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24th European Congress of Trauma & Emergency Surgery 

Prof. Dr.

Prof. Dr. med.

Prof.

Near-Patient Rapid neutrophil analysis in the Emergency Department to predict Infectious Complications after Trauma: A proof of concept for the PREDICT trial

Polytrauma

Research

Introduction Severe trauma triggers an inflammatory response, where activated neutrophils activation influencing the risk of infectious complications. Early assessment of neutrophil phenotypes may offer predictive insights, supporting immune protective management. This proof-of-concept study examines the feasibility of using near-patient flow cytometry to analyze neutrophil phenotypes as part of standard care in trauma patients, aiming to predict immune-related complications.Methods This single-center study was conducted at a level 1 trauma center, where automated flow cytometry was integrated into standard care for trauma patients with an Injury Severity Score (ISS) > 16. Neutrophil phenotypes were characterized into 7 categories (de Fraiture et al., 2023) ranging from no inflammation (0) to severe inflammation (5-6). Data collection followed standardized PREDICT protocols.Results Informed consent was obtained from forty-five patients for the use of their data for research. The median age was 55; 64% of the patients were male, with a median ISS of 21. Infectious complications occurred in 27% of the patients. Among patients in category 0, none developed infections, while 63% of those in categories 5-6 developed infections. No patients in this cohort developed sepsis.Conclusion This proof of concept demonstrates the successful implementation of automated near-patient flow cytometry as the first and only method for real-time neutrophil phenotype analysis in trauma care. These results validate our approach, setting the stage for implementation in other hospitals as outlined in proposed international collaboration.No

Quick shot presentation

Dr. med.

Neutrophil cell surface receptor dynamics following trauma: A systematic review

PurposeNeutrophils are essential effector cells in the immune response to traumatic injury. Although changes in receptor expression over time have been described in the literature, effective monitoring strategies are still lacking. This systematic review aims to analyses existing clinical research on neutrophil receptor expression changes after trauma, with the aim of characterizing the post-traumatic neutrophil profile. Materials & MethodsA systematic literature search on MEDLINE and Embase was performed which focused on clinical studies from 1995 to 2023 that report neutrophil receptor expressions after injury. Characteristics of the studies, patients, trauma and receptor alterations were extracted and analyzed. Results A total of 1,266 publications were identified and screened for eligibility. Finally, 34 articles reporting clinical studies with and neutrophil receptor expression analysis, were included. The most commonly analyzed parameter was integrin Mac-1/CD11b (25 studies), followed by L-selectin/CD62L (9 studies). Fifteen studies investigated post-traumatic changes in the Fcγ-receptor family. CD11b increases after moderate to severe trauma, peaking at 24 hours, then decreases, with prolonged elevation in severe cases up to 6 weeks, returning to homeostatic levels by 6 months. L-selectin shows early fluctuations, whereas CD16/CD32 decreases homogeneously after trauma. In contrast, CD64 increases consistently in all studies immediately after trauma. Conclusions The following systemic literature review on neutrophil receptor expression alterations after trauma resulted in the identification of a unique multi-parameter neutrophil receptor expression pattern. This may form the basis for future neuromonitoring after trauma. Validation of these findings from mainly monocenter studies in a prospective multicenter study should be the next step.no

Alcohol attenuates the biological effects of Neutrophil-derived extracellular vesicles on hepatic inflammation

Background:The early immune response in severely injured patients is driven by the innate immune system. Polymorphonuclear Leukocytes(PMNL) are among the first cells to infiltrate affected tissue and release mediators, such as extracellular vesicles(EVs). PMNL-EVs, cell-derived particles with immune-modulatory cargo, obtain the potential to influence remote organs. Given its role as key-regulator of inflammation, effects on the liver could affect the systemic posttraumatic inflammation. Thus, the EV-based crosstalk between differently primed PMNL and hepatocytes was analyzed. Methodes:PMNL of healthy volunteers were isolated and stimulated using FMLP+PMA with/without Ethanol for 1h. EVs were isolated via size-exclusion chromatography. Particle size and concentration were measured. Purity was confirmed using multiplex assay(MACSPlex). EVs were used to stimulate hepatocytes(HepG2).After 24h, viability and expression of surface markers were assessed via flow-cytometry. Further, the activation of Caspase-1 was analyzed.Results:PMNL-purity was >90% after isolation. MACSPlex confirmed the exclusive expression of granulocyte markers on PMNL-EVs. Median EV-size was increased from 117nm to 132.5nm after co-stimulation with ethanol. Stimulation with PMNL-EVs, lead in HepG2 cells to a significantly reduced viability and attenuated expression of CD54, CD95, GLUT-1, and to an increased caspase-1 activity. The addition of ethanol to PMNL-stimulation inhibited the effect of PMNL-EVs on hepatic CD54 expression and decreased caspase-1 activity. Conclusion: This study shows that PMNL-EVs affect the hepatic inflammatory response. These effects are significantly influenced by ethanol. Thereby, we underline the high potential of PMNL-EVs to guide the systemic posttraumatic inflammation in a stimulus-dependent pattern.This study was conducted in the framework of the NTF consortium FOR5417, funded by the DFG (DFG, German Research Foundation) project number 465409392 and DFG RE 3304/12-1No.

Univ. Prof. Dr. med.

PD Dr.

Prof. Dr. rer. nat.

New biomarker candidates for traumatic brain injury in polytrauma. Extracellular vesicles and their content

Introduction: Severe traumatic brain injury (TBI) in polytrauma (PT) is of high medical and socioeconomic relevance due to its morbidity and mortality. Its complex pathophysiology poses significant challenges for diagnosis and treatment, and current biomarkers often lack accuracy. Extracellular vesicles (EVs) are a heterogeneous group involved in intercellular communication. Studies show that EVs alter their miRNA and protein cargo after injury. EVs can cross the blood-brain barrier, playing roles in neuroglial communication, neuroinflammation, and the spread of pathogenic proteins.We hypothesized that the type of injured tissue is reflected in cell-specific surface epitopes of EVs, allowing identification of their origin. We also propose that the miRNA composition of EVs from TBI and polytrauma patients differs from that of healthy individuals, enabling identification of TBI-specific EVs and their potential as biomarkers.Methods: The study included patients with isolated TBI (AISHead≥4) and PT without TBI (ISS≥16, AISHead=0). EVs were isolated from plasma at admission to emergency room and 48 hours later (n=10 per cohort). Healthy volunteers (n=10) served as reference group. We enriched neuro-specific EVs (nEVs) using magnetic beads with L1-CAM and determined miRNA content in plasma, EVs, and nEVs via real-time PCR. EV surface epitopes were quantified using the MACSPlex EV Kit. Differentially expressed epitopes were validated by Western blot and correlated with clinical parameters.Results: Of the analyzed epitopes, 10 previously undescribed markers (e.g., CD49, C13) differed between groups, five of which were TBI-specific. These epitopes, including MBP, correlated with clinical parameters (e.g., Glasgow Coma Scale), potentially serving as indicators of brain damage. We also found miRNA expression patterns in plasma, EVs, and n EVs that varied with injury type (e.g., miR-21-5p, miR-338-3p). EVs and their content are promising biomarkers for severe TBI and PT.Funding This work was conducted in the framework of the NTF consortium FOR5417 funded by the German Research Foundation (DFG), project number 465409392.Competing interests The authors report no competing interests.

The early immune response to volume therapy in a human ex vivo polytrauma whole blood model

Trauma-induced coagulopathy is a serious complication of hemorrhagic shock and is associated with increased mortality within the first 6 hours post injury. Signs of coagulopathy can already be seen at the scene or hospital admission, thus, underlining that pre-hospital care might to be of particular importance. Since studies on the use of various blood products in pre-hospital car have shown contradictory results, we aimed to investigate the influence of different volume substitutes on the first line response of the intravascular immune system. In a polytraumatic ex vivo whole blood model, blood from healthy volunteers was exposed to a trauma-characteristic shock scenario including the addition of danger-associated molecular patterns, blood acidification and volume resuscitation. Resuscitation strategies were fulfilled by using either sodium chloride, component therapy or leukocyte-reduced fresh whole blood. Samples were either analyzed immediately after preparation or after 60 min incubation at 37 °C for clinically relevant blood parameters and the status of both cellular innate leukocyte and humoral cascade activation.RESULTSThis human whole blood model provides an adequate tool to study the effect of different volume substitutes in the context of polytrauma and hemorrhagic shock. In this setting, the use of blood products proved to be superior to crystalloids and resulted in less disturbance of the hemostatic system as well as the innate immune system. no

Adjacent long bone fractures associated with different trauma severity affect the expression of microRNA of the infrapatellar fat pad in a porcine polytrauma model

Introduction Long bone fractures are common in severely injured patients and can be associated with future osteoarthritis and immobility. Previous studies have shown that the infrapatellar fat pad (IPFP) can signal early pro-arthritic changes in the affected joint. Recent porcine models have indicated that both local and systemic inflammatory responses are influenced by the severity of trauma. MicroRNAs (miRNAs) are significant mediators for such responses. This study aimed to investigate the effect of an adjacent femur fracture and trauma severity on miRNA expression in the IPFP.Material & Methods German Landrace pigs were randomised into three study groups: sham (n=4), minor-multiple trauma (MiMT, n=4, blunt chest trauma, unilateral femoral fracture) and major-multiple trauma (MaMT, n=4; blunt chest trauma, unilateral femoral fracture, haemorrhagic shock). 90 minutes after trauma induction, pigs were stabilised by medication and surgical treatment (Fixateur externe). Pigs were sacrificed after 72 hours of observation in an intensive care unit. IPFP was extracted from fractured and non-fractured legs, miRNAs were isolated, qPCR array analysis followed by in silico mRNA target prediction was performed.Results The fractured leg of the MiMT group showed increased anti-inflammatory miRNAs (e.g., miR-16, miR-23b) and decreased pro-inflammatory miRNAs (e.g., miR-21, miR-223). In contrast, the fractured leg of the MaMT group exhibited higher expression of cells essential for bone tissue development and regeneration. Sequence analyses identified target structures related to immune responses and tissue regeneration.Conclusions This study indicates a correlation between miRNA expression in the IPFP and adjacent femoral fractures, as well as trauma severity. The different miRNA expression patterns suggest that the IPFP plays a crucial role in maintaining joint homeostasis after trauma. Further research is needed to investigate such associations.No disclosures

Multi-omic discrepancies between conventional and viscoelastic coagulopathy after trauma

Introduction: Trauma-induced coagulopathy (TIC) is a well-described phenomenon contributing to much of the morbidity and mortality following trauma. TIC is defined either via abnormal conventional assays (CCT) or viscoelastic assays (VE). While VE are the gold-standard for diagnosing TIC and guide blood-product resuscitation, abnormal CCT are associated with worse clinical outcomes. We hypothesized that patients with different coagulation phenotypes have distinct multi-omic signatures which are also associated with differences in clinical outcomes.Methods: Plasma samples were collected from trauma patients meeting the highest level of trauma activation upon arrival to the emergency department. Patients were cohorted into four groups (normal, abnormal CCT, abnormal VE, or both). Abnormal CCT defined as INR > 1.5 or aPTT > 35 sec; abnormal VE defined by ACT > 128, angle < 65, or MA < 55. Clinical data was collected and multi-omic analyses were performed via mass spectrometry.Results: Out of 100 patients, 69 were normal, 5 had abnormal CCT, 11 had abnormal VE, and 15 had both. There were no differences in age, BMI, gender, or injury type between groups. Abnormal CCT and both had decreased GCS and increased nISS, lactate, and base deficit compared to normal and abnormal VE. Abnormal CCT and both had increased transfusion of all blood products, ventilator days, and mortality. Metabolomic signatures differed in glycolysis and TCA intermediates, purine degradation products, polyamines, carnitines, and fatty acids. Proteomic signatures differed in coagulation proteins, complement factors, inflammatory mediators, hemolytic and energy metabolic proteins.Conclusion: Conventional coagulopathy is a biochemically distinct phenotype associated with increased hemolysis, inflammation, and energetic requirements. Future work will advance the idea of "personalized resuscitation" beyond correcting coagulopathy to modifying metabolic pathways to improve patient outcomes.No

PD. Dr.

Admission glucose levels as an independent predictor of coagulopathy in multiple trauma patients

Trauma and Emergency surgery | Miscellaneous

Background: Coagulopathy is a prevalent and severe complication in patients with multiple trauma, contributing significantly to morbidity and mortality. Hyperglycemia upon admission has been linked to hemorrhagic shock and mortality in trauma patients. This study aimed to evaluate whether admission glucose levels serve as an independent prognostic factor for coagulopathy in polytrauma patients.Methods: A retrospective cohort study was conducted involving 913 patients admitted to a level I trauma center between 2005 and 2020. Coagulopathy was defined as an international normalized ratio (INR) > 1.4 and/or activated partial thromboplastin time (aPTT) > 40 s. The relationship between admission glucose levels and coagulopathy was assessed using bivariate analysis and multivariate logistic regression.Results: Coagulopathy was present in 188 patients (20.6%) and was associated with higher mortality (26.1% vs. 4.6%, p < 0.001). Coagulopathy patients had significantly higher admission glucose levels (10.09 mmol/L vs. 7.97 mmol/L, p < 0.001). ROC analysis showed an AUC of 0.64 (95% CI 0.59–0.69), with a cut-off point of 12.35 mmol/L for predicting coagulopathy. Multivariate analysis revealed that glucose ≥ 12.35 mmol/L increased the odds of coagulopathy by 1.99 (95% CI 1.07–3.60, p = 0.039).Conclusion: Elevated glucose levels upon admission independently predict the risk of coagulopathy in multiply injured patients. Early glucose monitoring could assist in identifying high-risk patients, facilitating timely interventions and improving outcomes, particularly in resource-limited settings.References:Winkelmann M, et al. SICOT J. 2019;5:17.Kreutziger J, et al. Intensive Care Med. 2009;35(7):1234–9.Kreutziger J, et al. Injury. 2015;46(1):15–20.Johansson PI, et al. Scand J Trauma Resusc Emerg Med. 2012;20:47.Alexiou GA, et al. Brain Inj. 2014;28(4):438–41.Fig 1: Multivariate binary logistic regressionFig 2: ROC Curve - Associations between clinical and laboratory valuesThe authors declare that they have no conflicts of interest or financial ties to disclose. This study was conducted independently and was not funded by any external sources. All procedures performed were in accordance with ethical standards, and approval was obtained from the ethics committee of Hannover Medical School.

Identifying risk factors for early fibrinogen replacement in bleeding trauma patients: A single-center, retrospective cohort study

Introduction:Trauma remains one of the major causes of death and hemorrhage is a leading preventable cause of mortality for injured patients. In the bleeding injured patient, fibrinogen levels drop early to low levels. Fibrinogen replacement in response to low levels and early administration of fibrinogen supplements may improve survival.The primary objective was to explore the impact of early transfusion requirements, clinical parameters, and biochemical markers on the need for fibrinogen supplementation for injured patients.Methods:This is a retrospective cohort study of trauma patients presenting to single center between 2016 to 2021 and aged >18 years. We excluded patients who died before blood work was drawn. The primary outcome was the need for fibrinogen supplementation which was defined as an initial fibrinogen level below 1.5g/L. A multivariable logistic regression model explored the relationship between base excess, injury type, blood products received, time from injury, blood pressure; and an initial fibrinogen level of <1.5g/L.Results:A total of 4936 patients met inclusion criteria, of which 155 (3%) patients had initial fibrinogen level of <1.5g/L. The median age was 43 years and 73% were male.The adjusted odds of having hypofibrinogenemia increased for every unit of blood component transfused (OR=1.16, 95%CI=[1.09, 1.24]), when systolic blood pressure was less than 90 (OR=2.52, 95%CI=[1.04, 5.84]), and with each hour following injury (OR=1.03, 95%CI=[0.99, 1.07]). The odds of having hypofibrinogenemia decreased with increasing base excess (OR=0.84, 95%CI=[0.81, 0.87]) and with penetrating injuries (OR=0.43, 95%CI=[0.21 to 0.83]).Conclusion:Initial hypofibrinogenemia was associated with increased blood transfusion requirements, low base excess, and delayed presentation after the injury. A better understanding of which patients are hypofibrinogenemic may assist in earlier recognition and treatment.No

Metabolomics after polytrauma – A biobank analysis of 97 patients over the time course of 10 days

IntroductionSevere injury is known to have systemic effects at multiple levels, with the inflammatory response being a major focus of research in recent years. However, little is known about the perturbation of metabolic pathways after polytrauma. Therefore, we performed a metabolomic analysis of patients from our in-hospital polytrauma biobank, which contains up to ten days of samples from each patient.Material & MethodsPatients from the in-house polytrauma biobank with signed ethical consent were utilized. Sample time points were baseline (hospital admission), 8h, 24h, 48h, 5d and 10 days post trauma. Untargeted mass spectrometry was performed, while metabolites reliably identified using the KEGG/HMDB database were subset-analyzed in a semitargeted approach. Metabolic changes were identified using MetaboAnalyst 6.0 to detect pathways that were particularly affected and presented using enrichment ratios.Results97 severely injured patients (79.4% male / 20.6% female) were included in the study. The median ISS of this cohort was 29 (IQR=19). 46 metabolites were reliably identified. The immediate response (0-8h) shows increased activation of hemostasis and inflammation along with excessive corticosteroid production. In the 8-24h period, there is an excessive catabolic state with energy mobilization from fatty and amino acids. At 24-48 hours, detoxification, immune regulation and metabolic adjustments are primarily active. In the 5-10 day period, energy requirements are still elevated but reduced compared to the previous time points.ConclusionsSevere trauma causes a major disruption in the metabolism. Immediately after trauma, the body activates life-saving pathways and begins to mobilize excessive energy resources by breaking down fats and amino acids for ATP production. Initial treatment and intensive care should take this excessive energy demand into account and assess the extent to which organ-protective treatment (e.g. liver) may be beneficial to the patient.No

Injuries in thorax and abdomen cause excessive post-traumatic inflammatory responses

Visceral trauma

Introduction Traumatic injury induces an inflammatory response induced by the release of damage-associated molecular patterns (DAMPs) from damaged tissue. An excessive response can lead to acquired immunodeficiency, elevating infection risk. It is hypothesized that soft tissue injuries release more DAMPs, provoking a stronger inflammatory response than injuries to other regions, such as the head and extremities. The aim was to investigate inflammatory responses across various injured body regions.Method A retrospective analysis of a clinical registry was conducted in adult patients presenting at the trauma bay of a level 1 trauma center between March 2021 and November 2022, who routinely underwent analysis of the inflammatory response. Injury per body region was scored when Abbreviated Injury Severity (AIS) scores were ≥3. The primary outcome was the detection of neutrophil phenotypes consisting of 7 categories (de Fraiture 2023) ranging from zero to mild inflammation (0-2) to severe inflammation (5-6).Results In total, 549 patients were included. Patients with abdominal or thoracic injuries had a higher rate of severe inflammatory responses compared to those with injuries in other AIS regions (38%vs.14% and 13%vs.6%, respectively, both p<0.01). In contrast, patients with head or facial injuries showed a higher percentage of mild inflammatory responses compared to other regions (89%vs.83% p=0.05, and 92%vs.83% p=0.03, respectively).Conclusion Soft tissue injuries, i.e. abdominal and thoracic trauma, cause a more extensive post-traumatic inflammatory response than injuries to other regions, which is possibly due to a higher release of DAMPs. In contrast, head and face injuries are linked to lower inflammatory responses, which may be caused by lesser tissue damage. Understanding the differences in inflammatory response could aid in tailoring treatment approaches and managing infection risks in trauma patients more effectively.No

Dr. med. vet.

Dr. rer. nat.

Cytological effects of serum isolated from polytraumatized patients on human bone marrow-derived mesenchymal stem cells

Skeletal trauma and sports medicine

Introduction and ObjectiveHuman bone marrow derived mesenchymal stem cells (hBMSCs) have the potential to be useful in the treatment of patients suffering from polytrauma due to their immunomodulatory and regenerative capacity. Therefore, this study aimed to investigate which changes in the hBMSCs properties resulted from incubation with serum from polytraumatized patients, and to find out which time point could be successful for the treatment with hBMSCs.Materials and MethodsSera from 84 patients with polytrauma with an Injury Severity Score ≥ 16 and four healthy hBMSCs donors were used. Sera from the 1st (D1), the 5th (D5) and the 10th day (D10) after trauma as well as from healthy donors were pooled and added to cultured hBMSCs to perform the following methods: cell proliferation, colony forming unit fibroblast assay (CFU-F), cell viability and toxicity, cell migration, wound repair ability, osteogenic, and chondrogenic differentiation. LSD and Kruskal-Wallis test were used for statistical analysis.ResultsD5 serum from polytraumatized patients significantly reduced hBMSCs cell proliferation capacity (132,071.67 ± 25,770.13 cells; p < 0.05) compared to HS (224,842.50 ± 56,999.37 cells). This led to a significantly increased proportion of dead cells (6.56 ± 2.71%; p < 0.05) compared to D1 (3.37 ± 1.27%) and D10 (4.31 ± 3.17%) after 72 hours of cultivation. The CFU-F frequency of D5 (8.30 ± 5.95%; p < 0.05) and D10 (7.50 ± 5.22%; p < 0.05) were significantly reduced when compared to HS (16.30 ± 4.10%). The other analyzed parameters of D1, D5 and D10, however, were not significantly affected, namely cell migration, wound repair ability, osteogenic, and chondrogenic differentiation.ConclusionsThe serological effect of polytrauma on hBMSC was related to the time after trauma. The results suggested that it is disadvantageous to use hBMSCs in polytraumatized patients five days after the incidence.No

Quick shot session 3
Polytrauma I

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Quick shot session 3Polytrauma I

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Quick shot session 3
Polytrauma I