22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof. Dr.

Cardiovascular parameters on computed tomography are independently associated with in-hospital complications and outcomes in level-1 trauma patients

Polytrauma

Abstract text (incl. references and figure legends) Introduction: In-hospital complications after trauma may result in prolonged stays, higher costs, and adverse functional outcomes. Among reported risk factors for complications are pre-existing cardiopulmonary comorbidities. Objective and quick evaluation of cardiovascular risk would be beneficial for risk assessment. We aimed to assess the association between cardiopulmonary abnormalities visible on routine CT images and the development of in-hospital complications in level-1 trauma patients. Material &amp; Methods: All admitted trauma patients (≥16y) with CT imaging of the abdomen, thorax, or spine and in 2017 were included. Patients with active infection upon admission or severe neurological trauma were excluded. Routine trauma CT images were analyzed for visible abnormalities: pulmonary emphysema, coronary artery calcifications, and abdominal aorta calcification. Drug-treated complications were scored. Discharge condition was scored on the Glasgow Outcome Scale. Results: 433 patients (median age 50y, 67% male, 89% ASA 1-2) were analyzed. Median ISS and GCS score were 9 and 15, respectively. 76 patients suffered from at least one complication, mostly pneumonia (n=39, 9%) or delirium (n=19, 4%). Left main coronary artery calcification was independently associated with complications (OR 3.9, 95%CI 1.7–8.9). An increasing number of calcified coronary arteries showed a trend towards an association with complications (p=0.07) and was significantly associated with an adverse discharge condition (p=0.02). Pulmonary emphysema and aortic calcifications were not associated with complications. Conclusions: Coronary artery calcification, visible on routine CT imaging, is independently associated with in-hospital complications and an adverse discharge condition in level-1 trauma patients. The findings of this study may help to identify trauma patients quickly and objectively at risk for complications in an early stage without performing additional diagnostics or interventions.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Oral presentation

Dr. med.

Prof. Dr. med.

How to clear polytrauma patients for fracture fixation: Results of a systematic review of the literature

Emergency surgery

Abstract text (incl. references and figure legends) Introduction Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome, to improve decision making and identify patients who would benefit from early versus staged definitive surgical fixation. Material &amp; Methods Following the PRISMA guidelines, a systematic review of peer-reviewed articles published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue to determine the treatment strategy. Articles using quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles, discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained. Results The initial systematic search using MeSH criteria yielded 1550 publications. Included were articles to the following topics: coagulopathy (n=37), haemorrhage/shock (n=7), hypothermia (n=11), soft tissue injury (n=24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature: Coagulopathy: International Normalized Ratio, viscoelastic methods (Rotem/TEG); Haemorrhage/shock: lactate, systolic blood pressure, haemoglobin; Hypothermia: degrees celsius; Soft tissue trauma: traumatic brain injury, thoracic/abdominal and musculoskeletal trauma. Conclusion In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients. References NoneDisclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Thrombocyte aggregometry and rotational viscoelastometry function tests in coagulopathy of polytrauma patients

Abstract text (incl. references and figure legends) Coagulopathy (TIC) in traumatic injured patients is a highly complex process that is not yet fully understood. Blood loss, increased use of clotting factors, increased fibrinolytic activity and perturbation of platelet activation may all play a role. The aim of our present study protocol is to investigate platelet function and the coagulation cascade in polytrauma patients. Methods: Our prospective observational study (ClinicalTrials.gov NCT05004844) included severely injured (injury severity score (ISS) ≥16), bleeding patients aged ≥18 years from 1 September 2021. At arrival, platelet aggregometry (Multiplate) and rotational viscoelastometry (ROTEM) were performed on venous blood samples from injured patients. During ROTEM tests, EX and FIB tests were performed. In aggregometry, ADP and ASPI tests were performed. Our results were compared with mitochondrial respirometry studies of platelets isolated from parallel venous blood samples. Results: Platelets from polytraumatized patients (n=57) had significantly decreased ADP and arachidonic acid activated function (ADP test: 112±14 AUC vs 38±12 AUC, ASPI test 105±24 AUC vs 35±15 AUC) compared to control patients (n=48). In the EX tests and FIB tests, CT, CFT times were prolonged and MCF decreased. Platelet mitochondrial respirometry measurements were below those of the control group in the polytrauma patients, suggesting a probable impairment of platelet function (37±52 pmol/ml/sec vs 64±18 pmol/ml/sec). Conclusions: Our results confirm the development of TIC in polytraumatized injured patients. ADP-induced platelet activation is perturbed, with concomitant platelet mitochondrial dysfunction. In addition, the extrinsic coagulation pathway and fibrinogen polymerization are also disturbed in the patients studied; in parallel, respirometry of platelet mitochondria revealed their dysfunction. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Characteristics and demography of low energy fall injuries in the geriatric trauma population over a decade

Abstract text (incl. references and figure legends) Introduction A large group of elderly patients are admitted to hospital after falls, often low energy. Studies show that this group tends to be severely injured and is often undertriaged. We underwent a closer examination of this group regarding undertriage and mortality. Material &amp; Methods We identified patients ≥60 years of age with low energy fall (&lt;1 meter) as traumamechanism, from our trauma registry. The study period was between 01.01.11-31.12.20. Statistical analysis was done using Chi squared test for categorical variables and Mann-Whitney test for continuous variables. All tests are two-sided with statistical significance set to p &lt;0.05. Undertriage was defined as patients with an ISS&gt;15 without trauma team activation (TTA). Results In this period we identified 388 patients ≥60 years of age with fall Median age of the group was 78 years of age, ranging from 61 – 100, of which 53% were males. Location of major injury (LOMI) was head in 41% of the patients, lower extremities in 19% and thorax in 10%. Thirty day mortality was 9%. Fifty percent were discharged to private home, 31% to nursing home, and the remaining 10% to other hospitals or rehabilitation clinics. Ninety patients had an ISS &gt;15, 43 of these did not have TTA, i.e. the undertriage rate was 48% (95% confidence interval, 38 to 58%). There were more patients with GCS ≤13 among those with TTA than those without TTA (p&lt;0.001). In the undertriaged group 23% had GCS ≤13 (7/30). We found no differences with regard to age, sex, ASA score, etanol, heart rate or respiratory rate. Conclusions Geriatric patients with low energy falls with an ISS&gt;15 are undertriaged in half the cases, with GCS ≤13 seen in 1 of 4, mandating increased awareness of this often fragile group.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Diagnostic and therapeutic angiography for trauma in our environment: Results in a series of 264 patients

Abstract text (incl. references and figure legends) INTRODUCTION The use of angiography (AG) and angioembolization (AE) has tripled in the initial treatment of grade IV-V hepatosplenic injuries with hemodynamic stability or transient response, as well as in severe pelvic fractures with active bleeding. Likewise, we believe that it has been a decisive factor contributing to the decrease in morbidity and mortality. MATERIAL &amp; METHODS Single-center observational retrospective study, patients included from a prospective severe trauma registr, with 3 periods of study: P1 (anecdotal use of AG), P2 (between its firm implantation and the establishment of a massive transfusion protocol), and P3 (after said protocol). Clinical success in the main locations has been understood as the absence of the need for reembolization, surgical intervention due to rebleeding, or death due to hemorrhage. RESULTS Between 1993 and 2021, 264 patients with severe trauma underwent AG: 39 in P1, 105 in P2, and 120 in P3. We have not found statistically significant differences in demographic variables compared between groups, nor in the mechanism of injury. The main indications for AG were hepatosplenic and pelvic injuries, intra and extra abdominal vascular injuries and retroperitoneal hematomas. 162 AE were performed (61.5%): 3 in P1(7%), 67 in P2(63.8%), and 92 in P3(76.7%). The clinical success rate was 85.3%. EA has managed to avoid 35 potential surgical approaches for pelvic fractures, 14 liver, 14 splenic, and 10 kidney surgeries, reducing the time from admission to surgical intervention from 15.5h in P1 to 147 min at P2 and 62 min at P3.Mortality from bleeding from hepatosplenic trauma has decreased from 2.6% to 0.7%, and from 4.9% to 2.6% in severe pelvic trauma. CONCLUSIONS The use of AG and AE has tripled in the initial treatment of grade IV-V hepatosplenic injuries and severe pelvic fractures with hemodynamic stability or transient response, being a decisive factor contributing to the decrease in morbidity and mortality.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Prof.

Obesity influences the metabolomic and proteomic signatures of trauma

Abstract text (incl. references and figure legends) Introduction: With climbing obesity (OB) prevalence, more and more injured patients with OB are presenting to trauma centers worldwide. OB is associated with worse prognosis following trauma, but the effects of OB on multiple biochemical processes post-injury remain incompletely examined. We hypothesized that OB directly affects the metabolomic and proteomic signatures of injury, which are associated with poor outcomes. Material and Methods: Blood was collected on arrival from injured patients at a Level I Trauma Center. Patients were categorized into Group 1 "minimally injured/no shock" (ISS&lt;15, arrival base excess [BE]≥-6) and Group 2 "severely injured/shocked" (ISS≥15, BE&lt;-6). OB was defined as BMI≥30 kg/m2. Plasma metabolomics and proteomics were performed using liquid chromatography coupled with mass spectrometry. Results: Of the 97 patients included, 55 were Group 1 (33 without and 22 with OB) and 42 were Group 2 (33 without and 9 with OB). Compared to those without OB, severe injury was associated with distinct metabolomic and proteomic changes in patients with OB (Figure). These changes are consistent with a predisposition to erythrocyte oxidative damage and hemolysis, poor branched chain amino acid catabolism, altered phenylalanine/tyrosine degradation, and aberrant one-carbon/methionine metabolism. Increased soluble Fas receptor may also predispose patients with OB to excessive post-injury inflammation secondary to reduced innate immune cell apoptosis. Conclusions: OB influences the metabolomic and proteomic responses to injury. These data suggest key metabolic and inflammatory pathologies that may underlie the propensity for organ dysfunction and adverse outcomes in trauma patients with OB. Further elucidation of OB-related biochemical changes with injury is crucial to the development of targeted therapies for this patient population. References: Liu et al. The effect of obesity on outcomes in trauma patients: a meta-analysis. Injury. 2013. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

PD Dr. rer. nat.

Different intramedullary nailing strategies display homogeneous circulatory neutrophil kinetics in a porcine model of polytrauma

Abstract text (incl. references and figure legends) Introduction: Increased incidences of inflammatory complications have been described after intramedullary nailing (IMN) in polytrauma. It is believed that neutrophils dysregulation has a key role in the development of post-traumatic inflammatory complications. The impact of fracture fixation strategy on neutrophil homeostasis is unclear. We hypothesized that reamed femoral nailing (RFN) is associated with a more profound systemic neutrophil response than alternative treatment options (unreamed femoral nailing, UFN and Reamed-Irrigation and Aspiration (RIA)-nailing in cardiopulmonary polytrauma. Methods: A standardized porcine polytrauma model (thoraco-abdominal trauma plus hypovolemic shock and a femur fracture) was used. Cardiopulmonary compensated animals were thereafter treated by different protocols of IMN. Three intervention groups (N=18) and a sham group (N=6) were composed: Gr. UFN, Gr. RFN and Gr. RIA. Circulatory immune cells were isolated at baseline, prior to surgery and after 6hrs. Cell-surface receptor kinetics of Mac-1/CD11b and FcyRIII/CD16 were determined by flowcytometry. Results: All 24 animals survived the observation period. As anticipated, an instant upregulation of Mac-1-expression on blood neutrophils was seen after trauma. (62,3% rise (P=0.01) vs. 29.3% rise (P=0.2) in the sham-group). The circulatory neutrophils fraction, however, increased first after IMNg (43.2% to 71.0% (P&lt;0.01)). Neutrophil CD16-expression dropped gradually over time in all intervention groups (38,3% P&lt;0.01). No statistically significant differences between intervention groups were seen. Conclusion: This standardized large-animal study shows that trauma-induced alterations in activation status of blood neutrophils precede later changes in circulatory neutrophil numbers. Furthermore, in cardiopulmonary trauma, applied IMN-nailing technique does not affect circulatory neutrophil numbers or cell surface expression profiles. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

MicroRNAs and their role in multiple trauma: Profiling local and systemic expression levels

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) Objectives Cellular signalling and communication, both at the site of injury and over distance, are key in tissue regeneration after multiple trauma. Among others, surgical treatment strategies, such as early-total-care (ETC) and damage-control-orthopedics (DCO), influence tissue regeneration. To examine this, we investigated miRNA (miR) expression systemically and at the fracture site in a porcine multiple trauma model. Methods The model consisted of blunt chest trauma, liver laceration, bilateral femur fracture, and controlled haemorrhagic shock. Animals were monitored under ICU-standards for 72 hours. Three treatment groups were defined: sham (n=6), ETC (n=7), and DCO (n=8) (fig.1). Fracture hematoma, fractured bone, bone from an unfractured long bone, and Extracellular Vesicles (EVs) from blood plasma were sampled. MiRs were isolated, transcribed and pooled for qPCR array analysis followed by in silico mRNA target analysis. Results Array data revealed miR expression levels specific to the multiple trauma treatment method and sample type. Locally, in bone and fracture hematoma tissue, anti-inflammatory miR were upregulated in the ETC group compared to the DCO group. Systemically, upregulation of anti-inflammatory miR, packaged in EVs, was observed in the DCO group. Furthermore, a clear EV-derived miR signature showed expression of injury specific miR in the systemic circulation. A total of 177 mRNA targets were identified to interact with most deregulated miRs. Conclusion This study revealed multiple trauma specific, as well as treatment specific miR expression profiles at the site of injury, linked to key processes in inflammation, tissue regeneration, and fracture healing. Distinct patterns of acute phase miR expression were identified in plasma-derived EVs. This study showed that miRs are important in regulating tissue regeneration after trauma, that EVs are involved in miR transport over distance, and that their expression might be of prognostic value. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

SORTED: A New Zealand initiative to combine road injury data from multiple agencies

Education

Abstract text (incl. references and figure legends) Introduction Road trauma from all forms of transport is a significant contributor to the burden of injury. Road to Zero is the NZ Transport Agencies strategy to reduce deaths and serious injury on roads. However, there are significant gaps in data to inform where road trauma is occurring, and who is being injured. Many of the gaps concern motorcycling, cycling and pedestrian injuries. The SORTED study aims to address these some of these gaps. Materials and methods Nine health and transport agencies collaborated using six different datasets which spanned ambulance, Emergency Department, hospital admissions, trauma registry, accident insurance claims, and police investigations. Individuals injured were linked across the datasets, and additional information included such as deprivation and rurality, based on where the person lives. Ambulance and police data was used to undertake geospatial mapping of where the injury occurred. Results 44,000 (880/100,000) people are injured on New Zealand roads each year. Severity of injury was categorised into minor (73%), moderate (24%), serious (2%) and deaths (1%). Police investigations of hospitalised road trauma was low for motorcyclists (38%) and cyclists (19%). People who had serious injuries entered into the trauma registry accounted for only 2% of the total caseload, but 52% of the direct cost to health services. Conclusion Initiatives to achieve Road to Zero require information which is accurate and comprehensive, and studies such as SORTED which link individuals across health and transport datasets can make a useful contribution and address some of the current gaps in data. Collaborations such as these achieve more than any single agency can achieve on its own. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) I have nothing to declare

Results of emergency surgery for complicated acute diverticulitis in elderly patients. A single center control study

Abstract text (incl. references and figure legends) The incidence of diverticulitis has been increasing in last decades, in elderly patients. The surgical management is challenging for timing and treatment. The choice of surgical procedure varies according to the severity of the disease the age and general status of the patient. The aim of this study was to analyze the outcomes of emergency surgical management of complicated diverticular disease in our elderly population, comparing the results of Hartmann&quot;s procedure versus resection with primary anastomosis A retrospective analysis of our experience (2010–2022) was performed on a consecutive series of patients undergoing surgery for acute complicated diverticulitis. Patients were assessed for demographic data, operative indications, type of resection, intra- and postoperative complications, stoma reverse. The comparisons were made dividing the population in two groups: elderly patients (&gt;75 age years) (Group 1) and patients aged &lt;75 age years (Group 2). 201 patients underwent emergency surgery for acute complicated diverticulitis (Hinchey III-IV). 94(47%) patients were included in Group 1 and 107(53%) in Group 2. No differences in Hinchey classification were observed (P=NS). Similarly, no differences in intra- and post-operative complication rates and operative time were recorded (P=NS). Furthermore, we observed that patients who underwent primary colonic anastomosis with ileal diversion were recanalized more frequently than those who had a Hartmann&quot;s procedure (P&lt;.05). Noticeably, patients in Group 1 were significantly more represented than patients in Group 2 (P&lt;.05). Primary anastomosis can be performed safely, in elderly patients. In this subset of patients, the choice of the two surgical options (Hartmann versus primary anastomosis) should be correlated to the severity of diverticulitis and with the general status and co-existing comorbidities of the patients. Therefore, we suggest the use of Hartmann&quot;s procedure only to high-risk patients.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) NO

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