22nd European Congress of Trauma & Emergency Surgery

Prof.

Chairs

PD Dr.

Prof. Dr. med.

Prof. Dr.

Dr. med.

Analysis of the accuracy and outcome of navigated sacroiliac screw fixation

Polytrauma

Emergency surgery

Abstract text (incl. references and figure legends) Introduction Sacroiliac (SI) screw fixation is a feasible treatment option for posterior pelvic ring disruption. During the last decade, navigated screw fixation has been introduced, which provides a three-dimensional vision field for the surgeon. However, this technique requires a more advanced set up. The aim of this study was to compare the outcome of navigated SI-screws with non-navigated SI-screws. Material&amp;Methods A retrospective cohort study of patients with acute traumatic pelvic ring injuries at a level one trauma center was performed. Patients aged ≥15, treated with elective SI screw fixation were included. Patients were stratified according to treatment strategy (Group NV: Navigated screws vs. Group CV: conventional screws). Outcome: implant-related complications: breakage, loosening, intraforaminal/malpositioning of the screws, reoperations. Results A total of 204 (mean age 61±20 years, mean ISS 17±10) patients were included between 11/2014 and 08/2021. 65 patients (64±21 years) underwent navigated screw fixation, whereas 139 patients (59±20 years) received conventional percutaneous screws to the posterior pelvic ring. Both groups were comparable in terms of age, ISS, and fracture morphology. The navigated group had more severe comorbidities (ASA; NV: 2.92±0.78 vs. CV: 2.54±0.87, p=0.003). Overall hardware complication rates did not differ significantly (p=0.805). However, screw malpositioning only occurred in the CV-group with 6.5%, with 3.6% intraforaminal positioning (vs. NV: 0%). Furthermore, reoperation/implant removal rates after fracture consolidation were lower in the NV-group (NV: 9.2% vs. CV: 21.6%, p=0.05). Conclusion Navigated screw fixation of the posterior pelvic ring results in optimal accuracy of screw placement in trauma patients. Patients with severe comorbidities as well as difficult osseous corridors might benefit from a navigated intervention. Future studies should focus on patient selection criteria for navigated procedures. 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.) None

Oral presentation

Analysis of mitochondrial function of platelets from polytrauma patients

Abstract text (incl. references and figure legends) Introduction:The pathogenesis of trauma-induced coagulopathy (TIC) is not yet fully understood. However, platelet activation and subsequent clot formation are linked to mitochondrial activity suggesting a possible role for mitochondria in TIC. We aimed to investigate the mitochondrial function of platelets using high-resolution respirometry in TIC. Methods: Prospective observational study (ClinicalTrials.gov NCT05004844) included severely injured (injury severity score (ISS) ≥16), bleeding patients aged ≥18 years from 1 September 2021. Baseline respiratory activity and oxidative phosphorylation capacity (OxPhos) of platelet mitochondria isolated from venous blood samples at arrival, mitochondrial electron loss (after oligomycin), and maximum respiratory capacity (after FCCP) were assessed. The values obtained were normalized to the platelet count of the sample. Our results were compared with parallel aggregometric measurements of platelets (Multiplate ADPtest). Results: Baseline mitochondrial respiratory activity of isolated platelets from polytrauma patients (n=57) did not change compared to control patients (n=48). However, OxPhos was significantly decreased compared to controls (37±52 pmol/ml/sec vs 64±18 pmol/ml/sec). Lower oxygen consumption was measured after administration of oligomycin and FCCP, suggesting increased electron loss and impaired electron transport. Platelet functional tests in the polytrauma patients were all below the values of the control group, demonstrating severe coagulation disturbance (ADPtest: 112±14 AUC vs 85±69 AUC). Conclusions: Our results confirm the development of TIC in polytraumatized injured patients. ADP-induced platelet activation is perturbed, with concomitant detection of platelet mitochondrial dysfunction, including OxPhos required for platelet activation. A deeper understanding of maladaptive platelet responses after injury may provide a basis for the exploration of new therapeutic targets in polytrauma care.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

Zone 1 aortic occlusion provokes mitochondrial metabolic disturbances while zone 3 attenuates metabolite buildup

Disaster and military medicine

Abstract text (incl. references and figure legends) Introduction: Ischemia-reperfusion injury (IRI) occurs after hemorrhagic shock when blood flow to organs is restored. IRI results in the accumulation of succinate and further oxidative injury. Following reperfusion rapid metabolism of succinate into fumarate leads to reversal of the electron transport chain and generation of reactive oxygen species (Figure 1). The effects of aortic occlusion (AO) on mitochondrial function have not yet been elucidated. We hypothesized in our polytrauma swine model of hemorrhagic shock Zone 1 AO would worsen mitochondrial dysfunction evidenced by succinate accumulation. Material &amp; Methods: Swine underwent polytrauma with bilateral femur fractures, hemorrhagic shock to base excess -10, and blast head injury. Swine were randomized to 30 minutes of either no AO (n=6), AO at Zone 1 (above celiac artery; n=6), or Zone 3 (below renal arteries; n=4) during the last 30 minutes of shock followed by resuscitation. Plasma samples underwent to mass spectrometry-based metabolomics. Relative metabolic changes were compared using mixed models adjusting for false discovery rate. Results: The largest metabolite increases were seen in succinate, fumarate, and malate. At 60 minutes into resuscitation Zone 1 group metabolites remained significantly elevated above the others (p&lt;0.05). Regarding succinate, both Zone 1 and No AO groups had significant increases from baseline (p&lt;0.05), with almost 30x increases in succinate levels. Succinate accumulation following Zone 3 AO was not significant, with only a 10x increase. Conclusions: Zone 1 AO results in prolonged disturbances of mitochondrial metabolism. Zone 3 AO attenuated succinate buildup and compared to Zone 1 avoided accumulation of other mitochondrial metabolites. These findings suggest visceral ischemia is an important driver of IRI and Zone 3 AO may mitigate IRI. References: Chouchani et al. Ischaemic accumulation of succinate controls reperfusion injury through mitochondrial ROS. Nature. 2014Disclosure: 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.) This research is funded by the US Department of Defense contract W81XWH2010205, the US National Institute of General Medical Sciences of the National Institute of Health (T32 GM008315) and a US NIH RM1 grant (1RM1GM131968-01).

The changing pattern and fatality rates of mechanisms of injury at a uk trauma centre – A 10 year study

Visceral trauma

Abstract text (incl. references and figure legends) Introduction With an increasingly elderly major trauma population in the UK, lower energy transfer injuries are increasingly common, and understanding recent trends can help to guide trauma prevention resources. Materials and Methods Data were collected prospectively from 2012 to mid-2022 at a tertiary level UK major trauma centre and used to calculate the number and proportion of admissions by injury mechanism, as well as the case fatality rates. These were split up into falls under 2m, falls over 2m, vehicle collisions, shooting, stabbing, blast, blow, burn, crush and other injuries. Trends were calculated using linear regression models, and comparisons between annual mortality rates were made using a one-way ANOVA with post-hoc Tukey test. Results: There were 8894 major trauma admissions from 2012-2022, leading to 595 deaths. The most common mechanisms were falls under 2m, vehicle collisions and falls over 2m, making up 38.1%, 24.0% and 22.5% of admissions respectively. Falls under 2m caused the largest proportion of deaths (40.5%), followed by falls over 2m (28.2%) and vehicle collisions (18.5%), with significantly higher annual case fatality rates in the falls over 2m than the vehicle collisions group (p=0.005). Total and injury specific case fatality rates did not significantly change over the time period, with 7% mortality in falls under 2m, 8.3% in falls over 2m, 5.1% in vehicle collisions and 4.7% in stabbings. Between 2012 and 2021, total annual admissions nearly tripled from 404 to 1135 (p&lt;0.0001), as did annual deaths from 28 to 72 (p=0.0003). The proportion of admissions from falls under 2m increased from 39.6% to 47.8% (p=0.02), blow injuries decreased from 16.8% to 7.6% (p= 0.003), while other mechanisms did not significantly change. Conclusion: Falls from under 2m are causing an increasingly large burden of major trauma admissions and deaths. These results can help to address this by influencing civic and regional trauma prevention schemes.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.

Lipidomic profile change in a porcine polytrauma model align with injury patterns

Abstract text (incl. references and figure legends) Introduction: The role of lipid mediators in the posttraumatic response has been hypothesized but not yet proven. With vast advances in analytic technology, lipidomic profile changes can be characterized on a molecular level. Due to the large heterogeneity in the polytrauma population, we aimed to explore analyses in a translational large animal model. Methods: 48 male Pigs (50 ± 5kg) underwent general anesthesia for 6 hours. Monotrauma group (MT) and polytrauma group (PT) both received a femoral shaft fracture. PT received additional blunt chest trauma liver laceration and a controlled hemorrhagic shock. After 60 minutes, animals were resuscitated and fractures were stabilized with intramedullary nailing. Plasma was collected at 6 timepoints (baseline, trauma, resuscitation, 2h, 4h and 6h). Lipidomic analysis was performed via liquid chromatography mass spectrometry (LC-MS). After quality control and data cleaning, lipids were further processed and clustered by means of dimensionality reduction (PCA, heatmaps) based on structural and functional characteristics. Linear mixed models are programmed to analyze changes over time. Results: A total of 233 lipids were included in the analysis. Principle component analysis showed similar patterns in lipids with similar molecular characteristics (Image 1) and lipids were therefore organized into 17 subgroups. Lipid profile changes aligned precisely with injury pattern. This alignment was strongest after resuscitation (Image 2) and at 6h. Acylcarnitines (AcCas) showed a highly significant (p&lt;0.001) twofold increase after resuscitation in PT only. Multiple other lipid subgroups (TAGs, SMs, PCs) and their substrates (DAGs, CERs, LPCs) also showed significant profile changes over time and based on injury pattern. Conclusion: Lipidomic profile changes align with the type of injury. Causal inferences can be drawn based on the lipids functional characteristics, i.e. AcCas as a marker for oxidative stress after HS.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.) Nothing to declare

Impact of the COVID-19 pandemic on the treatment of major traumas during lockdown in a tertiary level trauma center in Rome

Abstract text (incl. references and figure legends) INTRODUCTION: On March 9, 2020, the Governor Italy declared a state of emergency and a public health emergency to contain the spread of the Coronavirus Disease 2019 (COVID-19) pandemic: the three-month nationwide lockdown implemented involved restrictions on social gatherings and non-essential services, resulting in marked changes to the distribution of time spent at home and in the workplace. We analyzed the changes in trauma presentation during this period. MATERIAL AND METHODS: An observational retrospective audit of the patient register at the San Camillo - Forlanini hospital was conducted, comparing the number e the type of trauma presentations between March 09 and May 18, 2020,data were therefore compared with those of the same period of 2019. Informations on age, gender, mechanism of injury, operations and outcome was abstracted for all patients presenting to the emergency department.. RESULTS: Compared to pre-lockdown levels there was an overall reduction of 22% of patients in the emergency deprtment during lockdown; moreover almost 30% of accesses were due to COVID-19 or its complications. Also for trauma there was a 20% decrease in accesses. However averange ISS was 6,4 during the 2019 and 11,1 during the 2020 (p&lt; 0,05) due to greater proportion of major trauma (ISS 16) during the lockdown period. Despite the significant decrease of patients injuried in road accidents, the severity of road related injuries was higher, and the number and the proportion of fall-related injuries were increased in the COVID-19 cohort: most of the patients with major trauma had a psychiatric disorder. Average lenght ICU stay, LOS and mortality were the same between the two cohorts. CONCLUSIONS: The volume of overall trauma presentations decreased during the lockdown, but the rate of major trauma did not decrease significantly due to the higher severity of road traffic injuries and the increasement of fall-related injuries due to loss of care in psychiatric pathologies 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

The effect of the post-trauma milieu on endothelial metabolism: Ex-vivo trauma plasma from severely injured and shocked patients causes oxidative stress, mitochondrial dysfunction, and fatty acid oxidation deficiency in human endothelial cells

Abstract text (incl. references and figure legends) Introduction: Trauma causes a thromboinflammatory milieu characterized by coagulopathy and metabolic perturbations, however, the specific metabolic response of endothelial cells remains unknown. We hypothesized that when exposed to ex-vivo trauma plasma, the metabolic underpinnings of the endothelial response to trauma can be elucidated and would be characterized by dysregulation of metabolic pathways. Material &amp; Methods: Ex-vivo plasma was collected upon arrival from trauma patients at a single level 1 trauma center. Patients were divided by injury severity score (ISS) and base deficit (BD) (Group 1 ISS=1 BD=0.6, Group 2 ISS=50 BD=16). Human umbilical vein endothelial cells were grown to 80% confluence and incubated with 10% trauma patient plasma. Cells and media were collected at multiple time points from 5 minutes to 24 hours and analyzed with mass spectrometry for metabolomic analysis. Significant metabolites were determined using FDR-corrected 2-way ANOVA (p&lt;0.05) as well as multivariate empirical Bayes time-series analysis. Results: The metabolic response of endothelial cells exposed to trauma plasma reflects a state of oxidative stress, mitochondrial dysfunction, and fatty acid oxidation deficiency. This state of oxidative stress is supported by increased dehydroascorbate in group 2, indicating an overwhelming of the glutathione reductase system (Fig 1). Group 2 had higher levels of succinate, malate, taurine, and creatine indicating mitochondrial dysfunction. Finally, group 2 exhibited increased acyl-carnitine species with decreased free fatty acids indicating an inability to oxidize fatty acids for ATP production (Fig 2). Conclusions: The post-trauma milieu causes signaling resulting in metabolic crisis. Future studies will further probe the mechanism underlying this phenotype to identify the mediators responsible for the post-trauma response. Endotyping the post-trauma response can guide improved personalized resuscitation and treatment after injury.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

Severity – Adjusted mortality from massive haemorrhage in trauma: Analysis in 3 periods of time

Abstract text (incl. references and figure legends) Introduction: Haemorrhagic shock is the most common preventable cause of early mortality in polytrauma. The aim of this study is to analyse the incidence, mechanism, and severity-adjusted mortality of massive haemorrhage in our center. Methods: Descriptive, retrospective study of patients dying from massive haemorrhage included in our registry of severe trauma. Results of three successive periods between 1993-2021 were compared. Associated injuries, trauma scores and time to death was analysed. The probability of survival (Ps) was calculated according to NTRISS methodology. The focus was on potentially preventable deaths (PPD) and identification of deviations from clinical practice. Results: From 3.209 trauma patients admitted to hospital, 125 died from massive haemorrhage: 45/789(5.7%) in the 1st period, 66/1.270(5.1%) in the 2nd, and 14/1.150(1.21%) in the 3rd, showing a clear decrease in mortality over the years. Blunt trauma was predominant (84.8%). We found a significant higher RTS in the 3rd period (p0.054), and a higher ISS in the 1st period (p0.002). Mortality from massive haemorrhage from pelvic fractures increased over time (p0.00). A gradual decrease in the number of deaths in the first 24h (p 0,021) and in deaths occurring at the radiology suite were observed, with an increase in ICU deaths in the 3rd period (p0.013). The expected Ps&gt;0.5 was of 29%, 39.5% and 50% respectively, with an overall misclassification rate of 38,6%. 52 (41%) PPD were detected with a decreasing tendency in the 3rd period. Conclusions: Mortality from severe haemorrhage has clearly decreased in recent years in our center, with the exception of pelvic fractures. However, the high misclassification rate of the NTRISS survival prediction model discards it as a useful objective tool to assess quality of care in this subgroup of patients. Careful review of deviations from clinical practice in this subgroup of trauma deaths remains the main tool for assessing the quality of care.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

Nerve lesions after blunt trauma – the importance of a careful trauma survey

Abstract text (incl. references and figure legends) A 23-years-old male presented to the emergency department after sustaining a motorbike accident. He had pain, bruising and limited range of motion in his right shoulder, and an open fracture of the first metatarsal head of his left foot(fig.1). After the initial trauma survey, radiographs showed no bone fracture in his shoulder and a comminuted fracture of the metatarsal head with partial bone loss and 180º rotation of the fragment(fig.2). He was taken to the operating room for debridement and fixation of his open fracture. His left foot developed wound necrosis after 2 weeks and later required skin grafting by the Plastic Surgery department. His inability to fully move his shoulder was attributed to the blunt trauma and an arm sling was used for comfort. Two weeks after the accident, in the outpatient clinic, the patient presented with muscle atrophy and hypoesthesia in his right deltoid, and subtle scapular winging. A plexus lesion was suspected and an urgent MRI was performed. He was referred to physical therapy at the same time. The MRI showed hyperintensity in the C5 root, but no avulsions or lesions in the plexus. Electromyography showed axonal lesion of the axillary nerve but no root or plexus alterations. The patient had a positive clinical evolution, with full healing of his left foot and improved mobility of his shoulder, although he did not fully recover skin sensation over the deltoid. Motorbike accidents often result in high energy trauma and can be associated with plexus and nerve lesions. This case illustrates the need for a careful initial evaluation and second look for hidden lesions. The need for urgent surgery of his right foot obscured his shoulder complaints, but fortunately, it was detected after only two weeks and the patient had a positive clinical evolution. DOI: 10.1016/j.ocl.2013.06.011 DOI: 10.1007/s10143-018-1009-2 DOI: 10.5435/00124635-200109000-00006 DOI: 10.2106/JBJS.RVW.16.00061Disclosure: 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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