Journal of Clinical Medicine

Research

Jump to: Review

12 pages, 1100 KiB

Open AccessArticle

Identifying Trauma Patients in Need for Emergency Surgery in the Prehospital Setting: The Prehospital Prediction of In-Hospital Emergency Treatment (PROPHET) Study

by Stefano Isgrò, Marco Giani, Laura Antolini, Riccardo Giudici, Maria Grazia Valsecchi, Giacomo Bellani, Osvaldo Chiara, Gabriele Bassi, Nicola Latronico, Luca Cabrini, Roberto Fumagalli, Arturo Chieregato, Fabrizio Sammartano, Giuseppe Sechi, Alberto Zoli, Andrea Pagliosa, Alessandra Palo, Oliviero Valoti, Michele Carlucci, Annalisa Benini and Giuseppe Foti Show full author list Hide full author list

J. Clin. Med. 2023, 12(20), 6660; https://doi.org/10.3390/jcm12206660 - 20 Oct 2023

Cited by 2 | Viewed by 1171

Abstract

Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional [...] Read more.

Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

11 pages, 1965 KiB

Open AccessArticle

Performance Assessment of Out-of-Hospital Use of Pelvic Circumferential Compression Devices for Severely Injured Patients in Switzerland: A Nationwide Retrospective Cross-Sectional Study

by Lionel Balet, François-Xavier Ageron, Mathieu Pasquier, Tobias Zingg and The Swiss Trauma Registry

J. Clin. Med. 2023, 12(17), 5509; https://doi.org/10.3390/jcm12175509 - 24 Aug 2023

Cited by 1 | Viewed by 1264

Abstract

Background: Patients with severe pelvic fractures carry a greater risk of severe bleeding, and pelvic compression devices (PCCD) are used to stabilize the pelvis on the pre-hospital scene. The aim of this study was to describe the use of PCCD in the pre-hospital [...] Read more.

Background: Patients with severe pelvic fractures carry a greater risk of severe bleeding, and pelvic compression devices (PCCD) are used to stabilize the pelvis on the pre-hospital scene. The aim of this study was to describe the use of PCCD in the pre-hospital setting on a nationwide scale (Switzerland) and determine the sensitivity, specificity and rates of over- and under-triage of the current application practices. The secondary objective was to identify pre-hospital factors associated with unstable pelvic fractures. Methods: Retrospective cross-sectional study using anonymized patient data (1 January 2015–31 December 2020) from the Swiss Trauma Registry (STR). Based on AIS scores, patients were assigned a unique principal diagnosis among three categories (unstable pelvic fracture—stable pelvic fracture—other) and assessed for use or not of PCCD. Secondarily, patient characteristics, initial pre-hospital vital signs, means of pre-hospital transport and trauma mechanism were also extracted from the database. Results: 2790 patients were included for analysis. A PCCD was used in 387 (13.9%) patients. In the PCCD group, 176 (45.5%) had an unstable pelvic fracture, 52 (13.4%) a stable pelvic fracture and 159 (41.1%) an injury unrelated to the pelvic region. In the group who did not receive a PCCD, 214 (8.9%) had an unstable pelvic fracture, 182 (7.6%) a stable pelvic fracture and 2007 (83.5%) an injury unrelated to the pelvic region. The nationwide sensitivity of PCCD application was 45.1% (95% CI 40.1–50.2), the specificity 91.2% (95% CI 90–92.3), with both over- and under-triage rates of 55%. The prevalence of unstable fractures in our population was 14% (390/2790). We identified female sex, younger age, lower systolic blood pressure, higher shock index, pedestrian hit and fall ≥3 m as possible risk factors for an unstable pelvic fracture. Conclusions: Our results demonstrate a nationwide both over- and under-triage rate of 55% for out-of-hospital PCCD application. Female gender, younger age, lower blood pressure, higher shock index, pedestrian hit and fall >3 m are possible risk factors for unstable pelvic fracture, but it remains unclear if those parameters are relevant clinically to perform pre-hospital triage. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Graphical abstract

9 pages, 540 KiB

Open AccessArticle

Occult Pneumothorax in Blunt Thoracic Trauma: Clinical Characteristics and Results of Delayed Tube Thoracostomy in a Level 1 Trauma Center

by Chang-Wan Kim, Il-Hwan Park, Young-jin Youn and Chun-Sung Byun

J. Clin. Med. 2023, 12(13), 4333; https://doi.org/10.3390/jcm12134333 - 28 Jun 2023

Cited by 1 | Viewed by 1683

Abstract

Occult pneumothorax in blunt trauma patients is often diagnosed only after computed tomography because supine chest X-ray (CXR) is preferred as an initial evaluation. However, improperly managed preexisting occult pneumothorax could threaten the vitality of patients. Therefore, this study aimed to evaluate the [...] Read more.

Occult pneumothorax in blunt trauma patients is often diagnosed only after computed tomography because supine chest X-ray (CXR) is preferred as an initial evaluation. However, improperly managed preexisting occult pneumothorax could threaten the vitality of patients. Therefore, this study aimed to evaluate the incidence, characteristics, risk factors, and outcomes of occult pneumothorax in a single trauma center. From 2020 to 2022, patients who were admitted to the level 1 trauma center were retrospectively investigated. Inclusion criteria focused on blunt chest trauma. Variables including demographic factors, image findings, injury-related factors, tube thoracostomy timing, and treatment results were evaluated. Of the 1621 patients, 187 who met the criteria were enrolled in the study: 32 with overt pneumothorax and 81 with occult pneumothorax. Among all of the pneumothorax cases, the proportion of occult pneumothorax was 71.7% (81/113), and its incidence in all admitted trauma victims was 5.0% (81/1621). Subcutaneous emphysema and rib fractures on supine CXR were risk factors for occult pneumothorax. Six patients underwent delayed tube thoracostomy; however, none had serious complications. Given that occult pneumothorax is common in patients with blunt chest trauma, treatment plans should be established that consider the possibility of pneumothorax. However, the prognosis is generally good, and follow-up is an alternative. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

12 pages, 1294 KiB

Open AccessArticle

Fracture Types Influence the Likelihood of Lower Urinary Tract Injuries in Patients with Pelvic Fractures

by Xuehui Zhao, Shun Lu, Bingzhi Wang, Xiaofeng Zhou, Fanxiao Liu, Weicheng Xu, Dongsheng Zhou, Lianxin Li and Jinlei Dong

J. Clin. Med. 2023, 12(8), 2967; https://doi.org/10.3390/jcm12082967 - 19 Apr 2023

Cited by 2 | Viewed by 3273

Abstract

Background: The combination of pelvic fractures with lower urinary tract injuries (LUTIs) is a severe traumatic injury. This study was performed to determine the relationship between LUTIs and pelvic fracture types. Methods: Patients who sustained pelvic fractures combined with LUTIs between 1 January [...] Read more.

Background: The combination of pelvic fractures with lower urinary tract injuries (LUTIs) is a severe traumatic injury. This study was performed to determine the relationship between LUTIs and pelvic fracture types. Methods: Patients who sustained pelvic fractures combined with LUTIs between 1 January 2018 and 1 January 2022 in our institution were retrospectively analyzed. The patients’ demographics, mechanism of injury, presence of open pelvic fractures, types of pelvic fractures, patterns of LUTIs, and early complications were analyzed. The association between pelvic fracture types and the identified LUTIs was statistically analyzed. Results: This study involved 54 patients diagnosed with pelvic fractures combined with LUTIs. The overall incidence of pelvic fractures combined with LUTIs was 7.7% (n = 54/698). All patients had unstable pelvic fractures. The male:female ratio was approximately 2.4:1.0. The incidence of LUTIs was higher in men than women with pelvic fractures (9.1% vs. 4.4%). Bladder injuries occurred at roughly equal rates in men and women (4.5% vs. 4.4%, p = 0.966), but urethral injuries were more frequent in men (6.1% vs. 0.5%, p = 0.001). The most common pelvic injury pattern was a type C fracture according to the Tile classification and a vertical-shear-type fracture according to the Young–Burgess classification. The Young–Burgess fracture classification was related to the severity of bladder injury in men (p = 0.037). There was no significant difference in bladder injury according to the two classifications among women (p = 0.524 vs. p = 1.000) or among the entire cohort (p = 0.454 vs. p = 0.342). Conclusions: Men and women are equally likely to sustain a bladder injury, but a urethral injury with pelvic fracture is more frequent in men. LUTIs tend to be accompanied by unstable pelvic fractures. It is imperative to be vigilant for potential bladder injury when men sustain vertical-shear-type pelvic fractures. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

13 pages, 5437 KiB

Open AccessArticle

High Fat-to-Muscle Ratio Was Associated with Increased Clinical Severity in Patients with Abdominal Trauma

by Jiang Li, Fengchan Xi, Yuanchen He, Chuanrui Sun, Wenkui Yu and Xiling Wang

J. Clin. Med. 2023, 12(4), 1503; https://doi.org/10.3390/jcm12041503 - 14 Feb 2023

Viewed by 1894

Abstract

Overweight and moderate obesity confer a survival benefit in chronic diseases such as coronary artery disease and chronic kidney disease, which has been termed the “obesity paradox”. However, whether this phenomenon exists in trauma patients remains controversial. We performed a retrospective cohort study [...] Read more.

Overweight and moderate obesity confer a survival benefit in chronic diseases such as coronary artery disease and chronic kidney disease, which has been termed the “obesity paradox”. However, whether this phenomenon exists in trauma patients remains controversial. We performed a retrospective cohort study in abdominal trauma patients admitted to a Level I trauma center in Nanjing, China between 2010 and 2020. In addition to the traditional body mass index (BMI) based measures, we further examined the association between body composition-based indices with clinical severity in trauma populations. Body composition indices including skeletal muscle index (SMI), fat tissue index (FTI), and total fat-to-muscle ratio (FTI/SMI) were measured using computed tomography. Our study found that overweight was associated with a four-fold risk of mortality (OR, 4.47 [95% CI, 1.40–14.97], p = 0.012) and obesity was associated with a seven-fold risk of mortality (OR, 6.56 [95% CI, 1.07–36.57], p = 0.032) compared to normal weight. Patients with high FTI/SMI had a three-fold risk of mortality (OR, 3.06 [95% CI, 1.08–10.16], p = 0.046) and double the risk of an intensive care unit length of stay ≥ 5 d (OR, 1.75 [95% CI, 1.06–2.91], p = 0.031) compared to patients with low FTI/SMI. The obesity paradox was not observed in abdominal trauma patients, and high FTI/SMI ratio was independently associated with increased clinical severity. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

11 pages, 1040 KiB

Open AccessArticle

Longitudinal D-Dimer Trajectories and the Risk of Mortality in Abdominal Trauma Patients: A Group-Based Trajectory Modeling Analysis

by Chuanrui Sun, Fengchan Xi, Jiang Li, Wenkui Yu and Xiling Wang

J. Clin. Med. 2023, 12(3), 1091; https://doi.org/10.3390/jcm12031091 - 30 Jan 2023

Cited by 1 | Viewed by 1991

Abstract

This study aimed to identify the long-term D-dimer trajectory patterns and their associations with in-hospital all-cause mortality in abdominal trauma patients. This is a retrospective cohort study of general adult abdominal trauma patients admitted to Jinling Hospital (Nanjing, China) between January 2010 and [...] Read more.

This study aimed to identify the long-term D-dimer trajectory patterns and their associations with in-hospital all-cause mortality in abdominal trauma patients. This is a retrospective cohort study of general adult abdominal trauma patients admitted to Jinling Hospital (Nanjing, China) between January 2010 and April 2020. Group-based trajectory modeling was applied to model D-dimer trajectories over the first 50 days post-trauma. A multivariable logistic regression was performed to estimate the associations between D-dimer trajectories and in-hospital all-cause mortality. A total of 309 patients were included. We identified four distinct D-dimer trajectories: group 1 (57.61%; “stable low”), group 2 (28.16%; “moderate-decline”), group 3 (8.41%; “high-rapid decline”), and group 4 (5.83%; “high-gradual decline”). The SOFA score (p = 0.005) and ISS (p = 0.001) were statistically higher in groups 3 and 4 than in groups 1 and 2. The LMWH and UFH did not differ between groups 3 and 4. Compared with the patients in group 1, only the patients in group 4 were at a higher risk of in-hospital all-cause mortality (OR = 6.94, 95% CI: 1.20–40.25). The long-term D-dimer trajectories post-trauma were heterogeneous and associated with mortality. An initially high and slowly-resolved D-dimer might function as the marker of disease deterioration, and specific interventions are needed. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

13 pages, 255 KiB

Open AccessArticle

In-Hospital Predictors of Need for Ventilatory Support and Mortality in Chest Trauma: A Multicenter Retrospective Study

by Elisa Reitano, Francesco Gavelli, Giacomo Iannantuoni, Silvia Fattori, Chiara Airoldi, Simone Matranga, Stefano Piero Bernardo Cioffi, Silvia Ingala, Francesco Virdis, Martina Rizzo, Nicole Marcomini, Alberto Motta, Andrea Spota, Matteo Maestrone, Roberta Ragozzino, Michele Altomare, Luigi Mario Castello, Francesco Della Corte, Rosanna Vaschetto, Gian Carlo Avanzi, Osvaldo Chiara and Stefania Cimbanassi Show full author list Hide full author list

J. Clin. Med. 2023, 12(2), 714; https://doi.org/10.3390/jcm12020714 - 16 Jan 2023

Viewed by 1892

Abstract

Chest trauma management often requires the use of invasive and non-invasive ventilation. To date, only a few studies investigated the predictors of the need for ventilatory support. Data on 1080 patients with chest trauma managed in two different centers were retrospectively analyzed. Univariate [...] Read more.

Chest trauma management often requires the use of invasive and non-invasive ventilation. To date, only a few studies investigated the predictors of the need for ventilatory support. Data on 1080 patients with chest trauma managed in two different centers were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the predictors of tracheal intubation (TI), non-invasive mechanical ventilation (NIMV), and mortality. Rib fractures (p = 0.0001) fracture of the scapula, clavicle, or sternum (p = 0.045), hemothorax (p = 0.0035) pulmonary contusion (p = 0.0241), and a high Injury Severity Score (ISS) (p ≤ 0001) emerged as independent predictors of the need of TI. Rib fractures (p = 0.0009) hemothorax (p = 0.0027), pulmonary contusion (p = 0.0160) and a high ISS (p = 0.0001) were independent predictors of NIMV. The center of trauma care (p = 0.0279), age (p < 0.0001) peripheral oxygen saturation in the emergency department (p = 0.0010), ISS (p < 0.0001), and Revised Trauma Score (RTS) (p < 0.0001) were independent predictors of outcome. In conclusion, patients who do not require TI, while mandating ventilatory support with selected types of injuries and severity scores, are more likely to be subjected to NIMV. Trauma team expertise and the level of the trauma center could influence patient outcomes. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

9 pages, 778 KiB

Open AccessArticle

Myocardial Injury Is Associated with the Incidence of Major Adverse Cardiac Events in Patients with Severe Trauma

by Alexandra Stroda, Carina Jaekel, René M’Pembele, Alexander Guenther, Theresa Tenge, Carl Maximilian Thielmann, Simon Thelen, Erik Schiffner, Dan Bieler, Michael Bernhard, Ragnar Huhn, Giovanna Lurati Buse and Sebastian Roth

J. Clin. Med. 2022, 11(24), 7432; https://doi.org/10.3390/jcm11247432 - 15 Dec 2022

Cited by 2 | Viewed by 1308

Abstract

Background: Severe trauma potentially results in end-organ damage such as myocardial injury. Data suggest that myocardial injury is associated with increased mortality in this cohort, but the association with the incidence of in-hospital major adverse cardiac events (MACE) remains undetermined. Methods: Retrospective cohort [...] Read more.

Background: Severe trauma potentially results in end-organ damage such as myocardial injury. Data suggest that myocardial injury is associated with increased mortality in this cohort, but the association with the incidence of in-hospital major adverse cardiac events (MACE) remains undetermined. Methods: Retrospective cohort study including adult patients with severe trauma treated at the University Hospital Duesseldorf between January 2016 and December 2019. The main exposure was myocardial injury at presentation. Endpoints were in-hospital incidence of MACE and incidence of acute kidney injury (AKI) within 72 h. Discrimination of hsTnT for MACE and AKI was examined by the receiver operating characteristic curve (ROC) and the area under the curve (AUC). We conducted multivariate logistic regression analysis. Results: We included 353 patients in our final analysis (72.5% male (256/353), age: 55 ± 21 years). The AUC for hsTnT and MACE was 0.68 [95% confidence interval (CI): 0.59–0.78]. The AUC for hsTnT and AKI was 0.64 [95% (CI): 0.55–0.72]. The adjusted odds ratio (OR) for myocardial injury and MACE was 2.97 [95% (CI): 1.31–6.72], and it was 2.14 [95% (CI): 1.03–4.46] for myocardial injury and AKI. Conclusion: Myocardial injury at presentation in patients with severe trauma is independently associated with the incidence of in-hospital MACE and AKI. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

8 pages, 669 KiB

Open AccessArticle

Early Mortality Risk in Acute Trauma Patients: Predictive Value of Injury Severity Score, Trauma Index, and Different Types of Shock Indices

by Guoyang Dai, Xin Lu, Feng Xu, Deli Xu, Pengfei Li, Xionghui Chen and Fengbao Guo

J. Clin. Med. 2022, 11(23), 7219; https://doi.org/10.3390/jcm11237219 - 5 Dec 2022

Cited by 4 | Viewed by 1901

Abstract

Objective: This study aimed to explore the predictive value of the Injury Severity Score (ISS), Trauma Index (TI) and different types of shock indices (SI) on the early mortality risk of acute trauma patients. Methods: Clinical data of acute trauma patients who met [...] Read more.

Objective: This study aimed to explore the predictive value of the Injury Severity Score (ISS), Trauma Index (TI) and different types of shock indices (SI) on the early mortality risk of acute trauma patients. Methods: Clinical data of acute trauma patients who met the inclusion and exclusion criteria of this study and were treated in the hospital from January 2020 to December 2020 were retrospectively collected, including gender, age, trauma mechanism, severe injury site, ISS, TI, admission vital signs, different types of shock indices (SI), death within 7 days, length of hospital stay, and Glasgow Outcome Score (GOS). The predictive value of the Injury Severity Score, Trauma Index, and different types of shock indices on the risk of early mortality in patients with acute trauma were compared using relevant statistical methods. Results: A total of 283 acute trauma patients (mean age 54.0 ± 17.9 years, 30.74% female) were included, and 43 (15.19%) of the patients died during 7 days of hospitalization. The admission ISS, TI, SI, MSI, and ASI in the survival group were significantly lower than those in the death group, and the difference was statistically significant (p < 0.05). Meanwhile, different trauma assessment tools included in the study have certain predictive value for early mortality risk of trauma patients. Conclusions: The TI indicates a better capability to predict the risk of early death in patients with acute trauma. As the most sensitive predictor, the SI has the greatest reference value in predicting the risk of early death in patients with traumatic shock. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

9 pages, 923 KiB

Open AccessArticle

Traumatic Brain Injury and Acute Kidney Injury—Outcomes and Associated Risk Factors

by Jesús Abelardo Barea-Mendoza, Mario Chico-Fernández, Manuel Quintana-Díaz, Lluís Serviá-Goixart, Ana Fernández-Cuervo, María Bringas-Bollada, María Ángeles Ballesteros-Sanz, Íker García-Sáez, Jon Pérez-Bárcena and Juan Antonio Llompart-Pou

J. Clin. Med. 2022, 11(23), 7216; https://doi.org/10.3390/jcm11237216 - 5 Dec 2022

Cited by 5 | Viewed by 2202

Abstract

Our objective was to analyze the contribution of acute kidney injury (AKI) to the mortality of isolated TBI patients and its associated risk factors. Observational, prospective and multicenter registry (RETRAUCI) methods were used, from March 2015 to December 2019. Isolated TBI was defined [...] Read more.

Our objective was to analyze the contribution of acute kidney injury (AKI) to the mortality of isolated TBI patients and its associated risk factors. Observational, prospective and multicenter registry (RETRAUCI) methods were used, from March 2015 to December 2019. Isolated TBI was defined as abbreviated injury scale (AIS) ≥ 3 head with no additional score ≥ 3. A comparison of groups was conducted using the Wilcoxon test, chi-square test or Fisher’s exact test, as appropriate. A multiple logistic regression analysis was conducted to analyze associated risk factors in the development of AKI. For the result, overall, 2964 (30.2%) had AIS head ≥ 3 with no other area with AIS ≥ 3. The mean age was 54.7 (SD 19.5) years, 76% were men, and the ground-level falls was 49.1%. The mean ISS was 18.4 (SD 8). The in-hospital mortality was 22.2%. Up to 310 patients (10.6%) developed AKI, which was associated with increased mortality (39% vs. 17%, adjusted OR 2.2). Associated risk factors (odds ratio (OR) (95% confidence interval)) were age (OR 1.02 (1.01–1.02)), hemodynamic instability (OR 2.87 to OR 5.83 (1.79–13.1)), rhabdomyolysis (OR 2.94 (1.69–5.11)), trauma-associated coagulopathy (OR 1.67 (1.05–2.66)) and transfusion of packed red-blood-cell concentrates (OR 1.76 (1.12–2.76)). In conclusion, AKI occurred in 10.6% of isolated TBI patients and was associated with increased mortality. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

13 pages, 906 KiB

Open AccessArticle

Multifactorial Shock: A Neglected Situation in Polytrauma Patients

by Jialiu Luo, Deng Chen, Liangsheng Tang, Hai Deng, Cong Zhang, Shunyao Chen, Teding Chang, Liming Dong, Wenguo Wang, Huaqiang Xu, Miaobo He, Dongli Wan, Gang Yin, Mengfan Wu, Fengsheng Cao, Yang Liu and Zhao-Hui Tang

J. Clin. Med. 2022, 11(22), 6829; https://doi.org/10.3390/jcm11226829 - 18 Nov 2022

Cited by 9 | Viewed by 3723

Abstract

Background: Shock after traumatic injury is likely to be hypovolemic, but different types of shock (distributive shock, obstructive shock, or cardiogenic shock) can occur in combination, known as multifactorial shock. Multifactorial shock is a neglected area of study, and is only reported sporadically. [...] Read more.

Background: Shock after traumatic injury is likely to be hypovolemic, but different types of shock (distributive shock, obstructive shock, or cardiogenic shock) can occur in combination, known as multifactorial shock. Multifactorial shock is a neglected area of study, and is only reported sporadically. Little is known about the incidence, characteristics, and outcomes of multifactorial shock after polytrauma. Methods: A retrospective, observational, multicenter study was conducted in four Level I trauma centers involving 1051 polytrauma patients from June 2020 to April 2022. Results: The mean Injury Severity Score (ISS) was 31.1, indicating a severely injured population. The most common type of shock in the early phase after polytrauma (≤48 h) is hypovolemic shock (83.2%), followed by distributive shock (14.4%), obstructive shock (8.7%), and cardiogenic shock (3.8%). In the middle phase after polytrauma (>48 h or ≤14 days), the most common type of shock is distributive shock (70.7%), followed by hypovolemic shock (27.2%), obstructive shock (9.9%), and cardiogenic shock (7.2%). Multifactorial shock accounted for 9.7% of the entire shock population in the early phase and 15.2% in the middle phase. In total, seven combinations of multifactorial shock were described. Patients with multifactorial shock have a significantly higher complication rate and mortality than those with single-factor shock. Conclusions: This study characterizes the incidence of various types of shock in different phases after polytrauma and emphasizes that different types of shock can occur simultaneously or sequentially in polytrauma patients. Multifactorial shock has a relatively high incidence and mortality in polytrauma patients, and trauma specialists should be alert to the possibility of their occurrence. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

11 pages, 1159 KiB

Open AccessArticle

Xuebijing Administration Alleviates Pulmonary Endothelial Inflammation and Coagulation Dysregulation in the Early Phase of Sepsis in Rats

by Jie Lv, Xiaoxia Guo, Huiying Zhao, Gang Zhou and Youzhong An

J. Clin. Med. 2022, 11(22), 6696; https://doi.org/10.3390/jcm11226696 - 11 Nov 2022

Cited by 7 | Viewed by 1769

Abstract

Ethnopharmacological relevance: Xuebijing injection is a Chinese herbal-derived drug composed of radix paeoniaerubra, rhizomachuanxiong, Salvia miltiorrhiza, floscarthami, and Angelica sinensis. This study aimed to investigate the effects of Xuebijing administration on pulmonary endothelial injury and coagulation dysfunction in a cecal ligation and puncture [...] Read more.

Ethnopharmacological relevance: Xuebijing injection is a Chinese herbal-derived drug composed of radix paeoniaerubra, rhizomachuanxiong, Salvia miltiorrhiza, floscarthami, and Angelica sinensis. This study aimed to investigate the effects of Xuebijing administration on pulmonary endothelial injury and coagulation dysfunction in a cecal ligation and puncture (CLP)-induced sepsis rat model. Materials and methods: A CLP-induced sepsis rat model was established. The CLP rats were treated with a vehicle or Xuebijing via intravenous infusion and sacrificed at 2, 4, 6, 8, or 12 h after CLP for lung tissue and blood sample collection. The mean arterial pressure (MAP) was monitored. Transmission microscopy examination and H&E staining were performed to observe pulmonary structural alterations. Enzyme linked immunosorbent assay (ELISA) was performed to measure the plasma levels of epithelial markers, proinflammatory cytokines, and coagulation-related proteins. Results: Compared with vehicle treatment, Xuebijing administration maintained the MAP in the normal range until 11 h after CLP. Transmission microscopy and H&E staining revealed that Xuebijing administration alleviated alveolar–capillary barrier impairments and lung inflammation in CLP rats. ELISA showed that Xuebijing administration effectively reversed CLP-induced elevations in the plasma levels of epithelial markers endothelin-1 and von Willebrand factor, starting 6 and 8 h after CLP, respectively. Xuebijing administration also significantly abolished CLP-induced rises in circulating proinflammatory cytokines interleukin 6 (IL-6) at 6 h after CLP, IL-1β at 2 and 12 h after CLP, and TNF-α at 2, 4, 6, 8, and 12 h after CLP. In addition, Xuebijing administration strongly reversed CLP-induced alterations in circulating active protein C and tissue-type plasminogen activator, starting 4 h and 2 h after CLP, respectively. Conclusions: Xuebijing ameliorates pulmonary endothelial injury, systemic inflammation, and coagulation dysfunction in early sepsis. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

13 pages, 1239 KiB

Open AccessArticle

Characteristics and Risk Factors of Myocardial Injury after Traumatic Hemorrhagic Shock

by Xiujuan Zhao, Fuzheng Guo, Chu Wang, Zhenzhou Wang, Panpan Chang, Haiyan Xue, Tianbing Wang and Fengxue Zhu

J. Clin. Med. 2022, 11(16), 4799; https://doi.org/10.3390/jcm11164799 - 17 Aug 2022

Cited by 6 | Viewed by 1864

Abstract

Myocardial injury increases major adverse cardiovascular events and mortality in patients with traumatic hemorrhagic shock, but its prevalence and risk factors remain unclear. This study aimed to assess the prevalence and risk factors of myocardial injury after traumatic hemorrhagic shock. This was an [...] Read more.

Myocardial injury increases major adverse cardiovascular events and mortality in patients with traumatic hemorrhagic shock, but its prevalence and risk factors remain unclear. This study aimed to assess the prevalence and risk factors of myocardial injury after traumatic hemorrhagic shock. This was an observational, retrospective cohort study of patients with traumatic hemorrhagic shock at a tertiary university hospital from November 2012 to July 2021. Patient characteristics and clinical variables were recorded in 314 patients. The outcome was the occurrence of myocardial injury after traumatic hemorrhagic shock. Risk factors for myocardial injury were identified using logistic regression. The incidence of myocardial injury after the traumatic hemorrhagic shock was 42.4%, and 95.5% of myocardial injuries occurred within the first three days after trauma. In the multivariate analysis, the independent risk factors for myocardial injury after traumatic hemorrhagic shock included heart rate of >100 beats/min (OR [odds ratio], 3.33; 95% confidence interval [CI], 1.56–7.09; p = 0.002), hemoglobin level of <70 g/L (OR, 3.50; 95% CI, 1.15–10.60; p = 0.027), prothrombin time of >15 s (OR, 2.39; 95% CI, 1.12–5.10; p = 0.024), acute kidney injury (OR, 2.75; 95% CI, 1.27–5.93; p = 0.01), and a higher APACHE II score (OR, 1.08; 95% CI, 1.01–1.15; p = 0.018). The area under the receiver operating characteristic curve for the prediction of myocardial injury after a traumatic hemorrhagic shock was 0.67 (95% CI, 0.68–0.79) for a heart rate of >100 beats/min, 0.67 (95% CI, 0.61–0.73) for hemoglobin level of <70 g/L, 0.66 (95% CI, 0.60–0.73) for prothrombin time of >15 s, 0.70 (95% CI, 0.64–0.76) for acute kidney injury, and 0.78 (95% CI, 0.73–0.83) for APACHE II scores. The incidence rate of myocardial injury in traumatic hemorrhagic shock is high, and heart rates of >100 beats/min, hemoglobin levels of <70 g/L, prothrombin times of >15 s, AKI and higher APACHE II scores are independent risk factors for myocardial injury after traumatic hemorrhagic shock. These findings may help clinicians to identify myocardial injury after traumatic hemorrhagic shock early and initiate appropriate treatment. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

Review

Jump to: Research

14 pages, 888 KiB

Open AccessReview

Trauma Patient Volume and the Quality of Care: A Scoping Review

by Wouter Foppen, Yvette Claassen, Debby Falck and Nardo J. M. van der Meer

J. Clin. Med. 2023, 12(16), 5317; https://doi.org/10.3390/jcm12165317 - 15 Aug 2023

Cited by 2 | Viewed by 1744

Abstract

Background: Healthcare stakeholders in the Netherlands came to an agreement in 2022 to deal with present and future challenges in healthcare. Among others, this agreement contains clear statements regarding the concentration of trauma patients, including the minimal required number of annual severe trauma [...] Read more.

Background: Healthcare stakeholders in the Netherlands came to an agreement in 2022 to deal with present and future challenges in healthcare. Among others, this agreement contains clear statements regarding the concentration of trauma patients, including the minimal required number of annual severe trauma patients for Major Trauma Centers. This review investigates the effects of trauma patient volumes on several domains of the quality of healthcare. Methods: PubMed was searched; studies published during the last 10 years reporting quantitative data on trauma patient volume and quality of healthcare were included. Results were summarized and categorized into the quality domains of healthcare. Results: Seventeen studies were included with a total of 1,517,848 patients. A positive association between trauma patient volume and survival was observed in 11/13 studies with adjusted analyses. Few studies addressed other quality domains: efficiency (n = 5), safety (n = 2), and time aspects of care (n = 4). None covered people-centeredness, equitability, or integrated care. Conclusions: Most studies showed a better survival of trauma patients when treated in high-volume hospitals compared to lower volume hospitals. However, the ideal threshold could not be determined. The association between trauma volume and other domains of the quality of healthcare remains unclear. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

31 pages, 2296 KiB

Open AccessReview

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

by Fabrizio G. Bonanno

J. Clin. Med. 2023, 12(1), 260; https://doi.org/10.3390/jcm12010260 - 29 Dec 2022

Cited by 16 | Viewed by 29600

Abstract

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an [...] Read more.

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The “physiological classification of HS” dictates the timely management and suits the ‘titrated hypotensive resuscitation’ tactics and the ‘damage control surgery’ strategy. In any hypotensive but not yet critical shock, the body’s response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/− lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/− upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps. Full article

(This article belongs to the Special Issue Evaluation and Management of Major Trauma)

► Show Figures

Figure 1

Journal Menu

Journal Browser

Evaluation and Management of Major Trauma

Share This Special Issue

Special Issue Editors

Special Issue Information

Keywords

Benefits of Publishing in a Special Issue

Published Papers (15 papers)

Research

Review

Further Information

Guidelines

MDPI Initiatives

Follow MDPI