Organization of provision of specialized medical care for polytrauma in multidisciplinary hospital

Technical progress facilitates to a significant increase in injuries and the severity of traumatic injuries. When providing treatment for patients with polytrauma in a multidisciplinary hospital the leading place is taken by the organization of the work of the hospital’s medical personnel, the development and implementation of standards for the guidelines specialized medical care to victims. The main priority of surgical intervention in polytrauma is to bleeding control, and staged treatment with final surgical correction after stabilization of the victim’s condition in 24–36 hours after the injury. An important role is played by standardized transfusion therapy for preventing the development of the lethal triad. Practice shows that a multidisciplinary approach is the cornerstone of providing specialized medical care for patients with polytrauma.

Hypothermia in Trauma

Hypothermia in trauma patients is a common condition. It is aggravated by traumatic hemorrhage, which leads to hypovolemic shock. This hypovolemic shock results in a lethal triad of hypothermia, coagulopathy, and acidosis, leading to ongoing bleeding. Additionally, hypothermia in trauma patients can deepen through environmental exposure on the scene or during transport and medical procedures such as infusions and airway management. This vicious circle has a detrimental effect on the outcome of major trauma patients. This narrative review describes the main factors to consider in the co-existing condition of trauma and hypothermia from a prehospital and emergency medical perspective. Early prehospital recognition and staging of hypothermia are crucial to triage to proper care to improve survival. Treatment of hypothermia should start in an early stage, especially the prevention of further cooling in the prehospital setting and during the primary assessment. On the one hand, active rewarming is the treatment of choice of hypothermia-induced coagulation disorder in trauma patients; on the other hand, accidental or clinically induced hypothermia might improve outcomes by protecting against the effects of hypoperfusion and hypoxic injury in selected cases such as patients suffering from traumatic brain injury (TBI) or traumatic cardiac arrest.

Resusitasi Pengendalian Kerusakan Di Unit Perawatan Intensif

Abstrak Resusitasi dengan pengendalian kerusakanmenggambarkan suatu pendekatan ke perawatan awal pada pasien dengan cedera berat. Tujuan pendekatan ini untuk menjaga pasien tetap stabil dengan menghindari intervensi dan kondisi yang berisiko kepada keadaan perburukan dengan mengendalikan trias kematian, yaitu hipotermia, koagulopati, dan asidosis. Merupakan hal yang penting bahwa konsep dan kepraktisan pendekatan ini dipahami oleh semua yang terlibat dalam manajemen awal pasien trauma. Pendekatan ini dimulai dengan pemberian produk darah sejak awal, penghentian perdarahan dan pengembalian volume darah yang bertujuan untuk mengembalikan stabilitas fisiologis dengan cepat. Resusitasi dengan pengendalian kerusakan memilikibeberapa tambahan pendekatan dari bidang farmakologis dan laboratorium untuk meningkatkan perawatan pasien yang mengalami perdarahan. Pendekatan ini termasuk trombelastografi sebagai ukuran rinci kaskade pembekuan, asam traneksamat sebagai antifibrinolitik. Kata kunci : hipotermia, koagulopati, asidosis, perdarahan masif Damage Control Resuscitation in Intensive Care Unit Abstract Damage control resuscitation (DCR) describes an approach to the early care of very seriously injured patients. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis.It is critical that the concepts and practicalities of this approach are understood by all those involved in the early management of trauma patients. Damage control resuscitation forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration, haemorrhage arrest and restoration of blood volume aiming to rapidly restore physiologic stability. The infusion of large volumes of crystalloid is no longer appropriate, instead the aim is to replace lost blood and avoid dilution and coagulopathy. In specific situations, permissive hypotension may also be of benefit, particularly in patients with severe haemorrhage from an arterial source. Damage control resuscitation has been augmented by both pharmacologic and laboratory adjuncts to improve the care of the hemorrhaging patient. These include thrombelastography as a detailed measure of the clotting cascade, tranexamic acid as an antifibrinolytic. Keywords: hypothermia, coagulopathy, acidosis, massive bleeding

Critical Care Considerations for Damage Control in a Trauma Patient

Traumatic injury remains the leading cause of death among individuals younger than age 45 years. Hemorrhage is the primary preventable cause of death in trauma patients. Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy. The principles of damage control surgery are rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure. Damage control resuscitation focuses on 3 key components: fluid restriction, permissive hypotension, and fixed-ratio transfusion. Rapid recognition and control of hemorrhage and implementation of resuscitation strategies to control damage have significantly improved mortality and morbidity rates. In addition to describing the basic principles of damage control surgery and damage control resuscitation, this article explains specific management considerations for and potential complications in patients undergoing damage control interventions in an intensive care unit.

Plasmatic and cell-based enhancement by microparticles originated from platelets and endothelial cells under simulated in vitro conditions of a dilutional coagulopathy

Background Aggressive fluid management and other external factors may lead to hypothermia, acidosis and hemodilution (defined as Lethal Triad, LT) contributing to a trauma-induced coagulopathy (TIC) that worsens patients’ outcomes. Procoagulant microparticles (MP) are crucial players at the interface of cellular and plasmatic coagulation. However, their functions remain largely unexplored. This study aimed to characterize effects of MP subtypes and concentrations on functional coagulation under in vitro simulated conditions. Methods Blood from eleven volunteers were collected to simulate in vitro conditions of hemodilution (HD) and LT, respectively. HD was induced by replacing a blood volume of 33% by crystalloids and for LT, samples were further processed by reducing the temperature to 32 °C and lowering the pH to 6.8. MP were obtained either from platelet concentrates (platelet-derived MP, PDMP) or from cell culture (ECV304 cells for endothelial-derived MP, EDMP) by targeted stimulation. After introducing MP to in vitro conditions, we measured their concentration-dependent effects (1.000, 10.000 and 15.000 MP/μl blood) on coagulation compared to whole blood (WB). For each condition, coagulation was characterized by flow cytometric platelet activation and by quantification of fibrin clot propagation using Thrombodynamics® technology. Results MP originated from platelets and endothelial cells affected blood coagulation in a concentration-dependent manner. Particularly, high PDMP quantities (10.000 and 15.000 PDMP/μl blood) significantly induced platelet activation and fibrin clot growth and size in HD conditions. In LT conditions as well, only high PDMP concentration induced platelet activation, clot growth and size. In contrast, EDMP did not induce platelet activation, but resulted in enhanced formation of spontaneous clots, irrespective of simulated condition. With increasing EDMP concentration, the time until the onset of spontaneous clotting decreased in both HD and LT conditions. Discussion The study demonstrates an essential role of MP within the coagulation process under simulated coagulopathic conditions. PDMP affected platelets promoting clot formation likely by providing a surface enlargement. EDMP presumably affected clotting factors of the plasmatic coagulation resulting in an increased formation of spontaneous clots. Conclusion Under simulated conditions of a dilutional coagulopathy, MP from different cellular origin indicate a divergent but both procoagulant mechanism within the coagulation process.

Place of preperitoneal pelvic packing in severe pelvic traumatisms: About 20 cases performed in a French military level one trauma center

BackgroundThe overall mortality of hemodynamically unstable pelvic fractures is high. Hemorrhage triggers off the Moore lethal triad. Hemostatic management during the golden hour is essential. Combined with pelvic stabilisation, preperitoneal pelvic packing (PPP) is proposed to control venous and bony bleeding, while arterioembolisation can stop arterial bleeding. No international consensus has yet prioritized these procedures. The aim of this study was to analyse a serie of PPP in a military level one trauma center and propose an algorithm for hemodynamically unstable pelvic traumas regardless of the military facility.MethodFrom January 2010 to December 2020, every patient from our military institution with a hemodynamically unstable pelvic fracture underwent PPP combined with pelvic stabilisation. Before 2012 data were retrospectively collected from database (PMSI), after 2012 data were prospectively recorded in our polytrauma database and retrospectively analysed. The care algorithm applied focused on hemodynamic status of polytraumatised patients on admission. Primary criteria were early hemorrhage-induced mortality (<24h) and overall mortality (<30d). Secondary criteria were systolic blood pressure (SBP) and red blood cells (RBC) units administered.Results20 patients with a pelvic fracture had a PPP. Mean age was 49,65 +/-23,97 years and median ISS was 49 (31; 67). The decrease of blood transfusion and increase of SBP between pre- and postoperative values were statistically significant. Eight patients (40%) had postoperative arterial pelvic blush and 7 patients were embolised. The early mortality by refractory hemorrhagic shock was 25% (5/20). Overall mortality at 30 days was 50% (10/20).ConclusionPPP is a quick, easy, efficient and safe procedure. It can control venous, bony and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it in first line. Angio-embolization remains complementary. Besides, PPP is the only means available in precarious conditions of practice, notably in military forward units.

The lethal triad: SARS-CoV-2 Spike, ACE2 and TMPRSS2. Mutations in host and pathogen may affect the course of pandemic

Variants of SARS-CoV-2 have been identified rapidly after the beginning of pandemic. One of them, involving the spike protein and called D614G, represents a substantial percentage of currently isolated strains. While research on this variant was ongoing worldwide, on December 20th 2020 the European Centre for Disease Prevention and Control reported a Threat Assessment Brief describing the emergence of a new variant of SARS-CoV-2, named B.1.1.7, harboring multiple mutations mostly affecting the Spike protein. This viral variant has been recently associated with a rapid increase in COVID-19 cases in South East England, with alarming implications for future virus transmission rates. Specifically, of the nine amino acid replacements that characterize the Spike in the emerging variant, four are found in the region between the Fusion Peptide and the RBD domain (namely the already known D614G, together with A570D, P681H, T716I), and one, N501Y, is found in the Spike Receptor Binding Domain – Receptor Binding Motif (RBD-RBM). In this study, by using in silico biology, we provide evidence that these amino acid replacements have dramatic effects on the interactions between SARS-CoV-2 Spike and the host ACE2 receptor or TMPRSS2, the protease that induces the fusogenic activity of Spike. Mostly, we show that these effects are strongly dependent on ACE2 and TMPRSS2 polymorphism, suggesting that dynamics of pandemics are strongly influenced not only by virus variation but also by host genetic background.

Plasmatic and cell-based enhancement by microparticles originated from platelets and endothelial cells under simulated in vitro conditions of a dilutional coagulopathy

Background: Aggressive fluid management and other external factors may lead to hypothermia, acidosis and hemodilution (defined as Lethal Triad, LT) contributing to a trauma-induced coagulopathy (TIC) that worsens patients’ outcomes. Procoagulant microparticles (MP) are crucial players at the interface of cellular and plasmatic coagulation. However, their functions remain largely unexplored. This study aimed to characterize effects of MP subtypes and concentrations on functional coagulation under in vitro simulated conditions. Methods: Blood from eleven volunteers were collected to simulate in vitro conditions of hemodilution (HD) and LT, respectively. HD was induced by replacing a blood volume of 33% by crystalloids and for LT, samples were further processed by reducing the temperature to 32 °C and lowering the pH to 6.8. MP were obtained either from platelet concentrates (platelet-derived MP, PDMP) or from cell culture (ECV304 cells for endothelial-derived MP, EDMP) by targeted stimulation. After introducing MP to in vitro conditions, we measured their concentration-dependent effects (1.000, 10.000 and 15.000 MP/µl blood) on coagulation compared to whole blood (WB). For each condition, coagulation was characterized by flow cytometric platelet activation and by quantification of fibrin clot propagation using Thrombodynamics® technology.Results: MP originated from platelets and endothelial cells affected blood coagulation in a concentration-dependent manner. Particularly, high PDMP quantities (10.000 and 15.000 PDMP/µl blood) significantly induced platelet activation and fibrin clot growth and size in HD conditions. In LT conditions as well, only high PDMP concentration induced platelet activation, clot growth and size. In contrast, EDMP did not induce platelet activation, but resulted in enhanced formation of spontaneous clots, irrespective of simulated condition. With increasing EDMP concentration, the time until the onset of spontaneous clotting decreased in both HD and LT conditions.Discussion: The study demonstrates an essential role of MP within the coagulation process under simulated coagulopathic conditions. PDMP affected platelets promoting clot formation likely by providing a surface enlargement. EDMP presumably affected clotting factors of the plasmatic coagulation resulting in an increased formation of spontaneous clots.Conclusion: Under simulated conditions of a dilutional coagulopathy, MP from different cellular origin indicate a divergent but both procoagulant mechanism within the coagulation process.