.

Decrease of exosomal miR-21-5p and the increase of CD62p+ exosomes are associated with the development of sepsis in polytraumatized patients.

Sepsis as a severe systemic inflammation leads oftentimes to organ dysfunction and subsequently to death. In polytrauma patients, septic complications represent with 45% the predominant cause of late death and are responsible for extremely high costs in the healthcare system. Therefore, clinicians have to detect as early as possible the begin of sepsis to improve the patient's outcome. One new promising diagnostic tool to diagnose septic complications in polytraumatized patients are exosomes. Plasma samples from polytraumatized patients (Injury Severity Score (ISS) ≥16) which developed sepsis (n = 10) and without sepsis (n = 10), were collected at emergency room (ER), 24h and 5 days after trauma. The EVs subpopulations were investigated by a bead-based multiplex flow cytometry measurement of surface epitopes and were compared with plasma EVs from healthy controls (n = 10). Moreover, exosomal cytokine concentrations were measured via high-sensitive ELISA and were correlated with systemic concentrations. For miRNA cargo analysis, we analysed the miRNAs miR-1298-5p, miR-1262, miR-125b-5p, miR-92a-3p, miR-93-5p, miR-155-5p and miR-21-5p and compared their exosomal concentrations by means of RT-qPCR. CD62p + exosomes were significantly increased in septic polytrauma-patients (p ≤ 0.05), while CD40+exosomes, as well as CD49e + exosomes were diminished (p ≤ 0.05). Furthermore, we observed that the exosomal IL-6 concentration reflects the systemic IL-6 concentration (r2 = 0.63) and did not significantly alter between patients with and without sepsis. The exosomal IL-10 concentration seemed to be constant in all patients and healthy controls. We observed that a decrease of miR-21-5p in exosomes was associated with the development of sepsis (p ≤ 0.05), while exosomal miR-93-5p, miR-155-5p and miR-92a-3p were not specifically altered in septic patients. Taken together, the present study in polytraumatized patients demonstrated that the development of sepsis is associated with an increase of CD62p + exosomes. Furthermore, the exosomal cargo was changed in septic patients: miR-21-5p was diminished.

Trends in pre-hospital volume resuscitation of blunt trauma patients: a 15-year analysis of the British (TARN) and German (TraumaRegister DGU®) National Registries.

INTRODUCTION: Fluid resuscitation has long been a cornerstone of pre-hospital trauma care, yet its optimal approach remains undetermined. Although a liberal approach to fluid resuscitation has been linked with increased complications, the potential survival benefits of a restrictive approach in blunt trauma patients have not been definitively established. Consequently, equipoise persists regarding the optimal fluid resuscitation strategy in this population. METHODS: We analysed data from the two largest European trauma registries, the UK Trauma Audit and Research Network (TARN) and the German TraumaRegister DGU® (TR-DGU), between 2004 and 2018. All adult blunt trauma patients with an Injury Severity Score > 15 were included. We examined annual trends in pre-hospital fluid resuscitation, admission coagulation function, and mortality rates. RESULTS: Over the 15-year study period, data from 68,510 patients in the TARN cohort and 82,551 patients in the TR-DGU cohort were analysed. In the TARN cohort, 3.4% patients received pre-hospital crystalloid fluids, with a median volume of 25 ml (20-36 ml) administered. Conversely, in the TR-DGU cohort, 91.1% patients received pre-hospital crystalloid fluids, with a median volume of 756 ml (750-912 ml) administered. Notably, both cohorts demonstrated a consistent year-on-year decrease in the volume of pre-hospital fluid administered, accompanied by improvements in admission coagulation function and reduced mortality rates. CONCLUSION: Considerable variability exists in pre-hospital fluid resuscitation strategies for blunt trauma patients. Our data suggest a trend towards reduced pre-hospital fluid administration over time. This trend appears to be associated with improved coagulation function and decreased mortality rates. However, we acknowledge that these outcomes are influenced by multiple factors, including other improvements in pre-hospital care over time. Future research should aim to identify which trauma populations may benefit, be harmed, or remain unaffected by different pre-hospital fluid resuscitation strategies.

Implementation of health-related quality of life in the German TraumaRegister DGU® - first results of a pilot study.

BACKGROUND: Approximately 30,000 people are affected by severe injuries in Germany each year. Continuous progress in prehospital and hospital care has significantly reduced the mortality of polytrauma patients. With increasing survival rates, the functional outcome, health-related quality (hrQoL) of life and ability to work are now gaining importance. Aim of the study is, the presentation of the response behavior of seriously injured patients on the one hand and the examination of the factors influencing the quality of life and ability to work 12 months after major trauma on the other hand. Building on these initial results, a standard outcome tool shall be integrated in the established TraumaRegister DGU® in the future. METHODS: In 2018, patients [Injury Severity Score (ISS) ≥ 16; age:18-75 years] underwent multicenter one-year posttraumatic follow-up in six study hospitals. In addition to assessing hrQoL by using the Short-Form Health Survey (SF-12), five additional questions (treatment satisfaction; ability to work; trauma-related medical treatment; relevant physical disability, hrQoL as compared with the prior to injury status) were applied. RESULTS: Of the 1,162 patients contacted, 594 responded and were included in the analysis. The post-injury hrQoL does not show statistically significant differences between the sexes. Regarding age, however, the younger the patient at injury, the better the SF-12 physical sum score. Furthermore, the physically perceived quality of life decreases statistically significantly in relation to the severity of the trauma as measured by the ISS, whereas the mentally perceived quality of life shows no differences in terms of injury severity. A large proportion of severely injured patients were very satisfied (42.2%) or satisfied (39.9%) with the treatment outcome. It should be emphasized that patients with a high injury severity (ISS > 50) were on average more often very satisfied with the treatment outcome (46.7%). A total of 429 patients provided information on their ability to work 12 months post-injury. Here, 194 (45.2%) patients had a full employment, and 58 (13.5%) patients were had a restricted employment. CONCLUSION: The present results show the importance of a structured assessment of the postinjury hrQoL and the ability to work after polytrauma. Further studies on the detection of influenceable risk factors on hrQoL and ability to work in the intersectoral course of treatment should follow to enable the best possible outcome of polytrauma survivors.

Modifiability of surgical timing in postinjury multiple organ failure patients.

BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late trauma deaths, with primarily non-modifiable risk factors. Timing of surgery as a potentially modifiable risk factor is frequently proposed, but has not been quantified. We aimed to compare mortality, hospital length of stay (LOS), and ICU LOS between MOF patients who had surgery that preceded MOF with modifiable timings versus those with non-modifiable timings. METHODS: Retrospective analysis of an ongoing 17-year prospective cohort study of ICU polytrauma patients at-risk of MOF. Among MOF patients (Denver score>3), we identified patients who had surgery that preceded MOF, determined whether the timing of these operation(s) were modifiable(M) or non-modifiable (non-M), and evaluated the change in physiological parameters as a result of surgery. RESULTS: Of 716 polytrauma patients at-risk of MOF, 205/716 (29%) developed MOF, and 161/205 (79%) had surgery during their ICU admission. Of the surgical MOF patients, 147/161 (91%) had one or more operation(s) that preceded MOF, and 65/161 (40%) of them had operation(s) with modifiable timings. There were no differences in age (mean (SD) 52 (19) vs 53 (21)years), injury severity score (median (IQR) 34 (26-41)vs34 (25-44)), admission physiological and resuscitation parameters, between M and non-M-patients. M patients had longer ICU LOS (median (IQR) 18 (12-28)versus 11 (8-16)days, p < 0.0001) than non-M-patients, without difference in mortality (14%vs16%, p = 0.7347), or hospital LOS (median (IQR) 32 (18-52)vs27 (17-47)days, p = 0.3418). M-patients had less fluids and transfusions intraoperatively. Surgery did not compromise patient physiology. CONCLUSION: Operations preceding MOF are common in polytrauma and seem to be safe in maintaining physiology. The margin for improvement from optimizing surgical timing is modest, contrary to historical assumptions.

Acute Gastrointestinal Injury in Polytrauma: Special Attention to Elderly Patients.

Background: Acute gastrointestinal injury (AGI) has been documented in critically ill patients, yet there remains a dearth of knowledge regarding its occurrence, predisposing factors, and outcomes in elderly polytrauma patients, a significant but overlooked population. This study aims to examine the frequency, risk factors, and clinical implications of AGI in elderly polytrauma patients. Methods: A retrospective, observational, multicenter study was carried out in two Level I trauma centers, encompassing a cohort of 1054 polytrauma patients from July 2020 to April 2022. Results: A total of 965 consecutive polytrauma patients were recruited who were divided into youth group (n=746) and elderly group (n=219). 73.5% of elderly patients after polytrauma were accompanied by AGI. An increasing ISS (OR=2.957, 95%CI: 1.285-7.714), SI (OR=2.861, 95%CI: 1.372-5.823), serum lactate (OR=2.547, 95%CI: 1.254-5.028), IL-6 (OR=1.771, 95%CI: 1.145-8.768), APTT (OR=1.462, 95%CI: 1.364-4.254) and a decreasing GCS (OR=0.325, 95%CI: 0.116-0.906) were each associated with an increasing risk of AGI in elderly polytrauma patients. Elderly polytrauma patients with AGI were presented relatively high 28-day mortality (40.4%) and super high 60-day mortality (61.2%) compared with elderly group without AGI and youth group with AGI. The area under the curve for predicting 28-day mortality in elderly polytrauma patients with AGI was 0.93 for AGI-III,IV with 96% sensitivity and 87% specificity. Conclusion: Elderly patients have a higher incidence and a worse prognosis of AGI after polytrauma. ISS, GCS, SI, serum lactate, IL-6, and APTT are identified as reliable prognostic markers to distinguish the AGI and N-AGI in elderly polytrauma patients. AGI-III,IV was the independent predictor of mortality in elderly polytrauma patients with AGI.

Nutrition and Food Security Among Veterans: Operationalizing Nutritional Functioning.

OBJECTIVE: To assess injured military veterans' experiences, beliefs, and daily physical and psychosocial functioning in relation to food and nutrition. DESIGN: We used a convergent mixed-methods study design and the International Classification of Functioning, Disability, and Health to operationalize the core constructs and influencing factors related to physical and psychosocial functioning, food, and nutrition. SETTING: Three Veterans Affairs polytrauma rehabilitation centers. PARTICIPANTS: Veterans who served in the United States military on or after September 11, 2001, and whose medical diagnoses met the criteria for polytrauma; at least 1 mild traumatic brain injury and at least 1 associated comorbidity (eg, posttraumatic stress disorder, chronic musculoskeletal pain, vestibular disturbances), for a total N of 43. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Themes from survey responses and semistructured interview data were pooled into core constructs and influencing factors. RESULTS: Thirty-seven veterans completed all surveys and participated in recorded interviews. Based on qualitative and quantitative data, veterans' relation to food and nutrition (ie, nutritional functioning) was found to be characterized by 5 core constructs, including food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces. Nutritional functioning was found to be shaped by 5 influencing factors, including injuries and health conditions, ideological and cultural exposures, relations, current beliefs, and current behaviors. CONCLUSIONS: Nutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, navigation to/of food spaces) among injured veterans is complex and shaped by multiple physical, psychosocial, economic, and cultural factors.

Pharmacokinetics of Tranexamic Acid (TXA) Delivered by Expeditious Routes in a Swine Model of Polytrauma and Hemorrhagic Shock.

OBJECTIVE: Hemorrhage is the leading cause of preventable death in civilian trauma centers and on the battlefield. One of the emerging treatment options for hemorrhage in austere environments is tranexamic acid (TXA). However, the landscape is not amenable to the current delivery standard. This study compared the pharmacokinetics of TXA via a standard 10-minute intravenous infusion (IV infusion), intravenous rapid push over 10 s (IV push), and intramuscular injection (IM) in a swine polytrauma and hemorrhagic shock model (trauma group) compared to uninjured controls (control group). METHODS: Thirty swine were randomized to the trauma or control group. Following anesthesia, the trauma group experienced a simulated blast injury and 40% controlled hemorrhage. Subjects in both groups were then randomized to receive 1 g/10 mL TXA via IV infusion, IV push, or IM. Animals were monitored for four hours with serial blood sampling. Serum TXA concentrations were measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and analyzed. RESULTS: The time to maximum TXA concentration (Tmax) was not affected by trauma in IV infusion or IV push, but was affected in the IM administration with Tmax significantly slower than the control group (p = 0.016). The minimum effective serum concentration of TXA (Ceff, 10 µg/mL) was reached in less than one minute with IV infusion and instantaneously with IV push. Despite lower bioavailability, the time to reach Ceff (Teff) was achieved via IM administration in less than 10 min for both groups (6.4 min trauma vs. 2.1 min control). CONCLUSIONS: In austere prehospital environments, an alternative to intravenous infusion of a life-saving medication is desired. Administration of TXA via all three methods reached the level needed to cause substantial inhibition of fibrinolysis within 10 min. The IV push method showed similar pharmacokinetics to IV infusion of TXA but can be delivered quickly without sacrificing an access site for 10 min.

Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report.

BACKGROUND: Fiberoptic-guided intubation is considered as "gold standard" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist. CASE PRESENTATION: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient's recovery was uneventful, and he was discharged from the hospital one month after the surgery. CONCLUSIONS: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

The therapeutic value of vacuum external fixation in polytrauma patients with multiple ribs fracture.

BACKGROUND: Multiple displaced rib fractures often result in a poor prognosis. Open reduction and internal fixation has been shown to provide benefits for patients with displaced rib fractures and flail chest. Nevertheless, for patients who are unwilling or unsuitable for surgery, the therapeutic options are limited. We developed a novel plastic vacuum device for rib fractures external stabilization. This study aims to compare the therapeutic efficacy of this device against a traditional chest strap in polytrauma patients with multiple rib fractures. METHODS: A retrospective investigation was conducted on polytrauma patients with multiple rib fractures admitted to our trauma center between March 2020 and March 2023. Patients were categorized into two groups: vacuum external fixation and chest strap. Comparative analysis was conducted on baseline parameters, injury characteristics, and clinical outcomes between the two groups. RESULTS: In this study, 54 patients were included, with 28 receiving chest strap and 26 undergoing vacuum external fixation. Results showed that, at 3 days and 7 days postintervention, the vacuum external fixation group had significantly lower visual analog scale scores during deep breathing and coughing (P < .05). Vacuum external fixation also reduced pleural drainage duration and volume, as well as lowered the risk of pneumonia and other complications (P < .05). Furthermore, the vacuum external fixation group demonstrated notable improvements in vital capacity, tidal volume, blood-gas test results, and a shorter hospital length of stay. CONCLUSIONS: According to the study findings, vacuum external fixation appears to offer benefits to patients with multiple rib fractures, potentially reducing the risk of complications and improving overall clinical outcomes.

Extremity fractures, attempted suicide, blood transfusion and thromboembolic events are independent risk factors for a prolonged hospital stay in severely injured elderly.

METHODS: Due to demographic change, the number of polytraumatized geriatric patients (> 64 years) is expected to further increase in the coming years. In addition to the particularities of the accident and the associated injury patterns, prolonged inpatient stays are regularly observed in this group. The aim of the evaluation is to identify further factors that cause prolonged inpatient stays. A study of the data from the TraumaRegister DGU® from 2016-2020 was performed. Inclusion criteria were an age of over 64 years, intensive care treatment in the GAS-region, and an Injury Severity Score (ISS) of at least 16 points. All patients who were above the 80th percentile for the average length of stay or average intensive care stay of the study population were defined as so-called long-stay patients. This resulted in a prolonged inpatient stay of > 25 days and an intensive care stay of > 13 days. Among other, the influence of the cause of the accident, injury patterns according to body regions, the occurrence of complications, and the influence of numerous clinical parameters were examined. RESULTS: A total of 23,026 patients with a mean age of 76.6 years and a mean ISS of 24 points were included. Mean ICU length of stay was 11 ± 12.9 days (regular length of stay: 3.9 ± 3.1d vs. prolonged length of stay: 12.8 ± 5.7d) and mean inpatient stay was 22.5 ± 18.9 days (regular length of stay: 20.7 ± 15d vs. 35.7 ± 22.3d). A total of n = 6,447 patients met the criteria for a prolonged length of stay. Among these, patients had one more diagnosis on average (4.6 vs. 5.8 diagnoses) and had a higher ISS (21.8 ± 6 pts. vs. 26.9 ± 9.5 pts.) Independent risk factors for prolonged length of stay were intubation duration greater than 6 days (30-fold increased risk), occurrence of sepsis (4x), attempted suicide (3x), presence of extremity injury (2.3x), occurrence of a thromboembolic event (2.7x), and administration of red blood cell concentrates in the resuscitation room (1.9x). CONCLUSIONS: The present analysis identified numerous independent risk factors for significantly prolonged hospitalization of the geriatric polytraumatized patient, which should be given increased attention during treatment. In particular, the need for a smooth transition to psychiatric follow-up treatment or patient-adapted rehabilitative care for geriatric patients with prolonged immobility after extremity injuries is emphasized by these results.

What Is the Relationship Between Maxillofacial Injury Location and Associated Injuries?

BACKGROUND: Patients sustaining maxillofacial fractures are at risk for associated injuries (AIs) to other body regions. The incidence of AIs is reported to be from 20 to 35%. AIs may be life-threatening and play a key role in considering first-line management at the emergency department, as well as planning the definitive treatment of maxillofacial fractures. PURPOSE: The study aimed to determine the frequency and risk factors for AIs in patients with maxillofacial fractures. STUDY DESIGN, SETTING, SAMPLE: The investigators designed and implemented a retrospective cohort study of patients with facial fractures treated at Central Hospital (Lahti, Finland) from January 1, 2009 through December 31, 2019. All adult patients with verified maxillofacial fractures were included. Patients under 18 years of age were excluded from the study. PREDICTOR VARIABLE: The predictor variable was the location of the maxillofacial fractures grouped into three categories: mandible alone, midface alone, and both midface and mandible. MAIN OUTCOME VARIABLE(S): The primary outcome variable was associated body region injuries coded as present or absent. The secondary outcome variable was the location of the AI categorized as skull, neck, thorax, pelvis, or extremity injuries. COVARIATES: Other study variables included demographic data (age, sex, alcohol use), Glasgow Coma Scale, and etiology (fall, traffic- and bicycle accident, assault, pedestrian hit by motor vehicle, work-related, or sports/free-time injuries). ANALYSES: Continuous variables were analyzed for normal distribution using the Shapiro-Wilks test and compared with categorical variables using the Mann-Whitney test. The univariate analyses of categorical variables were analyzed by the χ2 test (P ≤ .05 was considered statistically significant). RESULTS: During the study period, 443 adult (≥18) patients had maxillofacial fractures. AIs were present in 88 subjects (20%). The mean age was 47.6 years (range 18-91); 52 years with AIs (range 19-91), and 47 years (range 18-92) without AIs (P = .03). Subjects with midface and mandible + midface fractures had greater risk to AIs compared to mandibular fractures (relative risk 2.0, P = .002, relative risk 2.8, P = .009). CONCLUSION AND RELEVANCE: Every fifth maxillofacial trauma patient had an associated injury. Trauma patients should be evaluated in institutions with trauma protocols and imaging modalities before determining and executing the treatment plan for maxillofacial fractures.

Bilateral intertrochanteric fractures in an elderly patient following high-energy trauma: a case report.

BACKGROUND: Cases of bilateral hip fractures are rare, and even more so are cases of bilateral intertrochanteric fractures. Common causes include trauma, internal diseases, and primary or secondary bone diseases. We report a case of bilateral intertrochanteric fractures in an elderly patient following a severe car accident, a scenario not extensively reported in existing literature. CASE PRESENTATION: We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities. CONCLUSION: Managing bilateral intertrochanteric fractures, particularly in the elderly with severe trauma, is notably challenging due to their rarity. However, a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses.

Development and validation of a machine learning-based model to assess probability of systemic inflammatory response syndrome in patients with severe multiple traumas.

BACKGROUND: Systemic inflammatory response syndrome (SIRS) is a predictor of serious infectious complications, organ failure, and death in patients with severe polytrauma and is one of the reasons for delaying early total surgical treatment. To determine the risk of SIRS within 24 h after hospitalization, we developed six machine learning models. MATERIALS AND METHODS: Using retrospective data about the patient, the nature of the injury, the results of general and standard biochemical blood tests, and coagulation tests, six models were developed: decision tree, random forest, logistic regression, support vector and gradient boosting classifiers, logistic regressor, and neural network. The effectiveness of the models was assessed through internal and external validation. RESULTS: Among the 439 selected patients with severe polytrauma in 230 (52.4%), SIRS was diagnosed within the first 24 h of hospitalization. The SIRS group was more strongly associated with class II bleeding (39.5% vs. 60.5%; OR 1.81 [95% CI: 1.23-2.65]; P = 0.0023), long-term vasopressor use (68.4% vs. 31.6%; OR 5.51 [95% CI: 2.37-5.23]; P < 0.0001), risk of acute coagulopathy (67.8% vs. 32.2%; OR 2.4 [95% CI: 1.55-3.77]; P < 0.0001), and greater risk of pneumonia (59.5% vs. 40.5%; OR 1.74 [95% CI: 1.19-2.54]; P = 0.0042), longer ICU length of stay (5 ± 6.3 vs. 2.7 ± 4.3 days; P < 0.0001) and mortality rate (64.5% vs. 35.5%; OR 10.87 [95% CI: 6.3-19.89]; P = 0.0391). Of all the models, the random forest classifier showed the best predictive ability in the internal (AUROC 0.89; 95% CI: 0.83-0.96) and external validation (AUROC 0.83; 95% CI: 0.75-0.91) datasets. CONCLUSIONS: The developed model made it possible to accurately predict the risk of developing SIRS in the early period after injury, allowing clinical specialists to predict patient management tactics and calculate medication and staffing needs for the patient. LEVEL OF EVIDENCE: Level 3. TRIAL REGISTRATION: The study was retrospectively registered in the ClinicalTrials.gov database of the National Library of Medicine (NCT06323096).

The Association Between Inter-Hospital Transfers and the Prognosis of Pediatric Injury in the Emergency Department.

BACKGROUND: Inter-hospital transfers of severely injured patients are inevitable due to limited resources. We investigated the association between inter-hospital transfer and the prognosis of pediatric injury using the Korean multi-institutional injury registry. METHODS: This retrospective observational study was conducted from January 2013 to December 2017; data for hospitalized subjects aged < 18 years were extracted from the Emergency Department-based Injury in Depth Surveillance database, in which 22 hospitals are participating as of 2022. The survival rates of the direct transfer group and the inter-hospital transfer group were compared, and risk factors affecting 30-day mortality and 72- hour mortality were analyzed. RESULTS: The total number of study subjects was 18,518, and the transfer rate between hospitals was 14.5%. The overall mortality rate was 2.3% (n = 422), the 72-hour mortality was 1.7% (n = 315) and the 30-day mortality rate was 2.2% (n = 407). The Kaplan-Meier survival curve revealed a lower survival rate in the inter-hospital transfer group than in the direct visit group (log-rank, P < 0.001). Cox proportional hazards regression analysis showed that inter-hospital transfer group had a higher 30-day mortality rate and 72-hour mortality (hazard ratio [HR], 1.681; 95% confidence interval [CI], 1.232-2.294 and HR, 1.951; 95% CI, 1.299-2.930) than direct visit group when adjusting for age, sex, injury severity, and head injury. CONCLUSION: Among the pediatric injured patients requiring hospitalization, inter-hospital transfer in the emergency department was associated with the 30-day mortality rate and 72-hour mortality rate in Korea.