Evacuation Strategies for U.S. Casualties with Traumatic Brain Injury (TBI) with and without Polytrauma

ABSTRACT Introduction According to the Military Health System Traumatic Brain Injury (TBI) Center of Excellence, 51,261 service members suffered moderate to severe TBI in the last 21 years. Moderate to severe TBI in service members is usually related to blast injury in combat operations, which necessitates medical evacuation to higher levels of care. Prevention of secondary insult, and mitigation of the unique challenges associated with the transport of TBI patients in a combat setting are important in reducing the morbidity and mortality associated with this injury. The primary goal of this study was a secondary analysis comparing the impact of time to transport on clinical outcomes for TBI patients without polytrauma versus TBI patients with polytrauma transported out of the combat theater via Critical Care Air Transport Teams (CCATT). Our secondary objective was to describe the occurrence of in-flight events and interventions for TBI patients without polytrauma versus TBI with polytrauma to assist with mission planning for future transports. Materials and Methods We performed a secondary analysis of a retrospective cohort of 438 patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Polytrauma was defined as abbreviated injury scale (AIS) of at least three to another region in addition to head/neck. Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and examined the associations between time to transport and preflight characteristics, in-flight interventions and events, and clinical outcomes for TBI patients with and without polytrauma. Results We categorized patients into two groups, those who had a TBI without polytrauma (n = 179) and those with polytrauma (n = 259). Within each group, we further divided those that were transported within 1 day of injury, in 2 days, and 3 or more days. Patients with TBI without polytrauma transported in 1 or 2 days were more likely to have a penetrating injury, an open head injury, a preflight Glascow Coma Score (GCS) of 8 or lower, and be mechanically ventilated compared to those transported later. Patients without polytrauma who were evacuated in 1 or 2 days required more in-flight interventions compared to patients without polytrauma evacuated later. Patients with polytrauma who were transported in 2 days were more likely to receive blood products, and patients with polytrauma who were evacuated within 1 day were more likely to have had at least one episode of hypotension en route. Polytrauma patients who were evacuated in 2–3 days had higher hospital days compared to polytrauma with earlier evacuations. There was no significant difference in mortality between any of the groups. Conclusions In patients with moderate to severe TBI transported via CCATT, early evacuation was associated with a higher rate of in-flight hypotension in polytrauma patients. Furthermore, those who had TBI without polytrauma that were evacuated in 1–2 days received more in-flight supplementary oxygen, blood products, sedatives, and paralytics. Given the importance of minimizing secondary insults in patients with TBI, recognizing this in this subset of the population may help systematize ways to minimize such events. Traumatic Brain Injury patients with polytrauma may benefit from further treatment and stabilization in theater prior to CCATT evacuation.

Radiographic Outcomes following K-Wire Augmentation of Dorsal Spanning Plate Fixation for Intra-Articular Fractures of the Distal Radius

Background Restoration of articular surface alignment is critical in treating intra-articular distal radius fractures. Dorsal spanning plate fixation functions as an internal distraction mechanism and can be advantageous in the setting of highly comminuted fracture patterns, polytrauma patients, and patients with radiocarpal instability. The addition of K-wires to support articular surface reduction potentially augments fracture repair stability. Questions/Purposes We examined the radiographic outcomes and maintenance of reduction in patients with comminuted intra-articular distal radius fractures treated with K-wire fixation of articular fragments followed by dorsal spanning plate application. Patients and Methods We reviewed 35 consecutive patients with complex intra-articular distal radius fractures treated with dorsal spanning plate and K-wire fixation between April 2016 and October 2019. AO classification was recorded: B1 (3), B3 (2), C2 (2), C3 (28). A two-tailed paired t-test was used to compare findings immediately post-dorsal spanning plate surgery and at final follow-up after dorsal spanning plate removal. Results Mean patient age was 43.3 years (19–78 years). Mean follow-up was 7.8 months (SD 4.3 months) from surgery and 2.5 months from pin removal (SD 2.6 months). All patients achieved radiographic union. Radial height (mean interval change (MIC) 0.2 mm, SD 2.2, p = 0.63), articular step-off (MIC 0.1 mm, SD 0.6 mm, p = 0.88), and radial inclination (MIC −1.1 degrees, SD 3.7 degrees, p = 0.10) did not change from post-surgery to final follow-up. Ulnar variance (MIC −0.9 mm, SD 2.0 mm, p = 0.02) and volar tilt (MIC −1.5 degrees, SD 4.4 degrees, p = 0.05) were found to have decreased. Conclusion Dorsal spanning plate augmented with K-wire fixation for comminuted intra-articular distal radius fractures in polytrauma patients allows for immediate weightbearing and maintains articular surface alignment at radiographic union and may provide better articular restoration than treatment with dorsal spanning plate alone. Level of Evidence This is a Level IV, therapeutic study.

Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review

Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.

A Practical Triage and Risk Scoring for Prediction of Early Mortality in Polytrauma Patients: GAS-TRS

Background Accurate evaluation of mortality risk in polytrauma patients is crucial for guiding the precision treatment strategy. There are few scales designed to provide an early assessment of mortality risk. However, the complexity of available scoring systems limits their application in pre-hospital care. Here, we established a GAS-TRS system to estimate the risk of early death for individual polytrauma patients and assess the early mortality risk in the individual patient.Methods We performed a secondary analysis from public Database. RCS and Multivariate Logistic regression analyses were used to screen potential prognostic factors for nomogram model. The VIF method examined multicollinearity, and VIF ≥ 5 suggested multicollinearity in this model. CMA was used to characterize the causality relationship in nomogram model. A four-layer back-propagation artificial neural network (BP-ANN) model was built by neuralnet package on R software. AUC of ROC analysis or F1 score were used to analyze the quality of predictive performance of GAS-TRS system. DCA and precision-recall curves were used to make up for the limitations of ROC curves.Results A total of 2406 patients were included in this analysis. Logistic regression analysis predicted four independent risk factors for nomogram model, including age (OR=1.03, 95%CI:1.02~1.03), GCS (OR=0.83, 95%CI:0.79~0.86), BE (OR=0.95, 95%CI:0.91~0.99) and serum lactic acid (OR=1.30, 95%CI:1.20~1.41) with an AUC of 0.88. Causal mediation analysis performed the mediation effect that lactate, age and BE accounted for 1.7%,0.7% and 3.0% indirect effect.The calibration curve showed model has good highly consistent with actual condition after bootstrapping. DCA showed the net benefit probability was between 2% and 85% and could bring more benefits for predicting early mortality.Then the input neurons were selected step by step in BP-ANN model. An optimal BP-ANN with an AUC of 0.91and AUPRC of 0.79 was established.Conclusion We established a GAS-TRS predictive system which includes a quick prognostic nomogram model and a precise BP-ANN model to evaluate early mortality within 72 hours for polytrauma patients. This scoring system might be practical and more efficient in identifying high-risk polytrauma patients. Moreover, this system may also guide triaging and precise initial individual treatment strategy for pre-hospital medical personnel.

New Time-Related Insights into an Old Laboratory Parameter: Early CRP Discovered by IBM Watson Trauma Pathway Explorer© as a Predictor for Sepsis in Polytrauma Patients

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.