Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

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Early thromboelastography in acute traumatic coagulopathy: an observational study focusing on pre-hospital trauma care

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-020-01493-z ◽

2020 ◽

Author(s):

Alessandra Spasiano ◽

Cristina Barbarino ◽

Anna Marangone ◽

Daniele Orso ◽

Giulio Trillò ◽

...

Keyword(s):

Injury Severity ◽

Severe Trauma ◽

University Hospital ◽

Trauma Patients ◽

Acute Traumatic Coagulopathy ◽

Comprehensive Overview ◽

New Injury Severity Score ◽

Trauma Population ◽

Severity Of Injury ◽

Almost All

Abstract Background Major brain injury and uncontrolled blood loss remain the primary causes of early trauma-related mortality. One-quarter to one-third of trauma patients exhibit trauma-induced coagulopathy (TIC). Thromboelastometry (ROTEM) and thrombelastography (TEG) are valuable alternatives to standard coagulation testing, providing a more comprehensive overview of the coagulation process. Purpose Evaluating thromboelastographic profile, the incidence of fibrinolysis (defined as Ly30 > 3%) in severe trauma patients, and factors influencing pathological coagulation pattern. Methods Prospective observational 2 years cohort study on severe trauma patients assisted by Helicopter Emergency Medical System (HEMS) and Level 1 Trauma Center, in a tertiary referral University Hospital. Results Eighty three patients were enrolled, mean NISS (new injury severity score) 36 (± 13). Mean R value decreased from 7.25 (± 2.6) to 6.19 (± 2.5) min (p < 0.03); 48 (60%) patients had a reduction in R from T0 to T1. In NISS 25–40 and NISS > 40 groups, changes in R value increased their significance (p = 0.04 and p < 0.03, respectively). Pathological TEG was found in 71 (88.8%) patients at T0 and 74 (92.5%) at T1. Hypercoagulation was present in 57 (71.3%) patients at T0, and in 66(82.5%) at T1. 9 (11.3%) patients had hyperfibrinolysis at T0, 7 (8.8%) patients at T1. Prevalence of StO2 < 75% at T0 was greater in patients whose TEG worsened (7 patients, 46.7%) against whose TEG remained stable or improved (8 patients, 17.4%) from T0 to T1 (p = 0.02). 48 (57.8%) patients received < 1000 mL of fluids, while 35 (42.2%) received ≥ 1000 mL. The first group had fewer patients with hypercoagulation (20, 41.6%) than the second (6, 17.6%) at T1 (p < 0.03). No differences were found for same TEG pattern at T0, nor other TEG pattern. Conclusion Our population is representative of a non-hemorrhagic severe injury subgroup. Almost all of our trauma population had coagulation abnormalities immediately after the trauma; pro-coagulant changes were the most represented regardless of the severity of injury. NISS appears to affect only R parameter on TEG. Hyperfibrinolysis has been found in a low percentage of patients. Hypoperfusion parameters do not help to identify patients with ongoing coagulation impairment. Small volume resuscitation and mild hypotermia does not affect coagulation, at least in the early post-traumatic phase.

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Extracorporeal membrane oxygenation in trauma patients: a systematic review

World Journal of Emergency Surgery ◽

10.1186/s13017-020-00331-2 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Changtian Wang ◽

Lei Zhang ◽

Tao Qin ◽

Zhilong Xi ◽

Lei Sun ◽

...

Keyword(s):

Systematic Review ◽

Extracorporeal Membrane Oxygenation ◽

Median Time ◽

Injury Severity ◽

Case Reports ◽

Severe Trauma ◽

Trauma Patients ◽

Membrane Oxygenation ◽

Severity Scores ◽

Va Ecmo

Abstract Background Extracorporeal membrane oxygenation (ECMO) has evolved considerably over the past two decades and has been gradually utilized in severe trauma. However, the indications for the use of ECMO in trauma remain uncertain and the clinical outcomes are different. We performed a systematic review to provide an overall estimate of the current performance of ECMO in the treatment of trauma patients. Materials and methods We searched PubMed and MEDLINE databases up to the end of December 2019 for studies on ECMO in trauma. The PRISMA statement was followed. Data on demographics of the patient, mechanism of injury, injury severity scores (ISS), details of ECMO strategies, and clinical outcome were extracted. Results A total of 58 articles (19 retrospective reports and 39 case reports) were deemed eligible and included. In total, 548 patients received ECMO treatment for severe trauma (adult 517; children 31; mean age of adults 34.9 ± 12.3 years). Blunt trauma (85.4%) was the primary injury mechanism, and 128 patients had traumatic brain injury (TBI). The mean ISS was 38.1 ± 15.0. A total of 71.3% of patients were initially treated with VV ECMO, and 24.5% were placed on VA ECMO. The median time on ECMO was 9.6 days, and the median time to ECMO was 5.7 days. A total of 60% of patients received initially heparin anticoagulation. Bleeding (22.9%) and thrombosis (19%) were the most common complications. Ischemia of the lower extremities occurred in 9 patients. The overall hospital mortality was 30.3%. Conclusions ECMO has been gradually utilized in a lifesaving capacity in severe trauma patients, and the feasibility and advantages of this technique are becoming widely accepted. The safety and effectiveness of ECMO in trauma require further study. Several problems with ECMO in trauma, including the role of VA-ECMO, the time to institute ECMO, and the anticoagulation strategy remain controversial and must be solved in future studies.

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Comparison of revised Functional Capacity Index scores with Abbreviated Injury Scale 2008 scores in predicting 12-month severe trauma outcomes

Injury Prevention ◽

10.1136/injuryprev-2018-043085 ◽

2019 ◽

Vol 26 (2) ◽

pp. 138-146

Author(s):

Cameron S Palmer ◽

Peter A Cameron ◽

Belinda J Gabbe

Keyword(s):

Functional Capacity ◽

Injury Severity ◽

Severe Trauma ◽

Population Based ◽

Trauma Patients ◽

Trauma Outcomes ◽

Severity Scores ◽

Severity Of Injury ◽

Capacity Index ◽

Improved Model

IntroductionAnatomical injury as measured by the AIS often accounts for only a small proportion of variability in outcomes after injury. The predictive Functional Capacity Index (FCI) appended to the 2008 AIS claims to provide a widely available method of predicting 12-month function following injury.ObjectivesTo determine the extent to which AIS-based and FCI-based scoring is able to add to a simple predictive model of 12-month function following severe injury.MethodsAdult trauma patients were drawn from the population-based Victorian State Trauma Registry. Major trauma and severely injured orthopaedic trauma patients were followed up via telephone interview including Glasgow Outcome Scale—Extended, the EQ-5D-3L and return to work status. A battery of AIS-based and FCI-based scores, and a simple count of AIS-coded injuries were added in turn to a base model using age and gender.ResultsA total of 20 813 patients survived to 12 months and had at least one functional outcome recorded, representing 85% follow-up. Predictions using the base model varied substantially across outcome measures. Irrespective of the method used to classify the severity of injury, adding injury severity to the model significantly, but only slightly improved model fit. Across the outcomes evaluated, no method of injury severity assessment consistently outperformed any other.ConclusionsAnatomical injury is a predictor of trauma outcome. However, injury severity as described by the FCI does not consistently improve discrimination, or even provide the best discrimination compared with AIS-based severity scores or a simple injury count.

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Anion Gap as a Predictor of Trauma Outcomes in the Older Trauma Population: Correlations with Injury Severity and Mortality

The American Surgeon ◽

10.1177/000313481307901126 ◽

2013 ◽

Vol 79 (11) ◽

pp. 1203-1206 ◽

Cited By ~ 5

Author(s):

John J. Leskovan ◽

Carla F. Justiniano ◽

John A. Bach ◽

Charles H. Cook ◽

David E. Lindsey ◽

...

Keyword(s):

Injury Severity ◽

Traumatic Injury ◽

Serum Lactate ◽

Anion Gap ◽

Morbidity And Mortality ◽

Trauma Patients ◽

Metabolic Derangement ◽

Trauma Outcomes ◽

Tissue Hypoperfusion ◽

Trauma Population

The relationship among traumatic injury, the associated metabolic/physiologic responses, and mortality is well established. Tissue hypoperfusion and metabolic derangement may not universally correlate with initial clinical presentation. We hypothesized that anion gap (AG) could be a useful gauge of trauma-related physiologic response and mortality in older patients with relatively lower injury acuity. We retrospectively analyzed data from 711 trauma patients older than 45 years. Parameters examined included demographics, injury characteristics, laboratories, morbidity, and mortality. Univariate and survival analyses were performed using PASW 18. A step-wise correlation exists between increasing Injury Severity Score and AG. Although AG less than 8 to 15 was not associated with a significant increase in mortality, greater mortality was seen for AG greater than 16 with further stepwise increases for AGs greater than 22. Anion gap correlated moderately with serum lactate and poorly with base excess. Increasing AG also correlated with morbidity and greater incidence of intensive care admissions. The presence of any complication increased from 28.6 per cent for patients with AG 12 or less to 45.5 per cent for patients with AG 22 or greater ( P < 0.04). These findings support the contention that “low acuity” trauma patients with high AGs may not appear acutely ill but may harbor significant underlying metabolic and physiologic disturbances that could contribute to morbidity and mortality. Higher AG values (i.e., greater than 16) may be associated with worse clinical outcomes.

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Structured and Systematic Team and Procedure Training in Severe Trauma: Going from ‘Zero to Hero’ for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

World Journal of Surgery ◽

10.1007/s00268-021-05980-1 ◽

2021 ◽

Vol 45 (5) ◽

pp. 1340-1348

Author(s):

Maryam Meshkinfamfard ◽

Jon Kristian Narvestad ◽

Johannes Wiik Larsen ◽

Arezo Kanani ◽

Jørgen Vennesland ◽

...

Keyword(s):

Injury Severity ◽

Trauma System ◽

Severe Trauma ◽

Emergency Procedure ◽

Emergency Thoracotomy ◽

Severity Scores ◽

Time Periods ◽

Low Volume ◽

Time Critical ◽

Over Time

Abstract Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

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Splanchnic Hypoperfusion-Directed Therapies in Trauma: A Prospective, Randomized Trial

The American Surgeon ◽

10.1177/000313480507100317 ◽

2005 ◽

Vol 71 (3) ◽

pp. 252-260 ◽

Cited By ~ 7

Author(s):

Stephen M. Cohn ◽

Orlando Kirton ◽

Margaret Brown ◽

S. Morad Hameed ◽

...

Keyword(s):

Randomized Trial ◽

Injury Severity ◽

Ischemia Reperfusion ◽

Unit Group ◽

Severe Trauma ◽

Prospective Randomized Trial ◽

Gastric Tonometry ◽

Trauma Patients ◽

Splanchnic Perfusion ◽

Splanchnic Hypoperfusion

Splanchnic hypoperfusion as reflected by gastric intramucosal acidosis has been recognized as an important determinant of outcome in shock. A comprehensive splanchnic hypoperfusion-ischemia reperfusion (IRP) protocol was evaluated against conventional shock management protocols in critical trauma patients. The study was a prospective randomized trial comparing three therapeutic approaches to hypoperfusion after severe trauma in 151 trauma patients admitted to the intensive care unit. Group 1 patients received hemodynamic support based on conventional indicators of hypoperfusion. In group 2, resuscitation was further guided by gastric tonometry-derived estimates of splanchnic hypoperfusion and included more invasive hemodynamic monitoring and additional administration of colloid or crystalloid solutions, or inotropic support. Group 3 patients additionally received therapies specifically aimed at optimizing splanchnic perfusion and minimizing oxidant-mediated damage from reperfusion. The three groups were similar based on age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II Scores. There were no statistically significant differences in mortality rates, organ dysfunction, ventilator days, or length of stay between any of the interventions. Techniques of optimization of splanchnic perfusion and minimization of oxidant-mediated reperfusion injury evaluated in this study were not advantageous relative to standard resuscitation measures guided by conventional or tonometric measures of hypoperfusion in the therapy of occult and clinical shock in trauma patients.

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Non-Selective Thoracic Computed Tomography in Trauma Patients Results in Injury Severity Score Inflation

The American Surgeon ◽

10.1177/00031348211024973 ◽

2021 ◽

pp. 000313482110249

Author(s):

Leonardo Alaniz ◽

Omaer Muttalib ◽

Juan Hoyos ◽

Cesar Figueroa ◽

Cristobal Barrios

Keyword(s):

Computed Tomography ◽

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Treatment Plan ◽

Mortality Prediction ◽

Trauma Patients ◽

Mortality Benefit ◽

Severity Scores ◽

Score Inflation

Introduction Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit. Methods Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases. Results After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality ( P < 0.001), lower median total hospital LOS ( P < .001), ICU days ( P < .001), and ventilator days ( P = 0.008), compared to those that remained in the same ISS category. Conclusion Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.

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A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

European Geriatric Medicine ◽

10.1007/s41999-021-00546-9 ◽

2021 ◽

Author(s):

Y. Kalbas ◽

M. Lempert ◽

F. Ziegenhain ◽

J. Scherer ◽

V. Neuhaus ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Descriptive Analysis ◽

Patient Characteristics ◽

Severe Trauma ◽

Diagnostic Tools ◽

Trauma Patients ◽

Treatment Algorithms ◽

Injured Patients ◽

Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

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Abstract 287: Plasma PCSK9 Concentrations in Critically Ill Patients

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.32.suppl_1.a287 ◽

2012 ◽

Vol 32 (suppl_1) ◽

Author(s):

Bertrand Cariou ◽

Maëlle Le Bras ◽

Antoine Roquilly ◽

Fanny Feuillet ◽

Véronique Sebille ◽

...

Keyword(s):

Multiple Trauma ◽

Injury Severity ◽

Ldl Receptor ◽

Plasma Lipid ◽

Severity Of Illness ◽

Inverse Correlation ◽

Severe Trauma ◽

Trauma Patients ◽

Intensive Care Patients ◽

Pearson Coefficient

Objective. Pro-protein convertase subtilisin/kexin type 9 (PCSK9) is a circulating protein that impairs LDL clearance by promoting the LDL receptor (LDLR) degradation. Plasma lipid parameters (LDL-C and HDL-C) are related to severity of illness and survival in intensive care patients. Here, we aimed to determine whether circulating PCSK9 concentrations were correlated to the severity of illness in patients with multiple trauma. Methods/Results. Plasma PCSK9 were measured, at day 0 and 8 after admission, by ELISA in 111 patients hospitalized in ICU for severe trauma. Patients were included in the HIPOLYTE study and were randomly assigned to hydrocortisone therapy or placebo. Plasma PCSK9 levels were significantly increased by 161% at day 8 compared to day 0 (481 ± 227 vs 231 ± 117 ng/ml, P=0.0001). Hydrocortisone therapy did not alter PCSK9 concentrations at day 8 compared to placebo (451 ± 216 vs 511 ± 239ng/ml, P=0.33). In the whole population of the study, PCSK9 was positively associated with LDL-C (Pearson coefficient : 0.26, p=0.007) at day 0, but not with markers of severity illness. At day 8, an inverse correlation was found between PCSK9 and HDL-C (β =-653 ; P=0.004). Interestingly, PCSK9 concentrations at day 8 were related to markers of severity illness as injury severity score (β =6.17 ; P=0.0007), length of stay in ICU (β =6.14 ; P=0.0001), duration of both mechanical ventilation (β =8.26 ; P=0.0001) and cathecolamines infusion (β =18.57; P=0.015). Conclusion. PCSK9 appears as a late biomarker of severity illness in patients hospitalized for multiple trauma in ICU. These results open new perspectives for a role of PCSK9 in critical illness.

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Suburban geriatric trauma: the experiences of a level I trauma center

American Journal of Critical Care ◽

10.4037/ajcc1995.4.5.379 ◽

1995 ◽

Vol 4 (5) ◽

pp. 379-382 ◽

Cited By ~ 9

Author(s):

F DeKeyser ◽

D Carolan ◽

A Trask

Keyword(s):

Trauma Center ◽

Functional Outcomes ◽

Injury Severity ◽

The Elderly ◽

Mortality Rates ◽

Geriatric Trauma ◽

Trauma Patients ◽

Younger Patients ◽

Severity Scores ◽

Trauma Scores

BACKGROUND: As the mean age of the US population increases, so does the incidence of geriatric trauma. Investigators have shown that the elderly have high morbidity and mortality rates associated with traumatic injuries. OBJECTIVE: To compare the severity of injury, mortality, and functional outcomes of geriatric patients with younger patients admitted to a suburban trauma center. METHOD: A convenience sample of trauma patients who were 65 years old or older was compared with trauma patients who were 35 to 45 and 55 to 64 years old. Demographic data, injury data, Injury Severity Scores, Revised Trauma Scores, length of stay, and functional ability outcomes were abstracted from a trauma registry in aggregate form and then analyzed. RESULTS: The sample consisted of 766 subjects (age 35-45, n = 223; age 55-64, n = 135; age 65 and older, n = 408) with a mean age of 64.6 years. A larger percentage of the elderly were victims of falls; younger trauma patients were more likely to be victims of motor vehicle crashes. Significant differences were found between age groups on Glasgow Coma Scale scores. Revised Trauma Scores, and length of stay. Significant differences were not found on Injury Severity Scores, mortality rates, or functional outcomes. CONCLUSIONS: Although anatomic injury severity of elderly patients was similar to that of younger patients, the elderly demonstrated greater physiologic compromise and longer hospital stays. Mortality rates were lower for the elderly group, but this result might be because a larger proportion of elderly patients were hospitalized with minor or moderate injuries.

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