Presentation, clinical course and complications in trauma patients with concomitant COVID-19 infection.

BACKGROUND: This study investigated the impact of COVID-19 infection on hospitalized trauma patients. METHODS: A retrospective review of hospitalized trauma patients at a level I trauma center was performed from March-December 2020. Data pertaining to patient demographics, presentation and hospital course was compared between COVID positive and negative trauma patients. RESULTS: There were 4,912 patients and 179 (3.64%) were COVID-19 positive. Demographics and clinical presentation did not differ significantly between those with and without concomitant COVID-19. However, COVID positive trauma patients had higher rates of acute kidney injury (p = 0.016), sepsis (p = 0.016), unplanned intubation (p = 0.002) and unplanned return to the ICU (p = 0.01). The COVID positive cohort also had longer hospital stays (p < 0.01) with no significant difference in mortality. CONCLUSIONS: In the setting of an ongoing pandemic, awareness of the complications COVID positive trauma patients are predisposed to is important for providers.

Differences in arterial and mixed venous IL-6 levels: the lungs as a source of cytokine storm in sepsis.

BACKGROUND: Several investigators have shown that blood levels of interleukin 6 (IL-6) correlate with the severity of illness in critically ill or injured patients. However, little is known about differential arterial and venous blood levels of the cytokine, especially across the lungs. METHODS: We measured differences in IL-6 levels in pulmonary and systemic arterial blood and then documented the production or elimination of IL-6 by the lungs in 19 patients with severe illness. Prospective data were obtained from multiple, simultaneous systemic arterial (ART) and mixed venous (MV) blood samples that were drawn for IL-6 analysis from systemic arterial and pulmonary artery catheters in 7 patients awaiting vascular operation and in 12 trauma patients being treated in the intensive care unit. RESULTS: A lung disorder was present in 5 patients (pneumonia [n = 1], lung trauma [n = 4]) and absent in the remaining 14 patients. The following data were obtained (mean +/- SD) from the highest MV IL-6 levels (pg/mL) in each patient. In patients with a lung disorder (n = 5) compared with those with no disorder (n = 14), ART IL-6 was 9309 +/- 12,521 versus 134 +/- 128 (P =.010), MV IL-6 was 5516 +/- 7420 versus 137 +/- 129 (P =.011), the absolute difference was 3793 +/- 5271 versus -3 +/- 15 (P =.011), and the percentage difference was 37.4% +/- 29.8% versus 1.5% +/- 12.3% (P =.001). The ART and MV IL-6 levels tended to be much higher in the 5 patients with pneumonia (n = 1) and lung injuries (n = 4) than in the patients without apparent pulmonary problems. In addition, the patients with a primary lung disorder demonstrated a net increase in IL-6 levels across the lungs, whereas there was no increase, but rather, a net reduction of IL-6 levels across the lungs in patients without a lung disorder. CONCLUSIONS: The lung appears to be a major producer of IL-6 in patients with an inflammatory lung process. There is a 39% increase in the level of IL-6 as it passes through inflamed lung, producing a marked difference in ART and MV IL-6 levels. Normal lung demonstrated little effect on either ART or MV IL-6 levels.

The nutritional management of patients with head injuries.

Severe head injuries tend to be associated with hypermetabolism and hypercatabolism resulting in negative nitrogen balances which may exceed 30 grams day-1. Enteral feeding should begin as soon as the patient is hemodynamically stable, attempting to reach a non-protein caloric intake of at least 30-35 kcal kg-1 day-1 and a protein intake of 2.0-2.5 g kg-1 day-1 as soon as possible. With severe head injuries (Glasgow Coma Scale < 8), there is an increased tendency for gastric feeding to regurgitate into the upper airway. Keeping the patient upright and checking residuals is important in such patients. Jejunal feedings are less apt to be aspirated. If it is apparent that the gastro-intestinal tract cannot be used to reach the nutritional goals within three days, total parental nutrition is begun within 24-48 h so as to reach these nutrition goals by either one or both routes by the third or fourth day. Blood glucose levels exceeding 150-200 mg dl-1 tend to increase the severity of the neurologic problems and efforts should be made to prevent hyperglycemia by carefully regulating the glucose and insulin intake. Indirect calorimetry to determine the respiratory quotient and resting energy expenditure should be determined twice weekly. To determine N2 balance, urinary urea nitrogen should be measured in 24-h specimens. These tests should be performed once or twice weekly until it is clear that the nutrition is adequate.

Infectious complications following duodenal and/or pancreatic trauma.

Patients with pancreatic and/or duodenal trauma often have a high incidence of infectious complications. In this study we attempted to find the most important risk factors for these infections. A retrospective review of the records of 167 patients seen over 7 years (1989 through 1996) at an urban Level I trauma center for injury to the duodenum and/or pancreas was performed. Fifty-nine patients (35%) had isolated injury to the duodenum (13 blunt, 46 penetrating), 81 (49%) had isolated pancreatic trauma (18 blunt, 63 penetrating), and 27 (16%) had combined injuries (two blunt, 25 penetrating). The overall mortality rate was 21 per cent and the infectious morbidity rate was 40 per cent. The majority of patients had primary repair and/or drainage as treatment of their injuries. Patients with pancreatic injuries (alone or combined with a duodenal injury) had a much higher infection rate than duodenal injuries. The patients with duodenal injuries had significantly lower penetrating abdominal trauma indices, number of intra-abdominal organ injuries, and incidence of hypothermia. On multivariate analysis independent factors associated with infections included hypothermia and the presence of a pancreatic injury. Although injuries to the pancreas and duodenum often coexist it is the pancreatic injury that contributes most to the infectious morbidity.

Ostomy as a risk factor for posttraumatic infection in penetrating colonic injuries: univariate and multivariate analyses.

BACKGROUND: Primary repair for penetrating colonic injury is an acceptable practice in uncomplicated injuries, but it is still viewed with trepidation in high risk patients. METHODS: The records of 350 patients evaluated at an urban Level I trauma center for penetrating colonic injuries over an 8-year period (1989-1997) were reviewed. These included 33 stab and 317 gunshot wounds. Thirty-nine patients died within 48 hours. Of the remaining 311 patients, 78 (25%) developed 152 infections. These infections were classified as traumatic or nosocomial in nature. Traumatic infections (46%) included abdominal abscesses or peritonitis (28), wound infections (30), missile tract infections (8), and fistulas (4), whereas nosocomial infections (54%) included pneumonia (25), bacteremia (25), urinary tract infections (17), miscellaneous (8), empyema (4), and sinusitis (3). Significance for analyses was set at p < 0.05. RESULTS: Univariate analysis was performed to identify risk factors for the development of infections. The five most significant risk factors, using all infections as an outcome, were as follows: penetrating abdominal trauma index (PATI) greater than 30, presence of an ostomy, multiple transfusions, Injury Severity Score (ISS) of 16 or greater, and Revised Trauma Score less than 7.8. All were highly significant (p < 0.0001). Multivariate analysis with all infections as an outcome revealed that four of the five risk factors had independent effects, with the following significance: PATI greater than 30, ISS of 16 or greater, ostomy, and multiple transfusions. Multivariate analysis for traumatic infections revealed only two of the above to be independent risk factors: presence of an ostomy (p = 0.004) and a PATI greater than 30 (p = 0.039), both of which can be considered local factors. Conversely, multivariate analysis of nosocomial infections revealed independent risk for the two other factors, both of which can be considered systemic factors: multiple transfusions (p = 0.011) and ISS of 16 or greater (p = 0.026). CONCLUSION: Although most of the above factors are beyond the control of the trauma surgeon, the creation of an ostomy is a clinical decision. The creation of an ostomy in high-risk patients does not protect them from septic complications and, indeed, may independently contribute to local abdominal infections.

Pericytes augment the capillary barrier in in vitro cocultures.

UNLABELLED: Most in vitro studies of capillary permeability focus on endothelial cell (MVEC) monolayers and ignore the second cell that forms the capillary wall: the microvascular pericyte (PC). We describe a model to study the permeability characteristics of MVEC, PC, and MVEC:PC cocultures. METHODS: Semipermeable culture inserts were coated with collagen and then plated with early passage bovine pulmonary MVEC. On Day 3, bovine pulmonary PC were added at concentrations to approximate MVEC:PC ratios of 1:1, 5:1, and 10:1. Electrical resistance was measured on subsequent days and fluorescently labeled (FITC) albumin was used in a permeability assay to calculate an albumin clearance for each culture. RESULTS: The results for electrical resistance measurements and albumin assays showed a similar pattern. Resistance for endothelial cell monolayers was significantly higher and albumin permeability was significantly lower than that of controls. Addition of pericytes at a 10:1 and 5:1 ratios increased the permeability barrier compared to endothelial cells alone, although these cultures were not significantly different from one another. Cocultures at a 1:1 ratio had the best barrier, significantly better than all other cultures. CONCLUSIONS: Endothelial cell monolayers are an inadequate model of the microcirculation. As PC form a key component of the capillary wall in vivo and as addition of PC to MVEC monolayers in vitro, optimally at a 1:1 ratio, increase their barrier effect to large and small molecules, we believe it is necessary to include both cells in future in vitro studies.

Factors affecting mortality rates in patients with abdominal vascular injuries.

BACKGROUND: Major vessel injury is seen in 5% to 25% of patients admitted to hospitals with abdominal trauma, and this is the most common cause of death in these patients. METHODS: Data on 470 patients with abdominal vascular injuries seen at a Level I trauma center were reviewed retrospectively. RESULTS: The overall mortality rate was 45%. The incidence of various types of trauma were blunt in 51 patients (11%), gunshot wounds in 329 patients (70%), shotgun wounds in 21 patients (4%), and stab wounds in 69 patients (15%). The three vessels with the highest mortality rates were aorta (at and proximal to the renals) (32 of 35 [91%]), hepatic veins and/or retrohepatic vena cava (36 of 41 [88%]), and portal vein (25 of 36 [69%]). The most significant risk factors (p < 0.001) for death were a trauma score of 9 or less, initial operating room (OR) systolic blood pressure (SBP) < 90 mm Hg, final OR core temperature < 34 degrees C, 10 or more blood transfusions in the first 24 hours, and an initial emergency department SBP < 70 mm Hg. Of 120 patients with an initial OR SBP < 70 mm Hg, 103 (86%) died. Of 29 patients with a good response to a prelaparotomy thoracotomy with thoracic aortic cross-clamping (SBP > 90 mm Hg within 5 minutes), 11 (38%) survived. Of the remaining 87 patients, only 6 (7%) survived (p = 0.01). CONCLUSION: Rapid control of bleeding sites (to keep blood transfusions to < 10 units) and urgent correction of hypothermia seem to be the main factors improving survival over which the surgeon has some control.

Factors affecting prognosis with penetrating wounds of the heart.

OBJECTIVE: To determine factors affecting prognosis for patients with penetrating wounds of the heart. METHODS: A retrospective review of 302 patients with penetrating heart wounds undergoing emergency thoracotomy (August of 1980 through June of 1997) in a Level I trauma center. RESULTS: There were 148 patients with gunshot wounds (GSW) and 154 patients with stab wounds with 23% and 58% survival rates, respectively. Of 43 patients having no signs of life at the scene, 5 patients (12%) achieved some cardiac activity and were brought to the operating room (OR), but none survived. Of 67 patients "arresting" in the ambulance, 23 got to the OR, but only 3 patients (4%) survived. Of 27 patients "arresting" in the emergency department (ED), 18 patients reached the OR, but only 5 patients (19%) survived. Of 15 patients having an ED thoracotomy because of rapid deterioration there, 4 patients (27%) survived. Thus, of the 152 patients with an ED thoracotomy, 93 patients had gunshot wounds and none survived; of the 59 with stab wounds, 12 (20%) survived (p < 0.001). Of 150 patients having an OR thoracotomy, 111 (74%) survived. Single-chamber injuries had a survival rate of 51% (112 of 219 patients), but multiple chamber and/or intrapericardial great vessel injuries had only a 13% survival rate (11 of 83 patients) (p < 0.001). Intrapericardial aortic injuries were uniformly fatal in 15 patients. In patients with stab wounds, pericardial tamponade was associated with a higher survival rate (66%; 56 of 84 patients) than in those without tamponade (47%; 33 of 70 patients). CONCLUSION: The physiologic status of the patient at presentation, mechanism of injury, and presence of a tamponade were significant prognostic factors in this series of penetrating cardiac injuries. Multiple-chamber injuries, especially with great vessel involvement, were associated with a high mortality rate. ED thoracotomies for gunshot wounds of the heart were uniformly fatal.