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INTRODUCTION: Cervical spinal instability can be difficult to detect in the shock room setting even with the utilization of computed tomography (CT) scans. This may be especially true in patients with cervical degenerative disease, such as ankylosing spondylitis (AS). The purpose of this study was to investigate the influence AS has on various radiologic parameters used to detect traumatic and degenerative instability of the cervical spine, to assess if CT imaging in the shock room is diagnostically appropriate in this patient population. METHODS: A matched, case-control retrospective analysis of patients with AS and controls without AS admitted at two level-1 trauma centers was performed. All patients were admitted via shock room and received a polytrauma CT. Twenty-four CT parameters of atlanto-occipital dislocation/instability, traumatic and degenerative spondylolisthesis, basilar invagination, and prevertebral soft tissue swelling were assessed. Since the study was assessing normal values, study patients were included if they had no injury to the cervical spine. Study patients were matched by age and sex. RESULTS: A total of 78 patients were included (AS group, n = 39; control group, n = 39). The evaluated cervical radiologic parameters were largely within normal limits and showed no significant clinical or morphologic differences between the two groups. CONCLUSION: In this analysis, CT measurements pertaining to various cervical pathologies were not different between patients with and without AS. Parameters to assess for atlanto-occipital dislocation/instability, spondylolisthesis, or basilar invagination in the trauma setting may reliably be used in patients with AS.

Due to the ever-increasing elderly population worldwide, the incidence of geriatric (poly-) trauma patients will continue to rise for many years to come. In contrast to younger patients, low-energy trauma, such as a fall from standing height, may lead to severe injury in geriatric patients. Outcomes in geriatric patients differ significantly from those of younger patients due to reduced physiological compensation mechanisms and increased frailty. The current ATLS® guidelines do not discern between the initial management of elderly and young trauma patients. Further, most geriatric standard operating procedures (SOPs) address isolated, minor injuries such as femoral neck fractures or osteoporotic spine injuries. Other SOPs such as delirium prophylaxis, osteoporosis therapy and nutrition address geriatric inpatient care after the patient reaches the medical ward However, in the setting of multiple injured geriatric patients, treatment protocols are lacking. Geriatric SOPs addressing triage to the ICU and optimized treatment in the ICU should be developed.

Introduction Occult hypoperfusion (OH) is defined as persistent lactic acidosis despite normalization of vital parameters following trauma. The aim of this study was to analyze the association of occult hypoperfusion with local circulation and inflammation of injured soft tissue in a porcine polytrauma model. Methods This experimental study was performed with male landrace pigs who suffered a standardized polytrauma, including a femoral fracture, blunt chest trauma, liver laceration and a mean arterial pressure (MAP) controlled hemorrhagic shock. One hour after induction of trauma, the animals were resuscitated with retrograde femoral nailing, liver packing and volume replacement. Animals were stratified into Group Norm (normalizing lactate levels after resuscitation) and Group occult hypoperfusion (OH) (persistent lactate levels above 2 mmol/l with normalizing vital parameters after resuscitation). Local circulation (oxygen saturation, hemoglobin amount, blood flow) was measured with optical sensors at the subcutaneous soft tissue at the fractured extremity as well as at the stomach and colon. Local inflammatory parameters [interleukin (IL) 6, 8, 10, and heat shock protein (HSP)] were analyzed in the subcutaneous tissue of the fractured extremity. Results Group Norm (n = 19) and Group OH (n = 5) were comparable in baseline vital and laboratory parameters. The shock severity and total amount of blood loss were comparable among Group Norm and Group OH. Following resuscitation Group OH had significantly lower local relative hemoglobin amount at the injured soft tissue of the fractured extremity when compared with Group Norm (39.4, SD 5.3 vs. 63.9, SD 27.6 A.U., p = 0.031). The local oxygenation was significantly lower in Group OH compared to Group Norm (60.4, SD 4.6 vs. 75.8, SD 12.8, p = 0.049). Local IL-6 in the fatty tissue was significantly higher in Group OH (318.3, SD 326.6 [pg/ml]) when compared with Group Norm (73.9,SD 96.3[pg/ml], p = 0.03). The local circula

The pancreas is at risk of damage as a consequence of thoracolumbar spine injury. However, there are no studies providing prevalence data to support this assumption. Data from European hospitals documented in the TraumaRegister DGU® (TR-DGU) between 2008–2017 were analyzed to estimate the prevalence of this correlation and to determine the impact on clinical outcome. A total of 44,279 patients with significant thoracolumbar trauma, defined on Abbreviated Injury Scale (AIS) as ≥2, were included. Patients transferred to another hospital within 48 h were excluded to prevent double counting. A total of 135,567 patients without thoracolumbar injuries (AIS ≤ 1) were used as control group. Four-hundred patients with thoracolumbar trauma had a pancreatic injury. Pancreatic injuries were more common after thoracolumbar trauma (0.90% versus (vs.) 0.51%, odds ratio (OR) 1.78; 95% confidence intervals (CI), 1.57–2.01). Patients with pancreatic injuries were more likely to be male (68%) and had a higher mean Injury Severity Score (ISS) than those without (35.7 ± 16.0 vs. 23.8 ± 12.4). Mean length of stay (LOS) in intensive care unit (ICU) and hospital was longer with pancreatic injury. In-hospital mortality was 17.5% with and 9.7% without pancreatic injury, respectively. Although uncommon, concurrent pancreatic injury in the setting of thoracolumbar trauma can portend a much more serious injury.

Up to 20% of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients develop severe inflammatory complications with diffuse pulmonary inflammation, reflecting acute respiratory distress syndrome (ARDS). A similar clinical profile occurs in severe trauma cases. This review compares pathophysiological and therapeutic principles of severely injured trauma patients and severe coronavirus disease 2019 (COVID-19). The development of sequential organ failure in trauma parallels deterioration seen in severe COVID-19. Based on established pathophysiological models in the field of trauma, two complementary pathways of disease progression into severe COVID-19 have been identified. Furthermore, the transition from local contained disease into systemic and remote inflammation has been addressed. More specifically, the traumatology concept of sequential insults ('hits') resulting in immune dysregulation, is applied to COVID-19 disease progression modelling. Finally, similarities in post-insult humoral and cellular immune responses to severe trauma and severe COVID-19 are described. To minimize additional 'hits' to COVID-19 patients, we suggest postponing all elective surgery in endemic areas. Based on traumatology experience, we propose that immunoprotective protocols including lung protective ventilation, optimal thrombosis prophylaxis, secondary infection prevention and calculated antibiotic therapy are likely also beneficial in the treatment of SARS-CoV-2 infections. Finally, rising SARS-CoV-2 infection and mortality rates mandate exploration of out-of-the box treatment concepts, including experimental therapies designed for trauma care.

INTRODUCTION Survival rate after polytrauma increased over the past decades resulting in an increase of long-term complaints. These include physical and psychological impairments. The aim of this study was to describe the prevalence and risk factors for developing depression and anxiety more than twenty years after polytrauma. METHODS We contacted patients who were treated due to a polytrauma between 1973 and 1990 at one level 1 trauma center after more than 20 years. These patients received a self-administered questionnaire, to assess symptoms of depression and anxiety. Analysis based on multivariable logistic regression models include injury severity and non-injury related factors to determine risk factors associated with the development of depression and anxiety. RESULTS Patients included in this study (n = 337) had a mean ISS of 20.3 (4 to 50) points. In total, 173 (51.3%) showed psychiatric sequelae (depression n = 163, 48.2%; anxiety n = 14, 4.1%). Injury severity was not associated with the development of depression or anxiety. However, the patients, who required psychiatric therapy prior to the injury had higher risk of developing psychiatric symptoms (OR 1.3, 95%CI 1.1 to 1.8, p = 0.018) as did patients who suffered from additional psychiatric insults after the injury (OR 1.4, 95%CI 1.2 to 2.0, p = 0.049). CONCLUSION More than half of polytrauma patients developed psychiatric sequelae. Risk factors include mainly non-injury related factors such as psychiatric comorbidities and additional psychiatric insults after the injury.

BACKGROUND Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. METHODS Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14-15) of impaired mental status. Outcome was compared. RESULTS A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6-12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. CONCLUSION This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

BACKGROUND Information on long-term psychiatric sequelae after severe trauma is sparse. We therefore performed a survey addressing several symptoms related to post traumatic stress disorder (PTSD) in patients that sustained multiple injuries more than 20 years after trauma. METHODS Patients injured between January 1, 1973 and December 31, 1990 were contacted at least 20 years later. We included multiply injured patients aged between 3 and 60 years of age from a single level I Trauma center. A questionnaire based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria for PTSD, including individual symptoms related to intrusion, avoidance, and hyperarousal was sent to all patients. RESULTS 359 (56.35%) patients received a questionnaire. Out of these, 337 (93.87%) returned the questionnaire and were included in the study (223 males (66.17%) and 114 females (33.82%)). Mean follow-up was 29.5 ± 8.5 years. Nearly half the study population (47.18%) experienced lasting psychiatric sequelae, such as intrusive recollection (n= 65, 19.28%), avoidance (n= 92, 27.29%), or hyperarousal (n=95, 28.18%) at least monthly. Ten patients (2.96%) fulfilled all DSM-IV diagnostic criteria for PTSD. A total of 131 (38.87%) patients reported fair or poor general health status. There was no difference in injury severity in patients with or without PTSD (Injury Severity Score (ISS) 18.33 vs. 20.36, respectively, p = 0.52) or PTSD-related symptoms including intrusion (19.88 vs. 20.32, p=0.74), avoidance (19.99 vs. 20.3, p=0.79) and hyperarousal (19.36 vs. 20.68, p=0.26). CONCLUSION At least 20 years after injury, no correlation was found between the development of psychiatric complications and the severity of injury. While the rate of full-blown PTSD was low, nearly half the study population regularly suffered from at least one psychiatric symptom attributable to the initial trauma. Awareness for the development of psychiatric complications and early initiatio

Background Orthopedic trauma surgery has multiple, both patient-based and surgeon-based risk factors. Evaluating and modifying certain patient safety factors could mitigate some of these risks. This study investigates the influence that the time of day of surgery has on mortality and complication rates. Question/purpose This study evaluates whether the time of day of orthopedic trauma surgery influences complication or mortality rates. Patients and methods A prospective Swiss surgical database developed as a nationwide quality assurance project was reviewed retrospectively. All patients with trauma-coded diagnoses that were surgically treated in Swiss hospitals between 2004 and 2014 were evaluated. Surgery times were stratified into morning, afternoon, evening and night. The primary outcomes were in-hospital mortality and complication rates. Co-factors were sought in bivariate and multivariable analysis. Results Of 31,692 patients, 13,969 (44.3%) were operated in the morning, 12,696 (40.3%) in the afternoon, 4,331 (13.7%) in the evening, and 550 (1.7%) at night. Mortality rates were significantly higher in nighttime (2.4%, OR 1.26, p=0.04) and afternoon surgery (1.7%, OR 1.94, p=0.03) vs. surgery in the morning (1.1%). Surgery performed in the afternoon and at night showed significantly increased general complication rates vs. surgery performed in the morning. (OR 1.22, p=0.006 and OR 1.51, p=0.021, respectively). Conclusion This study observed higher complication and mortality rates for surgery performed after-hours, which correlates with other recent studies. Surgeon fatigue is a potential contributing factor for these increased risks. Other potential factors include surgeon experience, surgery type, and the potential for more severe or emergent injuries occurring after-hours.