Hyperkalaemia in bleeding trauma patients: A potential marker of disease severity - A retrospective cohort study.

Background: Hyperkalaemia is a common electrolyte abnormality seen in critically ill patients. In haemorrhagic shock, it may contribute to cardiac arrest and has been identified as a potential marker for tissue hypoxia. However, the significance of its role in haemorrhagic shock and its contribution to mortality remains unclear. This study aimed to examine the potential underlying pathophysiology and evaluate the incidence and characteristics of patients with hyperkalaemia on hospital arrival in bleeding trauma patients before transfusions and its mortality. Methods: A retrospective cohort study was conducted on adult patients with traumatic bleeding admitted to a European Major Trauma Centre between January 2016 and December 2021. Patients were classified according to their serum potassium levels on arrival, and relevant clinical parameters between non-hyperkalaemic and hyperkalaemic patients were compared. Results: Among the 83 patients in this study, 8 (9.6 %) presented with hyperkalaemia on arrival. The median shock index showed a higher tendency in the hyperkalaemic group. Hyperkalaemia was found to be more common among younger patients who sustained penetrating trauma. Mortality rates were higher in the hyperkalaemic group, but the difference was not statistically significant. Conclusion: Our results suggest that hyperkalaemia occurs frequently in bleeding trauma patients on hospital arrival pre-transfusions, indicating a more severe illness. Our findings provide insights into the pathophysiology and characteristics of hyperkalaemia in bleeding trauma patients. Further studies are required to investigate the mechanisms by which hyperkalaemia contributes to mortality in haemorrhagic shock patients.

Percutaneous ultrasound-guided versus open cut-down access to femoral vessels for the placement of a REBOA catheter.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be useful in treating exsanguinating trauma patients. This study seeks to compare rates of success, complications and time required for vascular access between ultrasound-guidance and surgical cut-down for femoral sheath insertion as a prospective observational case control study. Participating clinicians from either trauma surgery or anesthesiology were allocated to surgical cut-down or percutaneous ultrasound-guided puncture on a 1:1 ratio. Time spans to vessel identification, successful puncture, and balloon inflation were recorded. 80 study participants were recruited and allocated to 40 open cut-down approaches and 40 percutaneous ultrasound-guided approaches. REBOA catheter placement was successful in 18/40 cases (45%) using a percutaneous ultrasound guided technique and 33/40 times (83%) using the open cut-down approach (p < 0.001). Median times [in seconds] compared between percutaneous ultrasound-guided puncture and surgical cut-down were 36 (18-73) versus 117(56-213) for vessel visualization (p < 0.001), 136 (97-175) versus 183 (156-219) for vessel puncture (p < 0.001), and 375 (240-600) versus 288 (244-379) for balloon inflation (p = 0.08) overall. Access to femoral vessels for REBOA catheter placement is safer when performed by cut-down and direct visualization but can be performed faster by an ultrasound-guided technique when vessels can be identified clearly and rapidly.

Association of immediate versus delayed extubation of patients admitted to intensive care units postoperatively and outcomes: A retrospective study.

AIM OF THIS STUDY: This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation. RESULTS: 52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation. CONCLUSIONS: We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively.

Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis.

OBJECTIVES: We aim to describe incidence and outcomes of cardiopulmonary resuscitation (CPR) efforts and their outcomes in ICUs and their changes over time. DESIGN: Retrospective cohort analysis. SETTING: Patient data documented in the Austrian Center for Documentation and Quality Assurance in Intensive Care database. PATIENTS: Adult patients (age ≥ 18 yr) admitted to Austrian ICUs between 2005 and 2019. INTERVENTIONS: None. MEASUREMENTS ANDN MAIN RESULTS: Information on CPR was deduced from the Therapeutic Intervention Scoring System. End points were overall occurrence rate of CPR in the ICU and CPR for unexpected cardiac arrest after the first day of ICU stay as well as survival to discharge from the ICU and the hospital. Incidence and outcomes of ICU-CPR were compared between 2005 and 2009, 2010 and 2014, and 2015 and 2019 using chi-square test. A total of 525,518 first admissions and readmissions to ICU of 494,555 individual patients were included; of these, 72,585 patients (14.7%) died in hospital. ICU-CPR was performed in 20,668 (3.9%) admissions at least once; first events occurred on the first day of ICU admission in 15,266 cases (73.9%). ICU-CPR was first performed later during ICU stay in 5,402 admissions (1.0%). The incidence of ICU-CPR decreased slightly from 4.4% between 2005 and 2009, 3.9% between 2010 and 2014, and 3.7% between 2015 and 2019 ( p < 0.001). A total of 7,078 (34.5%) of 20,499 patients who received ICU-CPR survived until hospital discharge. Survival rates varied slightly over the observation period; 59,164 (12.0%) of all patients died during hospital stay without ever receiving CPR in the ICU. CONCLUSIONS: The incidence of ICU-CPR is approximately 40 in 1,000 admissions overall and approximately 10 in 1,000 admissions after the day of ICU admission. Short-term survival is approximately four out of 10 patients who receive ICU-CPR.

A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients.

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.

Is the Regular Intake of Anticoagulative Agents an Independent Risk Factor for the Severity of Traumatic Brain Injuries in Geriatric Patients? A Retrospective Analysis of 10,559 Patients from the TraumaRegister DGU®.

The purpose of this study was to assess anticoagulant medication as an independent factor influencing the occurrence of a severe traumatic brain injury in geriatric patients. Data were collected from the TraumaRegister DGU® between January 2015 and December 2018. We included patients with an age of ≥65 years with a blunt TBI; an AISHead ≥2 but no other relevant injuries. Patients were divided into five subgroups: no anticoagulant medication, anti-platelet drugs, vitamin K antagonists, direct-oral-anticoagulants, and heparinoids. Separation between moderate TBI (AISHead 2-3) and severe TBI (AISHead ≥ 4) and multivariable regression analysis were performed. The average age of 10,559 included patients was 78.8 years with a mean ISS of 16.8 points and a mortality of 22.9%. The most common cause of injury was a low fall of <3 m with 72.8%. With increasing age, the number of patients without any anticoagulant therapy decreased from 65.9% to 29.9%. The intake of coagulation medication increased mortality significantly. Severe TBI was observed in 51% of patients without medication and ranged from 61 to 67% with anticoagulant drugs. After adjusting for confounding variables, the intake of VKA or DOACs was significantly associated with an increased risk of severe TBI. The use of anticoagulant medication is an independent factor and is associated with an increased severity of TBI depending on the type of medication used.

Clamshell thoracotomy and open heart massage--A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study.

AIMS: Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. METHODS: We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. RESULTS: The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. CONCLUSION: Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.