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International Journal of Environmental... Aug 2021Hypothermia in trauma patients is a common condition. It is aggravated by traumatic hemorrhage, which leads to hypovolemic shock. This hypovolemic shock results in a... (Review)
Review
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.
Topics: Blood Coagulation Disorders; Heart Arrest; Hemorrhage; Humans; Hypothermia; Rewarming; Wounds and Injuries
PubMed: 34444466
DOI: 10.3390/ijerph18168719 -
Emergency Medicine Clinics of North... Feb 2018Airway management in the trauma patient presents numerous unique challenges beyond placement of an endotracheal tube and outcomes are dependent on the provider's ability... (Review)
Review
Airway management in the trauma patient presents numerous unique challenges beyond placement of an endotracheal tube and outcomes are dependent on the provider's ability to anticipate difficulty. Airway management strategies for the care of the polytrauma patient are reviewed, with specific considerations for those presenting with traumatic brain injury, suspected c-spine injury, the contaminated airway, the agitated trauma patient, maxillofacial trauma, and the traumatized airway. An approach to airway management that considers the potential anatomic and physiologic challenges in caring for these complicated trauma patients is presented.
Topics: Airway Management; Airway Obstruction; Craniocerebral Trauma; Humans; Intubation, Intratracheal; Wounds and Injuries
PubMed: 29132582
DOI: 10.1016/j.emc.2017.08.006 -
Medicine Jul 2019Acute compartment syndrome (ACS) is defined as a clinical entity originated from trauma or other conditions, and remains challenging to diagnose and treat effectively.... (Review)
Review
BACKGROUND
Acute compartment syndrome (ACS) is defined as a clinical entity originated from trauma or other conditions, and remains challenging to diagnose and treat effectively. The review was aim to present the controversy in diagnosing, treating ACS. It was found that there was no criterion about the ACS, and result unnecessary osteotomy. The presence of clinical assessment (5P) always means the necrosis of muscles and was the most serious or irreversible stage of ACS. Besides pressure methods, the threshold of pressure identifying ACS was also controversial.
METHODS
Immediate surgical fasciotomy was important to prevent severe suquelae of the ACS. However, there was still controversy about the right time that fasciotomy should be done to avoid irreversible ischemic changes. The most important thing to treat ACS was comprehension to the true injury mechanism, but a systemic classification about traumatic mechanism in most literature was not clear.
RESULTS
After observations to fracture patients with blister, we recommended that surgeons dealing with such emergencies should be vigilant, and the indication for fasciotomy should be strictly controlled following with injury mechanism especially for patients without severe soft tissue injury.
CONCLUSION
For those crushing and soft tissue injuries, the current evidence based strategies for managing patients was useful, but for those fracture related injury, more examination was necessary to avoid overtreatment especially for those patients with blister observed. In facing patients, medical history, injured mechanism should be paid special attention, and rigorous classification about traumatic etiology was the key for the treatment of these patients.
Topics: Acute Disease; Compartment Syndromes; Diagnostic Imaging; Fasciotomy; Humans; Prognosis; Wounds and Injuries
PubMed: 31277147
DOI: 10.1097/MD.0000000000016260 -
Critical Care (London, England) Mar 2019Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially...
BACKGROUND
Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.
METHODS
The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.
RESULTS
Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.
CONCLUSIONS
A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
Topics: Blood Coagulation; Encephalocele; Europe; Evidence-Based Medicine; Guidelines as Topic; Hemorrhage; Humans; Respiration, Artificial; Wounds and Injuries
PubMed: 30917843
DOI: 10.1186/s13054-019-2347-3 -
Archives of Medical Research Nov 2021Sepsis is a major cause of death following a traumatic injury. As a life-threatening medical emergency, it is defined as the body's extreme response to an infection.... (Review)
Review
Sepsis is a major cause of death following a traumatic injury. As a life-threatening medical emergency, it is defined as the body's extreme response to an infection. Without timely treatment, sepsis can rapidly lead to tissue damage, and organ failure The capacity to limit tissue damage through metabolic adaptation and repair processes is associated with an excessive immune response of the host. It is important to make an early prediction of sepsis, based on the quick Sepsis associated Organ Failure Assessment Score (qSOFA), so an accurate treatment can be initiated reducing the morbidity and mortality at the emergency and UCI services. Many factors increase the rate of complications and the development of sepsis in a trauma patient, representing a challenge to orthopedic surgeons. Several early biomarkers that help to identify and predict the inflammatory and immune responses of the host going through polytrauma and sepsis have been studied; procalcitonin (PCT), C-reactive protein (CRP), glycosylated hemoglobin (HbA1c), the Neutrophil/lymphocyte ratio (NLR), Interleukin-17 (IL-17), Caspase-1, Vanin-1, High-density lipoproteins (HDL), and the Thrombin-activable fibrinolysis inhibitor (TAFI). Once sepsis is diagnosed, treatment must be immediately initiated with an appropriate empiric antimicrobial, an all-purpose supporting treatment, and metabolic control, followed by the specific antibiotic therapy based on blood culture. Since the participation of sepsis in polytrauma has been recognized as a key event in the outcome of patients at the ICU, the ability of the specialist to early recognize a septic process has become a key feature to reduce mortality and improve clinical prognosis.
Topics: Biomarkers; C-Reactive Protein; Humans; Procalcitonin; Prognosis; Sepsis; Wounds and Injuries
PubMed: 34706851
DOI: 10.1016/j.arcmed.2021.10.007 -
Intensive Care Medicine Jan 2021Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs).
METHODS
This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI).
RESULTS
Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34).
CONCLUSION
There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.
Topics: Blood Coagulation Disorders; Hemorrhage; Hemostasis; Hemostatics; Humans; Multicenter Studies as Topic; Thrombelastography; Wounds and Injuries
PubMed: 33048195
DOI: 10.1007/s00134-020-06266-1 -
BMJ (Clinical Research Ed.) Dec 2018To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft.
DESIGN
Randomized controlled trial.
SETTING
Private or commercial aircraft between September 2017 and August 2018.
PARTICIPANTS
92 aircraft passengers aged 18 and over were screened for participation. 23 agreed to be enrolled and were randomized.
INTERVENTION
Jumping from an aircraft (airplane or helicopter) with a parachute versus an empty backpack (unblinded).
MAIN OUTCOME MEASURES
Composite of death or major traumatic injury (defined by an Injury Severity Score over 15) upon impact with the ground measured immediately after landing.
RESULTS
Parachute use did not significantly reduce death or major injury (0% for parachute 0% for control; P>0.9). This finding was consistent across multiple subgroups. Compared with individuals screened but not enrolled, participants included in the study were on aircraft at significantly lower altitude (mean of 0.6 m for participants mean of 9146 m for non-participants; P<0.001) and lower velocity (mean of 0 km/h mean of 800 km/h; P<0.001).
CONCLUSIONS
Parachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.
Topics: Accidents, Aviation; Adult; Aerospace Medicine; Aircraft; Death, Sudden; Female; Humans; Injury Severity Score; Male; Middle Aged; Protective Devices; Wit and Humor as Topic; Wounds and Injuries
PubMed: 30545967
DOI: 10.1136/bmj.k5094 -
Deutsches Arzteblatt International Oct 2018The conservative treatment of traumatic thoracolumbar vertebral fractures is often not clearly defined. (Review)
Review
BACKGROUND
The conservative treatment of traumatic thoracolumbar vertebral fractures is often not clearly defined.
METHODS
This review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for publications up to February 2018 dealing with the conservative treatment of traumatic thoracolumbar vertebral fractures. The search initially yielded 3345 hits, of which 35 were suitable for use in this review.
RESULTS
It can be concluded from the available original clinical research on the subject, including three randomized controlled trials (RCTs), that the primary diagnostic evaluation should be with plain x-rays, in the standing position if possible. If a fracture is suspected on the plain films, computed tomography (CT) is indicated. Magnetic resonance imaging (MRI) is additionally advisable if there is a burst fracture. The spinal deformity resulting from the fracture should be quantified in terms of the Cobb angle. The choice of a conservative or operative treatment strategy is based on the primary stability of the fracture, the degree of deformity, the presence or absence of disc injury, and the patient's clinical state. Our analysis of the three RCTs implies that early functional therapy without a corset should be performed, although treatment in a corset may be appropriate to control pain. Follow-up x-rays should be obtained after mobilization and at one week, three weeks, six weeks, and twelve weeks.
CONCLUSION
Further comparative studies of the indications for surgery and specific conservative treatment modalities would be desirable.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Conservative Treatment; Female; Germany; Humans; Lumbar Vertebrae; Lumbosacral Region; Magnetic Resonance Imaging; Male; Middle Aged; Radiography; Spinal Fractures; Thoracic Injuries; Wounds and Injuries
PubMed: 30479250
DOI: 10.3238/arztebl.2018.0697 -
Advanced Emergency Nursing JournalInjured patients with traumatic hemorrhagic shock often require resuscitation with transfusion of red blood cells, plasma, and platelets. Resuscitation with whole blood... (Review)
Review
Injured patients with traumatic hemorrhagic shock often require resuscitation with transfusion of red blood cells, plasma, and platelets. Resuscitation with whole blood (WB) has been used in military settings, and its use is increasingly common in civilian practice. We provide an overview of the benefits and challenges, guidelines, and unanswered questions related to the use of WB in the treatment of civilian trauma-related hemorrhage. Implications for advanced practice nurses and nursing staff are also discussed.
Topics: Adult; Blood Transfusion; Hemorrhage; Humans; Plasma; Resuscitation; Shock, Hemorrhagic; Wounds and Injuries
PubMed: 34699424
DOI: 10.1097/TME.0000000000000376 -
Journal of Trauma Nursing : the... 2018Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult...
Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care, and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting the use of TIC in practice. Of 147 participants, the majority were nurses (65%), followed by therapists (18%) and physicians (17%), with a median 3 years of experience; 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. Nineteen percent rated themselves as less than "somewhat competent." All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about retraumatizing patients. Self-rated competence was the most consistent predictor of providers' reported use of specific TIC practices. Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed and should aim to build providers' perceived competence in providing TIC.
Topics: Adult; Attitude of Health Personnel; Clinical Competence; Cross-Sectional Studies; Female; Health Knowledge, Attitudes, Practice; Health Personnel; Humans; Logistic Models; Male; Patient Care Team; Trauma Centers; Wounds and Injuries
PubMed: 29521782
DOI: 10.1097/JTN.0000000000000356