Possible effect of the early administration of tranexamic acid on myocardial injury in patients with severe trauma.

Hemodynamic stabilization plays a crucial role in the treatment of patients suffering from severe trauma. Current guidelines recommend the early administration of tranexamic acid (TXA) for bleeding control. While less blood loss can result in less end-organ damage, including myocardial injury, TXA also exhibits prothrombotic effects with potentially adverse myocardial effects. The aim of this study was to investigate the association between the administration of TXA and myocardial injury in patients with severe trauma. We conducted a monocentric cohort study including severely injured patients ≥ 18 years [defined by Injury severity score (ISS) ≥ 16], who were admitted to a tertiary care hospital between 2016 and 2019. Primary outcome measure was myocardial injury according to the fourth Universal Definition (= high sensitive troponin T ≥ 14 ng/l). Secondary endpoints were in-hospital major adverse cardiovascular events (MACE) and mortality. Main exposure was defined as administration of TXA during prehospital period. We conducted multivariate logistic regression models including predefined covariables. A total of 368 patients were screened. Among the 297 included patients (72% male, age. 55?21 years), 119 (40%) presented myocardial injury at hospital arrival. TXA was administered to 20/297 (7%) patients in the prehospital setting, and in 96/297 (32%) patients during pre-or in-hospital period. MACE incidence was 9% (26/297) and in-hospital mortality was 26% (76/297). The adjusted odds ratios (OR) for prehospital TXA and myocardial injury, MACE and mortality were 0.75 [95% confidence interval (CI): 0.25-2.23], 0.51 [95%CI: 0.06-4.30] and 0.84 [0.21-3.33], respectively. In the present cohort of patients suffering from severe trauma, prehospital TXA did not affect the incidence of myocardial injury.

Prevalence and clinical significance of incidental findings in chest and abdominopelvic CT scans of trauma patients; A cross-sectional study.

BACKGROUND: Imaging may inadvertently reveal pathologies unrelated to their performing purpose, known as incidental findings (IF). This study aimed to assess the prevalence, clinical significance, and documentation of IFs in chest and abdominopelvic computed tomography (CT) scans of trauma patients. METHODS: This observational study was conducted at two urban level-1 trauma centers from March 2019 through April 2022. Official radiology reports of trauma patients who underwent chest and/or abdominopelvic CT scans at the emergency department (ED) were explored, and IF were extracted. Predictive factors of the presence of IFs and their documenting were investigated. RESULTS: Out of 656 chest and 658 abdominopelvic CT scans, 167 (25.37%) and 212 (32.31%) scans harbored at least one IF, respectively. Patients with IFs tended to be of higher age and female in both chest (age: 48 [IQR: 35-62] vs. 34 [IQR: 25-42.5]; female: 31.14% vs 14.66%, p < 0.001 for both) and abdominopelvic CT scans (age: 41 [IQR: 30-57.5] vs 33 [IQR: 25-43], female: 26.42% vs. 13.96%, p < 0.001 for both). As for documentation of significant IFs, only 49 of 112 chest IFs (43.8%) and 55 of 176 abdominopelvic IFs (31.3%) were documented. Investigating factors associated with documentation of clinically significant IFs, shorter length of hospital stay (1.5 (IQR: 0-4) vs. 3 (IQR: 2-8), p = 0.003), and discharging by ED physicians (documentation rate: 13.2% vs 42.6%, p < 0.001) were associated with poorer documentation of IFs only in abdominopelvic scans. CONCLUSION: CT imaging in ED trauma patients often reveals incidental findings, especially in older patients. Over 50% of these findings are clinically significant, yet they are frequently ignored and not documented. Physicians need to be more vigilant in recognizing and documenting these incidental findings and informing patients of the need for further evaluation.

Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report.

BACKGROUND: Fiberoptic-guided intubation is considered as "gold standard" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist. CASE PRESENTATION: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient's recovery was uneventful, and he was discharged from the hospital one month after the surgery. CONCLUSIONS: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

Early hypocoagulable state in traumatic brain injury patients: incidence, predisposing factors, and outcomes in a retrospective cohort study.

Coagulopathy development in traumatic brain injury (TBI) is among the significant complications that can negatively affect the clinical course and outcome of TBI patients. Timely identification of this complication is of utmost importance in the acute clinical setting. We reviewed TBI patients admitted to our trauma center from 2015 to 2021. Demographic data, mechanism of injury, findings on admission, imaging studies, procedures during hospitalization, and functional outcomes were gathered. INR with a cutoff of 1.3, platelet count less than 100 × 109/L, or partial thromboplastin time greater than 40s were utilized as the markers of coagulopathy. A total of 4002 patients were included. Coagulopathy occurred in 38.1% of the patients. Age of the patients (Odds Ratio (OR) = 0.993, 95% Confidence Interval (CI) = 0.986-0.999, p = 0.028), systolic blood pressure (OR = 0.993, 95% CI = 0.989-0.998, p = 0.005), fibrinogen level (OR = 0.998, 95% CI = 0.996-0.999, p < 0.001), and hemoglobin level (OR = 0.886, 95% CI = 0.839-0.936, p < 0.001) were independently associated with coagulopathy. Furthermore, coagulopathy was independently associated with higher mortality rates and longer ICU stays. Coagulopathy had the most substantial effect on mortality of TBI patients (OR = 2.6, 95% CI = 2.1-3.3, p < 0.001), compared to other admission clinical characteristics independently associated with mortality such as fixed pupillary light reflex (OR = 1.8, 95% CI = 1.5-2.4, p < 0.001), GCS (OR = 0.91, 95% CI = 0.88-0.94, p < 0.001), and hemoglobin level (OR = 0.93, 95% CI = 0.88-0.98, p = 0.004). Early coagulopathy in TBI patients can lead to higher mortality rates. Future studies are needed to prove that early detection and correction of coagulopathy and modifiable risk factors may help improve outcomes of TBI patients.

Using interoperable nursing care data to improve outcomes for multiple traumas patients with Impaired Physical Mobility.

AIM(S): To demonstrate how interoperable nursing care data can be used by nurses to create a more holistic understanding of the healthcare needs of multiple traumas patients with Impaired Physical Mobility. By proposing and validating linkages for the nursing diagnosis of Impaired Physical Mobility in multiple trauma patients by mapping to the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) equivalent terms using free-text nursing documentation. DESIGN: A descriptive cross-sectional design, combining quantitative analysis of interoperable data sets and the Kappa's coefficient score with qualitative insights from cross-mapping methodology and nursing professionals' consensus. METHODS: Cross-mapping methodology was conducted in a Brazilian Level 1 Trauma Center using de-identified records of adult patients with a confirmed medical diagnosis of multiple traumas and Impaired Physical Mobility (a nursing diagnosis). The hospital nursing free-text records were mapped to NANDA-I, NIC, NOC and NNN linkages were identified. The data records were retrieved for admissions from September to October 2020 and involved medical and nursing records. Three expert nurses evaluated the cross-mapping and linkage results using a 4-point Likert-type scale and Kappa's coefficient. RESULTS: The de-identified records of 44 patients were evaluated and then were mapped to three NOCs related to nurses care planning: (0001) Endurance; (0204) Immobility Consequences: Physiological, and (0208) Mobility and 13 interventions and 32 interrelated activities: (6486) Environmental Management: Safety; (0840) Positioning; (3200) Aspiration Precautions; (1400) Pain Management; (0940) Traction/Immobilization Care; (3540) Pressure Ulcer Prevention; (3584) Skincare: Topical Treatment; (1100) Nutrition Management; (3660) Wound Care; (1804) Self-Care Assistance: Toileting; (1801) Self-Care Assistance: Bathing/Hygiene; (4130) Fluid Monitoring; and (4200) Intravenous Therapy. The final version of the constructed NNN Linkages identified 37 NOCs and 41 NICs. CONCLUSION: These valid NNN linkages for patients with multiple traumas can serve as a valuable resource that enables nurses, who face multiple time constraints, to make informed decisions efficiently. This approach of using evidence-based linkages like the one developed in this research holds high potential for improving patient's safety and outcomes. NO PATIENT OR PUBLIC CONTRIBUTION: In this study, there was no direct involvement of patients, service users, caregivers or public members in the design, conduct, analysis and interpretation of data or preparation of the manuscript. The study focused solely on analysing existing de-identified medical and nursing records to propose and validate linkages for nursing diagnoses.

[Serious burns associated with a fracture : how to react in emergency]. / Comment je traite en urgence des brûlures graves associées à une fracture.

The incidence of burns associated with one or even several fractures is rare and linked to high-energy mechanisms (traffic accidents, terrorist attacks, etc.). Treatment requires a multidisciplinary approach both at the medical and paramedical levels. The various stages of treatment require a systematic reassessment of the situation according to the patient's evolution. Detailed understanding of treatment strategies and outcomes is vital when managing these patients with multiple trauma. We will discuss about our experience with a focus on the management of burns, fractures and associated pathologies.

L'incidence des brûlures associées à une ou plusieurs fractures est rare et liée à des mécanismes à haute énergie (accidents de roulage, attentats…). La prise en charge nécessite une approche pluridisciplinaire tant au niveau médical que paramédical. Les diverses étapes de traitement nécessitent une réévaluation systématique de la situation en fonction de l'évolution du patient. La compréhension détaillée des stratégies de traitement et des résultats est vitale lors de la prise en charge de ces patients polytraumatisés. Nous allons discuter de notre expérience avec un focus sur la prise en charge des brûlures, des fractures et des pathologies associées.

Efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents exposed to single versus multiple traumas: meta-analysis of randomised controlled trials.

BACKGROUND: Previous meta-analyses of psychotherapies for children and adolescents with post-traumatic stress disorder (PTSD) did not investigate whether treatment efficacy is diminished when patients report multiple (versus single) traumas. AIMS: To examine whether efficacy of psychological interventions for paediatric PTSD is diminished when patients report multiple (versus single) traumas. METHOD: We systematically searched PsycInfo, MEDLINE, Web of Science and PTSDpubs on 21 April 2022 and included randomised controlled trials (RCTs) meeting the following criteria: (a) random allocation; (b) all participants presented with partial or full PTSD; (c) PTSD is the primary treatment focus; (d) sample mean age <19 years; (e) sample size n ≥ 20. Trauma frequency was analysed as a dichotomous (single versus ≥2 traumas) and continuous (mean number of exposures) potential moderator of efficacy. RESULTS: Of the 57 eligible RCTs (n = 4295), 51 RCTs were included in quantitative analyses. Relative to passive control conditions, interventions were found effective for single-trauma-related PTSD (Hedges' g = 1.09; 95% CI 0.70-1.48; k = 8 trials) and multiple-trauma-related PTSD (g = 1.11; 95% CI 0.74-1.47; k = 12). Psychotherapies were also more effective than active control conditions in reducing multiple-trauma-related PTSD. Comparison with active control conditions regarding single-event PTSD was not possible owing to scarcity (k = 1) of available trials. Efficacy did not differ with trauma exposure frequency irrespective of its operationalisation and subgroup analyses (e.g. trauma-focused cognitive-behavioural therapy only). CONCLUSIONS: The current evidence base suggests that psychological interventions for paediatric PTSD can effectively treat PTSD in populations reporting single and multiple traumas. Future trials for PTSD following single-event trauma need to involve active control conditions.

Serum pro-B-type natriuretic peptide levels and cardiac index as adjunctive tools of blunt cardiac injury.

BACKGROUND: Blunt cardiac injury (BCI) has a variety of symptoms that may be a potentially life-threatening injury that can lead to death. Depending on the diagnosis of BCI, treatment direction and length of stay may vary. In addition, the utility of other diagnostic tests for cardiac disease as diagnostic tools for BCI remain unclear. The purpose of this study was to investigate the competence of N-terminal pro-B-type natriuretic peptide (NT pro-BNP) and cardiac index (C.I) as adjunctive diagnostic tools for BCI. METHODS: From January 2018 to March 2020, severe trauma patients with sternum fracture who were admitted to the traumatic intensive care unit (TICU) were included this study. Patients with sternum fracture, 18 years of age or older, and with an injury severity score > 16 who required intensive care were included. Invasive measurement for the analysis of the pulse contour for C.I monitoring and intravenous blood sampling for NT pro-BNP measurement were performed. Sampling and 12-lead electrocardiogram were performed at different time points as follows: immediately after TICU admission and at 24 h and 48 h after trauma. RESULTS: Among 103; 33 patients with factors that could affect NT pro-BNP were excluded; therefore, 63 patients were included in this study. According to the American Association for the Surgery of Trauma Cardiac Injury Scale, 33 patients were diagnosed with non-BCI, and 30 patients constituted with BCI. The median ages of the patients were 58 (52-69), and 60 (45-69) years in the non-BCI and BCI groups, respectively (p = 0.77). The median NT pro-BNP values were higher in the BCI group on admission, hospital day (HD) 2, and HD 3, however, no statistical difference was observed (125 (49-245) vs. 130 (47-428) pg/mL, p = 0.08, 124 (68-224) vs. 187 (55-519) pg/mL, p = 0.09, and 121(59-225) vs. 133 (56-600) pg/mL, p = 0.17, respectively). On the contrary, significantly lower values were observed in the median C.I measurement on admission and HD 3 in the BCI group (3.2 (2.8-3.5) vs. 2.6 (2.3-3.5) L/min/m2, p < 0.01 and 3.2 (3.1-3.9) vs. 2.9 (2.4-3.2) L/min/m2, p < 0.01, respectively); however, no significant difference was observed on HD 2 (3.4 (3.0-3.7) vs. 2.6 (2.4-3.4) L/min/m2, p = 0.17), Furthermore, The median lactate levels in the BCI group upon admission, HD 2, and HD 3 were significantly higher than those in the non-BCI group (1.8 (1.1-2.6) vs. 3.1 (2.1-4.4) mmol/L, p < 0.01; 1.3 (0.8-2.3) vs. 3.0 (2.2-4.7) mmol/L, p < 0.01; and 1.5 (0.9-1.5) vs. 2.2 (1.3-3.7) mmol/L, p < 0.01, respectively). CONCLUSION: Consecutive values of NT pro-BNP and C.I show no correlation with ECG-based BCI diagnosis. However, lactate level measurement may help in the early recognition of BCI as an adjunctive tool. It should be noted that this is a hypothesis-generating study for BCI diagnosis. Further studies should be conducted in larger populations with a prospective approach.

Incidence, risk factors and potential timing of occurrence of pulmonary embolism in fatal trauma: An autopsy based case-control study on 2705 victims.

BACKGROUND: Pulmonary embolism (PE) following trauma is a potentially preventable but highly lethal complication. We sought to investigate the incidence, risk factors and potential timing of occurrence of post-traumatic PE in a large cohort of trauma fatalities. METHODS: A case-control study on 9266 consecutive trauma fatalities (between 1996 and 2005) from a regional autopsy-based trauma registry. Injuries were classified according to the Abbreviated Injury Scale-1990 edition (AIS-90) and the Injury Severity Score (ISS) was calculated. Hospitalized victims were categorized according to the presence or absence of PE on autopsy. Univariate comparisons and multivariate logistic regression analysis for probabilities of association (odds ratios-OR) were performed. RESULTS: Out of 2705 subjects who met the inclusion criteria, 116 had autopsy findings of PE and constituted the PE group (incidence of 4,3%), while the remaining victims formed the control group. The survival time of the PE group ranged from 0.66 to 104.73 days. Victims in the PE group were older (median age 69.5 vs 59), had lower ISS values (median 16 vs 26) and longer post-injury survival times (median 13.6 vs 5.7 days). Positively associated risk factors were AIS2-5 pelvic ring injuries (OR:2.23) and secondary deaths following an uneventful hospital discharge (OR:3.97), while AIS2-5 head (OR:0.33) and abdominal injuries (OR:0.23) showed a reverse association. CONCLUSIONS: Trauma fatalities with autopsy findings of PE were associated with less severe trauma indicating that PE was likely detrimental to the fatal outcome. Both the early and delayed occurrence of PE was reaffirmed. Prophylactic measures should be initiated promptly and extended post discharge for high risk patients to prevent secondary deaths.

Risk assessment scales to predict risk of lower extremity deep vein thrombosis among multiple trauma patients: a prospective cohort study.

BACKGROUND: Deep vein thrombosis (DVT) is a common complication in orthopedic patients. Previous studies have focused on major orthopedic surgery.There are few studies with multiple trauma. We aimed to describe the prevalence of DVT and compare the predictive power of the different risk assessment scales in patients with multiple trauma. METHODS: This prospective cohort study involved multiple trauma patients admitted to our hospital between October 2021 and December 2022. Data were prospectively collected for thrombotic risk assessments using the Risk Assessment Profile for thromboembolism(RAPT), the DVT risk assessment score (DRAS), and the Trauma Embolic Scoring System (TESS), respectively. The receiver operation characteristic (ROC) curve and the area under the curve (AUC) were evaluated to compare the predictive power. The whole leg duplex ultrasound of both lower extremities Doppler ultrasound was used to determine DVT incidence. RESULTS: A total of 210 patients were included, and the incidence of DVT was 26.19%. Distal DVT accounted for 87.27%; postoperative DVT, 72.73%; and bilateral lower extremity thrombosis, 30.91%. There were significant differences in age, education degree, pelvic fracture, surgery, ISS, D-dimer level, length of hospital stay and ICU stay between the thrombosis group and the non-thrombosis group. The AUCs for RAPT, DRAS, and TESS were 0.737, 0.710, and 0.683, respectively. There were no significant differences between the three ROC curves. CONCLUSIONS: The incidence of DVT was relatively high during hospitalization. We prospectively validated the tests to predict risk of DVT among patients with multiple trauma to help trauma surgeons in the clinical administration of DVT prophylaxis.

Treatment strategy on traumatic mid-lumbar spondyloptosis with concomitant multiple injuries: A case report and literature review.

Spondyloptosis in the clinic is rarely reported. We herein present a 47-year-old female, who suffered from a crush injury directly by a heavy cylindrical object from the lateral side. She was diagnosed to have traumatic L3 spondyloptosis with multiple traumas. Staged surgical procedures were conducted and a three-year follow-up was obtained. Eventually, normal spinal alignment was restored, and neurological deficits were gradually improved. At three years follow-up, the motor strength scores and function of the sphincters were incompletely improved. Previously published reports on traumatic lumbar spondyloptosis were reviewed and several critical points for management of this severe type of spinal injury were proposed. First, thoracolumbar and lumbosacral junction were mostly predilection sites. Second, numerous patients involving traumatic lumbar spondyloptosis were achieved to American Spinal Injury Association grade A. Third, lumbar spondyloptosis was commonly coupling with cauda equina injury. Finally, the outcomes were still with poorly prognosis and recovery of patients was correlation to spondyloptosis severity. Based on this case report and literatures review, we highlighted that the spinal alignment restoration relying on staged operations and following rehabilitation hereof are both important once facing with multiple traumas. Furthermore, we suggested to perform routine CT angiography during lumbar spondyloptosis to justify whether there are large vessel compression or injury.

"You can't wash your hands in a house without running water": pandemic precautionary behaviors after Hurricane Laura.

Hurricane Laura made landfall in southwestern Louisiana in August 2020 while the world was several months into the COVID-19 pandemic. In the present research, we examined pandemic precautionary behaviors in a sample of adults who varied in exposure and damage due to Hurricane Laura, a destructive Category 4 hurricane. A total of 127 participants responded to an online survey that assessed pandemic worry and precautionary behaviors, hurricane exposure and damage, and health-related quality of life. We found that Hurricane Laura victims neglected pandemic precautionary behaviors at significantly higher levels in the weeks immediately following Hurricane Laura than did indirectly impacted control participants, although the two comparison groups did not differ in COVID-19 worry or adherence to precautionary pandemic behavior 14-22 months after Hurricane Laura made landfall. Older age was negatively correlated with COVID-19 worry prior to Hurricane Laura, which was unexpected given that older people in general were more vulnerable to COVID-19 by their membership in a high-risk group. Future directions for research on post-disaster vulnerabilities during a global pandemic are discussed.

Emergency whole-body CT scans in pediatric patients with trauma: patterns of injuries, yield of dual-phase scanning, and influence of second read on detection of injuries.

OBJECTIVES: To describe injury patterns in children with multiple trauma (MT), evaluate the yield of dual-phase whole-body CT (WBCT), and quantify missed injuries detected on second reading. METHODS: Remotely analyzed WBCT performed between 2011 and 2020 in 63 emergency departments on children admitted for MT were included. Second reading occurred within 24 h. Collected data included age, sex, mechanism, Injury Severity Score (ISS), radiologists' experience, time and duration of first reading, conclusion of both readings, and dosimetry. Melvin score assessed the clinical impact of missed injuries. RESULTS: Overall, 1114 patients were included, 1982 injuries were described in 662 patients (59.4%), 452/1114 (40.6%) WBCT were negative, and 314 (28.2%) patients had MT (≥ 2 body parts injured). The most frequent injuries were pulmonary contusions (8.3%), costal fractures (6.2%), and Magerl A1 vertebral fractures (4.9%). Overall, 151 injuries were missed in 92 (8.3%) patients. Independent predictors for missed injuries were age ≤ 4 years (p = 0.03), number of injured body parts ≥ 2 (p = 0.01), and number of injuries ≥ 3 (p < 0.001). Melvin score grade 3 lesions were found in 16/92 (17.4%) patients with missed injuries (1.4% of all WBCT), where only prolonged follow-up was necessary. Thirteen active bleeding or pseudoaneurysms were detected (0.7% of injuries). CONCLUSION: Injuries were diagnosed in 59.4% of patients. Double-reading depicted additional injuries in 8.3% of patients, significantly more in children ≤ 4 years, with ≥ 3 injuries or ≥ 2 injured body parts. As 28 % of patients had MT and 1.1% had active extravasation or pseudoaneurysm, indication for WBCT should be carefully weighted. KEY POINTS: • When performed as a first-line imaging evaluation, approximately 41% of WBCT for MT children were considered normal. • The three most common injuries were pulmonary contusions, costal fractures, and Magerl A1 vertebral fractures, but the patterns of traumatic injuries on WBCT depended on the children's age and the trauma mechanism. • The independent predictors of missed injuries were age ≤ 4 years, number of body parts involved ≥ 2, and total number of injuries ≥ 3.

Neutrophil Gene Expression Patterns in Multiple Trauma Patients Indicate Distinct Clinical Outcomes.

INTRODUCTION: Patients after polytrauma suffer from posttraumatic immune system dysregulation and multiple organ dysfunction. Genome-wide microarray profiling in monocytes revealed a regulatory network of inflammatory markers around the transcription factor AP-1 in severely injured patients. Recent research focuses on the role of neutrophils in posttraumatic inflammation. The aim of this study was, therefore, to evaluate the impact of this inflammatory network in neutrophils. MATERIALS AND METHODS: Blood sampling and neutrophil separation were performed on admission of the patient and at 6 h, 12 h, 24 h, 48 h, and 72 h after trauma. Neutrophil expression levels of the target genes c-Jun, c-Fos, BCL2A, MMP-9, TIMP-1, ETS-2, IL-1ß, and MIP-1ß were quantified by RT-qPCR. Patients were assorted into groups according to distinct clinical parameters like massive transfusion (>10 RBC units/24 h), injury severity (ISS), 90-d survival, and the presence of traumatic brain injury (defined by ICI on head CT). Statistics were calculated by Mann-Whitney Rank-Sum Test, Receiver Operating Curves, and binary multiple logistic regression. RESULTS: Forty severely injured patients (mean ISS 36 ± 14) were included. BCL2A, MMP-9, TIMP-1, and ETS2 levels showed a significant correlation to 90-d-survival in the early posttraumatic period (6 h-24 h). Furthermore, differential BCL2A, IL-1ß, MIP-1ß, and MMP-9 regulation was observed in patients requiring massive transfusion. We could further show a significant TIMP-1 response in trauma PMN associated with traumatic brain injury. CONCLUSIONS: This study of seriously injured patients highlights very early posttraumatic transcriptional changes in PMNs, which were clearly associated with posttraumatic events and outcomes.

Use of tranexamic acid in major trauma: a sex-disaggregated analysis of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2 and CRASH-3) trials and UK trauma registry (Trauma and Audit Research Network) data.

BACKGROUND: Women are less likely than men to receive some emergency treatments. This study examines whether the effect of tranexamic acid (TXA) on mortality in trauma patients varies by sex and whether the receipt of TXA by trauma patients varies by sex. METHODS: First, we conducted a sex-disaggregated analysis of data from the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH)-2 and CRASH-3 trials. We used interaction tests to determine whether the treatment effect varied by sex. Second, we examined data from the Trauma and Audit Research Network (TARN) to explore sex differences in the receipt of TXA. We used logistic regression models to estimate the odds ratio for receipt of TXA in females compared with males. Results are reported as n (%), risk ratios (RR), and odds ratios (OR) with 95% confidence intervals. RESULTS: Overall, 20 211 polytrauma patients (CRASH-2) and 12 737 patients with traumatic brain injuries (CRASH-3) were included in our analysis. TXA reduced the risk of death in females (RR=0.69 [0.52-0.91]) and in males (RR=0.80 [0.71-0.90]) with no significant heterogeneity by sex (P=0.34). We examined TARN data for 216 364 patients aged ≥16 yr with an Injury Severity Score ≥9 with 98 879 (46%) females and 117 485 (54%) males. TXA was received by 7198 (7.3% [7.1-7.4%]) of the females and 19 697 (16.8% [16.6-17.0%]) of the males (OR=0.39 [0.38-0.40]). The sex difference in the receipt of TXA increased with increasing age. CONCLUSIONS: Administration of TXA to patients with bleeding trauma reduces mortality to a similar extent in women and men, but women are substantially less likely to be treated with TXA.

Chronic Physical Health Conditions After Injury: A Comparison of Prevalence and Risk in People With Orthopedic Major Trauma and Other Types of Injury.

OBJECTIVES: To determine (1) the prevalence of chronic physical health conditions reported preinjury, at the time of injury, up to 1 year postinjury, and 1 to 5 years postinjury; and (2) the risk of chronic physical health conditions reported 1 to 5 years postinjury in people with orthopedic and other types of major trauma. DESIGN: Cohort study using linked trauma registry and health administrative datasets. SETTING: This study used linked data from the Victorian State Trauma Registry (VSTR), the Victorian Registry of Births, Deaths and Marriages (BDM), the Victorian Admitted Episodes Dataset (VAED), and the Victorian Emergency Minimum Dataset (VEMD). PARTICIPANTS: Major trauma patients (N=28,522) aged 18 years and older who were registered by the VSTR, with dates of injury from 2007 to 2016, and who survived to at least 1 year after injury, were included in this study. Major trauma cases were classified into 4 groups: (1) orthopedic injury, (2) severe traumatic brain injury (s-TBI), (3) spinal cord injury, and (4) other major trauma. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Prevalence of chronic physical health conditions. RESULTS: The cumulative prevalence of any chronic physical health condition for all participants was 69.3%. The s-TBI group had the highest cumulative prevalence of conditions. The most common conditions were arthritis and arthropathies, cancer, and cardiovascular diseases. Preinjury chronic conditions were most common in people with s-TBI (19.3%) and were least common in people with other types of major trauma (6.6%). The highest prevalence of new-onset conditions after injury was found in people with s-TBI (21.7%) and orthopedic major trauma (21.4%), whereas the lowest prevalence was found in people with other types of major trauma (9.2%). For the orthopedic injury group, there were no significant differences in the adjusted risk of conditions reported 1 to 5 years postinjury compared with other major trauma groups. CONCLUSIONS: Chronic physical health conditions were common among all injury groups. There was no significant difference in the risk of chronic conditions among injury groups. Rehabilitation practitioners should be aware of the risk of chronic conditions in people with orthopedic and other types of major trauma. Long-term follow-up care after injury should include prevention and treatment of chronic conditions.

Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions. DESIGN: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up. SETTING: Department of Veterans Affairs medical facility. PARTICIPANTS: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions. INTERVENTIONS: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility. MAIN OUTCOME MEASURES: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect. RESULTS: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms). CONCLUSION: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®.

INTRODUCTION: Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS: Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS: The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION: DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

Provision of acute care pathways for older major trauma patients in the UK.

BACKGROUND: The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known. OBJECTIVE: The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK. METHODS: A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each. RESULTS: Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age. CONCLUSIONS: This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

Early start of thromboprophylaxis does not increase risk of intracranial hematoma progression in multiply injured patients with traumatic brain injury.

BACKGROUND: Venous thromboembolism (VTE) in severely injured patients with severe traumatic brain injury (TBI) is a risk during the clinical course. Data on the safety of an early initiation of pharmacological VTE prophylaxis in severely injured patients with concomitant severe TBI is sparse. METHODS: Admissions to our level-1-trauma center between January 2015 and December 2018 were screened. Patients suffering from severe TBI (Abbreviated Injury Scale (AIS) of the head ≥3) and at least one further AIS ≥ 3 in any other body region were included. Demographic data, thromboembolic events, and progression of the intracranial hemorrhage were extracted from the patient's charts. According to the first application of pharmacological thromboprophylaxis (VTEp), patients were categorized either to the early, the late (later than 24 h) or the no therapy group. RESULTS: In 79 patients (early: n = 35, late: n = 29, no therapy: n = 15) the Injury Severity Score (ISS) was 36.7 ± 12.7 points (AIShead 4.1 ± 0.8). No differences were found regarding the progression of the intracranial hemorrhage after initiation of the VTE prophylaxis (adj. p = 0.8). The VTE rate was low (n = 1, 1.6%). CONCLUSION: In severely injured patients with severe TBI, the early administration of pharmacological thromboprophylaxis did not result in a higher rate of intracranial hematoma progression.