Pelvic trauma mortality reduced by integrated trauma care.

OBJECTIVES: A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period. METHODS: A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis. RESULTS: There were 1213 patients with a serious pelvic injury (Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 (P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10; 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders. CONCLUSIONS: Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes.

Modulation of the Redox Expression and Inflammation Response in the Critically Ill Polytrauma Patient with Thoracic Injury. Statistical Correlations between Antioxidant Therapy.

BACKGROUND: One of the major causes of mortality in the world is represented by multiple traumas. Thoracic trauma is commonly associated with polytraumas. A series of physiopathological complications follow polytraumas, leading to a significant decrease in the survival rate. As a result of injuries, significant quantities of free radicals (FR) are produced, responsible for oxidative stress (OS). To minimize the effects of OS, we recommend the administration of antioxidant substances. In this study we want to highlight statistically significant correlations between antioxidant therapy and a series of clinical variables. METHODS: This retrospective study included 132 polytrauma patients admitted to the ICU-CA between January 2013 and December 2014. The selection criteria were: injury severity score (ISS) ≥ 16, ≥ 18 years, presence of thoracic trauma (abbreviated injury scale, AIS ≥ 3). Eligible patients (n = 82) were divided into two groups: Group 1 (n = 32, antioxidant free, patients from 2013) and Group 2 (n = 50 antioxidant therapy, patients from 2014). Antioxidant therapy consisted in the administration of vitamin C (i.v.), vitamin B1 (i.v.), and N-acetylcysteine (i.v.). Clinical and biological tests were repeated until discharge from ICU-CA or death. RESULTS: Between Group 1 and Group 2 statistically significant differences were highlighted regarding the ISS score (p = 0.0030). 66% of patients from Group 2 were admitted at more than 24 hours after the trauma, in contrast to the patients from Group 1, where 62.5% were directly admitted to the ICU (p = 0.0114). Compared with the patients from Group 1, patients who received antioxidant therapy show improved parameters: leukocytes (p < 0.0001), platelets (p = 0.0489), urea (p = 0.0199), total bilirubin (p = 0.0111), alanine transaminase (p = 0.0010), lactat dehydrogenase (p < 0.0001). Between the two groups there were no statistically significant differences regarding the length of stay in the ICU-CA (p = 0.4697) and mortality (p = 0.1865). CONCLUSIONS: Following the study, we can affirm that due to the administration of antioxidant substances, posttraumatic complications are greatly reduced. Moreover, the administration of high dose of antioxidants remarkably improves the clinical status of the critical patient.

Early autologous fresh whole blood transfusion leads to less allogeneic transfusions and is safe.

BACKGROUND: The practice of transfusing ones' own shed whole blood has obvious benefits such as reducing the need for allogeneic transfusions and decreasing the need for other fluids that are typically used for resuscitation in trauma. It is not widely adopted in the trauma setting because of the concern of worsening coagulopathy and the inflammatory process. The aim of this study was to assess outcomes in trauma patients receiving whole blood autotransfusion (AT) from hemothorax. METHODS: This is a multi-institutional retrospective study of all trauma patients who received autologous whole blood transfusion from hemothorax from two Level I trauma centers. Patients who received AT were matched to patients who did not receive AT (No-AT) using propensity score matching in a 1:1 ratio for admission age, sex, mechanism, type of injury, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, systolic blood pressure, heart rate, hemoglobin, international normalized ratio (INR), prothrombin time, partial prothrombin time, and lactate. AT was defined as transfusion of autologous blood from patient's hemothorax, which was collected from the chest tubes and anticoagulated with citrate phosphorous dextrose. Outcome measures were in-hospital complications, 24-hour INR, and mortality. In-hospital complications were defined as adult respiratory distress syndrome, sepsis, disseminated intravascular coagulation, renal insufficiency, and transfusion-related acute lung injury. RESULTS: A total of 272 patients (AT, 136; No-AT, 136) were included. There was no difference in admission age (p = 0.6), ISS (p = 0.56), head Abbreviated Injury Scale (AIS) score (p = 0.42), systolic blood pressure (p = 0.88), and INR (p = 0.62) between the two groups. There was no significant difference in in-hospital complications (p = 0.61), mortality (p = 0.51), and 24-hour postadmission INR (0.31) between the AT and No-AT groups. Patients who received AT had significantly lower packed red blood cell (p = 0.01) and platelet requirements (p = 0.01). Cost of transfusions (p = 0.01) was significantly lower in the AT group compared with the No-AT group. CONCLUSION: The autologous transfusion of the patient's shed blood collected through chest tubes for hemothorax was found to be safe without complications in this study. It also reduced the need for allogeneic transfusions and decreased hospital costs. This study demonstrates safety data that would help in designing larger prospective multicenter studies to determine whether this practice is truly safe and effective. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Outcome after severe head injury treated by an integrated trauma system.

OBJECTIVES: To describe outcome after treatment of severe head injury within an integrated trauma system. METHODS: A retrospective analysis of all patients with severe head injury admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) between 1991 and 1994. Type of injury was defined on initial computed tomography of the head and outcomes assessed 12 months after injury using the Glasgow outcome score. RESULTS: 6.5% of HEMS patients had long term severe disability (severe disability or persistent vegetative state on the outcome score); 34.5% made a good recovery. CONCLUSIONS: The concern that a large number of severely disabled long term survivors might result as a consequence of this system of trauma management is not confirmed. The case mix of severity of extracranial injuries in these patients makes comparison with other published series difficult, but these data fit the hypothesis that pre-hospital correction of hypoxia and hypotension after head injury improves outcome.