Background
The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of ...on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients.
Methods
A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH). The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson’s correlation test and logistic regression analysis were also performed.
Results
During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (
p
= 0.005), lower Trauma Injury Severity Score (
p
= 0.01) and lower GCS (
p
= 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%;
p
= 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39–33.68) points was found more in hyperglycemia than normoglycemia group (
p
= 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (
r
= 0.40,
p
= 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076–5.447,
p
= 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion.
Conclusions
In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment.
Trial registration
This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016.
https://clinicaltrials.gov/ct2/show/NCT02999386
.
Contaminated soil samples were collected from Al-Kasak refinery and Al-Qayyarah refinery in western and southern Nineveh, at specific distances in six dimensions (0, 50, 100, 150, 200, 300) meters ...from the source of pollution, to study the concentrations of heavy metals Pb, Mn, Ni, Cd, and the effect of oil refinery pollutants on some soil pollution standards, in addition to some physical and chemical properties of the soil and their concentrations. The results showed an increase in the concentration of heavy metals in the soil near the sources of pollution, with cadmium significantly superior to Al-Qayyarah site over Al-Kasak site (491.744) mg/kg, and lead, nickel and manganese recorded a higher concentration at Al-Kasak site compared to Al-Qayyarah site (166.356, 114.687, 36.487) mg/kg, respectively, and the order of mineral elements in the two study sites was Cd>Pb>Ni>Mn. As for the Contamination Factor (CF), it was Cd > Pb > Ni > Mn with values of 684.50, 9.91, 5.13, and 0.1701, where the concentration factor was highly polluted for cadmium and lead, and with significant contamination for nickel, while manganese was low in contamination, cadmium recorded severe pollution at Al-Qayyarah site compared to Al-Kasak site, while lead, nickel and manganese recorded significant contamination at Al-Kasak site compared to Al-Qayyarah. In addition, the pollution load index (PLI) was at the level of 5.81, 4.67 highly polluted at D1 and D2, while the rest of the percentages were at the level of 2, moderate pollution, Al-Kasak site had the highest pollution (PLI) value of (6.28), while the ecological risk (ER) averaged (20534.88, 16896.71, 19867.11, 19063.14, 18721.07, 18888.61), which indicates that all the sites had very high pollution, and the ecological risk index was also within the limits of very high pollution, with the highest value on D1 recorded (20568.45), and the potential ecological risk of cadmium was very high at Al-Qayyarah site with a value of (19410.95) compared to Al-Kasak site, where the ecological risk of lead, nickel and manganese was very high, and the ecological risk indices for Al-Qayyarah site were high compared to Al-Kasak site. The aim of the study is to estimate the concentration of heavy metals, according to environmental indices and the impact of oil refineries on the ecosystem in raising the level of heavy metal concentration.
Phenytoin is one of the commonly used anti.seizure medications in nontraumatic seizures. However, its utility and safety in young patients with traumatic brain injury (TBI) for the prevention of ...early-onset seizures (EOS) are debatable. We sought to explore the use of phenytoin as a seizure prophylaxis following TBI. We hypothesized that administering phenytoin is not effective in preventing EOS after TBI.
This was a retrospective observational study conducted on adult TBI patients. EOS was defined as a witnessed seizure within a week postinjury. Data were compared as phenytoin versus no-phenytoin use, EOS versus no-EOS, and among TBI severity groups.
During 1 year, 639 TBI patients were included with a mean age of 32 years; of them, 183 received phenytoin as seizure prophylaxis, and 453 received no prophylaxis medication. EOS was documented in 13 (2.0%) patients who received phenytoin, and none had EOS among the nonphenytoin group. The phenytoin group was more likely to have a higher Marshall Score (
= 0.001), lower Glasgow Coma Scale (GCS) (
= 0.001), EOS (
= 0.001), and higher mortality (
= 0.001). Phenytoin was administrated for 15.2%, 43.2%, and 64.5% of mild, moderate, and severe TBI patients, respectively. EOS and no-EOS groups were comparable for age, gender, mechanism of injury, GCS, Marshall Score, serum phenytoin levels, liver function levels, hospital stay, and mortality. Multivariable logistic regression analysis showed that low serum albumin (odds ratio OR 0.81; 95% confidence interval CI 0.676.0.962) and toxic phenytoin level (OR 43; 95% CI 2.420.780.7) were independent predictors of EOS.
In this study, the prophylactic use of phenytoin in TBI was ineffective in preventing EOS. Large-scale matched studies and well-defined hospital protocols are needed for the proper utility of phenytoin post-TBI.
Grade (III–V) blunt splenic injuries (BSI) in hemodynamically stable patients represent clinical challenges for successful non-operative management (NOM). In 2014, Our institution proposed a ...treatment protocol requiring splenic angiography and embolization for stable, intermediate, and high-grade BSI. It also included a follow-up CT scan for grade III BSI. We sought to assess the success rate of NOM in treating intermediate and high-grade BSI, following a standardized treatment protocol at a level 1 trauma center.
An observational retrospective study was conducted. Data of patients with BSI from June 2011 to September 2019 were reviewed using the Qatar National Trauma Registry. Patients’ demographics, CT scan and angiographic findings, grade of splenic injuries, and outcomes were analyzed. The pre- and post-implementation of treatment protocol periods were compared.
During the study period, a total of 552 hemodynamically stable patients with BSI were admitted, of which 240 had BSI with grade III to V. Eighty-one patients (33.8%) were admitted in the pre-protocol implementation period and 159 (66.2%) in the post-protocol implementation period. The NOM rate increased from 50.6% in the pre-protocol group to 65.6% in the post-protocol group (p = 0.02). In addition, failure of the conservative treatment did not significantly differ in the two periods, while the requirement for blood transfusion dropped from 64.2% to 45.9% (p = 0.007). The frequency of CT scan follow-up (55.3% vs. 16.3%, p = 0.001) and splenic arterial embolization (32.7% vs. 2.5%, p = 0.001) in NOM patients increased significantly in the post-protocol group compared to the pre-protocol group. Overall mortality was similar between the two periods. However, hospital and ICU length of stay and ventilatory days were higher in the post-protocol group.
NOM is an effective and safe treatment option for grade III-V BSI patients. Using standardized treatment guidelines for intermediate-to high-grade splenic injuries could increase the success rate for NOM and limit unnecessary laparotomy. Moreover, angioembolization is a crucial adjunct to NOM that could improve the success rate.
•The management of Grade III-V Splenic Injury remains a clinical challenge for trauma surgeons.•The utility of standardized treatment protocol for moderate to severe splenic injuries is effective and safe.•This protocolized approach resulted in improved non-operative management rates from 50.6% to 65.6%.•The protocol decreased the surgical intervention from 49.4% to 34.6%, and blood transfusion from 64.2% to 45.9%.•However, as with any treatment modality, the cost and risk of complications must be considered.
Background
Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We ...aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma.
Method
We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications.
Results
A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (
n
= 16), intra-abdominal abscess (
n
= 13), and anastomotic leak (
n
= 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01–1.60;
p
= 0.04) was found to be the independent predictor of postoperative complications.
Conclusion
Repair of traumatic blunt bowel injury remains a surgical challenge.
Cadmium recorded a significant superiority in the soil of the Qayyarah site with a peak of (491.744) mg/kg compared to the Kasak site, which showed its highest concentration in the soil of (D1) at ...(0) metres. The highest value was recorded at (520.217) mg/kg, which indicates high pollution. Compared to the rest of the dimensions, the lowest concentration of cadmium was in the soil (D2) at a distance of (50) meters, amounting to (428,050) mg/kg.
While we note that the Qayyarah site recorded the lowest values of cadmium at the distance (S2D2) (50 metres), with a concentration rate of (450.867) mg/kg. As for cadmium, its highest concentration was at the distance (S2D3) (100 metres) and (S2D5). It reached (521.867) mg/kg.
While the Kasak site recorded the highest value of cadmium at a distance of (S1D1) (0 metres) with a concentration of (527.667) mg/kg, while the lowest concentration of cadmium was at point (S1D2) (50 metres) with a value of (405.233) mg/kg.
Background: Cervical spine clearance in intubated patients due to blunt trauma remains contentious. Accumulating evidence suggests that a normal computed tomography (CT) cervical spine can be used to ...clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department. However, whether this strategy can safely be employed by critical care physicians with intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, has not been definitively studied. Methods: A retrospective review of 730 intubated victims of trauma who presented to the Level 1 Trauma center of a tertiary hospital was conducted. The rates of missed cervical injuries in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine, were reviewed. Secondary outcomes included rates of collar-related complications. Results: Three hundred and fifty patients had their cervical collars removed by Trauma ICU doctors based on a high-quality, radiologist-interpreted normal CT cervical spine. Seventy percent of patients were sedated and/or comatose at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%. Conclusion: Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be associated with increased complications. An algorithm is suggested to assist critical care decision-making in this patient cohort.
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