22nd European Congress of Trauma & Emergency Surgery

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Prof. Dr. med.

Dr. med.

A new parameter for early prediction of sepsis in polytrauma patients: The 24hr leukocyte-gap (24hr-LCG)

Polytrauma

Abstract text (incl. references and figure legends) Introduction: Prediction of septic complications after trauma remains challenging. Early post-traumatic episodes of both leukopenia and leucocytosis have been linked with sepsis in critically ill patients. The goal of the study was to develop and test a novel immune parameter to predict sepsis: the 24hr-leukocyte gap (24hr-LCG), defined as the difference between blood leukocyte numbers on admission and after 24 hours. Methods: Adults trauma patients were selected from a prospectively trauma registry. First, patients were grouped according to the absence or presence of septic complications. Thereafter, a multivariable regression analysis was utilized to identify specific predictive immune parameters for septic complications, septic shock and mortality. Results: A total of 1592 patient have been identified, of whom 251 developed sepsis. Patients diagnosed with sepsis were younger (p&lt;0.002) and had higher ISS scores/worse hemodynamics on admission (p&lt;0.001). The 24hr-LCG was identified as an independent immunological predictive parameter for sepsis by the multivariable analysis. Moreover, a 24hr-LCG ≥ 10, was associated with significantly increased rates of septic shock (12,4% vs. 4.3%, p&lt;0.001) and mortality 6.0 vs. 2.7%, p=0.036), compared with other patients. Conclusion: This study is the first to show that a novel parameter: the 24hr-leukocyte gap is an independent early predictor for sepsis in trauma patients. The 24hr-LCG is an easy parameter to determine with conventional laboratory measurements. This parameter may support future decision making and more specifically timing of surgery in trauma 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.

Oral presentation

Non‑operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: A multicenter prospective cohort study

Emergency surgery

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) INTRODUCTION Patients with multiple rib fractures without a clinical flail chest are increasingly being treated with rib fixation;however, high-quality evidence to support this development is lacking. MATERIAL &amp; METHODS We conducted a prospective multicenter observational study comparing rib fixation to non-operative treatment in all patients aged 18 years and older with computed tomography confirmed multiple rib fractures without a clinical flail chest. Three centers performed rib fixation as standard of care. For adequate comparison, the other three centers performed only non-operative treatment. As such clinical equipoise formed the basis for the comparison in this study. Patients were matched using propensity score matching. RESULTS In total 927 patients with multiple rib fractures were included. In the three hospitals that performed rib fixation, 80 (14%) out of 591 patients underwent rib fixation. From the nonoperative centers, on average 71 patients were adequately matched to 71 rib fixation patients after propensity score matching. Rib fixation was associated with an increase in hospital length of stay (HLOS) of 4.9 days (95%CI 0.8–9.1, p = 0.02) and a decrease in quality of life (QoL) measured by the EQ5D questionnaire at 1 year of 0.1 (95% CI − 0.2–0.0, p = 0.035) compared to non-operative treatment. A subgroup analysis of patients who received operative care within 72 h showed a similar decrease in QoL. Up to 22 patients (28%) who underwent surgery experienced implant-related irritation. CONCLUSIONS We found no benefits and only detrimental effects associated with rib fixation. Based on these results, we do not recommend rib fixation as the standard of care for patients with multiple rib fractures.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 work was financially supported by the DePuy Synthes (grant number DPS-TCMF-2017-036). The organization was not involved in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. All researchers are independent from the funder. All authors had full access to all of the data (includingstatistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Computed tomographic bone mineral density is independently associated with adverse in-hospital outcomes in Dutch level-1 trauma patients

Abstract text (incl. references and figure legends) Introduction: Aging, inactivity, and malnutrition are risk factors for adverse in-hospital outcomes and can manifest in bone loss. Use of bone mineral density (BMD) as an objective marker might improve early identification of patients at risk for complications. This study aimed to assess the association of computed tomography (CT) determined BMD values of the first lumbar vertebra with in-hospital complications and outcomes in trauma patients. Material &amp; Methods: All consecutive hospitalized trauma patients (≥16 years) that underwent CT-imaging within 7 days of admission in 2017 were included. Patients with an active infection or antibiotic treatment upon admission, severe neurologic trauma, or an unassessable vertebra were excluded. BMD at the first lumbar vertebra was determined with CT by placing a circular region of interest in homogeneous trabecular bone to obtain mean Hounsfield Units (HU). Regression analyses were performed to assess the association of BMD with in-hospital complications and outcomes. Results: In total, 410 patients were included (median age 49 years [interquartile range 30 – 64], 68.3% men, mean BMD 159±66 HU). A total of 94 complications, primarily infection-related, were registered in 74 patients. After adjustment for covariates, a decrease of BMD by one standard deviation was significantly associated with increased risk of complications (odds ratio [OR] 1.9, 95% confidence interval (CI) 1.1 – 3.1), pneumonia (OR 2.2, 95% CI 1.2 – 4.5), delirium (OR 4.5, 95% CI 1.7 – 13.5), and intensive care unit (ICU) admission (OR 1.8, 95% CI 1.1 – 2.9). Conclusions: Bone mineral density of the first lumbar vertebra is independently associated with in-hospital complications, pneumonia, delirium, and ICU admission. These findings could help identify patients at risk early.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 accuracy of pre-hospital clinical assessment of major traumatic haemorrhage

Visceral trauma

Abstract text (incl. references and figure legends) Introduction Traumatic haemorrhage is the largest cause of potentially preventable death after injury. Pre-hospital diagnosis of major haemorrhage (MH) can be difficult, even for expert clinicians. The aim was to determine the accuracy of pre-hospital MH diagnosis, and analyse factors associated with missed MH diagnosis and mortality. Material &amp; Methods Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019-2020, assessed by expert clinicians in a mature pre-hospital trauma system, and admitted to a Major Trauma Centre. Diagnostic performance to identify MH pre-hospital was compared to in-hospital diagnosis. Pre-hospital MH protocol activation was used as a surrogate for MH diagnosis. MH was defined using the critical admission threshold (CAT+): ≥3 units of red blood cells given within any 60min period in the first 24hr of injury. Multivariate logistical regression analyses were conducted, with different dependent variables: missed MH diagnosis and mortality. Results There were 947 patients included in the study. Median age was 31 years (IQR 23-47), 821 (87%) were male, 569 (60%) had blunt injury, median injury severity score was 10 (IQR 4-22), and 79 (8%) died. Pre-hospital clinicians correctly diagnosed MH in 97/138 CAT+ patients (sensitivity 70%; 95% CI 62-77%), and correctly ruled out MH in 764/809 CAT- patients (specificity 94%; 95% CI 93-96%, Tab 1). Factors associated with missed MH diagnosis were penetrating mechanism (OR 2.4; 95% CI 1.2-4.7) and major abdominal bleeding injury (OR 4.0; 95% CI 1.7-8.7, Tab 2). The odds of mortality increased by 3.3 (95% CI 1.1-9.7) when MH was missed. Conclusions Clinical assessment by expert clinicians had only moderate ability to identify MH in the pre-hospital setting. Understanding the limitations of clinical assessment, and developing solutions to aid identification of MH are warranted. Tab 1. Contingency table of MH vs CAT Tab 2. Multivariate logistic regression of missed MH 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.) JMW, RSS, EP, EK, WM, ZP, and NT have received research funding from the United States Department of Defense. RSS is also funded by the Royal College of Surgeons of Edinburgh and Orthopaedic Research UK. JMW has received funding from the Royal College of Surgeons of England. For the remaining authors none were declared.

The effect of age on resilience of health-related quality of life among polytrauma patients – A cross-sectional multicenter study

Abstract text (incl. references and figure legends) Introduction The aim of this study was to determine the impact of age on patient-reported health-related quality of life (HRQoL) and the capacity to show resilience – i.e. the ability to adapt to stressful adverse events – after sustaining a polytrauma. Methods A cross-sectional multicenter cohort was conducted between 2013 and 2016 that included surviving polytrauma patients (ISS ≥ 16). HRQoL was obtained by the Short Musculoskeletal Function assessment and EuroQol (SMFA and EQ-5D-5L). The effect of age on HRQoL was tested with linear regression analysis. Next, the individual scores were compared with age- and sex-matched normative data to determine whether they showed resilience. Multivariate binary logistic regression was used to assess the effect of age on reaching the normative threshold of the surveys, correcting for several confounders. Results A total of 363 patients responded (57%). Overall, patients had a mean EQ-5D-5L score of 0.73. With higher age, scores on the SMFA subscales "upper extremity dysfunction", "lower extremity dysfunction", and "daily activities" significantly dropped. Only 42% of patients were classified as being resilient, based on the EQ-5D-5L score. Patients aged 60-69 showed the highest resilience (56%), 22% of the patients aged 30-40 showed resilience, those aged 80+ showed the lowest resilience (0%). Conclusion Sustaining a polytrauma leads to a serious decline in HRQoL. Ageing is associated with a decline in the physical components of HRQoL. No clear relationship with age was seen on the non-physical components of quality of life. Octogenarians, and to a lesser extent septuagenarians and tricenarians, showed to be very vulnerable groups, with low rates of resilience after surviving a polytrauma. Figure 1: Standardized EQ-5D-5L utility score and SMFA subscales scores for different age decades. Figure 2: Resilience on subscales SMFA and EQ-5D-5L utility score for the different age decades. 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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