Should we change our approach to resuscitating victims of femoral fracture?A clinical experience in a busy trauma hospital in Shiraz,Iran

Purpose Traumatic hemorrhagic shock is a life-threatening event worldwide.Severe brain trauma accompanying femoral fractures can trigger inflammatory responses in the body and increase pre-inflammatory cytokines such as TNF-α,IL-1.The primary treatment in these cases is hydration with crystalloids,which has both benefits and complications.The purpose of this study was to investigate the effects of fluid therapy on the hemodynamics,coagulation profiles,and blood gases in such patients.Methods In this cross-sectional study,patients were divided into two groups:femoral fracture group and non-femoral group.The hemodynamic status,coagulation profile,and blood gases of patients in both groups were evaluated upon arrival at the hospital and again 2 h later.Data were analyzed by t-test and ANOVA with repeated data and paired samples t-test.Results A total of 681 trauma patients(605 men and 76 women)participated in this study,including 69(86.3%)men and 11(13.8%)women in femoral fracture group and 536 men(89.2%)and 65 women(10.8%)in non-femoral group.The laboratory parameters were evaluated in response to the equal amount of crystalloid fluid given upon arrival and 2 h later.Blood gases decreased in the fracture group despite fluid therapy(p<0.003),and the coagulation profile worsened although the change was not statistically significant.Conclusion The treatment of multiple-trauma patients with femoral bone fractures should be more concerned with the need for the infusion of vasopressors such as norepinephrine.If there is evidence of clinical shock,excessive crystalloid infusion(limited to 1 L)should be avoided,and blood and blood products should be started as soon as possible.

Do clinical and paraclinical findings have the power to predict critical conditions of injured patients after traumatic injury resuscitation?Using data mining artificial intelligence

Purpose The triage and initial care of injured patients and a subsequent right level of care is paramount for an overall outcome after traumatic injury.Early recognition of patients is an important case of such decision-making with risk of worse prognosis.This article is to answer if clinical and paraclinical signs can predict the critical conditions of injured patients after traumatic injury resuscitation.Methods The study included 1107 trauma patients,16 years and older.The patients were trauma victims of Levels I and II triage and admitted to the Rajaee(Emtiaz)Trauma Hospital,Shiraz,in 2014–2015.The cross-industry process for data mining methodology and modeling was used for assessing the best early clinical and paraclinical variables to predict the patients’prognosis.Five modeling methods including the support vector machine,K-nearest neighbor algorithms,Bagging and Adaboost,and the neural network were compared by some evaluation criteria.Results Learning algorithms can predict the deterioration of injured patients by monitoring the Bagging and SVM models with 99%accuracy.The most-fitted variables were Glasgow Coma Scale score,base deficit,and diastolic blood pressure especially after initial resuscitation in the algorithms for overall outcome predictions.Conclusion Data mining could help in triage,initial treatment,and further decision-making for outcome measures in trauma patients.Clinical and paraclinical variables after resuscitation could predict short-term outcomes much better than variables on arrival.With artificial intelligence modeling system,diastolic blood pressure after resuscitation has a greater association with predicting early mortality rather than systolic blood pressure after resuscitation.Artificial intelligence monitoring may have a role in trauma care and should be further investigated.

An increase in heart rate variability can be an index for end point of resuscitation in trauma patients

Purpose: The measurement of heart rate variability (HRV) is a non-invasive method to analyze the balance of the autonomic nervous system. The aim of this study was to compare the changes of HRV and base deficit (BD) during the treatment of trauma patients. Methods: Forty-three trauma patients with a low injury severity scores (ISS < 24) and negative base excess on admission were included in this study. Based on the BD changes, patients were divided into three groups:‘end pointed’ group (n =13), patients' BDs instantly cleared after primary hydration;‘needs further resuscitation’ group (n=21), patients' BDs did not reach the end point and thus required further hydration or packed red blood cells transfusion;and ‘hydration minimal change’ group (n=9), patients' BDs lower than 2.5 mmol/L at the onset of admission and thereafter had minimal change (near normal range). The changes in HRV during fluid resuscitation were detected and compared to BD changes in their arterial blood gases. All data were analysed using the SPSS software Version 15.0. Repeated measures ANOVA was used to determine the changes in HRV, heart rate, blood pressure, and BD among groups. Results: A significant reverse correlation was found between the BD ratio and the HRV ratio (r=0.562;p= 0.01). The HRV of patients with aggravated BDs after fluid resuscitation was decreased. There was an increase in HRV at the time of BD clearance. A decrease in HRV after primary crystalloid hydration bore a significant connection with the need for an ICU (p = 0.021) and transfusion of packed red blood cells (p < 0.001). Conclusion: Increase in HRV may be a new non-invasive index for the end point of resuscitation in trauma patients.

Evaluating the effect of montelukast tablets on respiratory complications in patients following blunt chest wall trauma:A double-blind,randomized clinical trial

Purpose:Patients with multiple traumas are at high risk of developing respiratory complications,including pneumonia and acute respiratory distress syndrome.Many pulmonary complications are associated with systemic inflammation and pulmonary neutrophilic infiltration.Leukotriene-receptor antagonists are anti-inflammatory and anti-oxidant drugs subsiding airway inflammation.The present study investigates the effectiveness of montelukast in reducing pulmonary complications among trauma patients.Methods:This randomized,double-blind,placebo-control trial was conducted in patients with multiple blunt traumas and evidence of lung contusion detected via CT scan.We excluded patients if they met at least one of the following conditions:< 16 years old,history of cardiopulmonary diseases or positive history of montelukast-induced hypersensitivity reactions.Patients were allocated to the treatment (10 mg of montelukast) or placebo group using permuted block randomization method.The primary measured outcome was the volume of pulmonary contusion at the end of the trial.The secondary outcomes were intensive care unit and hospital length of stay,ventilation days,multi-organ failure,and the in-hospital mortality rate.Results:In total,65 eligible patients (treatment = 31,placebo = 34) were included for the final analysis.The treatment group had more pulmonary contusion volume (mean (SD),mm3) at the right (68726.97 (93656.54)vs.59730.27 (76551.74)) and the left side (67501.71 (91514.04)vs.46502.21 (80604.21)),higher initial C-reactive peptide level (12.16 (10.58)vs.10.85 (17.87)) compared to the placebo group,but the differences were not statistically significant (p > 0.05).At the end of the study,the mean (SD) of pulmonary contusion volume (mm3) (right side = 116748.74 (361705.12),left side = 64522.03 (117266.17)) of the treatment group were comparable to that of the placebo group (right side = 40051.26 (64081.56),left side = 25929.12 (47417.13),p = 0.228 and 0.082,respectively).Moreover,both groups have statistically similar hospital (mean (SD),days) (10.87 (9.83)vs.13.05 (10.12)) and intensive care unit length of stays (mean (SD),days) (7.16 (8.15)vs.7.82 (7.48)).Of note,the frequency of the in-hospital complications (treatmentvs.control group) including acute respiratory distress syndrome (12.9%vs.8.8%,p = 0.71),pneumonia (19.4%vs.17.6%,p = 0.85),multi-organ failure (12.9%vs.17.6%,p = 0.58) and the mortality rate (22.6%vs.14.7%,p = 0.41) were comparable between the groups.Conclusion:Administrating montelukast has no preventive or therapeutic effects on lung contusion or its complications.