Abstract Introduction The inflammatory response is an important part of the pathophysiology of severe injury and, in particular, of severe traumatic brain injury (TBI). This study evaluates the ...inflammatory course following major trauma and focuses on the effect of severe TBI on inflammatory markers. Material and methods This was a retrospective analysis of prospectively collected data in 123 severely injured (ISS ≥16) trauma patients. The study cohort was divided into patients with isolated TBI (Head AIS ≥3, all other AIS <3), polytraumatized patients with severe TBI (Head AIS ≥3; AIS of other body area ≥3; Polytrauma + TBI) and polytraumatized patients without TBI (Head AIS <3; Polytrauma). Levels of inflammatory markers (Interleukin-6 IL-6, C-reactive Protein CRP, leukocytes) measured upon arrival and through hospital days 1–3 were compared between the groups. Results On admission and through hospital day 3, IL-6 levels were significantly different between the 3 groups (admission: isolated TBI vs. Polytrauma + TBI vs. Polytrauma; 94 ± 16 vs. 149 ± 20 vs. 245 ± 50 pg/mL; p < 0.05). Interleukin-6 levels peaked on hospital day 1 and declined thereafter. C-reactive protein and leukocyte counts were not significantly different between the cohorts on arrival and peaked on hospital day 2 and 1, respectively. In patients with severe TBI, admission IL-6 levels significantly predicted the development of septic complications (ROC analysis, AUC: 0.88, p = 0.001, 95% CI: 0.79–0.97) and multiple organ dysfunction (ROC analysis, AUC: 0.83, p = 0.001, 95% CI: 0.69–0.96). Conclusion Severe TBI reduced the inflammatory response following trauma. Significant correlations between admission IL-6 values and the development of MOF, sepsis and the neurological outcome were found in patients with TBI.
IntroductionThe Revised Injury Severity Classification II (RISC II) score represents a data-derived score that aims to predict mortality in severely injured patients. The aim of this study was to ...assess the discrimination and calibration of RISC II in secondary transferred polytrauma patients.MethodsThis study was performed on the multicentre database of the TraumaRegister DGU. Inclusion criteria included Injury Severity Score (ISS)≥9 points and complete demographic data. Exclusion criteria included patients with ‘do not resuscitate’ orders or late transfers (>24 hours after initial trauma). Patients were stratified based on way of admission into patients transferred to a European trauma centre after initial treatment in another hospital (group Tr) and primary admitted patients who were not transferred out (group P). The RISC II score was calculated within each group at admission after secondary transfer (group Tr) and at primary admission (group P) and compared with the observed mortality rate. The calibration and discrimination of prediction were analysed.ResultsGroup P included 116 112 (91%) patients and group Tr included 11 604 (9%) patients. The study population was predominantly male (n=86 280, 70.1%), had a mean age of 53.2 years and a mean ISS of 20.7 points. Patients in group Tr were marginally older (54 years vs 52 years) and a had slightly higher ISS (21.5 points vs 20.1 points). Median time from accident site to hospital admission was 60 min in group P and 241 min (4 hours) in group Tr. Observed and predicted mortality based on RISC II were nearly identical in group P (10.9% and 11.0%, respectively) but predicted mortality was worse (13.4%) than observed mortality (11.1%) in group Tr.ConclusionThe way of admission alters the calibration of prediction models for mortality in polytrauma patients. Mortality prediction in secondary transferred polytrauma patients should be calculated separately from primary admitted polytrauma patients.
Chest trauma has a significant relevance on outcome after severe trauma. Clinically, impaired lung function typically occurs within 72 hours after trauma. However, the underlying pathophysiological ...mechanisms are still not fully elucidated. Therefore, we aimed to establish an experimental long-term model to investigate physiological, morphologic and inflammatory changes, after severe trauma. Male pigs (sus scrofa) sustained severe trauma (including unilateral chest trauma, femur fracture, liver laceration and hemorrhagic shock). Additionally, non-injured animals served as sham controls. Chest trauma resulted in severe lung damage on both CT and histological analyses. Furthermore, severe inflammation with a systemic increase of IL-6 (p = 0.0305) and a local increase of IL-8 in BAL (p = 0.0009) was observed. The pO
/FiO
ratio in trauma animals decreased over the observation period (p < 0.0001) but not in the sham group (p = 0.2967). Electrical Impedance Tomography (EIT) revealed differences between the traumatized and healthy lung (p < 0.0001). In conclusion, a clinically relevant, long-term model of blunt chest trauma with concomitant injuries has been developed. This reproducible model allows to examine local and systemic consequences of trauma and is valid for investigation of potential diagnostic or therapeutic options. In this context, EIT might represent a radiation-free method for bedside diagnostics.
The purpose of this study was to define the relationship between cardiac depression and morphological and immunological alterations in cardiac tissue after multiple trauma. However, the mechanistic ...basis of depressed cardiac function after trauma is still elusive. In a porcine polytrauma model including blunt chest trauma, liver laceration, femur fracture and haemorrhage serial trans-thoracic echocardiography was performed and correlated with cellular cardiac injury as well as with the occurrence of extracellular histones in serum. Postmortem analysis of heart tissue was performed 72 h after trauma. Ejection fraction and shortening fraction of the left ventricle were significantly impaired between 4 and 27 h after trauma. H-FABP, troponin I and extracellular histones were elevated early after trauma and returned to baseline after 24 and 48 h, respectively. Furthermore, increased nitrotyrosine and Il-1β generation and apoptosis were identified in cardiac tissue after trauma. Main structural findings revealed alteration of connexin 43 (Cx43) and co-translocation of Cx43 and zonula occludens 1 to the cytosol, reduction of α-actinin and increase of desmin in cardiomyocytes after trauma. The cellular and subcellular events demonstrated in this report may for the first time explain molecular mechanisms associated with cardiac dysfunction after multiple trauma.
Purpose
Severe life-threatening injuries in Western Europe are mostly caused by blunt trauma. However, penetrating trauma might be more common in urban regions, but their characteristics have not ...been fully elucidated.
Methods
Retrospective analysis of data from patients admitted to our urban university level I trauma center between 2008 and 2013 with suspicion of severe multiple injuries. Collection of data was performed prospectively using a PC-supported online documentation program including epidemiological, clinical and outcome parameters.
Results
Out of 2095 trauma room patients admitted over the 6-year time period 194 (9.3 %) suffered from penetrating trauma. The mean Injury Severity Score (ISS) was 12.3 ± 14.1 points. In 62.4 % (
n
= 121) the penetrating injuries were caused by interpersonal violence or attempted suicide, 98 of these by stabbing and 23 by firearms. We observed a widespread injury pattern where mainly head, thorax and abdomen were afflicted. Subgroup analysis for self-inflicted injuries showed higher ISS (19.8 ± 21.8 points) than for blunt trauma (15.5 ± 14.6 points). In 82.5 % of all penetrating trauma a surgical treatment was performed, 43.8 % of the patients received intensive care unit treatment with mean duration of 7.4 ± 9.3 days. Immediate emergency surgical treatment had to be performed in 8.0 vs. 2.3 % in blunt trauma (
p
< 0.001). Infectious complications of the penetrating wounds were observed in 7.8 %.
Conclusions
Specific characteristics of penetrating trauma in urban regions can be identified. Compared to nationwide data, penetrating trauma was more frequent in our collective (9.3 vs. 5.0 %), which may be due to higher crime rates in urban areas. Especially, self-inflicted penetrating trauma often results in most severe injuries.
Purpose
Intramedullary nailing (IMN) of fractures is associated with increased rates of inflammatory complications. The pathological mechanism underlying this phenomenon is unclear. However, ...polymorphonuclear granulocytes (PMNs) seem to play an important role. We hypothesized that a femur fracture and standardized IMN in pigs is associated with altered appearance of PMNs in circulation and enhanced activation status of these cells.
Methods
A porcine model including a femur fracture and IMN was utilized. Animals were randomized for control anesthesia + mechanical ventilation only (A/MV) and intervention A/MV and unilateral femur fracture (FF) + IMN conditions. PMN numbers and responsiveness, integrin (CD11b), L-selectin (CD62L) and Fc
γ
-receptor (CD16 and CD32)-expression levels were measured by flowcytometry of blood samples. Animals were observed for 72 h.
Results
Circulatory PMN numbers did not differ between groups. Early PMN-responsiveness was retained after insult. PMN-CD11b expression increased significantly upon insult and peaked after 24 h, whereas CD11b in control animals remained unaltered (
P
= 0.016). PMN-CD16 expression levels in the FF + IMN-group rose gradually over time and were significantly higher compared with control animals, after 48 h (
P
= 0.016) and 72 h (
P
= 0.032). PMN-CD62L and CD32 expression did not differ significantly between conditions.
Conclusion
This study reveals that a femur fracture and subsequent IMN in a controlled setting in pigs is associated with enhanced activation status of circulatory PMNs, preserved PMN-responsiveness and unaltered circulatory PMN-presence. Indicating that monotrauma plus IMN is a specific and substantial stimulus for the cellular immune system. Early alterations of circulatory PMN receptor expression dynamics may be predictive for the intensity of the post traumatic response.
Background and Purpose. Leukocyte migration into alveolar space plays a critical role in pulmonary inflammation resulting in lung injury. Acute ethanol (EtOH) exposure exerts anti-inflammatory ...effects. The clinical use of EtOH is critical due to its side effects. Here, we compared effects of EtOH and ethyl pyruvate (EtP) on neutrophil adhesion and activation of cultured alveolar epithelial cells (A549). Experimental Approach. Time course and dose-dependent release of interleukin- (IL-) 6 and IL-8 from A549 were measured after pretreatment of A549 with EtP (2.5–10 mM), sodium pyruvate (NaP, 10 mM), or EtOH (85–170 mM), and subsequent lipopolysaccharide or IL-1beta stimulation. Neutrophil adhesion to pretreated and stimulated A549 monolayers and CD54 surface expression were determined. Key Results. Treating A549 with EtOH or EtP reduced substantially the cytokine-induced release of IL-8 and IL-6. EtOH and EtP (but not NaP) reduced the adhesion of neutrophils to monolayers in a dose- and time-dependent fashion. CD54 expression on A549 decreased after EtOH or EtP treatment before IL-1beta stimulation. Conclusions and Implications. EtP reduces secretory and adhesive potential of lung epithelial cells under inflammatory conditions. These findings suggest EtP as a potential treatment alternative that mimics the anti-inflammatory effects of EtOH in early inflammatory response in lungs.
Zusammenfassung
Fragestellung
In Deutschland verletzen sich jährlich bis zu 35.000 Menschen bei Verkehrs‑, Arbeits- oder Freizeitunfällen schwer. Die optimale Versorgung setzt eine zeitlich ...unbegrenzte Vorhaltung von Schockraum‑, Operations- und Intensivkapazität voraus. Die vorliegende Arbeit wertet die Entwicklung der Schockraumauslastung der vergangenen Jahre eines überregionalen Traumazentrums aus.
Methodik
Die klinikeigenen Daten der Jahre 2005–2016 wurden retrospektiv hinsichtlich Zahl der Schockraumanmeldungen durch die Rettungsleitstelle und daraus resultierenden schwer verletzten Patienten („Injury Severity Score“, ISS ≥ 16) nach Abschluss der Diagnostik analysiert. Weitere Information bezüglich Schockraumzuweisungen wie Indikation nach Unfallhergang, Arztbegleitung, Beatmung und Reanimation wurden dem internetbasierten, interdisziplinären Versorgungsnachweis (IVENA) entnommen (Erfassung 2012 bis 2016), sodass ein Vergleich der Schockraumanmeldungen und der tatsächlichen Schockraumpatienten ab 2012 möglich ist.
Ergebnisse
Die Daten des IVENA-Systems dokumentierten über den Fünfjahresbeobachtungszeitraum (von 2012 bis 2016) eine kontinuierliche Zunahme der Gesamtzahl an Schockraumzuweisungen von 367 auf 623 (Zunahme von 70 %). Korrespondierend stiegen die Zahlen an zugewiesenen Patienten unter Reanimation (
n
= 15 auf
n
= 45), der primär beatmeten Patienten (
n
= 78 auf
n
= 139), aber auch der Schockraumzuweisungen ohne Arztbegleitung (
n
= 38 auf
n
= 132) und der Schockraumindikationen nach Unfallhergang (
n
= 84 auf
n
= 194). Das Verhältnis von Schockraumzuweisungen zu Patienten mit ISS ≥ 16 stieg von 3,1 (2012) auf 5,4 (2015) bzw. 4,6 (2016).
Schlussfolgerungen
Die vorliegenden Zahlen belegen eine konstante Zahl an Schwerverletzen an einem universitären überregionalen Traumazentrum in den letzten Jahren. Die Ressource Schockraum wird dagegen in steigender Zahl in Anspruch genommen. Ein nichtunerheblicher Anteil an Patienten weist nach abgeschlossener Diagnostik keine traumatologische Diagnose auf. Insbesondere nichtarztbegleitete Patienten und Schockraumindikationen nach Unfallhergang tragen in unserem Kollektiv zu dieser Entwicklung bei, die eine erhöhte Einsatzbereitschaft der Schockraumteams erfordert.
Schuss- und Stichverletzungen Störmann, P.; Wutzler, S.; Sommer, K. ...
Notfall & Rettungsmedizin,
09/2016, Letnik:
19, Številka:
6
Journal Article
Recenzirano
Zusammenfassung
Hintergrund
Das Verletzungsausmaß im Rahmen von Stich- oder Schussverletzungen kann von einer einfachen Weichteilwunde bis hin zu komplexen und lebensbedrohlichen Multiorganläsionen ...reichen. Diese Übersichtsarbeit soll eine Grundlage für ein strukturiertes Vorgehen beim Vorliegen einer solchen Verletzungsentität liefern.
Methode
Recherche und Auswertung aktueller Literatur.
Ergebnisse und Schlussfolgerungen
Das Schockraum-Management wird gemäß ATLS®-Konzept und den Vorgaben der S3-Leitlinie Polytrauma gestaltet. Im Vordergrund steht das Erkennen lebensbedrohlicher Verletzungen, um insbesondere bei hämodynamisch instabilen Patienten ohne Zeitverlust eine operative Versorgung anzustreben. Die klinische Untersuchung bildet die Basis für Diagnostik und Therapie und beinhaltet eine detaillierte Inspektion der penetrierenden Verletzung sowie eine Ganzkörperuntersuchung zum Ausschluss weiterer Verletzungen. Mittels FAST (Focused Assessment with Sonography for Trauma) kann freie intraperitoneale bzw. perikardiale Flüssigkeit schnell nachgewiesen werden. Die weiterführende Diagnostik richtet sich in der Folge nach dem hämodynamischen Status des Patienten. Bei hämodynamisch instabilen Patienten können noch im Rahmen der Schockraumversorgung eine Perikardpunktion oder direkt operative Damage-Control-Konzepte wie eine Notfallthorakotomie oder -laparotomie Anwendung finden.
Introduction
The local circulatory changes induced by intramedullary reaming are not fully understood. This study aimed to analyse the short-term local microcirculation associated with different ...surgical strategies in a porcine model with a mid-shaft fracture.
Methods
German landrace pigs were subjected to a standardised femoral fracture under standard anaesthesia and intensive care monitoring. One group was subjected to intramedullary reaming and nailing (nail group), while a second group was stabilised with external fixation (fix ex group). Microcirculation e.g. relative blood flow (flow), oxygen saturation and relative haemoglobin concentration was measured in the vastus lateralis muscle adjacent to the fracture using an O2C (oxygen to see, LEA Medizintechnik GMBH) device at 0 (before fracture, baseline), 6 (90-min posttreatment), 24, 48 and 72 h.
Results
A total of 24 male pigs were used (nail group,
n
= 12; fix ex group,
n
= 12). During the observation period, a significant increase of flow was found at 6 (
P
= 0.048), 48 (
P
= 0.023) and 72 h (
P
= 0.042) in comparison with baseline levels. Local oxygen delivery was significantly higher at 48 (
P
= 0.017) and 72 h (
P
= 0.021) in animals in the nail group compared to animals in the external fixation group.
Conclusion
This study used a standardised porcine femoral fracture model and determined a significant increase in local blood microcirculation (e.g. flow and oxygen delivery) in animals treated with intramedullary reaming compared to external fixation. These changes may be of importance for fracture healing and local and systemic inflammatory responses. Further studies in this area are justified.
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