Pre-Trauma Pain Is the Strongest Predictor of Persistent Enhanced Pain Patterns after Severe Trauma: Results of a Single-Centre Retrospective Study.

Background and Objectives: Traumatic injuries are a significant public health issue worldwide, with persistent enhanced pain being a common complication following severe trauma. Persistent and chronic pain can have a profound impact on patients' quality of life, affecting physical, emotional, and social functioning. This study aimed to investigate the pain patterns of trauma patients before and after severe trauma, and identify the predictors of persisting pain after injury. Materials and Methods: A total of 596 patients of a level-one trauma centre with severe trauma were included in this study. The Trauma Outcome Profile Scale was used to assess pain severity before and after trauma, and a logistic regression analysis was performed to determine the most significant predictors of relevant pain after severe trauma. Results: The mean age of the included patients was 48.2 years, and 72% were males. The most frequent cause of injury was traffic accidents, and the mean Injury Severity Score was 17.6. Nearly half of the patients experienced reduced pain-related quality of life after trauma, with persisting pain predominantly occurring in the neck, spine, shoulder, pelvis, hip, knee, and feet. Even minor injuries led to increased pain scores. Preexisting pain before injury (OR: 5.43; CI: 2.60-11.34), older age (OR: 2.09, CI: 1.22-3.27), female gender (OR: 1.08, CI: 0.73-1.59), and high injury severity (OR: 1.80, CI: 1.20-2.69) were identified as significant predictors of enhanced pain. Conclusions: These findings highlight the importance of considering pre-existing pain, body area, and injury severity in assessing the risk of persistent pain in trauma patients.

[Volume therapy in the severely injured patient : Recommendations and current guidelines]. / Volumentherapie beim schwerverletzten Traumapatienten : Empfehlungen und aktuelle Leitlinien.

BACKGROUND: Volume therapy is a cornerstone of early resuscitation of severely injured trauma patients, but the optimal strategy remains under debate. A recent Cochrane review could not find evidence for or against early volume replacement or large versus small amounts of fluid. METHOD: Current recommendations and guidelines regarding volume therapy in severely injured patients are summarized based upon the updated European Trauma Guideline on the management of major bleeding and coagulopathy following trauma (fourth edition) and the S3-Guideline Polytrauma and combined with a selective review of the literature. RESULTS AND DISCUSSION: Current guidelines and recommendations advocate the initiation of volume replacement at a reduced level in bleeding and hypotensive trauma patients in terms of "permissive hypotension," with the aim of maintaining mean arterial blood pressure (MAP) at 65 mm Hg and/or target systolic blood pressure at 80-90 mm Hg so as not to exacerbate the bleeding until its source can be controlled. Advanced Trauma Life Support principles, together with independent measurements of hemoglobin, base excess, and/or lactate, are recommended as sensitive tests for assessing the extent of bleeding and shock. Isotonic crystalloid solutions should be used as first-line volume replacement in bleeding, hypotensive trauma patients. Specific recommendations apply for patients with traumatic brain injury.

Frequency of relevant back pain two years after trauma and the effect on health-related quality of life.

BACKGROUND: Persisting back pain is a frequent consequence after severe trauma including injury to the spine. Reports on the incidence and relevance of back pain in severely injured patients in the absence of direct injury to the spine are scarce. OBJECTIVE: To assess the frequency of relevant back pain and its effect on health-related quality of life (HRQoL) in trauma patients with spine injury compared to patients without direct impact to spine postdischarge and two years after trauma within an observational study. METHODS: A two-year follow-up survey by using the Polytrauma Outcome Chart (PoloChart) and a set of specific questionnaires on socioeconomic and other HRQoL aspects was conducted among adult patients that had been treated for severe traumatic injuries (ISS ⩾ 9) at a German level 1 trauma center between 2008 and 2017. Patient subgroups included patients with relevant (VAS ⩾ 3) versus non-relevant back pain (VAS < 3) stratified by visual analogue scale (VAS 0-10). Patients with relevant back pain were separated into patients with (AIS spine ⩾ 1) and without spine injury (AIS spine = 0) according to the Abbreviated Injury Score (AIS). RESULTS: 543/1010 questionnaires were returned yielding a response rate of 54%. Patients were predominantly male (n= 383/543; 71%) with a mean age 45 ± 19 years, mostly blunt trauma (n= 524/543; 97%) and a mean ISS 18 ± 12 points. 32.4% of patients had sustained a spine injury defined by an AIS spine ⩾ 1 (n= 176/543). Half of these patients suffered from relevant back pain two years after trauma (n= 90/176; 51.1%); in contrast, in non-spine injured patients one in three patients reported relevant back pain (n= 127/367; 34.6%). Patients with relevant back pain reported significantly lower HRQoL as measured by the 36-Item Short Form Health Survey and the Trauma Outcome Profile. The use of pain medication after discharge and at two years after trauma was significantly higher in patients with relevant back pain (n= 183/211; 86.7% vs. n= 214/318; 75.8%; p< 0.001; pain medication 2 years after trauma: n= 113/210, 53.8% vs. 68/317, 21.5%, p< 0.001). CONCLUSION: Persisting back pain is frequent at two years after trauma independent of presence or absence of initial injury to the spine and associated with lower HRQoL in almost every dimension including physical, mental and social domains.

Introduction of a novel questionnaire to assess the quality of postdischarge outpatient care and socioeconomic state after severe multiple injury.

BACKGROUND AND AIM: Trauma registries provide knowledge about the pathophysiological events that follow severe injuries but only little is known about outpatient care and socioeconomic consequences at later stages in case of survival. We introduce a novel questionnaire to specifically assess the quality of postdischarge outpatient care and socioeconomic burden up to two years after severe multiple injury. DESIGN: Observational Study. SETTING: Postdischarge outpatient treatment and socioeconomic burden within two years after severe trauma. POPULATION: Severely injured adult trauma patients (Injury Severity Score 9 and ICU admission). METHODS: A new questionnaire was introduced in context of a two-year follow-up mail survey. RESULTS: The response rate was 57% (150/264 patients; 73% male, mean 45 years, mean ISS 17/New ISS 22; 99% blunt trauma). Rehabilitation measures were conducted in 70% of patients while 87% underwent outpatient treatment after discharge from the acute care facility. Further in-hospital stays were observed in 63% of patients and 19% reported the need for ongoing permanent care. Pain medication was taken by 74% of patients after discharge while 32% were still on pain medication at two years. 35% had been on sick leave >1 year while 18% had entirely lost their job. Every second patient reported financial disadvantages. CONCLUSIONS: The questionnaire yielded detailed information about the quality of outpatient care after discharge and confirmed the high socioeconomic burden among patients at two years after severe multiple injury. CLINICAL REHABILITATION IMPACT: Long- term impairments after severe trauma are described frequently. Evaluation of ambulant treatment is the first step to optimize long- term rehabilitation and re-integration.

Functional capacity of reconstituted blood in 1:1:1 versus 3:1:1 ratios: a thrombelastometry study.

INTRODUCTION: Different transfusion ratio concepts of packed red blood cells (pRBCs), fresh frozen plasma (FFP) and platelets (PLTs) have been implemented in trauma care, but the optimal ratios are still discussed. In this study the hemostatic potential of two predefined ratios was assessed by using an in vitro thrombelastometric approach. Furthermore, age effects of reconstituted blood were analyzed. METHODS: Whole blood (WB) of voluntary donors was separated into pRBCs, FFP and PLTs and reconstituted into the ratios 1:1:1 and 3:1:1 at day 1, 4, 14, and 24. Standard blood count, electrolytes and coagulation proteins were quantified. The functional coagulation in ratio- and age-specific groups was evaluated using rotational thromboelastometry (ROTEM). RESULTS: Several coagulation factors reduced significantly in the 3:1:1 ratio and were consistent with increased INR, decelerated clot formation times and A10 (amplitude 10 minutes after clotting time (CT)), flattened α-angle during the EXTEM and diminished MCF for distinct time points during the INTEM, FIBTEM and APTEM assays. With rising age of pRBCs the pH, sodium and potassium reached non-physiological levels. CONCLUSION: Under standardized in vitro conditions the higher amount of pRBCs in the 3:1:1 ratio diluted coagulation factors significantly on the expense of its functional coagulation capacity as revealed by ROTEM results. Thus, the coagulation functionality of the 1:1:1 ratio predominated.

Quality of life two years after severe trauma: a single-centre evaluation.

INTRODUCTION: Trauma related injuries are a main cause for long-lasting morbidity and disability especially in younger patients with their productive years ahead. On a routine basis, we assessed health related quality of life two years after trauma of severely injured patients at our level-I trauma centre via posted survey. PATIENTS AND METHODS: The posted survey included (1) POLO-Chart questionnaire with European Quality of Life (EuroQoL), Short Form Health Survey-36 (SF 36) and the recently developed and validated Trauma Outcome Profile (TOP) combined with (2) single centre data according to TraumaRegister DGU(®) data sets including trauma mechanism, injuries and initial treatment. Inclusion criteria were severely injured patients ≥ 18 years, treated between 2008 and 2010. Exclusion criteria were death, cognitive impairment, lack of German language and denial of participation. RESULTS: 129 datasets were eligible for analysis reflecting a typical trauma collective with mean age 44 years, predominantly male (67%), mean ISS 22 and 98% blunt trauma. Two years after trauma, 62% of the patients reported of relevant remaining pain and 64% of severe functional deficit in at least one body region. Sixty-four percent of the patients suffered from decreased overall quality of life (EuroQoL≤0.8). Additionally, all domains of SF-36 were impaired compared to an age and gender adjusted cohort of healthy individuals, especially domains of pain and activity of daily living. These impairments were associated with decreased 'social functioning' and 'emotional role functioning'. TOP results confirmed these findings: Quality of life was decreased in almost every dimension. TOP additionally identified sequels especially in domains of "Mental Functioning" and impairments in psychological recovery including post-traumatic stress disorder, depression and anxiety. Socioeconomic impairments were frequent including further hospitalisations (62%), duration of inability to work ≥ 6 month (54%), financial disadvantages (45%) and work loss (26%). CONCLUSION: Our results demonstrate that multiple trauma patients two years after injury suffer from impairments including persisting pain, functional deficits, mental and socioeconomic deficits. The 'Trauma Outcome Profile' instrument seems a proper tool to discover impairments in trauma patients early on and guide proper rehabilitation resources to the best of the patient.