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Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Emergency Medicine".

Deadline for manuscript submissions: closed (1 November 2022) | Viewed by 9354

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Dr. Ladislav Mica

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Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
Interests: polytrauma; trauma inflammation; artificial intelligence; orthopaedic trauma; spine

Special Issue Information

Dear Colleagues,

It is always challenging to treat critically injured patients. Decision making, timing and strategical planning are highly individualised and require long years of experience. In this sense, critical injury means a multi-system involvement and not only orthopaedic trauma. To find the best path in the treatment of such patients, a polypragmatic approach is often necessary, with sometimes unsatisfying results. New efforts and approaches have to be found to improve standards and outcomes in the treatment of multiply-injured patients. Besides the conventional scientific efforts, interprofessional projects could lead to new insights, interpretations, and unexpected conclusions in this dramatic field of medicine.

Dr. Ladislav Mica
Guest Editor

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Keywords

new interpretations of polytrauma
new insights on polytrauma
inflammation
polytrauma
multi system injury
sepsis
laboratory parameters
damage control
systemic inflammatory response syndrome
multi-organ failure

Published Papers (6 papers)

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Research

8 pages, 559 KiB

Open AccessArticle

Chest CT Findings and SARS-CoV-2 Infection in Trauma Patients—Is There a Prediction towards Higher Complication Rates?

by Fabrice Scheurer, Sascha Halvachizadeh, Till Berk, Hans-Christoph Pape and Roman Pfeifer

J. Clin. Med. 2022, 11(21), 6401; https://doi.org/10.3390/jcm11216401 - 29 Oct 2022

Cited by 3 | Viewed by 875

Abstract

Background: Polytrauma patients with SARS-CoV-2 infections may be associated with an increased complication rate. The main goal of this study was to analyze the clinical course of trauma patients with COVID infection and a positive CT finding. Methods: This was a retrospective in-hospital study. Polytrauma patients diagnosed with SARS-CoV-2 infections were included in our analysis. The outcome parameters were pulmonary complication during admission, pulmonary embolism, pleural effusion, pneumonia, mortality, length of stay and readmission < 30 days. Results: 48 patients were included in the study. Trauma patients in the age-adjusted matched-pair analysis with typical changes in SARS-CoV-2 infection in CT findings showed significantly more pulmonary complications in general and significantly more cases of pneumonia (complications: 56% vs. 11%, p = 0.046; pneumonia 44% vs. 0%, p = 0.023). In addition, the clinical course of polytrauma patients with SARS-CoV-2 infection showed a high rate of pulmonary complications in the inpatient course (53%). Conclusion: The results of our study show that the changes in the CT findings of trauma patients with SARS-CoV-2 infection are a good indicator of further inpatient outcomes. Similarly, polytrauma patients with a SARS-CoV-2 infection and positive CT findings are shown to have increased risk for pulmonary complications. Full article

(This article belongs to the Special Issue Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions)

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13 pages, 2817 KiB

Open AccessArticle

Outcome Comparison of Acute Respiratory Distress Syndrome (ARDS) in Patients with Trauma-Associated and Non-Trauma-Associated ARDS: A Retrospective 11-Year Period Analysis

by Lilian Jo Engelhardt, Claudio Olbricht, Marcel Niemann, Jan Adriaan Graw, Oliver Hunsicker, Björn Weiss, Victoria Bünger, Steffen Weber-Carstens, Sebastian Daniel Boie, Sophie K. Piper, Felix Balzer and Mario Menk

J. Clin. Med. 2022, 11(19), 5734; https://doi.org/10.3390/jcm11195734 - 28 Sep 2022

Cited by 4 | Viewed by 1386

Abstract

(1) Background: Acute respiratory distress syndrome (ARDS) is a rare complication in multiply injured patients. Due to the rarity of ARDS development after trauma, little is known about outcomes of patients with trauma-associated ARDS compared to patients with non-trauma-associated ARDS. (2) Methods: This retrospective analysis included n = 1038 ARDS patients admitted to the ARDS center of Charité—Universitätsmedizin Berlin between 2007 and 2018. Patients with trauma-associated ARDS (n = 62) were compared to patients with non-trauma-associated ARDS (n = 976). In a secondary analysis, patients from the group with non-trauma-associated ARDS were 1:1 nearest neighbor matched to patients with trauma-associated ARDS. The primary outcomes were 28-day in-hospital mortality, 60-day in-hospital mortality, and overall in-hospital mortality. (3) Results: Overall in-hospital mortality in trauma-associated ARDS was 29.0% compared to 40.5% in all patients with non-trauma-associated ARDS (p = 0.074). The in-hospital mortality rate in matched patients with non-trauma-associated ARDS (33.9%) was comparable to the trauma-associated ARDS cohort (p = 0.701). Kaplan–Meier curves indicated time-sensitive variations in 28-day and 60-day in-hospital survival. (4) Conclusion: Mortality was not different in patients with trauma-associated ARDS compared to patients with non-trauma-associated ARDS. Survival rate in the Kaplan–Meier curves stabilized after the critical initial phase and throughout the further 60-day period in patients with trauma-associated ARDS compared to patients with non-trauma-associated ARDS. Since this divergence was less pronounced in the matched cohort, it may be related to the younger age, fewer comorbidities, and lower ARDS severity in patients with trauma-associated ARDS. Patients with trauma-associated ARDS remain a very different cohort compared to patients with non-trauma-associated ARDS. Therefore, the outcome comparison is limited, even after matching. Full article

(This article belongs to the Special Issue Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions)

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10 pages, 1825 KiB

Open AccessArticle

Evaluation of a New Echocardiographic Tool for Cardiac Output Monitoring: An Experimental Study on A Controlled Hemorrhagic Shock Model in Anesthetized Piglets

by Thibaut Markarian, Laura Grau-Mercier, Céline Occelli, Florian Ajavon, Pierre-Géraud Claret, Fabien Coisy and Xavier Bobbia

J. Clin. Med. 2022, 11(18), 5420; https://doi.org/10.3390/jcm11185420 - 15 Sep 2022

Cited by 1 | Viewed by 1737

Abstract

Background: Cardiac output (CO) monitoring is recommended in patients with shock. The search for a reliable, rapid, and noninvasive tool is necessary for clinical practice. A new echocardiographic CO flow index (COF) is the automatic calculation of the sub-aortic VTI multiplied by the automatic calculation of the heart rate (HR). The primary objective of this study was to show the correlation between COF and CO measured by thermodilution (COth) in a controlled hemorrhagic shock model in anesthetized piglets. Secondary objectives were to show the correlation between COth and CO calculated from left outflow tract (LVOT) measurement and manual VTI (COman), and CO measured by LVOT measurement and VTIauto (COauto). Methods: Prospective interventional experimental study. In seventeen ventilated and anesthetized piglets, a state of hemorrhagic shock was induced, maintained, then resuscitated and stabilized. The gold standard for CO and stroke volume measurement was thermodilution (COth). Results: 191 measurements were performed. The correlation coefficients (r) between COth and COF, COman, and COauto were 0.73 [0.62; 0.81], 0.66 [0.56; 0.74], and 0.73 [0.63; 0.81], respectively. Conclusions: In this study, the COF appears to have a strong correlation to the COth. This automatic index, which takes into account the HR and does not require the measurement of LVOT, could be a rapidly obtained index in clinical practice. Full article

(This article belongs to the Special Issue Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions)

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16 pages, 4669 KiB

Open AccessArticle

Traumatic Brain Injury Induces a Differential Immune Response in Polytrauma Patients; Prospective Analysis of CD69 Expression on T Cells and Platelet Expansion

by Alexander Ditsch, Lea Hunold, Friederike Hefele, Frederik Greve, Olivia Mair, Peter Biberthaler, Laura Heimann and Marc Hanschen

J. Clin. Med. 2022, 11(18), 5315; https://doi.org/10.3390/jcm11185315 - 09 Sep 2022

Cited by 2 | Viewed by 1071

Abstract

Background: Accidents and injuries are the leading causes of mortality in young people. CD4+ regulatory T cells (CD4+ Tregs), Th17 cells and platelets could be identified as key players in post-traumatic immunological dysfunction, which is a common cause of late mortality in trauma patients. The mechanisms of activation of these cell types and their interaction remain mostly unclear. Since CD69 is not only a leukocyte marker but has also immunoregulatory functions, we postulate a role for CD69 after trauma. The present study investigates the expression of CD69 on CD4+ Tregs and Th17 cells, as well as the posttraumatic expansion of platelets and hemostatic function. Subgroup analysis was performed to assess the differences between polytrauma patients with and without severe traumatic brain injury (TBI). Methods: In this non-interventional prospective clinical trial, we analyzed sequential blood samples over a period of 10 days from 30 patients after multiple traumas with an ISS ≥ 16. Platelet function was assessed by rotational thromboelastometry (ROTEM analysis). CD4+ Tregs and Th17 cells were stained with surface markers and analyzed by flow cytometry. Results: We were able to demonstrate a significantly increased expression of CD69 on CD4+ Tregs after trauma. Subgroup analysis revealed that the absence of severe TBI is associated with a significantly higher expression of CD69 on CD4+ Tregs and on Th17 cells. Platelets expanded and showed signs of dysfunction, while an overall tendency of posttraumatic hypercoagulation was detected. Conclusions: Our results support the concept of injury-specific immune responses and add to a further understanding of the complex pathophysiology of post-traumatic immune dysfunction. Full article

(This article belongs to the Special Issue Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions)

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13 pages, 739 KiB

Open AccessArticle

Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision

by Manuel Florian Struck, Christian Kleber, Sebastian Ewens, Sebastian Ebel, Holger Kirsten, Sebastian Krämer, Stefan Schob, Georg Osterhoff, Felix Girrbach, Peter Hilbert-Carius, Benjamin Ondruschka and Gunther Hempel

J. Clin. Med. 2022, 11(14), 4043; https://doi.org/10.3390/jcm11144043 - 13 Jul 2022

Cited by 3 | Viewed by 2126

Abstract

The rate of occult pneumothorax in intubated and mechanically ventilated trauma patients until initial computed tomography (CT) remains undetermined. The primary aims of this study were to analyze initial chest CTs with respect to the thoracic pathology of trauma, the clinical injury severity, and chest tube placement (CTP) before and after CT. In a single-center retrospective analysis of 616 intubated and mechanically ventilated adult patients admitted directly from the scene to the emergency department (ED), 224 underwent CTP (36%). Of these, 142 patients (62%) underwent CTP before CT, of which, 125 (88%) had significant chest injury on CT. Seventeen patients had minor or absent chest injuries, most of which were associated with transient or unrecognized tracheal tube malposition. After CT, CTP was performed in another 82 patients, of which, 56 (68.3%) had relevant pneumothorax and 26 had minor findings on CT. Sixty patients who had already undergone CTP before CT received another CTP after CT, of which, 15 (25%) had relevant pneumothorax and 45 (75%) had functionality issues or malposition requiring replacement. Nine patients showed small pneumothorax on CT, and did not undergo CTP (including four patients with CTP before CT). The physiological variables were unspecific, and the trauma scores were dependent on the CT findings for identifying patients at risk for CTP. In conclusion, the clinical decisions for CTP before CT are associated with relevant false-negative and false-positive cases. Clinical assessment and CT imaging, together, are important indicators for CTP decisions that cannot be achieved by using clinical assessment or CT alone. Full article

(This article belongs to the Special Issue Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions)

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7 pages, 1474 KiB

Open AccessArticle

by Ladislav Mica, Hans-Christoph Pape, Philipp Niggli, Jindřich Vomela and Cédric Niggli

J. Clin. Med. 2021, 10(23), 5470; https://doi.org/10.3390/jcm10235470 - 23 Nov 2021

Cited by 3 | Viewed by 1328

Abstract

The University Hospital Zurich together with IBM^® invented an outcome prediction tool based on the IBM Watson technology, the Watson Trauma Pathway Explorer^®. This tool is an artificial intelligence to predict three outcome scenarios in polytrauma patients: the Systemic Inflammatory Response Syndrome (SIRS) and sepsis within 21 days as well as death within 72 h. The knowledge of a patient’s future under standardized trauma treatment might be of utmost importance. Here, new time-related insights on the C-reactive protein (CRP) and sepsis are presented. Meanwhile, the validated IBM Watson Trauma Pathway Explorer^® offers a time-related insight into the most frequent laboratory parameters. In total, 3653 patients were included in the databank used by the application, and ongoing admissions are constantly implemented. The patients were grouped according to sepsis, and the CRP was analyzed according to the point of time at which the value was acquired (1, 2, 3, 4, 6, 8, 12, 24, and 48 h and 3, 4, 5, 7, 10, 14, and 21 days). The differences were analyzed using the Mann–Whitney U-Test; binary logistic regression was used to determine the dependency of prediction, and the Closest Top-left Threshold Method presented time-specific thresholds at which CRP is predictive for sepsis. The data were considered as significant at p < 0.05, all analyses were performed in R. The differences in the CRP value of the non-sepsis and sepsis groups are starting to be significant between 6 and 8 h (p < 0.05) after admission inclusive of post hoc analysis, and the binary logistic regression depicts a similar picture. The level of significance is reached between 6 and 8 h (p < 0.05) after admission. The knowledge of the outcome reflected by the CRP in polytrauma patients improves the surgeon’s tactical position to indicate operations to reduce antigenic load and avoid an infectious adverse outcome. Full article

(This article belongs to the Special Issue Polytrauma and Shock Room Management: Current Status, Challenges and Future Directions)

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