Managing polytrauma patients

Berwin, James T; Pearce, Oliver; Harries, Luke; Kelly, Michael

doi:10.1016/j.injury.2020.07.051

Cited by 23 publications

(24 citation statements)

References 37 publications

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“…Timing of surgery remains an ongoing debate and many strategies for treating polytrauma patients are described in literature with a recent interest in EAC [ 13 ]. The question is whether there is a clinically relevant difference between EAC and ETC.…”

Section: Discussionmentioning

confidence: 99%

“…Some authors have questioned liberal DCS and warned for the overuse of damage control surgery [7,10]. This has swung the pendulum once again resulting in a philosophy of providing Early Appropriate Care (EAC) [11][12][13]. EAC defined as providing a plan of action based on continual reassessment and reaction to the response to injury and surgery is mainly used in the context of orthopedic trauma and basically suggests to fix the bones at an early stage unless physiology deteriorates and definitive fixation should be abandoned [11][12][13].…”

Section: Introductionmentioning

confidence: 99%

“…This has swung the pendulum once again resulting in a philosophy of providing Early Appropriate Care (EAC) [11][12][13]. EAC defined as providing a plan of action based on continual reassessment and reaction to the response to injury and surgery is mainly used in the context of orthopedic trauma and basically suggests to fix the bones at an early stage unless physiology deteriorates and definitive fixation should be abandoned [11][12][13]. However, it remains important that DCS is performed in the correctly selected patients in whom the benefit of the procedure exceeds its expected negative consequences.…”

Section: Introductionmentioning

confidence: 99%

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Physiology dictated treatment after severe trauma: timing is everything

Wessem

Leenen

Hietbrink

2022

Eur J Trauma Emerg Surg

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Introduction Damage control strategies in resuscitation and (fracture) surgery have become standard of care in the treatment of severely injured patients. It is suggested that damage control improves survival and decreases the incidence of organ failure. However, these strategies can possibly increase the risk of complications such as infections. Indication for damage control procedures is guided by physiological parameters, type of injury, and the surgeon’s experience. We analyzed outcomes of severely injured patients who underwent emergency surgery. Methods Severely injured patients, admitted to a level-1 trauma center ICU from 2016 to 2020 who were in need of ventilator support and required immediate surgical intervention ( ≤24 h) were included. Demographics, treatment, and outcome parameters were analyzed. Results Hundred ninety-five patients were identified with a median ISS of 33 (IQR 25–38). Ninety-seven patients underwent immediate definitive surgery (ETC group), while 98 patients were first treated according to damage control principles with abbreviated surgery (DCS group). Although ISS was similar in both groups, DCS patients were younger, suffered from more severe truncal injuries, were more frequently in shock with more severe acidosis and coagulopathy, and received more blood products. ETC patients with traumatic brain injury needed more often a craniotomy. Seventy-four percent of DCS patients received definitive surgery in the second surgical procedure. There was no difference in mortality, nor any other outcome including organ failure and infections. Conclusions When in severely injured patients treatment is dictated by physiology into either early definitive surgery or damage control with multiple shorter procedures stretched over several days combined with aggressive resuscitation with blood products, outcome is comparable in terms of complications.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Physiology dictated treatment after severe trauma: timing is everything

Wessem

Leenen

Hietbrink

2022

Eur J Trauma Emerg Surg

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“…Adequate temperature management has long been established to be a fundamental principle in emergency medicine. Not only in burn injury but also in other sorts of trauma, maintenance of normothermia is crucial and advised [ 78 , 79 ]. Hypothermia is a part of the aforementioned lethal triad not only in burn patients, but generally.…”

Section: Discussionmentioning

confidence: 99%

Current understanding of thermo(dys)regulation in severe burn injury and the pathophysiological influence of hypermetabolism, adrenergic stress and hypothalamic regulation—a systematic review

et al. 2022

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Background In this systematic review, we summarize the aetiology as well as the current knowledge regarding thermo(dys)regulation and hypothermia after severe burn trauma and aim to present key concepts of pathophysiology and treatment options. Severe burn injuries with >20% total body surface area (TBSA) affected commonly leave the patient requiring several surgical procedures, prolonged hospital stays and cause substantial changes to body composition and metabolism in the acute and long-term phase. Particularly in severely burned patients, the loss of intact skin and the dysregulation of peripheral and central thermoregulatory processes may lead to substantial complications. Methods A systematic and protocol-based search for suitable publications was conducted following the PRISMA guidelines. Articles were screened and included if deemed eligible. This encompasses animal-based in vivo studies as well as clinical studies examining the control-loops of thermoregulation and metabolic stability within burn patients Results Both experimental animal studies and clinical studies examining thermoregulation and metabolic functions within burn patients have produced a general understanding of core concepts which are, nonetheless, lacking in detail. We describe the wide range of pathophysiological alterations observed after severe burn trauma and highlight the association between thermoregulation and hypermetabolism as well as the interactions between nearly all organ systems. Lastly, the current clinical standards of mitigating the negative effects of thermodysregulation and hypothermia are summarized, as a comprehensive understanding and implementation of the key concepts is critical for patient survival and long-term well-being. Conclusions The available in vivo animal models have provided many insights into the interwoven pathophysiology of severe burn injury, especially concerning thermoregulation. We offer an outlook on concepts of altered central thermoregulation from non-burn research as potential areas of future research interest and aim to provide an overview of the clinical implications of temperature management in burn patients.

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“…The higher the initial contamination and trauma load, the higher the CRP value might rise. During the time course of polytrauma management surgery and definitive care, the CRP level might variate, and at some point in time, the diagnosis of sepsis might be set [ 11 , 12 , 13 ]. Considering the whole situation in the time dimension and the SIRS/CARS theory, it could be imaginable that SIRS might be individually limited in its duration and severity, leading to an inflammatory burnout overtaken by a CARS-like situation as the dominating immunological reaction [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

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

Mica

Pape

Niggli

et al. 2021

JCM

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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.

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Managing polytrauma patients

Cited by 23 publications

References 37 publications

Physiology dictated treatment after severe trauma: timing is everything

Physiology dictated treatment after severe trauma: timing is everything

Current understanding of thermo(dys)regulation in severe burn injury and the pathophysiological influence of hypermetabolism, adrenergic stress and hypothalamic regulation—a systematic review

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

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