SVF Therapy of Delayed Fracture Union in Patients with Multiple Combat Injury. Case Report.

Delayed union of fractures is one of the most frequent complications in orthopedic practice, especially in polytrauma patients. With the development of new methods of regenerative medicine, including the use of adipose derived stromal cells as a component of the stromal-vascular fraction (SVF), new possibilities for conservative treatment of this problem have emerged. This article presents a clinical case of conservative treatment of delayed union of a radial bone fracture using local SVF injections. In the fracture space, SVF with PRP creates a pool of cells that could differentiate towards surrounding tissue, releases various inducers of tissue growth and, via an indirect chemotactic effect on receptors, mobilizes the body's own resources and creates conditions for angiogenesis and trophism in the injured segment. In the patient with delayed consolidation after SFV-therapy, progress in clinical and radiological dynamics was noted with complete healing within 7 months. The positive clinical result provides a basis for further study and implementation in practice.

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.

Effect of damage control strategy combining pre-hospital emergency treatment with in-hospital treatment on pelvic fracture complicated by multiple injuries.

OBJECTIVE: To analyze the application value of damage control strategies combining pre-hospital emergency treatment with in-hospital treatment for multiple injuries in treating pelvic fracture complicated by multiple injuries. METHODS: 120 patients with pelvic fracture complicated by multiple injuries admitted to our hospital from January 2020 to January 2023 were selected and divided into a damage control group (early temporary reduction after resuscitation, n = 60) and a control group (no reduction and resuscitation only, n = 60) by treatment methods. The control group was treated with conventional methods, while the damage control group was treated with the damage control strategy combining pre-hospital emergency treatment combined with in-hospital treatment in addition to conventional methods. The mortality rate, complication rate, fracture reduction quality, long-term efficacy, and patient satisfaction of the two groups were compared. RESULTS: The mortality rate of the damage control group was lower than that of the control group, and the difference has statistical significance (P<0.05); the incidence of infection, DIC, and MODS of the damage control group were lower than that of the control group, with the difference being statistically significant (P<0.05); the incidence of ARDS in the two groups is not that different (P>0.05); the fracture reduction quality and long-term therapeutic effect of patients in the two groups were statistically different, with the damage control group outperforming the control group in both aspects; the difference between the two groups in terms of patient satisfaction was statistically significant (P<0.05), with the patient satisfaction of the damage control group being higher than that of the control group. CONCLUSION: For patients with pelvic fracture, the application of the damage control strategy combining pre-hospital emergency treatment and in-hospital treatment is a boon to the standardization of the treatment process, the improvement of the treatment success rate and fracture reduction quality and the reduction of complications, and therefore is worth promoting in clinical practice. the early application of external fixation has helped with the definitive reduction at a time when the patuent was stable.

Damage-control orthopedics or early total care: What you need to know.

ABSTRACT: Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

[Prehospital management in trauma patients and the increasing number of helicopter EMS transportations : An epidemiological study of the TraumaRegister DGU®]. / Präklinisches Management bei Traumapatienten und die zunehmende Zahl von Helikopter-Rettungstransporten : Eine epidemiologische Studie des TraumaRegister DGU®.

BACKGROUND/OBJECTIVE: To compare the prehospital treatment modalities and intervention regimens for major trauma patients with comparable injury patterns between Austria and Germany. PATIENTS AND METHODS: This analysis is based on data retrieved from the TraumaRegister DGU®. Data included severely injured trauma patients with an injury severity score (ISS) ≥ 16, an age ≥ 16 years, and who were primarily admitted to an Austrian (n = 4186) or German (n = 41,484) level I trauma center (TC) from 2008 to 2017. Investigated endpoints included prehospital times and interventions performed until final hospital admission. RESULTS: The cumulative time for transportation from the site of the accident to the hospital did not significantly differ between the countries (62 min in Austria, 65 min in Germany). Overall, 53% of all trauma patients in Austria were transported to the hospital with a helicopter compared to 37% in Germany (p < 0.001). The rate of intubation was 48% in both countries, the number of chest tubes placed (5.7% Germany, 4.9% Austria), and the frequency of administered catecholamines (13.4% Germany, 12.3% Austria) were comparable (Φ = 0.00). Hemodynamic instability (systolic blood pressure, BP ≤ 90 mmHg) upon arrival in the TC was higher in Austria (20.6% vs. 14.7% in Germany; p < 0.001). A median of 500 mL of fluid was administered in Austria, whereas in Germany 1000 mL was infused (p < 0.001). Patient demographics did not reveal a relationship (Φ = 0.00) between both countries, and the majority of patients sustained a blunt trauma (96%). The observed ASA score of 3-4 was 16.8% in Germany versus 11.9% in Austria. CONCLUSION: Significantly more helicopter EMS transportations (HEMS) were carried out in Austria. The authors suggest implementing international guidelines to explicitly use the HEMS system for trauma patients only a) for the rescue/care of people who have had an accident or are in life-threatening situations, b) for the transport of emergency patients with ISS > 16, c) for transportation of rescue or recovery personnel to hard to reach regions or, d) for the transport of medicinal products, especially blood products, organ transplants or medical devices.

Prehospital Time Following Traumatic Injury Is Independently Associated With the Need for In-Hospital Blood and Early Mortality for Specific Injury Types.

OBJECTIVE: Treating traumatic hemorrhage is time sensitive. Prehospital care and transport modes (eg, helicopter and ground) may influence in-hospital events. We hypothesized that prehospital time (on-scene time [OST] and total prehospital time [TPT]) and transport mode are associated with same-day transfusion and mortality. Furthermore, we sought to identify regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. METHODS: We obtained prehospital, in-hospital, and trauma registry data from an 8-center cohort of adult nonburn trauma patients from 2017 to 2022 directly transported from the scene to the hospital and having an Injury Severity Score (ISS) > 9 for the Task Order 1 project of the Linking Investigators in Trauma and Emergency Services research network. We excluded patients missing prehospital times, patients < 18 years of age, patients from interfacility transfers, and recipients of prehospital blood. Our same-day outcomes were in-hospital transfusions within 4 hours and 24-hour mortality. Each outcome was adjusted using multivariable logistic regression for covariates of prehospital phases (OST and TPT), mode of transport (helicopter and ground), age, sex, ISS, Glasgow Coma Scale motor subscale score < 6, and field hypotension (systolic blood pressure < 90 mm Hg). We evaluated the association of prehospital time on outcomes for scene missions by transport mode across severe injury patterns defined by Abbreviated Injury Scale > 2 body regions. RESULTS: Of 78,198 subjects, 34,504 were eligible for the study with a mean age of 47.6 ± 20.3 years, ISS of 18 ± 11, OST of 15.9 ± 9.5 minutes, and TPT of 48.7 ± 20.3 minutes. Adjusted for injury severity and demographic factors, transport type significantly modified the relationship between prehospital time and outcomes. The association of OST and TPT with the odds of 4-hour transfusion was absent for the ground emergency medical services (GEMS) cohort and present for the helicopter emergency medical services (HEMS) ambulance cohort, whereas these times were associated with decreased 24-hour mortality for both transport types. When stratifying by injury to most anatomic regions, OST and TPT were associated with a decreased need for 4-hour transfusions in the GEMS cohort. However, OST was associated with increased early transfusion only among patients with severe injuries of the thorax, and this association persisted after adjusting additionally for injury type (odds ratio [OR] = 1.03; 95% confidence interval [CI], 1.00-1.05; P = .02). The presence of polytrauma supported an association between prehospital time and decreased 24-hour mortality for the GEMS cohort (OST: OR = 0.97; 95% CI, 0.95-0.99; P < .01; TPT: OR = 0.99; 95% CI, 0.98-0.99; P = .02), whereas no injuries showed significant association of helicopter prehospital time on mortality after adjustment. CONCLUSION: We determined that transport type affects the relationship between prehospital time and hospital outcomes (4-hour transfusion: positive relationship for HEMS and negative for GEMS, 24-hour mortality: negative for both transport types). Furthermore, we identified regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. Of these regions, most notable were severe isolated injuries to the thorax that supported a positive relationship between HEMS OST and 4-hour transfusions and polytrauma that showed a negative relationship between GEMS OST or TPT and 24-hour mortality after adjustment.

The Diagnostic, Therapeutic and Prognostic Relevance of Neutrophil Extracellular Traps in Polytrauma.

Neutrophil extracellular traps (NETs) represent a recently discovered polymorphonuclear leukocyte-associated ancient defence mechanism, and they have also been identified as part of polytrauma patients' sterile inflammatory response. This systematic review aimed to determine the clinical significance of NETs in polytrauma, focusing on potential prognostic, diagnostic and therapeutic relevance. The methodology covered all major databases and all study types, but was restricted to polytraumatised humans. Fourteen studies met the inclusion criteria, reporting on 1967 patients. Ten samples were taken from plasma and four from whole blood. There was no standardisation of methodology of NET detection among plasma studies; however, of all the papers that included a healthy control NET, proxies were increased. Polytrauma patients were consistently reported to have higher concentrations of NET markers in peripheral blood than those in healthy controls, but their diagnostic, therapeutic and prognostic utility is equivocal due to the diverse study population and methodology. After 20 years since the discovery of NETs, their natural history and potential clinical utility in polytrauma is undetermined, requiring further standardisation and research.

[Initial Treatment of Multiple Trauma].

Head trauma is a common neurosurgical complication. It is encountered daily at neurosurgical outpatient departments or after-hour emergency outpatient departments. In addition, most cases of patients with trauma transported by ambulance involve those with head trauma. Head trauma is a common and unavoidable neurosurgical injury. In case of a head injury, the neurosurgeon should verify the level of consciousness and perform a proper neurological examination. A head computed tomography should be performed immediately for any abnormalities. However, currently, severe trauma is often complicated by head trauma and various other injuries. When medical examinations and treatments focus only on head trauma, preventable trauma death cannot be avoided. Functional prognosis due to secondary brain injury may be exacerbated. This article presents a standardized procedure for the initial care of patients with multiple trauma and head injuries.

Hiperfiltración glomerular en el paciente traumático grave / Glomerular hyperfiltration in patients with severe trauma

Antecedentes y objetivo El aclaramiento renal aumentado o hiperfiltración glomerular (HFG) puede afectar significativamente a los resultados clínicos de los fármacos eliminados por vía renal al promover la exposición subterapéutica al fármaco. La agresión sufrida en los pacientes que presentan trauma grave supone un predisponente a manifestar HFG y la identificación de estos pacientes sigue siendo un desafío clínico. El objetivo principal de este estudio fue describir la prevalencia de HFG en una cohorte de pacientes críticos traumatizados en la primera semana de ingreso. Materiales y métodos Estudio prospectivo observacional de una cohorte de pacientes adultos ingresados en la UCI de Anestesiología del Complejo Hospitalario Universitario de Albacete (España) tras sufrir un trauma grave o politraumatismo. Se calculó el aclaramiento de creatinina (ClCr) en muestra de recolección de orina 4h a las 24, 72 y 168h de ingreso aplicando la fórmula ClCr: [Diuresis en ml (orina/4h)×Creatinina en orina (mg/dl)]÷[240 (minutos)×Creatinina en plasma (mg/dl)]. Un CrCl por encima de 130ml/min fue considerado HFG. Los análisis se realizaron con el software estadístico R versión 4.0.4. Resultados Se incluyeron 85 pacientes. La edad mediana de los pacientes fue de 51 años (RIQ 26); 68 pacientes fueron varones (78,82%). El 75,29% de los pacientes fueron politraumatizados; 61 pacientes (71,76%) presentaron HFG en algún momento de la determinación del ClCr. A las 24h de ingreso el 56,34% de los pacientes presentaron HFG con ClCr medio de 195,8ml/min, el 61,11% de los pacientes lo presentaban a las 72h con ClCr medio de 186ml/min y el 56,52% presentaban HFG a las 168h de ingreso con ClCr medio de 207ml/min. Se encontró una relación positiva importante (p=0,07) entre la HFG manifestada a las 72h y a las 168h. Se observó relación estadísticamente significativa entre este fenómeno con edades más jóvenes, puntuaciones ISS más bajas y creatininas plasmáticas más bajas (AU)

Background and objective Augmented renal clearance or glomerular hyperfiltration (GHF) can significantly affect the clinical outcomes of renally eliminated drugs by promoting subtherapeutic drug exposure. The aggression suffered in patients who suffer severe trauma is a predisposition to manifest GHF and the identification of these patients remains a clinical challenge. The main objective of this study was to describe the prevalence of GHF in a cohort of critically ill trauma patients. Materials and methods Prospective observational study of a cohort of adult patients admitted after suffering severe trauma or polytrauma in the Anesthesiology ICU of the University Hospital of Albacete (Spain). Creatinine clearance (ClCr) was calculated in a 4-h urine collection sample at 24, 72 and 168h after admission applying the formula: CrCl: [diuresis in ml (urine/4h)×creatinine in urine (mg/dl)]÷[240 (min)×creatinine in plasma (mg/dl)]. A CrCl above 130ml/min was considered GHF. The analyzes were performed with the statistical software R version 4.0.4. Results Eighty-five patients were included. The median age of the patients was 51 years (IQR 26). Sixty-eight patients were male (78.82%). 75.29% of the patients were polytraumatized. Sixty-one patients (71.76%) presented GHF at some point in the CrCl determination. At 24h of admission, 56.34% of the patients presented GHF with a mean CrCl of 195.8ml/min, 61.11% of the patients presented it at 72h with a mean CrCl of 186ml/min and 56.52% presented GHF at 168h of admission with a mean CrCl of 207ml/min. A significant positive relationship (p=0.07) was found between GHF manifested at 72h and at 168h. We observed a statistically significant relationship between this phenomenon with younger ages, lower ISS scores and lower plasma creatinines (AU)

Heterogeneity in defining multiple trauma: a systematic review of randomized controlled trials.

INTRODUCTION: While numerous randomized controlled trials (RCTs) have been conducted in the field of trauma, a substantial portion of them are yielding negative results. One potential contributing factor to this trend could be the lack of agreement regarding the chosen definitions across different trials. The primary objective was to identify the terminology and definitions utilized for the characterization of multiple trauma patients within randomized controlled trials (RCTs). METHODS: A systematic review of the literature was performed in MEDLINE, EMBASE and clinicaltrials.gov between January 1, 2002, and July 31, 2022. RCTs or RTCs protocols were eligible if they included multiple trauma patients. The terms employed to characterize patient populations were identified, and the corresponding definitions for these terms were extracted. The subsequent impact on the population recruited was then documented to expose clinical heterogeneity. RESULTS: Fifty RCTs were included, and 12 different terms identified. Among these terms, the most frequently used were "multiple trauma" (n = 21, 42%), "severe trauma" (n = 8, 16%), "major trauma" (n = 4, 8%), and trauma with hemorrhagic shock" (n = 4, 8%). Only 62% of RCTs (n = 31) provided a definition for the terms used, resulting a total of 21 different definitions. These definitions primarily relied on the injury severity score (ISS) (n = 15, 30%), displaying an important underlying heterogeneity. The choice of the terms had an impact on the study population, affecting both the ISS and in-hospital mortality. Eleven protocols were included, featuring five different terms, with "severe trauma" being the most frequent, occurring six times (55%). CONCLUSION: This systematic review uncovers an important heterogeneity both in the terms and in the definitions employed to recruit trauma patients within RCTs. These findings underscore the imperative of promoting the use of a unique and consistent definition.

Implantación de un equipo de asistencia al trauma grave. Análisis de la activación y tiempos de asistencia en pacientes ingresados en UCI / Implementation of a severe trauma assistance team: Analysis of activation and attendance times in patients admitted to the ICU

Objetivo Analizar los factores asociados a la activación del equipo de asistencia al trauma grave (EATG) en pacientes que ingresan en la Unidad de Cuidados Intensivos (UCI), medir su repercusión en los tiempos de asistencia, y analizar los grupos de pacientes según activación y nivel de afectación anatómica. Diseño Estudio de cohortes prospectivo del trauma grave que ingresan en UCI. Desde junio 2017 a mayo 2019. Factores de riesgo de la activación analizados con regresión logística y árbol de clasificación tipo CART. Ámbito UCI hospital de segundo nivel. Pacientes Pacientes ingresados de forma consecutiva. Intervenciones Ninguna. Variables de intereses principales Activación del EATG. Variables demográficas. Puntuación de la gravedad de la lesión (ISS), intencionalidad, mecanismo, tiempos de asistencia, complicaciones evolutivas y mortalidad. Resultados Ingresaron un total de 188 pacientes (46,8% de activación EATG), edad mediana de 52 (37-64) años (activados 47 (27-62) vs. no activados 55 (42-67) p = 0,023), varones 84,0%. No diferencias en la mortalidad según activación. El modelo logístico encuentra como factores: la atención (16,6 [2,1-13,2]) e intubación prehospitalaria (4,2 [1,8-9,8]) y, la lesión grave de extremidades inferiores (4,4 [1,6-12,3]). Padecer una caída accidental (0,2 [0,1-0,6]) hace menos probable la activación. El modelo CART selecciona el tipo de mecanismo del traumatismo y es capaz de separar los traumatismos de alta y baja energía. Conclusiones Los factores asociados con activación del ETAG fueron la atención prehospitalaria, requerir intubación previa, mecanismos de alta energía y lesiones graves de extremidades inferiores. Menores tiempos de asistencia si activación sin influir en la mortalidad. Debemos mejorar la activación en pacientes mayores con traumatismos de baja energía y sin atención prehospitalaria (AU)

Objective To analyse the factors associated with the activation of the severe trauma care team (STAT) in patients admitted to the ICU, to measure its impact on care times, and to analyse the groups of patients according to activation and level of anatomical involvement. Design Prospective cohort study of severe trauma admitted to the ICU. From June 2017 to May 2019. Risk factors for the activation of the STAT analysed with logistic regression and CART type classification tree. Setting Second level hospital ICU. Patients Patients admitted consecutively. Interventions No. Main variables of interest STAT activation, demographic variables, injury severity (ISS), intentionality, mechanism, assistance times, evolutionary complications, and mortality. Results A total of 188 patients were admitted (46.8% of STAT activation), median age of 52 (37–64) years (activated 47 (27–62) vs. not activated 55 (42–67), p = 0.023), males 84.0%. No difference in mortality according to activation. The logistic model finds as factors: care (16.6 (2.1–13.2)) and prehospital intubation (4.2 (1.8–9.8)) and severe lower extremity injury (4.4 (1.6–12.3)). Accidental fall (0.2 (0.1–0.6)) makes activation less likely. The CART model selects the type of trauma mechanism and can separate high and low energy trauma. Conclusions Factors associated with STAT activation were prehospital care, requiring prior intubation, high-energy mechanisms, and severe lower extremity injuries. Shorter care times if activated without influencing mortality. We must improve activation in older patients with low-energy trauma and without prehospital care (AU)

[Traumatic injuries of the kidney and the urinary tract in blunt abdominal trauma]. / Traumatische Verletzungen der Nieren und der ableitenden Harnwege bei stumpfen Bauchtraumata.

BACKGROUND: In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment. METHODS: The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature. RESULTS: Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4-5) are now treated by interventional radiology. CONCLUSION: Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology.

[Preclinical care of children with multiple trauma]. / Präklinische Versorgung von polytraumatisierten Kindern.

Severe multiple trauma in children is rare with approximately 380-550 cases per year in Germany. In addition to the S3 guideline "Polytrauma", which was published more than a decade ago, the S2K guideline "Severe multiple trauma care in childhood" was published in 2020. Accidents and especially the resulting traumatic brain injuries still represent the most frequent cause of death in children. While prehospital treatment according to Prehospital Trauma Life Support (PHTLS®) is basically analogous to that in adults which is based on the ABCDE concept (airway, breathing, circulation, disability, exposure), knowledge of age-dependent anatomical-physiological characteristics is essential. For simplification, various tools and dosing aids, such as the pediatric emergency ruler and specific emergency tables, are available. Further treatment after initial preclinical care should take place in an interdisciplinary manner in designated pediatric trauma centers.

Team Approach: The Unstable Trauma Patient.

¼ A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.¼ The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries¼ Effective and open dialog with consulting specialists is paramount for effective team-based care.¼ Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

In vitro evaluation of a computer-assisted decision support system for the primary care of polytrauma patients.

INTRODUCTION: The management of polytraumatized patients is set in a stressful environment with numerous critical decisions in a brief amount of time. Working along a standardised procedure can improve the outcome for these patients and reduce mortality. To help clinical practitioners, we developed "TraumaFlow", a workflow management system for the primary care of polytrauma patients based on the current treatment guidelines. This study sought to validate the system and investigate its effect on user performance and perceived workload. METHODS: The computer-assisted decision support system was tested in two scenarios in a trauma room of a level 1 trauma centre by 11 final-year medical students and 3 residents. In simulated polytrauma scenarios, the participants functioned as a trauma leader. The first scenario was performed without decision support and the second with support by "TraumaFlow" via tablet. During each scenario, the performance was evaluated in a standardized assessment. After each scenario, the participants answered a questionnaire on workload [NASA Raw Task Load Index (NASA RTLX)]. RESULTS: In total, 14 participants (mean 28 ± 4 years, 43% female) managed 28 scenarios. During the first scenario without computer-assisted support, the participants achieved a mean of 6.6 out of 12 points (SD 1.2, range 5 to 9). With the support of TraumaFlow, the mean performance score was significantly higher with 11.6 out of 12 points (SD 0.5, range 11 to 12, p < 0.001). In the 14 scenarios performed without support, there was no run in which no errors were made. In comparison, ten of the 14 scenarios performed with TraumaFlow ran free of relevant errors. The mean improvement in the performance score was 42%. There was a significant decrease in the mean self-reported mental stress level in scenarios with support of TraumaFlow (55, SD 24) as compared to scenarios without support (72, SD 13, p = 0.041). CONCLUSION: In a simulated environment, computer-assisted decision-making improved the performance of the trauma leader, helped to adhere to clinical guidelines, and reduced stress in a fast-acting environment. In reality, this may improve the treatment outcome for the patient.

Treatment management and outcome of polytraumatized patients in a German certified trauma center - comparing standard versus maximum care.

German hospitals are classified as basic, standard and maximum care facilities within the German trauma networks. The Municipal Hospital Dessau was upgraded in 2015 as a maximum care provider. The aim of this study is to investigate whether a change in treatment management and outcome of polytraumatized patients has occurred afterwards. The study compared polytraumatized patients, treated in the Dessau Municipal Clinic as a standard care facility (DessauStandard) from 2012-2014 vs. those treated in the Dessau Municipal Clinic as a maximum care facility (DessauMax) from 2016-2017. Data of the German Trauma Register were analysed using the chi-square test, t-test and odds ratios with 95% confidence intervals.In DessauMax (238 patients; Ø 54 years, SD 22.3; ♂ 160, ♀ 78), the shock room time with 40.7 min (SD 21.4) was shorter than in DessauStandard (206 patients; Ø 56.1 years, SD 22.1; ♂ 133, ♀ 73 ) with 49 min (SD 25.1) (p=0.001). The transfer rate of 1.3% (n=3) to another hospital was lower in DessauMax (p=0.01). DessauStandard had 9 (4%) thromboembolic events and DessauMax 3 (1.3%) (p=0.7). Multiorgan failure was more common in DessauStandard, (16%) than in DessauMax (1.3%; p=0,001). DessauStandard showed a mortality of 13.1% (n=27), and DessauMax 9.2% (n=22) (p=0.22; OR=0.67, 95% CI, 0.37-1.23). The GOS in DessauMax (4.5, SD 1.2) was higher than in DessauStandard (4.1, SD 1.3) (p=0.002).The Dessau Municipal Clinic as a maximum care facility has achieved improved shock room time, fewer complications, lower mortality and an improved outcome.

Hemoperfusion in Trauma.

Major trauma care has seen significant improvements in early mortality, reflecting improvements in prehospital techniques for hemorrhage control and speed of access to specialized trauma centers. However, many patients then go on to die in the intensive care unit (ICU), and improvements in immediate trauma care are presenting intensivists with greater numbers of severely injured patients who might previously have died shortly after injury. It is theorized that, despite initial survival, these patients deteriorate due to massive release of damage associated molecular patterns (DAMPs) after traumatic and ischemic tissue injury. These trigger a vicious cycle of overactive pro- and anti-inflammatory pathways, leading to organ dysfunction and immunoparesis. Extracorporeal hemoperfusion, with its ability to adsorb both DAMPs and inflammatory mediators from the bloodstream, has the potential to break this cycle and could, in theory, then prevent early death or organ dysfunction in the ICU. However, currently, there has been little research around the indications for, and efficacy of, this therapy in the setting of polytrauma. Here we outline potential molecular targets, summarize existing exploratory studies, and suggest areas for future research required to establish the benefits of hemoperfusion as an adjunct therapy in major polytrauma.

Slow Intravenous Infusion of a Novel Damage Control Cocktail Decreases Blood Loss in a Pig Polytrauma Model.

BACKGROUND: Our objective was to optimize a novel damage control resuscitation (DCR) cocktail composed of hydroxyethyl starch, vasopressin, and fibrinogen concentrate for the polytraumatized casualty. We hypothesized that slow intravenous infusion of the DCR cocktail in a pig polytrauma model would decrease internal hemorrhage and improve survival compared with bolus administration. METHODS: We induced polytrauma, including traumatic brain injury (TBI), femoral fracture, hemorrhagic shock, and free bleeding from aortic tear injury, in 18 farm pigs. The DCR cocktail consisted of 6% hydroxyethyl starch in Ringer's lactate solution (14mL/kg), vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) in a total fluid volume of 20mL/kg that was either divided in half and given as two boluses separated by 30 minutes as control or given as a continuous slow infusion over 60 minutes. Nine animals were studied per group and monitored for up to 3 hours. Outcomes included internal blood loss, survival, hemodynamics, lactate concentration, and organ blood flow obtained by colored microsphere injection. RESULTS: Mean internal blood loss was significantly decreased by 11.1mL/kg with infusion compared with the bolus group (p = .038). Survival to 3 hours was 80% with infusion and 40% with bolus, which was not statistically different (Kaplan Meier log-rank test, p = .17). Overall blood pressure was increased (p < .001), and blood lactate concentration was decreased (p < .001) with infusion compared with bolus. There were no differences in organ blood flow (p > .09). CONCLUSION: Controlled infusion of a novel DCR cocktail decreased hemorrhage and improved resuscitation in this polytrauma model compared with bolus. The rate of infusion of intravenous fluids should be considered as an important aspect of DCR.

Design and implementation of a "crisis resource management" training program for the initial assessment of polytrauma patients.

INTRODUCTION: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. METHODS: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. RESULTS: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of "leadership" and "roles", in 4 of 5 items of "situational awareness", and in 4 of 8 items of "communication". Mean values obtained in the ECC questionnaire were also very high. CONCLUSIONS: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team.

Results of the Spanish National Polytrauma Registry. Where are we and where are we heading?

INTRODUCTION: In 2017, the Spanish National Polytrauma Registry (SNPR) was initiated in Spain with the goal to improve the quality of severe trauma management and evaluate the use of resources and treatment strategies. The objective of this study is to present the data obtained with the SNPR since its inception. METHODS: We conducted an observational study with prospective data collection from the SNPR. The trauma patients included were over 14 years of age, with ISS ≥ 15 or penetrating mechanism of injury, from a total of 17 tertiary hospitals in Spain. RESULTS: From 1/1/17 to 1/1/22, 2069 trauma patients were registered. The majority were men (76.4%), with a mean age of 45 years, mean ISS 22.8, and mortality 10.2%. The most common mechanism of injury was blunt trauma (80%), the most frequent being motorcycle accident (23%). Penetrating trauma was presented in 12% of patients, stab wounds being the most common (84%). On hospital arrival, 16% of patients were hemodynamically unstable. The massive transfusion protocol was activated in 14% of patients, and 53% underwent surgery. Median hospital stay was 11 days, while 73.4% of patients required intensive care unit (ICU) admission, with a median ICU stay of 5 days. CONCLUSIONS: Trauma patients registered in the SNPR are predominantly middle-aged males who experience blunt trauma with a high incidence of thoracic injuries. Early addressed detection and treatment of these kind of injuries would probably improve the quality of trauma care in our environment.