22nd European Congress of Trauma & Emergency Surgery

Prof.

Chairs

Delayed diagnosis of injuries in total-body CT scanning during the initial assessment after severe trauma

Polytrauma

Emergency surgery

Abstract text (incl. references and figure legends) Introduction: Despite the existence of the ATLS- and other diagnostic guidelines for the initial assessment of trauma patients, injuries can still be missed and/or diagnosed with delay. The aim of this study was to quantify delayed diagnosed injuries during the initial assessment of trauma patients using a total-body CT (TBCT)-scan in a Level 1 Trauma Center in the Netherlands. Methods: We conducted a retrospective cohort study of all trauma patients who were assessed in the trauma room of the Amsterdam University Medical Center (AUMC), location AMC, using a TBCT-scan between January 2017 and December 2020. A delayed diagnosed injury was defined as an injury sustained during the initial trauma and not discovered nor suspected upon admission to the Intensive Care Unit (ICU) or nursery ward following the initial assessment, diagnostic studies, or surgery. To identify variables associated with delayed diagnosis, the Wald test for a univariate logistic regression was performed. Results : In total, 697 trauma patients with a median age of 46 years (IQR 30-61) and a median Injury Severity Score (ISS) of 16 (IQR 9-25) were included. Delayed diagnosed injuries were found in 97 patients (13.9%). Forty-eight of the delayed diagnosed injuries (49.5%) were within the TBCT-scanned area. Ten delayed diagnosed injuries had an Abbreviated Injury Scale (AIS) score of ≥3. Most injuries were diagnosed before or during the tertiary survey (60.8%). The median time of delay was 34,5 (IQR 17.5 – 157.25) hours. Variables associated with delayed diagnosis were primary ICU admission (OR 1.986, p=0.003), an ISS ≥16 (OR 1.579, p = 0.042), and 40+ days of hospitalization (OR 8,500, p = 0.000). Conclusion: Delayed diagnosed injuries in patients after severe trauma are unavoidable despite the use of a TBCT-scan, especially in multi trauma patients. A close follow-up and a high suspicion of delayed diagnosed injuries within multi trauma patients assessed with a TBCT-scan remains mandatory.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

Does implementation of a standardized blunt thoracic trauma score (BTTS) lead to improved outcomes?

Visceral trauma

Abstract text (incl. references and figure legends) Introduction: Blunt thoracic injury continues to be a major source of morbidity and mortality. Managing the trauma sustained can be a clinical challenge requiring optimal triage of the patient. Prior studies have demonstrated that a standardized score can predict BTI complications. We implemented a novel standardized score incorporating age, number of rib fractures, negative inspiratory force, vital capacity, pain scale, strength of cough, presence of pulmonary contusions, base deficit and history of COPD or smoking to differentiate which patients could benefit from admission to the intensive care unit. Methods: Patients admitted to NYU Langone-Long Island (2018-2020) with BTI who were assigned a BTTS and compared to a random sample of patients from 2014-2017 (prior to implementation of BTTS). Those with BTTS greater than six were admitted to the ICU. Logistic and negative binomial regressions were used for multivariable analyses. Using ROC and AUC, the optimal cut-off was determined to predict the need for ICU admission. Results: From the pre-BTTS period, 39 patients were included in the study, and from the post-BTS period 225 patients identified. Median injury severity score (ISS) in both groups was nine. Pre-BTTS ICU, admission rate was 61.5% and post-BTS was 43.1%, p=.03. Median (IQR) ICU length of stay (LOS) for pre-BTTS was 3 (2-4), and post-BTTS was 2 (1-3) days, p=.01. Median (IQR) hospital LOS for pre-BTTS was 5 (4-7), and post-BTS was 3 (2-6) days, p&lt;.0001. BTTS&gt;6 was associated with higher hospital LOS (IRR 1.70, 95% CI =1.27-2.28) p&lt; .0001. Analysis using the ROC curve and AUC showed that a BTTS of 7 was the optimal cutoff (sensitivity .87, specificity .86) for determining the need for ICU admission. Conclusion: Use of a standardized BTTS is associated with improved ICU resource allocation and decreased ICU/hosp-LOS. Prospective analysis of the BTS will allow further refinement and optimal utility for triage of patients suffering blunt thoracic injuryDisclosure: 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. Dr.

PD Dr.

Risk factors for delayed mortality in polytraumatized patients

Abstract text (incl. references and figure legends) Introduction In polytraumatized patients, factors of trauma-induced mortality are time-dependent. While early deaths are predominantly associated with injury severity, late deaths are often triggered by complications.1 In this retrospective analysis we assessed risk factors for a delayed mortality and the influence of different clusters of complications. Materials &amp; Methods Inclusion criteria: primary admission to a level I trauma center, Injury Severity Score (ISS) &gt;16, age &gt;18 years. We compared immediate (death within the first 24h after admission), early (death within 24-72h after admission) and delayed mortality (death later than 72h after admission). Statistical analysis was performed via SPSS software (IBM), using Mann-Whitney-U-Test and binominal logistic regression analysis. Results A total of 382 patients (71.1% male, mean age 51.5 years, median ISS of 23) were included. A delayed death occurred in 31 patients (8%). Immediate and early death were significantly influenced by the ISS, but were not affected by the development of complications. Significant influence on a delayed mortality were observed by severe head injuries (AIS &gt; 2; OR 3.4; 95%-CI 1.154; 10.036; p=0.026), age (OR 1.04; 95%-CI 1.017; 1.063; p&lt;0.001) and the development of infectious complications (OR 2.665; 95%-CI 1.221; 5.814; p=0.014). Duration of mechanical ventilation (337h vs. 284h; p=0.039) and mean duration of ICU stay (15d vs. 13d; p=0.041) were significantly longer in patients with a delayed death. Conclusion Infectious complications are a main factor of delayed mortality. Special attention should be applied to older patients and those with severe head injuries. Further studies are needed to understand the underlaying effects of trauma- and ventilation associated infections to reduce rates of posttraumatic infections. References 1Pfeifer et al., PLoS One. 2016Disclosure: 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

Serum electrolyte levels in predicting outcomes of patients with traumatic brain injury: A retrospective study

Abstract text (incl. references and figure legends) Introduction Electrolyte derangements are a common sequel of traumatic brain injury (TBI) which may lead to the death of patients or prolong their hospital stay [1,2]. The study aims to determine the role of electrolyte imbalance in predicting the in-hospital mortality of patients with severe TBI. Material &amp; Methods A retrospective analysis of data on ICU-admitted TBI patients in the Hamad Trauma Center (HTC) between mid-2016 and mid-2021 was conducted. Serum levels of electrolytes (sodium, potassium, calcium, magnesium, phosphorus) were collected at the time of admission. Comparative analyses between in-hospital survivors and non-survivors were performed. Univariate and multivariate logistic regression analyses were performed to determine the predictive role of different variables on mortality. Results A total of 922 patients were included in the study. The mean age was 32 years; 94% were males. Road traffic injuries (59%) were the most frequent cause of TBI, followed by falls (25%). Subarachnoid hemorrhage (42%) and subdural hematoma (35%) were more common. The prevalence of electrolyte imbalances was hypocalcemia (82%) hypophosphatemia (67%), hypokalemia (35%), and hypomagnesemia (31%). In-hospital mortality was 22%. The multivariate logistic regression revealed that hypocalcemia was a significant predictor of mortality (Adjusted Odds Ratio:0.33, 95% CI: 0.12-0.93, p-value 0.04) along with high shock index, low GCS, high head AIS, hyperglycemia and prolonged activated partial thromboplastin time. Conclusion Hypocalcemia is significantly associated with increased trauma-induced coagulopathy and higher post-injury mortality. Calcium supplementation should be the first-tier treatment for high-risk injuries. References Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: a review. Epilepsia. 2003; 44(suppl 10):2-10. Fleminger S, Ponsford J. Long term outcome after traumatic brain injury. BMJ. 2005;331:1419-1420 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. Dr. med.

Dr. med.

PD Dr. Dr.

Motorcycle-related injuries: Relationship of age to injury type and severity – A retrospective analysis in a level I trauma center

Abstract text (incl. references and figure legends) Background: Motorcycling is a common means of transport and also a popular recreational activity. At the same time, motorbike accidents often result in serious injuries due to the high speeds possible. In recent years, even minors from the age of 16 years are allowed to ride specific motorcycles in Switzerland. This study examines the incidence and type of injuries, as well as the effect of age on these variables. Methods: Retrospective analysis of all motorcycle accidents admitted to our level I trauma center from 01/2016 to 12/2021. Injury severity and specific injuries sustained by the riders were analyzed according to age groups (&lt;18 years, 18-65 years, &gt;65 years). Results: During the study period, a total of 392 patients were included. There were 54 (13.78%) &lt;18 years, 312 (79.59%) 18-65 years and 26 (6.63%) &gt;65 years. The most frequently injured body regions were the extremities (81.6%), followed by the head (44.6%). The incidence of head injuries significantly increased in a stepwise fashion with increasing age, ranging from 38.9% in patients &lt;18 years to 69.2% in patients &gt;65 years (p=0.027). Severe chest trauma was observed in 30.6% of the patients, and likewise increased with age, ranging from 5.6% in the age stratum &lt;18 years to 38.5% in the age group &gt;65 years (p&lt;0.001). Conclusion: Motorcycle-related injuries are associated with a high incidence of extremity fractures and head injuries. Age plays an important role in severity and anatomic distribution of injuries sustained, with elderly patients having significantly more severe head and chest trauma compared to their younger counterparts. Further evaluation of specific preventive measures, especially for elderly motorcyclists is warranted. 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

One stage Masquelets technique – Evaluation of different forms of membrane filling with and without bone marrow mononuclear cells (bmc) in large femoral bone defects in rats

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) The classic two-stage Masquelet technique is a widely used and effective procedure for the treatment of large bone defects. Our group could show that the induced membrane can be replaced by a decellularized dermis (DD) (Epiflex, DIZG). Thus, one procedure can be avoided and the two-stage procedure can be turned into a one-stage procedure. Previously, syngeneic cancellous bone (SCB) was used to fill the membrane wrapped around a 5 mm femoral defect in the rat. Translated to clinical conditions, this means additional trauma in terms of cancellous bone harvesting by RIA or iliac crest harvesting. The focus of this work was to clarify whether the syngeneic cancellous bone can be replaced by granular (G) or fibrous (f) demineralized bone matrix (DBM) and whether additional colonization with bone marrow mononuclear cells (BMC) leads to improved bone healing. In 125 Sprague-Dawley rats (in 10 groups), a critical femoral bone defect 5 mm in length was stabilized with a plate and then encased in decellularised dermis. Filling with syngeneic cancellous bone served as a control group. Subsequently, the defect was filled with SCB, GDBM or f-DBM, with or without BMC. After a healing period of eight weeks, the femurs were harvested and subjected to histological, radiological, and biomechanical analysis. The results show equal bone formation and bone stability for the BMC-populated DD group compared to control. With one exception, the filling has no significant influence. The use of BMC colonized DD and BMC colonized f-DBM as filling shows a significantly higher bone density (p&lt;0.05). The results suggest that the use of BMC colonized membranes and BMC colonized filling material in the single stage masquelet technique can eliminate the need for SCB. This would result in significantly less surgical trauma.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.) This research was in part funded by the German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), 12555 Berlin, Germany. Institutional

A quality improvement approach to critical haemorrhage

Abstract text (incl. references and figure legends) Introduction Critical haemorrhage is a potentially preventable cause of in-hospital death after injury. While a systematic approach to initial assessment as per ATLS© protocol has reduced the prevalence of this outcome over the last 30 years, a baseline of 10-12% of in-hospital haemorrhage deaths had been reached in New Zealand (NZ). Taking the position that this was an avoidable event, a quality improvement approach was initiated to reduce haemorrhage deaths Methods Using a collaborative quality improvement methodology to engage stakeholders, a Code Crimson notification system was developed and refined. This ensured relevant staff were notified as soon as practicable and were available in the Emergency Department to make decisions about the patient disposition when a patient with severe shock was arriving. Simultaneously, the massive haemorrhage protocol was modified to ensure maximum haemostatic content and appropriate fluid volumes. Both changes were introduced into all 20 trauma hospitals in NZ. The protocol was adapted for small, medium and large hospitals. Results Compared to the previous 4 years, in 2022 in-hospital haemorrhage related death dropped from 11.4% to 5.6%. Using a risk adjusted methodology there was no difference in the risk of haemorrhage deaths between these time periods. In addition, the overall number of trauma deaths in NZ was reducing at the same time Conclusions In-hospital haemorrhage death is largely preventable. Use of a contemporary massive haemorrhage protocol and a system which ensures decision-makers are immediately available to correctly implement haemostatic interventions can significantly reduce in-hospital haemorrhage death.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

Investigation of screw osseointegration enhancement by extracellular vesicles (EV) and bone morphogenetic protein 2 (BMP-2) in a rat animal model – A novel study design

Abstract text (incl. references and figure legends) Particularly in osteoporotic bone, loosening of osteosynthesis material is a well-known problem. This leads to secondary fracture dislocation and non-healing. The aim of this study is to improve the stability of screws inserted into bone by adding Extracellular Vesicles (EVs) or Bone-Morphogenetic-Protein-2 (BMP-2) with alginate (Alg) as a carrier material. Operations were performed on 30 rats. These were divided into 3 groups of equal size: Alg only, Alg EV, and Alg BMP-2. To analyze the osseointegration, a novel surgical procedure and biomechanical protocol were established. A diaphyseal fracture was created with a Gigli saw (0.66mm) and angular stable 5-hole plate osteosynthesis was used with four 1.5mm screws. The 4.0mm long proximal and distal screws were inserted monocortically in a 2.0mm hole that was too wide, so the screw had no contact area with the bone (Fig. 1). The hole was filled with the substances mentioned above. The 2 screws next to the osteotomy were placed bicortically to stabilize the fracture. After the endpoint (6 weeks postoperative), µ-CT, and a biomechanics pull-out test and a stiffness analysis were performed. µ-CT scan shows significantly more Bone Volume/Tissue Volume in the BMP-2 group compared to the EV one (*p= 0.0203) (Fig. 2). The screw-bone contact area was significantly increased in the BMP-2 group compared to the EV group (**p= 0.0063), the contact area was significantly increased in the Alg only group compared to the Alg EV group (*p= 0.0438), too. The biomechanical pull-out test showed a significant increase of the maximal force of the BMP-2 group compared to the EV one (*p= 0.0240). The stiffness of the BMP-2 group was significantly higher compared to the Alg EV group (*p= 0.0414) and the Alg only group (*p= 0.0363). The results indicate that the use of BMP-2 can improve the osseointegration of osteosynthesis materials. The use of EVs seems to have a rather negative effect on osseointegration in this animal model.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

Trauma-related preventable death: Data analysis and panel review in a level 1 trauma center in Amsterdam, the Netherlands

Education

Abstract text (incl. references and figure legends) Introduction Trauma-related death is used as a parameter to evaluate the quality of trauma care. In addition, trauma-related preventable death (TRPD) is used to identify cases in which mortality could have been prevented under optimal trauma care conditions. The aim of this study was to analyse TRPD within our region by an expert panel. Methods The trauma-related deaths between January 2020 and January 2022 in the Amsterdam University Medical Centre, location AMC were collected. The fatal polytrauma patients were included for TRDP analysis by an external panel. The panel contained a trauma surgeon, anesthesiologist, emergency physician, neurosurgeon and forensic pathologist. Panel members were given digital case descriptions and were asked to independently classify deaths as non-preventable, potentially preventable and preventable. Agreements between the five observers were assessed by Fleiss kappa statistics. Results A total of 95 trauma-related deaths were identified, 36 were due to polytrauma. Of these polytrauma patients 75% was male, mean age 55 ± 25, mean ISS 35 ± 15 and was due to a fall (50%) or traffic accident (33%). The panel considered 30 cases as non-preventable and six cases as potentially preventable. Interobserver agreement was moderate for survivability (Fleiss kappa 0.44) but low for the categorical preventable death classification (Fleiss kappa 0.17). The majority of the disagreements was due to differences between non-preventable and potentially preventable with care that could have been improved. The panel judged 25 errors to have occurred in the TRNPD and five in the TRPPD group. Errors included system-, assessment-, treatment errors and errors in timely care. Conclusion Analysis of trauma-related survivability suffered from moderate interobserver agreement. Unfortunately, the use of a TRPD classification regards a large interobserver agreement. In order to improve the assessment of TRPD a definition of TRPD should be established and evaluated.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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