Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people.

Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.

Flow Cytometric Analysis of Hematopoietic Populations in Rat Bone Marrow. Impact of Trauma and Hemorrhagic Shock.

Severe injury and hemorrhagic shock (HS) result in multiple changes to hematopoietic differentiation, which contribute to the development of immunosuppression and multiple organ failure (MOF). Understanding the changes that take place during the acute injury phase may help predict which patients will develop MOF and provide potential targets for therapy. Obtaining bone marrow from humans during the acute injury phase is difficult so published data are largely derived from peripheral blood samples, which infer bone marrow changes that reflect the sustained inflammatory response. This preliminary and opportunistic study investigated leucopoietic changes in rat bone marrow 6 h following traumatic injury and HS. Terminally anesthetized male Porton Wistar rats were allocated randomly to receive a sham operation (cannulation with no injury) or femoral fracture and HS. Bone marrow cells were flushed from rat femurs and immunophenotypically stained with specific antibody panels for lymphoid (CD45R, CD127, CD90, and IgM) or myeloid (CD11b, CD45, and RP-1) lineages. Subsequently, cell populations were fluorescence-activated cell sorted for morphological assessment. Stage-specific cell populations were identified using a limited number of antibodies, and leucopoietic changes were determined 6 h following trauma and HS. Myeloid subpopulations could be identified by varying levels CD11b expression, CD45, and RP-1. Trauma and HS resulted in a significant reduction in total CD11b + myeloid cells including both immature (RP-1(-)) and mature (RP-1+) granulocytes. Multiple B-cell lymphoid subsets were identified. The total percentage of CD90+ subsets remained unchanged following trauma and HS, but there was a reduction in the numbers of maturing CD90(-) cells suggesting movement into the periphery. © 2019 The Authors. Cytometry Part A published by Wiley Periodicals, Inc. on behalf of International Society for Advancement of Cytometry.

Modeling Acute Traumatic Hemorrhagic Shock Injury: Challenges and Guidelines for Preclinical Studies.

Trauma is responsible for a large proportion of the world's burden of disease, and is by far the biggest killer of young adults. Hemorrhage is the leading cause of preventable death and its effects are directly correlated with the incidence multi-organ failure in survivors. Trauma research is challenging due to patient heterogeneity, limited randomized controlled trials, and in vitro studies that fail to mimic the systemic injury response. Preclinical research remains essential for mechanistic and therapeutic discovery. Yet modeling the multifaceted nature of traumatic injury poses important experimental and welfare challenges associated with the onset of injury and prehospital and intra-operative care, the limited inter-species validation of coagulation profiles, the use of anesthesia/analgesia, and its impact on the systemic response to trauma; and the challenge of sustaining intensive care in recovery models. Proper model selection depends on the purpose of a given model and the criteria by which the experimental readouts will be clinically relevant. Such complexity warrants further refinement of experimental methodology and outcome measures to improve its clinical efficacy, while ensuring animal well-being. We review the experimental methodologies currently used for modeling traumatic hemorrhagic shock and addressing their impact on clinical translation. The aim of the review is to improve transparency and form a consensus when reporting methodology in trauma modeling.

Blast Wave Exposure to the Extremities Causes Endothelial Activation and Damage.

Extremity injury is a significant burden to those injured in explosive incidents and local ischaemia can result in poor functionality in salvaged limbs. This study examined whether blast injury to a limb resulted in a change in endothelial phenotype leading to changes to the surrounding tissue.The hind limbs of terminally anaesthetized rabbits were subjected to one of four blast exposures (high, medium, low, or no blast). Blood samples were analyzed for circulating endothelial cells pre-injury and at 1, 6, and 11 h postinjury as well as analysis for endothelial activation pre-injury and at 1, 6, and 12  h postinjury. Post-mortem tissue (12  h post-injury) was analysed for both protein and mRNA expression and also for histopathology. The high blast group had significantly elevated levels of circulating endothelial cells 6  h postinjury. This group also had significantly elevated tissue mRNA expression of IL-6, E-selection, TNF-α, HIF-1, thrombomodulin, and PDGF. There was a significant correlation between blast dose and the degree of tissue pathology (hemorrhage, neutrophil infiltrate, and oedema) with the worst scores in the high blast group. This study has demonstrated that blast injury can activate the endothelium and in some cases cause damage that in turn leads to pathological changes in the surrounding tissue. For the casualty injured by an explosion the damaging effects of hemorrhage and shock could be exacerbated by blast injury and vice versa so that even low levels of blast become damaging, all of which could affect tissue functionality and long-term outcomes.

A pre-clinical evaluation of silver, iodine and Manuka honey based dressings in a model of traumatic extremity wounds contaminated with Staphylococcus aureus.

Prevention of extremity war wound infection remains a clinical challenge. Staphylococcus aureus is the most common pathogen in delayed infection. We hypothesised that choice of wound dressings may affect bacterial burden over 7 days reflecting the current practice of delayed primary closure of wounds within this timeframe. A randomised controlled trial of 3 commercially available dressings (Inadine(®) (Johnson & Johnson, NJ, USA), Acticoat(®) (Smith & Nephew, Hull, UK), Activon Tulle (Advancis Medical, Nottingham, UK)) was conducted in a rabbit model of contaminated forelimb muscle injury. A positive control group treated with antibiotics was included. Groups were compared to a saline soaked gauze control. The primary outcome was a statistically significant reduction (p < 0.05) in tissue S. aureus at 7 days post-injury. Secondary outcome measurements included bacteraemias, observational data, whole blood determination, ELISA for plasma biomarkers, PCR array analysis of wound healing gene expression and muscle/lymph node histopathology. Antibiotic, Inadine and Acticoat groups had statistically significant lower bacterial counts (mean 7.13 [95% CI 0.00-96.31]×10(2); 1.66 [0.94-2.58]×10(5); 8.86 [0.00-53.35]×10(4)cfu/g, respectively) and Activon Tulle group had significantly higher counts (2.82 [0.98-5.61]×10(6)cfu/g) than saline soaked gauze control (7.58 [1.65-17.83]×10(5)cfu/g). There were no bacteraemias or significant differences in observational data or whole blood determination. There were no significant differences in muscle/loss or pathology and lymph node cross-sectional area or morphology. There were some significant differences between treatment groups in the plasma cytokines IL-4, TNFα and MCP-1 in comparison to the control. PCR array data demonstrated more general changes in gene expression in the muscle tissue from the Activon Tulle group than the Inadine or Acticoat dressings with a limited number of genes showing significantly altered expression compared to control. This study has demonstrated that both Acticoat(®) and Inadine(®) dressings can reduce the bacteria burden in a heavily contaminated soft tissue wound and so they may offer utility in the clinical setting particularly where surgical treatment is delayed.

Endothelial activation and chemoattractant expression are early processes in isolated blast brain injury.

Blast injuries are an increasing problem in military conflicts and terrorist incidents. Blast-induced traumatic brain injury has risen to prominence and represents a specific form of primary brain injury, with sufficiently different physical attributes (and possibly biological consequences) to be classified separately. There is increasing interest in the role of blast in initiating inflammatory responses, which may be linked to the pathological processes seen clinically. Terminally anaesthetised rats were exposed to a blast wave directed at the cranium, using a bench-top blast wave generator. Control animals were not exposed to blast. Animals were killed after 8 h, and the brains examined for evidence of an inflammatory response. Compared to controls, erythropoietin, endothelial integrins, ICAM and sVCAM, and the pro-inflammatory cytokine, monocyte chemoattractant protein-1 (MCP-1) were significantly elevated. Other pro-inflammatory cytokines, including MIP-1α, were also detectable, but levels did not permit accurate quantification. Six inflammatory genes examined by qRT-PCR exhibited a biologically significant increase in activity in the blast-exposed animals. These included genes supporting chemokines responsible for monocyte recruitment, including MCP-1, and chemokines influencing T cell movement. Brain injury is usually accompanied by pathological neuro-inflammation. This study shows that blast brain injury is no exception, and the data provide important mechanistic clues regarding the drivers of such inflammation. Whilst this effect alone is unlikely to be responsible for the totality of consequences of blast brain injury, it suggests a mechanism that may be priming the cerebral inflammatory response and rendering cerebral tissue more susceptible to the deleterious effects of systemic inflammatory reactions.

The development of an experimental model of contaminated muscle injury in rabbits.

Extent of tissue trauma and contamination determine outcome in extremity injury. In contrast to fracture, osteomyelitis, and closed muscle injury studies, there are limited small animal models of extremity muscle trauma and contamination. To address this we developed a model of contaminated muscle injury in rabbits. Twenty-eight anesthetized New Zealand White rabbits underwent open controlled injury of the flexor carpi ulnaris (FCU). Twenty-two animals had subsequent contamination of the injured muscle with Staphylococcus aureus. All animals were sacrificed at 48 hours and the level of muscle injury and contamination determined by quantitative histological and microbiological analysis. A 1-kg mass dropped 300 mm onto the mobilized FCU resulted in localized necrosis of the muscle belly. Delivery of a mean challenge of 3.71 × 10(6) cfu/100 µL S aureus by droplet spread onto the injured muscle produced a muscle contamination of 8.79 × 10(6) cfu/g at 48 hours. Ipsilateral axillary lymph nodes demonstrated clinically significant activation. All animals had normal body temperature and hematological parameters throughout and blood and urinalysis culture at autopsy were negative for organisms. This model allows reproducible muscle injury and contamination with the organism ubiquitous to extremity wound infection at a level sufficient to allow quantitative assessment of subsequent wound care interventions without incurring systemic involvement.

Extremity trauma, dressings, and wound infection: should every acute limb wound have a silver lining?

The manner in which high-energy transfer limb injuries are dressed can alter the wound environment through manipulation of the bacterial burden, thus minimizing tissue degradation and influencing healing potential. Infection is the principal complication of such wounds, and antiseptic soaked gauze is accepted in early coverage of extremity wounds despite a lack of evidence to support this practice. There has been resurgence in the use of silver in acute wounds, through dressings manipulated to deliver sustained elemental silver to the wound interface. In vitro and in vivo experimentation of silver dressings are characterized however by methodological compromise, primarily through lack of similarity of models to the physiology of the healing wound. Results from in vitro studies caution against the use of silver because of evidence of cytotoxicity, but this is not reproduced in in vivo or clinical experimentation, leading to ambiguity. Review of silver dressing application in burns and chronic wound studies fails to support its use over other dressing systems. Similarly, evidence for the use of silver in acute limb wounds is lacking. This article provides a comprehensive overview of the use of silver dressings in acute wound care and highlights in particular the paucity of evidence regarding its routine use in extremity injury.

Limb wounding and antisepsis: iodine and chlorhexidine in the early management of extremity injury.

Extremity injury and contamination as consequence are features of high-energy wounding. A leading cause of disability and the commonest cause of late complications, prevention of wound infection determines the ultimate outcome in these populations. Multiple variables influence the development of infection, one of which is the dressing used on the wound. Antiseptic-soaked gauze dressings feature in the early management of limb trauma despite a lack of evidence to support this. Iodine and chlorhexidine are ubiquitous in other aspects of health care however, and a plethora of studies detail their role in skin antisepsis, the recommendations from which are often anecdotally applied to acute wounding. To contextualize the role for antiseptic dressing use in acute, significant limb injury this review explores the evidence for the use of chlorhexidine and iodine in skin antisepsis. The paucity of experimental data available for antiseptic use in early wound management and the need for further research to address this evidence void is highlighted.

Cardiopulmonary effects of combined xylazine-guaiphenesin-ketamine infusion and extradural (inter-coccygeal lidocaine) anaesthesia in calves.

OBJECTIVE: To investigate the cardiopulmonary effects of a xylazine-guaiphenesin-ketamine infusion combined with inter-coccygeal extradural (lidocaine) anaesthesia in calves. STUDY DESIGN: Prospective study. ANIMALS: Five Holstein Friesian calves (one steer, four heifers) aged 6 weeks weighing 65.2 +/- 2.7 kg. MATERIALS AND METHODS: Calves were anaesthetized with isoflurane in oxygen for instrumentation. At least 12 hours later, xylazine (0.2 mg kg(-1) i.m.) was given. After 15 minutes, an infusion of xylazine hydrochloride (0.1 mg mL(-1)), guaiphenesin (50 mg mL(-1)) and ketamine (1 mg mL(-1)) (X-G-K) was infused at a rate of 1.1 mL kg(-1) hour-1 i.v. Oxygen (4 L minute(-1)) was delivered by nasotracheal tube 30 minutes later. Inter-coccygeal (Co1-Co2) extradural anaesthesia (lidocaine 2%, 0.18 mL kg(-1)) was administered 30 minutes later. Cardiopulmonary variables were obtained in the unsedated standing calves 10 minutes after xylazine, 15 and 30 minutes after X-G-K without O2, 15 and 30 minutes after X-G-K with O2 and 5, 15, 30, 45 and 60 minutes after extradural anaesthesia. Data were analysed using a repeated measurement analysis of variance including an autoregressive covariance structure of order 1 (correlations at different time intervals). RESULTS: Xylazine caused significant (p<0.05) decreases in heart rate (HR), cardiac output (Qt) and index (CI), stroke volume and stroke index, mean, systolic and diastolic arterial blood pressure (MAP, SAP, DAP), left (LVWSI) and right ventricular stroke work index (RVWSI), mean, systolic and diastolic pulmonary arterial pressure (MPAP, SPAP, DPAP), arterial pH, arterial oxygen tension (PaO2), arterial base excess, arterial HCO3- concentration, arterial saturation, packed cell volume, arterial and venous oxygen content (CaO2, CvO2), O2 consumption and O2 delivery (VO2, DO2). Increases in systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) were observed. During X-G-K infusion without O2, HR, Qt and CI increased gradually while SVR, PVR and MAP decreased. Left ventricular stroke work index and PaO2 remained constant, while O2 supplementation improved PaO2. Coccygeal extradural anaesthesia had little effect on cardiopulmonary variables. Respiratory rate (f) and PaCO2 significantly increased over the experiment. CONCLUSIONS AND CLINICAL RELEVANCE: Xylazine caused adverse cardiopulmonary effects in calves. Improvement occurred during xylazine-guaiphenesin-ketamine infusion. Cardiac index and arterial blood pressure remained below baseline values while sustained increases in respiration rate and PaCO2 were observed. Inter-coccygeal extradural anaesthesia had only minor effects. Oxygen supplementation proved advantageous during guaiphenesin, ketamine and xylazine infusion in healthy calves in combination with coccygeal extradural anaesthesia induced persistent cardiopulmonary depression.