Intravenous administration of mesenchymal stromal cells leads to a dose-dependent coagulopathy and is unable to attenuate acute traumatic coagulopathy in rats.

BACKGROUND: Mesenchymal stromal cells (MSCs) express surface tissue factor (TF), which may affect hemostasis and detract from therapeutic outcomes of MSCs if administered intravenously. In this study, we determine a safe dose of MSCs for intravenous (IV) administration and further demonstrate the impact of IV-MSC on acute traumatic coagulopathy (ATC) in rats. METHODS: Tissue factor expression of rat bone marrow-derived mesenchymal stromal cell (BMSC) or adipose-derived mesenchymal stromal cell (AMSC) was detected by immunohistochemistry and enzyme-linked immunosorbent assay. The coagulation properties were measured in MSC-treated rat whole blood, and blood samples were collected from rats after IV administration of MSCs. Acute traumatic coagulopathy rats underwent polytrauma and 40% hemorrhage, followed by IV administration of 5 or 10 million/kg BMSCs (BMSC-5, BMSC-10), or vehicle at 1 hour after trauma. RESULTS: Rat MSCs expressed TF, and incubation of rat BMSCs or AMSCs with whole blood in vitro led to a significantly shortened clotting time. However, a dose-dependent prolongation of prothrombin time with reduction in platelet counts and fibrinogen was found in healthy rat treated with IV-MSCs. Bone marrow-derived mesenchymal stromal cells at 5 million/kg or less led to minimal effect on hemostasis. Mesenchymal stromal cells were not found in circulation but in the lungs after IV administration regardless of the dosage. Acute traumatic coagulopathy with prolonged prothrombin time was not significantly affected by 5 or 10 million/kg BMSCs. Intravenous administration of 10 million/kg BMSCs led to significantly lower fibrinogen and platelet counts, while significantly higher levels of lactate, wet/dry weight ratio, and leukocyte infiltration in the lung were present compared with BMSC-5 or vehicle. No differences were seen in immune or inflammatory profiles with BMSC treatment in ATC rats, at least in the acute timeframe. CONCLUSION: Intravenous administration of MSCs leads to a risk of coagulopathy associated with a dose-dependent reduction in platelet counts and fibrinogen and is incapable of restoring hemostasis of rats with ATC after polytrauma and hemorrhagic shock.

Changes of pituitary adenylate cyclase activating polypeptide (PACAP) level in polytrauma patients in the early post-traumatic period.

In polytrauma patients who survive the primary insult, the imbalance between the pro- and anti-inflammatory processes seems to be responsible for life-threatening complications such as sepsis or multiple organ dysfunction syndrome. Measurement of C-reactive protein (CRP) and procalcitonin (PCT) is a standard way for differentiating between infectious (bacterial) and non-infectious inflammation. Monitoring of immune cell functions, like leukocyte anti-sedimentation rate (LAR) can also be useful to diagnose infectious complications. Pituitary adenylate cyclase activating polypeptide (PACAP) is a neuropeptide with well-known immunomodulatory and anti-inflammatory effects. The aim of our study was to determine the changes of PACAP38 levels in polytrauma patients in the early post-traumatic period in intensive care unit and analyse possible correlation of its level with conventional (CRP, PCT) and unconventional (LAR) laboratory parameters. Twenty polytrauma patients were enrolled. Blood samples were taken daily for five days. We observed significant correlation between PACAP38 and CRP levels on day 4 and 5 as well as between PACAP38 and LAR levels all of the days. This could be due to the anti-inflammatory and cytoprotective functions of PACAP38 as part of an endogenous response to the trauma induced systemic inflammatory response syndrome. These significant correlations could have clinical importance in monitoring the dynamic balance of pro- and anti-inflammatory processes in case of polytraumatic patients.

Prehospital evaluation and detection of induced coagulopathy in trauma: The PREDICT study.

BACKGROUND: Hemorrhage with trauma-induced coagulopathy (TIC) and hyperfibrinolysis (HF) increases the mortality risk after severe trauma. While TIC at hospital admission is well studied, little is known about coagulopathy at the incident site. The aim of the study was to investigate coagulation disorders already present on scene. METHODS: In a prospective single-center observational study, blood samples of trauma patients obtained before and at hospital admission were analyzed. Data on rotational thromboelastometry, blood gas analysis, prehospital treatment, injury severity, in-hospital blood transfusions, and mortality were investigated according to the presence of coagulation disorders at the incident site. The patients were divided into three groups according to the presence of coagulation disorders (no coagulopathy, TIC, TIC with HF). In a subgroup analysis, patients with a Trauma-Induced Coagulopathy Clinical Score (TICCS) of ≥10 were investigated. RESULTS: Between August 2015 and February 2018, 148 patients were enrolled in the study. The mean Injury Severity Score was 22.1, and overall mortality was 7.4%. Trauma-induced coagulopathy and HF were already detectable at the incident site in 18.2% and 6.1%, respectively. Patients with HF had significantly altered circulation parameters with significant changes in pH, hemoglobin, lactate, and base excess at the incident site. In patients with TICCS of ≥10 (14.2%), TIC was detected in 47.6% of the cases and HF in 28.6%. Furthermore, in these patients, blood gas parameters significantly changed and the need for blood transfusion and mortality. CONCLUSION: Trauma-induced coagulopathy and HF can be detected in severely injured patients even before medical treatment is started. Furthermore, in patients with HF and TICCS of ≥10, blood gas parameters were significantly changed at the incident site. LEVEL OF EVIDENCE: Prognostic study, level III.

Systemic T Cell Exhaustion Dynamics Is Linked to Early High Mobility Group Box Protein 1 (HMGB1) Driven Hyper-Inflammation in a Polytrauma Rat Model.

We previously reported an early surge in high mobility group box protein 1 (HMGB1) levels in a polytrauma (PT) rat model. This study investigates the association of HMGB1 levels in mediating PT associated dysregulated immune responses and its influence on the cellular levels of receptor for advanced glycation end products (RAGE) and toll-like receptor 4 (TLR4). Using the same PT rat model treated with anti-HMGB1 polyclonal antibody, we evaluated changes in circulating inflammatory cytokines, monocytes/macrophages and T cells dynamics and cell surface expression of RAGE and TLR4 at 1, 3, and 7 days post-trauma (dpt) in blood and spleen. Notably, PT rats demonstrating T helper (Th)1 and Th2 cells type early hyper-inflammatory responses also exhibited increased monocyte/macrophage counts and diminished T cell counts in blood and spleen. In blood, expression of RAGE and TLR4 receptors was elevated on CD68+ monocyte/macrophages and severely diminished on CD4+ and CD8+ T cells. Neutralization of HMGB1 significantly decreased CD68+ monocyte/macrophage counts and increased CD4+ and CD8+ T cells, but not γδ+TCR T cells in circulation. Most importantly, RAGE and TLR4 expressions were restored on CD4+ and CD8+ T cells in treated PT rats. Overall, findings suggest that in PT, the HMGB1 surge is responsible for the onset of T cell exhaustion and dysfunction, leading to diminished RAGE and TLR4 surface expression, thereby possibly hindering the proper functioning of T cells.

Identification of unique microRNA expression patterns in bone marrow hematopoietic stem and progenitor cells after hemorrhagic shock and multiple injuries in young and old adult mice.

BACKGROUND: After severe trauma, the older host experiences more dysfunctional hematopoiesis of bone marrow (BM) hematopoietic stem and progenitor cells (HSPCs), and dysfunctional differentiation of circulating myeloid cells into effective innate immune cells. Our main objective was to compare BM HSPC microRNA (miR) responses of old and young mice in a clinically relevant model of severe trauma and shock. METHODS: C57BL/6 adult male mice aged 8 to 12 weeks (young) and 18 to 24 months (old) underwent multiple injuries and hemorrhagic shock (polytrauma [PT]) that engenders the equivalent of major trauma (Injury Severity Score, >15). Pseudomonas pneumonia (PNA) was induced in some young and old adult mice 24 hours after PT. MicroRNA expression patterns were determined from lineage-negative enriched BM HSPCs isolated from PT and PT-PNA mice at 24 and 48 hours postinjury, respectively. Genome-wide expression and pathway analyses were also performed on bronchoalveolar lavage (BAL) leukocytes from both mouse cohorts. RESULTS: MicroRNA expression significantly differed among all experimental conditions (p < 0.05), except for old-naive versus old-injured (PT or PT-PNA) mice, suggesting an inability of old mice to mount a robust early miR response to severe shock and injury. In addition, young adult mice had significantly more leukocytes obtained from their BAL, and there were greater numbers of polymorphonuclear cells compared with old mice (59.8% vs. 2.2%, p = 0.0069). Despite increased gene expression changes, BAL leukocytes from old mice demonstrated a more dysfunctional transcriptomic response to PT-PNA than young adult murine BAL leukocytes, as reflected in predicted upstream functional pathway analysis. CONCLUSION: The miR expression pattern in BM HSPCs after PT (+/-PNA) is dissimilar in old versus young adult mice. In the acute postinjury phase, old adult mice are unable to mount a robust miR HSPC response. Hematopoietic stem and progenitor cell miR expression in old PT mice reflects a diminished functional status and a blunted capacity for terminal differentiation of myeloid cells.

Extrathoracic multiple trauma dysregulates neutrophil function and exacerbates pneumonia-induced lung injury.

BACKGROUND: Forty percent of critically ill trauma patients will develop an infectious complication. Pneumonia is the most common cause of death of trauma patients surviving their initial insult. We previously demonstrated that polytrauma (PT), defined as two or more severe injuries in at least two areas of the body, induces emergency hematopoiesis characterized by accelerated myelopoiesis in the bone marrow and increased myeloid cell frequency in the peripheral tissues. We hypothesized that PT alone induces priming of neutrophils, resulting in hyperactivation upon secondary exposure to bacteria and causing acute lung injury and increased susceptibility to secondary exposure to Pseudomonas aeruginosa pneumonia. METHODS: C57BL/6 mice were subjected to PT consisting of a lower extremity pseudofracture, liver crush injury, and 15% blood-volume hemorrhage. Pneumonia was induced by intratracheal injection of 5 × 106 CFU live P. aeruginosa or 1 × 107 of heat-killed P. aeruginosa (HKPA). For reactive oxygen species (ROS), studies polymorphonuclear neutrophils (PMNs) were isolated by immunomagnetic bead negative selection and stimulated ex-vivo with HKPA. Reactive oxygen species production was measured by immunofluorescence. For histology, lung sections were stained by hematoxylin-eosin and analyzed by a blinded grader. RESULTS: Polytrauma induced persistent changes in immune function at baseline and to secondary infection. Pneumonia after injury resulted in increased mortality (60% vs. 5% p < 0.01). Blood neutrophils from PT mice had higher resting (unstimulated) ROS production than in naive animals (p < 0.02) demonstrating priming of the neutrophils following PT. After intratracheal HKPA injection, bronchoalveolar lavage PMNs from injured mice had higher ROS production compared with naive mice (p < 0.01), demonstrating an overexuberant immunopathologic response of neutrophils following PT. CONCLUSION: Polytrauma primes neutrophils and causes immunopathologic PMN ROS production, increased lung injury and susceptibility to secondary bacterial pneumonia. These results suggest that trauma-induced immune dysfunction can cause immunopathologic response to secondary infection and suggests neutrophil-mediated pulmonary damage as a therapeutic target for posttrauma pneumonia.

Valproic Acid Protects Against Acute Kidney Injury in Hemorrhage and Trauma.

INTRODUCTION: Trauma is the leading cause of death among young people. These patients have a high incidence of kidney injury, which independently increases the risk of mortality. As valproic acid (VPA) treatment has been shown to improve survival in animal models of lethal trauma, we hypothesized that it would also attenuate the degree of acute kidney injury. METHODS: We analyzed data from two separate experiments where swine were subjected to lethal insults.  Model 1: hemorrhage (50% blood volume hemorrhage followed by 72-h damage control resuscitation). Model 2: polytrauma (traumatic brain injury, 40% blood volume hemorrhage, femur fracture, rectus crush and grade V liver laceration). Animals were resuscitated with normal saline (NS) +/- VPA 150 mg/kg after a 1-h shock phase in both models (n = 5-6/group). Serum samples were analyzed for creatinine (Cr) using colorimetry on a Liasys 330 chemistry analyzer. Proteomic analysis was performed on kidney tissue sampled at the time of necropsy. RESULTS: VPA treatment significantly (P < 0.05) improved survival in both models. (Model 1: 80% vs 20%; Model 2: 83% vs. 17%). Model 1 (Hemorrhage alone): Cr increased from a baseline of 1.2 to 3.0 in NS control animals (P < 0.0001) 8 h after hemorrhage, whereas it rose only to 2.1 in VPA treated animals (P = 0.004). Model 2 (Polytrauma): Cr levels increased from baseline of 1.3 to 2.5 mg/dL (P = 0.01) in NS control animals 4 h after injury but rose to only 1.8 in VPA treated animals (P = 0.02). Proteomic analysis of kidney tissue identified metabolic pathways were most affected by VPA treatment. CONCLUSIONS: A single dose of VPA (150 mg/kg) offers significant protection against acute kidney injury in swine models of polytrauma and hemorrhagic shock.

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.

Effect of Massive Transfusion Protocol on Coagulation Function in Elderly Patients with Multiple Injuries.

OBJECTIVE: To evaluate the effect of massive transfusion protocol on coagulation function in elderly patients with multiple injuries. METHODS: In this retrospective cohort study, clinical data were collected from a total of 94 elderly patients with multiple injuries, including 44 cases who received routine transfusion protocol (control group) and 50 cases who concurrently received massive transfusion protocol in our hospital (research group). The changes in platelet parameters, coagulation function, and organ dysfunction scores at admission and 24 h after transfusion were compared between the two groups. The 24-hour plasma and red blood cell transfusion volume, length of stay, complications, and mortality of the two groups were analyzed statistically. RESULTS: Twenty-four hours after blood transfusion, the hematocrit, platelets, and hemoglobin in the research group were higher than those in the control group, while the activated partial thromboplastin time, prothrombin time, thrombin time, fibrinogen, and scores of Marshall scoring system and Sequential Organ Failure Assessment were lower than those in the control group (P < 0.01). The 24-hour plasma transfusion volume was higher, and the length of intensive care unit (ICU) stay and total length of stay were lower in the research group compared with the control group (P < 0.01). No significant difference was found in the mortality rate between the research group and the control group (10.00% vs. 13.64%, P > 0.05). The incidence of complications in the research group was lower than that in the control group (12.00% vs. 31.82%, P < 0.05). CONCLUSION: Massive transfusion protocol for elderly patients with multiple injuries can improve their coagulation function and platelet parameters, alleviate organ dysfunction, shorten length of ICU stay, and decrease the incidence of complications, which is conducive to improving the prognosis of patients.

Arachidonic Acid-Dependent Pathway Inhibition in Platelets: its Role in Multiple Injury-Induced Coagulopathy and the Potential Mechanisms.

BACKGROUND: Our previous study demonstrated the types of platelet dysfunction varied at early stage (∼3 h) in trauma-induced coagulopathy (TIC) caused by different types of injuries. And arachidonic acid (AA)-dependent pathway inhibition in platelet seemed to be specific for TIC caused by multiple injury (MI). The aim of this research was to further study AA-dependent pathway inhibition in platelets in a rat model of TIC caused by MI and to explore its potential mechanisms. METHODS: Sprague-Dawley rat model of TIC caused by MI was established. We used thrombelastography with platelet mapping as a measure of platelet function to assess the inhibitory extent of AA-dependent activation pathway. Flow cytometry was used to determine the expression of activation-dependent granular protein P-selectin (CD62P). In addition, the plasma levels of 6-Keto-prostaglandin F1 alpha (6-Keto-PGF1α), Prostaglandin E2, and Thromboxane B2 were assessed by enzyme-linked immuno sorbent assay. RESULTS: The inhibition rate of AA-dependent pathway after injury was significantly higher than that of control. The maximum amplitude decreased in the MI group, compared with that of control. The percentage of CD62P expression in the MI group was remarkably lower than that of control after AA treatment. The plasma concentrations of 6-Keto-PGF1α and PGE2 increased in the MI group. CONCLUSION: Platelets inhibition was observed in TIC caused by MI at early stage after injury, which might be partially attributed to AA-dependent activation pathway dysfunction. The increase of plasma Prostacyclin and PGE2 levels may contribute to the inhibition process.

Hematological and Chemical Profiles in a Porcine Model of Severe Multiple Trauma.

BACKGROUND: Clinical chemistry and hematological tests are widely used to monitor the clinical course of several diseases. However, these parameters are sparse in large-animal models of multiple trauma (MT). Thus, we aimed to provide these missing data to improve future experimental setups in trauma research. METHODS: Male pigs (German Landrace pigs) were randomized into either an MT group (n = 8) including blunt thoracic trauma, tibial fracture, and controlled hemorrhage or a sham group (n = 8) without any trauma. After trauma induction, all animals received intensive care treatment for 72 h under anesthesia, including mechanical ventilation and volume resuscitation. Blood and urine samples were obtained to measure common hematological and chemical parameters before trauma (0 h), after trauma (1.5 h), during resuscitation (2.5 h), after fracture stabilization (3.5 h), and at 12, 24, 48, and 72 h. Statistical analyses were performed using a linear mixed model (group × time) and Welch's ANOVA. RESULTS: MT led to a perceptible immunological reaction. Between groups, significantly different time courses of leukocyte counts (p = 0.034) and lymphocyte proportions (p = 0.001) were observed. Moreover, MT changed the time course of total protein (p = 0.006). Significantly lower concentrations compared to sham were found in MT at each single time point starting at 1.5 h to the end of the observation period (all p < 0.05). CONCLUSIONS: Our results indicate that a traumatic insult leads to significant alterations in the immune system already shortly after trauma. Together with the additional catabolic reactions observed, these alterations might contribute to the occurrence of later complications. The presented data provide valid references for further experimental setups with prolonged observation times, especially in similar porcine models of MT.

Complement C5a Induces Pro-inflammatory Microvesicle Shedding in Severely Injured Patients.

Initially underestimated as platelet dust, extracellular vesicles are continuously gaining interest in the field of inflammation. Various studies addressing inflammatory diseases have shown that microvesicles (MVs) originating from different cell types are systemic transport vehicles carrying distinct cargoes to modulate immune responses. In this study, we focused on the clinical setting of multiple trauma, which is characterized by activation and dysfunction of both, the fluid-phase and the cellular component of innate immunity. Given the sensitivity of neutrophils for the complement anaphylatoxin C5a, we hypothesized that increased C5a production induces alterations in MV shedding of neutrophils resulting in neutrophil dysfunction that fuels posttraumatic inflammation. In a mono-centered prospective clinical study with polytraumatized patients, we found significantly increased granulocyte-derived MVs containing the C5a receptor (C5aR1, CD88) on their surface. This finding was accompanied by a concomitant loss of C5aR1 on granulocytes indicative of an impaired cellular chemotactic and pro-inflammatory neutrophil functions. Furthermore, in vitro exposure of human neutrophils (from healthy volunteers) to C5a significantly increased MV shedding and C5aR1 loss on neutrophils, which could be blocked using the C5aR1 antagonist PMX53. Mechanistic analyses revealed that the interaction between C5aR1 signaling and the small GTPase Arf6 acts as a molecular switch for MV shedding. When neutrophil derived, C5a-induced MV were exposed to a complex ex vivo whole blood model significant pro-inflammatory properties (NADPH activity, ROS and MPO generation) of the MVs became evident. C5a-induced MVs activated resting neutrophils and significantly induced IL-6 secretion. These data suggest a novel role of the C5a-C5aR1 axis: C5a-induced MV shedding from neutrophils results in decreased C5aR1 surface expression on the one hand, on the other hand it leads to profound inflammatory signals which likely are both key drivers of the neutrophil dysfunction which is regularly observed in patients suffering from multiple traumatic injuries.

Characterization of the cortisol response to traumatic hemorrhage and intra-abdominal contamination models in Cynomologus Macaques.

INTRODUCTION: Trauma, hemorrhage, and peritonitis have widely varying impacts on endocrine response in the injured patient. We sought to examine cortisol response in established non-human primate models of traumatic hemorrhage and intra-abdominal contamination. METHODS: Cynomologus Macaques were separated into two experimental groups, the polytrauma and hemorrhage model, involving a laparoscopic liver resection with uncontrolled hemorrhage, cecal perforation, and soft tissue excision; and the traumatic hemorrhage model, involving only liver resection and uncontrolled hemorrhage. Cortisol levels were measured pre-operatively, at the time of injury, and at regular intervals until post-operative day 1. RESULTS: Cortisol levels increased 600% from the pre-operative value in the polytrauma and hemorrhage model, with minimal changes (20%) in the hemorrhage only model. CONCLUSION: Cortisol levels increase dramatically in response to polytrauma and intra-abdominal contamination as compared to hemorrhage only. The lack of response in the hemorrhage only group may be due to relative adrenal insufficiency caused by the shock state or lack of enticing stimuli from fecal peritonitis.

Reaming of femoral fractures with different reaming irrigator aspirator systems shows distinct effects on cardiac function after experimental polytrauma.

Cardiac injuries are recorded after multiple trauma and are associated with a poor patient outcome. Reaming prior to locked intramedullary nailing is a frequently used technique to stabilize femoral diaphysis fractures. However, in polytraumatized patients, complications such as fat emboli and acute respiratory distress syndrome have been associated with reaming. The reaming irrigator aspirator (RIA) system provides concomitant irrigation and suction of the intramedullary contents, and should, therefore, reduce reaming-associated complications. The aim of the study was to investigate cardiac function after multiple trauma with regard to two different RIA devices (RIAI vs RIAII). 15 male pigs were included in the study. Pigs received either sham treatment or multiple trauma (chest trauma, femur fracture, liver laceration, and hemorrhagic shock), followed by intramedullary nailing after reaming with either the RIAI or RIAII system (RIAII: reduced diameter of the reamer, improved control of irrigation and suction). Cardiac function was assessed by transesophageal echocardiography and systemic inflammation as well as local cardiac damage examined. Pigs of both treatment groups showed impaired cardiac function, valvular insufficiency, and cardiac damage. Systemic inflammation and local cardiac alterations were observed which might contribute to early myocardial damage in vivo. Multiple trauma including long-bone fracture and subsequent intramedullary reaming induces cardiac dysfunction and valvular insufficiency, which might be linked to both mechanical cardiac injury and increased systemic inflammation. 6 hours after trauma there are less differences between RIAI and RIAII treatment with regard to post-traumatic cardiac consequences in multiple injured pigs, indicating no beneficial effect of RIAII over RIAI.

Increased S-100 B levels are associated with fractures and soft tissue injury in multiple trauma patients.

BACKGROUND: S-100 B protein was identified as a biomarker for traumatic brain injury, but studies suggest that extracranial injuries may also lead to increased S-100 B serum levels. In this study, we aim to quantify the impact of injury patterns on S-100 B levels in patients with suspected multiple trauma. METHODS: Patients with suspected multiple trauma treated at a Level 1 Trauma centre in Switzerland were included in this retrospective patient chart review. Extent of injuries and severity was assessed and S-100 B levels on admission measured. Potential predictors of increased S-100 B levels (>0.2 µg/L) were identified through uni- and multivariable analyses. RESULTS: In total, 1,338 patients with suspected multiple trauma were included. Multivariable logistic regression showed a significant association with increased S-100 B levels in long bone fracture (OR 2.3, 95% CI: 1.3-4.1, p = 0.004), non-long bone fracture (OR 3.0, 95% CI: 2.2-4.3, p<0.001), thoracic injury (OR 2.6, 95% CI: 1.6-4.2, p<0.001), and deep tissue injury/wounds (OR 1.9, 95% CI: 1.4-2.6, p<0.001). Head trauma with intracerebral bleeding was only weakly associated (OR 2.0, 95% CI 1.2-3.5, p = 0.01) and head trauma without intracranial bleeding was not associated with an increased S-100 B protein level (p = 0.71). Trauma severity was also related to increased S-100 B levels (OR per ISS: 1.1, 95% CI 1.0-1.1, p<0.001). S-100 B levels <0.57 µg/L had a high diagnostic value to rule out in-hospital mortality (negative predictive value: 1.0, 95% CI: 0.98-1.00). CONCLUSION: Fractures and thoracic injuries appeared as main factors associated with increased S-100 B levels. Head injury may only play a minor role in S-100 B protein elevation in multiple trauma patients. A normal S-100 B has a good negative predictive value for in-hospital mortality. S100-B levels were associated with trauma severity and might thus be of use as a prognostic marker in trauma patients.

Study on coagulation profiles and platelet function in trauma-induced coagulopathy caused by three types of injury.

BACKGROUND: Traumatic coagulopathy is a major public health issue globally with undefined mechanisms. We established rat models of hemorrhagic shock (HS), multiple injury (MI) and traumatic brain injury (TBI) to investigate the diversity of traumatic coagulopathy, especially platelet dysfunction. METHODS: Seventy male SD rats were divided randomly into seven groups(n = 10): control, HS30min, HS3h, MI30min, MI3h, TBI30min and TBI3h. Plasma or whole blood was collected for conventional coagulation tests, thromboelastography and platelet mapping. X-ray, 7T magnetic resonance imaging and hematoxylin-eosin staining of injured tissues were conducted to confirm the injuries of rats model. RESULTS: The activated partial thromboplastin time (aPTT) prolonged significantly in HS30min and MI3h groups, compared with those in control (P = 0.0403 and P = 0.0076, respectively). R values decreased in HS30min and HS3h groups, compared with those in control (P < 0.0001 and P < 0.0001, respectively). The maximum amplitude (MA) were 71.8 ± 0.6 mm, 71.9 ± 0.5 mm, 71.8 ± 0.7 mm, 70.0 ± 0.7 mm, 72.6 ± 0.9 mm, 70.4 ± 0.9 mm in HS30min, HS3h, MI30min, MI3h, TBI30min and TBI3h groups respectively, which were lower than those in control (P = 0.0304, P = 0.0205, P = 0.0431, P = 0.0007 and P = 0.0066, respectively). The platelet counts were 539±46 × 109/L, 523±31 × 109/L, 629 ± 18 × 109/L and 636±20 × 109/L in HS30min, HS3h, MI3h and TBI3h groups respectively, which were lower than those in control (P = 0.0040, P = 0.0001, P = 0.0127 and P = 0.0232, respectively). The adenosine diphosphate (ADP) inhibition rate decreased in HS30min group, compared with that in control (P = 0.0355). While, ADP inhibition rate increased in HS3h and TBI3h groups (P = 0.0041 and P = 0.0433 vs. control, respectively). The arachidonic acid (AA) inhibition rate increased in MI30min and MI3h groups, compared with control (P = 0.0029 and P = 0.0185, respectively). CONCLUSION: These results demonstrated that it might be the failure of forming a strong clot instead of the prolonged clot time, which contributed to traumatic coagulopathy. The platelet dysfunctions might contribute to trauma-induced coagulopathy in different ways. The loss of platelets might be the main reason for HS-induced coagulopathy. While, AA-dependent pathway inhibition might account for MI-induced coagulopathy. ADP-dependent pathway inhibition might be the major contributor for TBI-induced coagulopathy.

Effects of in-house cryoprecipitate on transfusion usage and mortality in patients with multiple trauma with severe traumatic brain injury: a retrospective cohort study.

BACKGROUND: Hypofibrinogenaemia is a common complication of multiple trauma with severe traumatic brain injury (Abbreviated Injury Scale score of the head ≥4; body ≥3). In Japan, neither fibrinogen concentrate nor cryoprecipitate is permitted to treat acquired hypofibrinogenaemia with the purpose of rapidly restoring a haemostatic level of fibrinogen. The aim of this study was to investigate transfusion usage and mortality in patients with multiple trauma and severe traumatic brain injury who were given a cryoprecipitate prepared in-house, comparing those administered the product early or later. MATERIAL AND METHODS: We prepared and produced cryoprecipitate from fresh-frozen plasma beginning in March 2013. We performed a retrospective cohort study of patients admitted to our single tertiary medical centre with severe multiple trauma with traumatic brain injury from March 2013 to June 2018, sorting them into those given the cryoprecipitate infusion within 90 minutes of admission (Early group) and those given it more than 90 minutes after admission (Late group). Clinical outcomes were compared between the two groups using chi-square or Fisher's exact tests and the Wilcoxon test as appropriate. RESULTS: There were 26 and 16 patients in the Early and Late groups, respectively. The 24-hour mortality tended to be lower in the Early group than in the Late group (8 vs 13%, respectively). The patients were more severely anaemic and thrombocytopenic after haemostatic therapy in the Late group than in the Early group. Transfusion usage in the Early group was lower than that in the Late group (red blood cells: 7±1 units vs 17±3 units, p<0.05; fresh-frozen plasma: 9±1 units vs 16±3 units, p<0.05; platelet concentrate: 3±1 units vs 15±4 units, p<0.05, respectively). DISCUSSION: Early administration of an in-house cryoprecipitate may reduce transfusion usage in patients with multiple trauma with severe traumatic brain injury.

Severe Trauma and Hemorrhage Leads to Platelet Dysfunction and Changes in Cyclic Nucleotides in The Rat.

INTRODUCTION: Rats subjected to polytrauma and hemorrhage develop a coagulopathy that is similar to acute coagulopathy of trauma in humans, and is associated with a rise in prothrombin time and a fall in clot strength. Because platelet aggregation accounts for a major proportion of clot strength, we set out to characterize the effects of polytrauma on platelet function. METHODS: Sprague-Dawley rats were anesthetized with isoflurane. Polytrauma included laparotomy and damage to 10 cm of the small intestines, right and medial liver lobes, right leg skeletal muscle, femur fracture, and hemorrhage (40% of blood volume). No resuscitation was given. Blood samples were taken before and after trauma for the measurement of impedance electrode aggregometry, and intracellular levels of cyclic adenosine and guanosine monophosphate (cAMP, cGMP), inositol trisphosphate (IP3), and adenosine and guanosine triphosphates (ATP, GTP). RESULTS: Polytrauma significantly increased the response of collagen (24%) and thrombin (12%) to stimulate platelet aggregation. However, aggregation to adenosine diphosphate (ADP) or arachidonic acid (AA) was significantly decreased at 2 (52% and 46%, respectively) and 4 h (45% and 39%). Polytrauma and hemorrhage also led to a significant early rise in cAMP (101 ±â€Š11 to 202 ±â€Š29 pg/mL per 1,000 platelets), mirrored by a decrease in cGMP (7.8 ±â€Š0.9 to 0.6 ±â€Š0.5). In addition, there was a late fall in ATP (8.1 ±â€Š0.7 to 2.2 ±â€Š0.6 ng/mL per 1,000 platelets) and GTP (1.5 ±â€Š0.2 to 0.3 ±â€Š0.1). IP3 rose initially, and then fell back to baseline. CONCLUSIONS: Polytrauma and hemorrhage led to a deficit in the platelet aggregation response to ADP and AA after trauma, likely due to the early rise in cAMP, and a later fall in energy substrates, and may explain the decrease in clot strength and impaired hemostasis observed after severe trauma.