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(RSS) Trauma Research Blog

Selected new & juicy research papers, with editorial comment.

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Trauma Research Blog

Selected new & juicy research papers, with editorial comment.

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PubMed ID: 7935634
N Engl J Med. 1994 Oct 27;331(17):1105-9
Authors: Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL

Abstract:

BACKGROUND. Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. METHODS. We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure of < or = 90 mm Hg. The study setting was a city with a single centralized system of pre-hospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. RESULTS. Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group. CONCLUSIONS. For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.

Notes & Commentary:

Spent a surprisingly enjoyable journal club discussing this paper today.  It was in the running for most important trauma paper of all time at one point.  It's certainly perhaps the trauma paper that has generated the most controversy.  The study's been criticised on many fronts but it's often overlooked how extraordinarily difficult it is to conduct a study like this.  It marked the beginning of a sea-change in the way patients were resuscitated. The whole paper needs to be read and digested to fully appreciate the implications of the results. 

PubMed ID: 19479650
Ultrastruct Pathol. 2009;33(3):102-11
Authors: Castejon OJ

Abstract:

In a vascular anomaly showing moderate edema, the extracellular space appeared apparently normal, exhibiting a membrane to membrane space of about 20 nm in width. In congenital hydrocephalus, this space appeared notably enlarged and occupied by an electron transparent, nonproteinaceous interstitial edema fluid, due to abnormal accumulation of cerebrospinal fluid. In brain trauma, the distended extracellular space contained either electron-lucid nonproteinaceous or electron-dense proteinaceous edema fluid. Hemorrhagic foci, fibrinoid material, and non-nervous invading cells, such as macrophages and monocytes, were also found. In brain tumors, the widened extracellular space showed electron-dense proteinaceous edema fluid and bundles of fibrinoid material. The enlarged extracellular space found in congenital hydrocephalus, vascular anomalies, brain trauma, and tumors is closely related to the clinical symptoms exhibited by the patients under study.

Notes & Commentary:

How simplistic our clinical view of traumatic brain injury is.  We think only of intracranial pressure, perfusion pressure, and cerebral oxygen delivery & utilization.  We understand cerebral oedema only as a hydrostatic effect to be treated with osmotic therapy.  This study shows that cerebral oedema in traumatic brain injury is far from a simple fluid shift but is instead a complex phenomenon, probably containing a complex of proinflammatory and coagulant mediators of the innate immune system.  We need to rapidly develop a more complex approach to our clinical understanding of these injuries if we are to make any progress in their management - progress which has been relatively disappointing over the past few decades.

PubMed ID: 19204518
J Trauma. 2009 Feb;66(2):429-35
Authors: Fang JF, Shih LY, Wong YC, Lin BC, Hsu YP

Abstract:

BACKGROUND: Most arterial hemorrhage associated with pelvic fracture can be adequately controlled by a single transcatheter arterial embolization (TAE). However, there is a small group of patients who remain hemodynamically unstable after TAE, have no other identifiable source of bleeding, and who benefit from repeat TAE of the pelvis. METHODS: We conducted a retrospective study of patients with hemorrhage from pelvic fractures between January 2001 and June 2006. Clinical parameters and results were compared between patients requiring more than one pelvic TAE and those undergoing a single TAE. Risk factors for repeat TAE were identified by univariate and stepwise logistic regression analyses. RESULTS: During the study period, 174 of 964 patients with pelvic fracture received pelvic angiography for suspected arterial hemorrhage. One hundred forty TAEs were performed. Thirty-four (24.3%) patients underwent more than one angiography for suspected recurrent arterial hemorrhage, and 26 (18.6%) underwent repeat TAE. Repeat angiography was performed 3 to 58 hours (mean, 21 hours) after initial TAE. Patients with repeat TAE had significantly more blood transfusions, higher mortality rate, and longer intensive care unit stay. Independent predictors for repeat TAE included initial hemoglobin level lower than 7.5 g/dL (OR, 6.22), superselective arterial embolization in initial TAE (OR, 3.22), and more than 6 units of blood transfusion after initial TAE (OR, 3.22). CONCLUSION: Careful monitoring and prompt recognition of patients requiring repeat TAE is paramount. The arterial access sheath should remain in place for up to 72 hours after angiography. Initial hemoglobin level lower than 7.5 g/dL and more than 6 units of blood transfusion after initial angiography are predictors for repeat TAE. Superselective TAE is associated with a significantly higher risk of recurrent hemorrhage, and its use should be limited.

Notes & Commentary:

This paper and several others have discussed the incidence of subsequent haemorrhage following embolisation for pelvic haemorrhage.  While there is certainly the potential for rebleeding, certainly our rates are much lower than this (in fact I don't remember one in the last few years).  One possible explanation for this discrepancy is that we have had to re-learn how to read an angiogram for arterial distruption in the presence of haemorrhagic shock.  A contrast blush is rarely seen in these patients - blood pressure is low with permissive hypotension regimens and they are maximally vasoconstricted.  If vessels are not embolized because no blush is seen, when blood pressure is restored active haemorrhage will again ensue.  CT seems a lot better at picking up this contrast extravasation that angio - probably because of the delayed phase of the CT scan.  However of course CT is often bypassed in the exsanguinating patient.

Here's a patient with a left vertical shear fracture of the pelvis.  This is the initial left common iliac angiogram.  There's no blush or otherwise abnormal appearance.

supglutealangio3

However it's only when you look closely at the image that you can see that there is disruption in the superior gluteal artery territory.  On this close-up you can see severe 'pruning' of the vessels rather than the usual branching tree pattern.

supglutealangio3

Similarly if a patient is very haemodynamically unstable and has a unstable pelvic fracture, with no other obvious source for haemorrhage (abdomen, chest etc), we will gelfoam embolise both divisions of the internal iliac artery on that side (or sometimes bilaterally), even if no blush is seen.  We call this Damage Control Angioembolization, maybe others do too.

PubMed ID: 6623052
Sci Am. 1983 Aug;249(2):28-35.
Authors: Trunkey DD

Abstract:

Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research.

Notes & Commentary:

Is this the most important trauma paper ever written?  This is Donald Trunkey's review of trauma epidemiology in the United States, publushed in Scientific American in 1983.  The core of the article relates in part to his paper with Baker published in 1980 describing the trimodal distribution of trauma deaths [PMID:7396078].

Why have I chosen it as the most important of all trauma papers?  This was the paper the first described trauma as a disease.  It brought together centuries of knowledge about wounds and their management into a paper that demonstrated that, if considered together, all these injuries can be described as a single disease entity, with its own epidemiology, pathophysiology, management and prognosis.  Once trauma was recognised as a disease, it would join cardiovascular disease and infectious diseases as some of the world's biggest killers.  Importantly - this is Scientific American - a popular science magazine with a huge audience.  This is the article that brought trauma to the masses.

So its my vote for all-time most important trauma paper, and a fitting start to our new research blog.  A global trauma journal club if you like.  What's your most important trauma paper of all time? Leave a comment below. 

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