key: cord-0029999-tqzul4l3
authors: nan
title: ECTES Abstracts 2022
date: 2022-04-19
journal: Eur J Trauma Emerg Surg
DOI: 10.1007/s00068-022-01944-9
sha: f682d259aaf08d0116daeccbb3ed830db6430191
doc_id: 29999
cord_uid: tqzul4l3

nan

Introduction: Due to an aging population, the incidence of geriatric hip fractures in older patients has increased in developed countries over the past decades and will continue to increase in the future. Risk factors associated with mortality after hip fracture include: older age, male sex, cognitive impairment including dementia, living in an institutional care facility, comorbidities and a higher ASA. The significance of these risk factors for mortality is likely to variate during follow-up after hip fracture. These variations play a vital role in prognosis after hip fracture. Identification of the associated effect of time on risk factors for mortality and in-hospital complications could help guide medical decision making and it could enhance personalized treatment plans for patients undergoing hip fracture surgery. Material & methods: All patients with a hip fracture aged 70 years or above admitted to our hospital between the 1st of January 2016 and the 26th of May 2018 were included in this retrospective study. The primary outcome was mortality after 1 year. Secondary outcomes were mortality after 30 days, 90 days, 2 years, and complications during hospitalization. Kaplan Meier curves for risk factors were generated to measure and visualize the probability of survival over time Results: A total of 685 patients with geriatric hip fractures were included with a 1-year mortality of 27%. The study population consisted of 190 (28%) males and 495 females with a median age of 85 (80-90), in total 27% of the patients were diagnosed with dementia. The adjusted odds ratios (AOR) found differ over time. Five risk factors for mortality investigated in this study differed over time; age, pre-fracture living situation, dementia, ASA classification and sex. Conclusions: Five risk factors for mortality and their impact over time with a were visualized for geriatric patients with a hip fracture. The variation in effect observed in these risk factors play a vital role in prognosis. Especially the first 90 days after trauma are critical for the geriatric patient in terms of mortality. Shared decision-making could be supported by using these risk factors for a more tailored medical treatment for geriatric patients with a hip fracture. Introduction: Fractures of the pelvis and acetabulum are associated with osteoporosis, and their incidence is rising in older adults. In the last decade an increasing number of these fractures are being operated in older patients in certain regions. The goal of this study was to describe the incidence of pelvic and acetabular fractures in Belgium between 1988 and 2018. Material & methods: This retrospective, nationwide, populationbased study was conducted with the help of the national health insurance database from the Belgian National Institute for Health and Disability Insurance (NIHDI-RIZIV-INAMI) . Multiple codes that are used for the reimbursement of the diagnosis and treatment of pelvic and acetabular fractures were linked to the patients'' age group, sex and region. Results: Between 1988 and 2018, 91 .317 pelvic and acetabular fractures were diagnosed. The age-adjusted incidence increased from 15,8/100.000 persons per year in 1988 to 29,7/100.000 persons per year in 2006 and to 37,6/100.000 persons per year in 2018. The fracture incidence showed a bimodal incidence, with a small peak in children (particularly boys), and an increasing incidence in older adults, particularly in women. Between 2006 and 2018, 5 .957 patients underwent surgical treatment for their pelvic fracture. 2.088 patients underwent an osteosynthesis of the acetabulum and 3869 patients underwent an osteosynthesis of the pelvic ring. There were 3622 osteosynthesises (60.8%) in patients younger than 60 years old and 2335 (39,1%) in patients over 60 years old. Conclusions: There is an increasing incidence of pelvic and acetabular fractures in Belgium with the majority of these fractures occurring in older people. Younger adults have the highest proportion of surgical treatment, but given the much higher incidence in older adults, there is a considerable amount of operations in older adults too. Powered by Mode of anesthesia is not associated with adverse outcomes following emergency hip fracture surgery: A population-level cohort study A. Mohammad Ismail 1,2 , M. P. Forssten 1,2 , G. A. Bass 1,3 , D. Trivedi 4 , L. Ekestubbe 5 , I. Ioannidis 1,2 , C. C. Duffy 6 , C. J. Peden 7,6 , S. Mohseni 4,1 31, 2017. Patients were extracted from the National Quality Registry for Hip Fracture (RIKSHÖ FT), and their electronic medical records were reviewed. The association between the type of anesthesia and postoperative severe complications (Clavien-Dindo C 3a) and 90-day mortality was analyzed using a Poisson regression model with robust standard errors, while the association with post-operative mortality up to 1-year was analyzed using Cox proportional hazards model. All analyses were preformed while adjusting for relevant demographic, preoperative comorbidities, specific fracture type, surgical method, as well as other clinical characteristics. Results: A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of severe complications [adj. IRR (95% CI): 1.24 (0.85-1.82 Introduction: The most frequent postoperative complication after hip fracture surgery in elderly patients is a delirium 1 . Delirium is associated with prolonged hospital admission and impaired functional and cognitive recovery. The aim of this study was to identify risk factors for delirium during admission for hip fracture surgery. Material & methods: All consecutively admitted patients with a surgically treated proximal hip fracture in two level II trauma teaching hospitals between 1 January 2018 and 11 January 2021 were included in this prospective cohort study. Delirium was diagnosed by an observatory judgment by geriatric medicine specialists combined with the Delirium Observation Screening Scale. Results: In total 2051 patients were enrolled in this study of which 326 patients (16%) developed a delirium during hospital stay. Multivariable logistic regression showed a significant association between delirium and age (OR 1.07, p \ 0.001), female gender (OR 0.50, p \ 0.001), dementia (OR 1.63, p = 0.001), Parkinson''s disease (OR 2.44 , p \ 0.001), KATZ-ADL score (OR 1.07, p = 0.02), infection during admission (OR 3.64, p \ 0.001) and haemoglobin loss (OR 1.20, p = 0.013). Patients with a postoperative delirium had a significant longer admission duration (9 (6-14)days versus 6 (4-9)days). Also, patients with delirium had significant higher in-hospital (10% vs. 2%, p \ 0.001), 30-day (16% vs. 6%, p \ 0.001) and 1-year mortality (42% vs. 22%), p \ 0.001). Conclusions: Risk factors for development of delirium during admission were age, male gender, dementia, Parkinson''s disease, KATZ-ADL, infection during admission and haemoglobin loss. Patients with delirium had longer hospital admission and higher inhospital, 30-day and 1-year mortality. References Introduction: Surgeons who specialize in calcaneal fracture agree that in most patients surgical managements yield the best result. Functional outcome is largely dependent on preventing complications and restoring anatomy of the calcaneus. Stephan (2013) described a computational tool that performed several measurements on 3 D reconstruction images of healthy pairs of feet of patients. He found symmetrical values, and therefore he proposed the use of these 3 D measurements to assess the quality of the calcaneal reduction, by comparing the 3 D reconstruction images of the treated bone to its uninjured counterpart. His automated algorithm proposes ''to quantify the integrity of the joint surfaces of the calcaneus.'' Another study on healthy feet found symmetry (Misselyn 2018) . We used one of these measurements, the orientation angle of the posterior subtalar joint facet of the calcaneus (OAC), to assess the reduction quality of calcaneal fractures.

The use of 3 D imaging makes sense: it is very close to the conditions during surgery.

The use of the PTC as anatomical landmark also makes sense: it is a well-known, easily identifiable anatomical structure on 3 D CT images (much harder to recognize on X-ray images) and its congruency must absolutely be restored in order to avoid subtalar osteoarthritis.

The aim of this study is to see if the OAC described by Stephan on healthy feet could be used on fractured calcaneus to assess the quality of the reduction after surgical treatment. After measuring the OAC of the calcaneus after osteosynthesis, a value lower than the uninjured side may imply a worse outcome, while a value close to the uninjured side implies a good outcome. Material & methods: Bilateral CT scans of fifty-four patients with unilateral displaced calcaneal fracture were obtained before and after osteosynthesis. Orientation angle of the posterior subtalar joint facet (PTC) of displaced intra-articular calcaneal fractures of 54 patients was measured on segmented 3 D images before and after surgery and compared to the uninjured side. This orientation angle (OAC) is the average of every normal vector of each point of the PTC, as compared to the main calcaneal axis (calculated by first principal component analysis). The PTC is a well-known anatomical structure, relatively easy to identify on 3 D imaging. Results: This OAC angle was low before surgery (mean = 95°, std dev = 6°), statistically significantly different from the uninjured side value, p \ 0.001. The OAC angle of the operated bone was nearly equal to the uninjured side (mean = 103°, std dev = 5°), without any statistically significant difference between postoperative values and uninjured side values. We found linear correlation between the quality of the reduction when assessed with this OAC and the functional score (AOFAS) (Adjusted R 2 = 0.62, p = 0.04). Conclusions: This angle seems to be useful to quantify the quality of the operative reduction of displaced intra-articular calcaneal fractures. Introduction: Despite anatomical reconstruction of tibial plateau fractures, early onset osteoarthritis may still occur due to irreversible initial damage to the articular surface. Currently used classification systems and measurement methods are insufficient to assess fracture displacement and inform patients and physicians about prognosis. In this study, a novel 3D measure for fracture displacement is introduced and correlated to risks on conversion to total knee arthroplasty (TKA). Material & methods: A cross-sectional study was performed including 534 patients treated for a tibial plateau fracture between 2003-2018, with a mean follow-up of 6.7 ± 3.6 years. Fifty-eight (10.8%) patients developed severe posttraumatic arthritis and received a TKA. For each patient, a 3D model was created using the pre-operative CT. The 3D gap area (mm 2 ) was determined in order to quantify the degree of initial fracture displacement. A critical cut-off value was determined using ROC curves. Multivariate analysis was performed to assess the association of 3D gap area with conversion to TKA. Subgroups with increasing levels of 3D gap area were identified and Kaplan Meier survival curves were plotted to assess native knee survival. Results: A 3D gap area C 550 mm 2 (critical cutoff value) was independently associated with conversion to TKA (HR 8.4; p = 0.001). Four prognostic groups with different ranges of the 3D gap area were identified: excellent (0-150 mm 2 ), good (151-550 mm 2 ), moderate (551-1000 mm 2 ), and poor ([ 1000 mm 2 ). Native knee survival at 2-year follow-up was 98.4%, 97.8%, 91.4% and 80.3% respectively in the excellent, good, moderate and poor group. At 10-year follow-up knee survival rates were 96.4%, 95%, 75.5%, and 58.5%, respectively. Conclusions: An quantitative 3D measurement method was developed in order to determine the degree of initial fracture displacement of tibial plateau fractures. 3D fracture assessment could be used as an addition to the current fracture classification methods to identify patients at risk for progressive osteoarthritis and conversion to TKA at follow-up. Introduction: Minimal invasive stabilization is a common treatment in patients with insufficiency fractures of the pelvic ring. There are several biomechanical studies investigating and comparing stability of different treatment methods, but there is few information about how the available implants behave in osteoporotic bone. In this study, we compared the stability of two different treatment options for the dorsal pelvic ring in osteoporotic bone models. Material & methods: A standardized FFP IIIc fracture was generated in 16 osteoporotic bone models. Half of the samples were stabilized with a long semi-threaded SI screw in S1 and an additional fullthreaded SI screw reaching towards the promontory of S1. The other half was stabilized with a trans sacral bar and also an additional fullthreaded SI in S1. The anterior pelvic ring fracture was addressed with a retrograde transpubic screw in both groups. Each bone model was tested under cyclical axial loading from 25 to 1200 N for 1000 cycles and movement was detected pressure based and visually by separate cameras. Results: All samples finished the 1000 test cycles. The group stabilized with the trans sacral bar showed less movement on the fracture site under cyclic loading than the group fixated with two SI screws. In both groups new fractures of the sacral ala of the contra lateral side were observed.

Conclusions: The treatment with trans sacral bar provides at least similar stability as a conventional SI screws in FFP IIIc fractures.

The effects of optimization of 3D printed, individualized, bone samples for biomechanical testing. Introduction: Although the artificial bones (e.g. Sawbones) are easy to handle and not as cost consuming as the cadaver bones, they do not adequately reproduce the unique internal structure and visco-elastic properties of a human bones. We developed 3D individualized bones (3D-IB) with additive manufacturing. These bones were then mechanically tested in four different loading types to compare them with human bones and artificial bones (Composite metacarpals, Sawbones).

Material & methods: Based on CT data from a scan of fresh-frozen metacarpal cadaver bones (MC 2-5) we transformed these data to digital models with three layers in the Standard Tessellation Language (STL) according to the requirements of the additive manufacturing. The polyamid 12 (PA12) was used as a standard material (DuraForm, 3D Systems) to produce 3D-IB. Four different models of 3D-IB were developed with:

1. vertical lammelar structure (PA12V) 2. vertical lammelar structure and a bold cortical layer (PA12V ?) 3. fiber-reinforced material (PA12 HST) 4. horizontal lammelar structure (PA12H)

The testing for torsion, pull, bending and shearing were performed at the purposely designed loading set-up. The different 3D-IB were compared with sawbones and cadaver bones. Results: We tested 45 samples. The force, angle and distance until failure were recorded. In the bending test the 3D-IBs were more elastic as the Sawbones and similar to human bones. In the shearing test the Sawbones needed twice the force of human bones and 3D-IB to fail. During pull tests the 3D-IBs showed similar pattern of failure to human bones. In the torsion test neither Sawbones nor 3D-IB were similar to human bones. The exact data are shown in the Table 1 . Conclusions: The 3D-IB developed so far differ substantially from the Sawbones usually used for mechanical implant testing and are more similar to the parameters of the human bones. No one type of 3D-IB is perfectly mirroring the properties of the human bone so further development is needed. Introduction: Increased life expectancy changed the characteristics of patients who require emergency surgery; not only are older but also frailer1. Frailty gives an increased risk of postoperative morbidity and mortality, extended stays and dependency 1, 2. The Clinical Frailty Scale (CFS) 3 is a visual and simple scale to classify our patients according to their frailty, and has shown to be useful in emergency surgery patients 4, 5, 6. The main goal of the current study was to determine the influence of frailty on the postoperative outcomes in emergency surgery, using the CFS as frailty measure.

Material & methods: Our prospective cohort study included all patients who underwent emergency surgery from July 2018 to February 2020. Two groups were defined: frail (CFS C 4) and nonfrail. All patients were followed 30 days after surgery, registering length of stay, need for nursing facilities at discharge, and their complications, classified according to Clavien Dindo score and the Comprehensive Complication Index. Results: During the studied period, 387 patients underwent emergency surgery: 48 were identified as frail and 339 as non-frail. As expected, the frail group was statistically different (p \ 0,05): the mean age was higher, women were predominant, most patients were on multiple medications, and had higher ASA (Class III o more). At follow-up, frail patients showed longer hospital stay (7,9 days); higher rate of complications (62%), which were more severe (mean CCI of 35,1); and higher mortality (19%). The differences were statistically significant (p \ 0,05 In the final regression model, time to operation, age, modified frailty index and presence of an associated fistula, were the significant risk factors for mortalities in all patients with operation. In patients who were not operated, age significantly increased the odds of mortality. In elderly patients with no operation, presence of an associated fistula significantly increased the odds of mortality. Conclusions: Delay in operation, age, presence of a fistula and modified frailty index were the common risk factors of mortality in operated patients with the primary diagnosis of empyema admitted emergently. In elderly patients who did not undergo an operation and were diagnosed with an empyema, having an associated fistula also significantly predicted higher odds of mortality Ö rebro University, Department of Clinical Epidemiology and Biostatistics, Department of Surgery, Ö rebro, Sweden …for the SnapAppy Group* *all collaborators will be listed on PubMed as authors Introduction: Performance improvement in acute care surgery requires continuous cyclical re-evaluation of diagnostics, operative decision-making, and perioperative care. The contemporary management of appendicitis exhibits great heterogeneity for such a common condition. Snapshot audits are prospective observational studies of strictly controlled consecutive patient cohorts, with simultaneous time-bound patient accrual and follow-up across multiple centers. Observing pragmatic ''real world'' unvarnished differences in epidemiology and clinical practice patterns across different healthcare systems, outside of a randomized clinical trial setting, provides granular data that is both illuminating in terms of the nuances of clinical practice, as well as hypothesis-generating for further study.

Material & methods: We undertook a prospective observational cohort study (ClinicalTrials.gov Registration: NCT04365491), simultaneously accruing in 69 centers across 14 countries from November 1st 2020-August 31st 2021 with a 3-month consecutive case inclusion with a 90-day follow-up from admission date, under the umbrella of ESTES. The study collected only routine, anonymized data with no change to clinical care pathways. Results: Four-thousand five hundred eighty adult patients [2,532 male (55%), median (IQR) age 36 (25-51) years, admitted for the treatment of acute appendicitis. Just 1.8% of patients were SARS-CoV-2 (COVID-19) positive at time of admission. A positively-skewed distribution of symptom duration was observed, with over 70% of patients presenting within 48 h of onset of symptoms. Appendectomy was performed in 4,358 patients (95.2%), and within 24 h of presentation in 83.4%. Laparoscopic appendectomy was converted to open in 2.7%, while 9.4% of procedures were performed open. Antibiotics were administered on admission in 96.5%, while postoperative antibiotics were continued in 59.6%. A histologically-normal appendix was seen in 3.4% and neoplasm in 1.5%. Wide heterogeneity in operating surgeon seniority, technique for controlling the mesoappendix and the appendix base were observed. Conclusions: Snapshot audit has proven successful in advancing the scientific mission of ESTES. Real-world granular data update our epidemiologic understanding of this common surgical condition and demonstrate variable practice patterns and adherence to the WSES Jerusalem guidelines. The current data will be used as hypothesisgenerating for future ESTES implementation science initiatives. Introduction: An early delivery of blood products when massive transfusion protocols (MTP) are triggered is mandatory to improve trauma patients survival. Scores predicting massive transfusion (MT) have already been described (1) . The aim of our study is to compare scores for predicting MT and identify the best trigger for MTP. Material & methods: Multicentric retrospective study from the Trauma Registry of the Spanish Surgeons Association. Severe trauma patients (Injury Severity Score [ISS] C 15), admitted to 18 different Level 1 Trauma Centers, from January 2017 to September 2021 were included. Demographic and clinical information was recorded, and predictive scores for MT were assessed. Results: 1894 patients were included. Mean age was 46.7 ± 18.9 years, 1459 (77.0%) were male. Median ISS was 20 (IQR 15). In 3.2% of the patients a MT (defined as C 10 units of packed RBC) was necessary, while a MTP was triggered in 12.4%. Surgery was performed in 63.9%. The overall mortality was of 9.2%. Predictive scores for MT were compared: GAP (Glasgow Coma Scale, Age, systolic blood Pressure), Shock Index (SI), Assessment of Blood Consumption (ABC) and mABC (modified ABC). AUROC for GAP was 0.760 ± 0.030, SI 0.905 ± 0.020, ABC 0.847 ± 0.026 and mABC 0.850 ± 0.026 ( Fig. 1) , showing differences between IS (best score), GAP (worst score) and the others, p \ 0.05. Best cut-off points were calculated. SI C 0.8 better predicts MT with a sensitivity 91.5%, specificity 67.3%, positive and negative predictive values 9.2% and 99.9%. Conclusions: SI, ABC and mABC are all good scores for predicting MT in our population. Appealing by its simplicity, we recommend SI as the best trigger for MTP. Protocols should be standardized to improve the accuracy of MTP activation for trauma patients. Introduction: The Dutch armed forces have been using -80°C deep-frozen platelets (DTC) for transfusion in operational medicine since 2001. The aim of this study was to investigate the quality of DTCs over a 20 years period to reveal product production was consistent and in compliance with European quality requirements. Material & methods: This was a prospective cross-sectional quality analysis performed for all DTCs from 2001 until 2021. Pre-freeze and post thaw quality (up to six years) was determined by comparing product content and product recovery with both the European guidelines for frozen and liquid stored platelets (minimum recovery of 50% of the original platelet product and a platelet count of [ 200 9 109). Results: From 2001 until 2021 pre-freeze and post-thaw quality control data of 1759 thawed DTC units was available (n = 1100 transfused, n = 417 for training, n = 242 for quality control). Of the thawed products, 97.9% meet the European guideline of 50% recovery. For platelet content, 98.5% of the products exceeded the minimum [ 200 9 109. After thaw median product content was 302 9 109 [Interquartile range (IQR) 75] and median product freezethaw recovery was 74% [IQR 15 ]. Duration of frozen storage did not affect product content or recovery significantly if frozen beyond 0.5 years (short) up to six years (long). Short stored products show a significantly (P \ 0.001) lower product content and recovery ( Introduction: The Norwegian National Burn Center was established in Bergen in 1984 at Haukeland University Hospital and is the country''s only burn center to manage patients with severe burns. From the start, the burn center established a local quality registry where key parameters for these patients were registered. In total, the registry included care pathway data on 2964 patients until January 1st, 2021. The registry does not include data on elective reconstructive surgery, re-admissions, and patients treated at the center for non-burnrelated diagnoses. The quality registry data were reviewed to compare patient care pathways, treatment results, and mortality in different time periods since the burn center opened 37 years ago.

Material & methods: The quality registry contains pseudonymous data, including length of stay, the body surface area burned (%TBSA), health status at discharge, age, sex, and county of residence. Burn severity and mortality rates in different time periods were evaluated by comparing Baux scores (patient age ? %TBSA). The regional ethics committee (REK) approved the project, December 15th, 2020. Results: There was a significant increase in the total number of patients from the five years 2006-2010 (n = 384) until 2016-2020 (n = 706) . In this latter period, most of the increase were patients Abstracts between 0-2 years, whereas the patients'' age distribution was relatively stable from 1986 to 2010. Though there were minor gender variations in some periods, men were overrepresented at 67.5% overall (2003 of 2964 patients were men). Analysis of percentage burned surface area (%TBSA) showed a more significant increase in the patient group from 0-4%, increasing threefold the last ten years of the study. On the contrary, there was a decline of patients with [ 20% TBSA, especially in the latest five-year period. Although admissions nearly doubled from 2006-2010 to 2016-2020, the total accumulated length of stays in the same periods did not increase accordingly, thus reducing the average length of stay. When considering Baux score categories in the latest 30-year period, 1991-2020, 68% had low Baux scores (below 60), and only 165 of 2549 patients (6.5%) had a score of C 100. In the latest ten years (2011-2020), there was a marked increase in survivability for patients with Buax scores C 100, with 29 out of 60 patients surviving. Despite the increased number of patients, the overall mortality rate declined from 10. 9% (1986-1990) to 3% (2016-2020) . Conclusions: The number of admissions increased over the last ten years, whereas the overall mortality rate declined. Simultaneously, patients with severe burns have improved survivability, specifically for patients with Baux scores above 100. Introduction: The content of early fracture hematoma (FH) dictates the outcome of fracture healing. Different reaming protocols for intramedullary nailing (IMN) of long bone fractures are available. However, the impact of reaming strategies on immune cell characteristics in early fracture hematoma is unclear. We hypothesized that the application of Reamed Irrigation and Aspiration (RIA)-techniques is associated with enhanced immune cell content of FH. Material & methods: Twenty-four adult male pigs standardized unilateral fracturing of the femoral bone. Animals were exposed to different protocols of IMN. Fractures were treated with conventional reamed femoral nailing (RFN); unreamed femoral nailing (UFN); reaming with a reamer irrigator aspirator device (RIA). Fracture hematoma was collected 6 h after reaming and immune cells were studied by flowcytometry. FH-cell apoptosis and neutrophil receptor expression (Mac-1/CD11b and FccRIII/CD16) were studied. Results: All animals survived the observation period. Apoptosis-rates of FH-immune cells were significantly lower in group RIA (3.50 ± 0.53%) when compared with non-RIA groups: (group UFN 12.50 ± 5.22%, p = 0.028 UFN vs. RIA), (group RFN 13.30 ± 3.18%, P \ 0.001, RFN vs. RIA). Moreover, RIA-FH showed lower neutrophil CD11b/CD16 expression when compared with RFN (mean difference of 43.0% MFI, P = 0.02; and mean difference of 35.3% MFI, P = 0.04, respectively). Conclusions: This experimental study reveals that utilized reaming strategies influence immunologic cellular FH-content. Reamed Irrigation-Aspiration-augmented protocols are associated with decreased FH-immune cell apoptosis and reduced activation of FH-neutrophils and thereby with optimized FH-immune cell content. This underlines the important role of IMN in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma.

Lipidomic analysis shows significant changes in circulating Diand Triglycerides after intramedullary reaming in a porcine Polytrauma model with a femur fracture. Material & methods: 54 male Pigs (Swiss landrace) weighing 50 ± 5 kg underwent general anesthesia for 6 h. Pigs were split in 3 groups: polytrauma (PT), monotrauma (MT) and sham (S). MT received an isolated femoral shaft fracture, while PT received an additional blunt chest trauma with lung contusion, a grade II (AAST) liver laceration and controlled hemorrhagic shock (mean arterial pressure (MAP) 30 ± 5 mm Hg for 60 min). After resuscitation, we used different means of intramedullary reaming and nailing (Syn-Ream (SR), Reamer-Irrigator-Aspirator System (RIA) and introduction without reaming (NO)). Venous blood was taken regularly from baseline (B) to 6 h post trauma. Lipid concentrations and lipid composition were investigated using mass spectrometry. 233 specific lipids were analyzed. Results: We organized lipids into 17 subgroups based on molecular characteristics. Total lipid concentration showed a significant (p \ 0.01) decrease after polytrauma and remained low over the course of observation. Di-and Triacylglycerols (DAGs and TAGs) initially follow this trend but then show a significant increase right after intervention: (95.8 ± 52.4 to 235.2 ± 202.6 nM/ml (p = 0.01) and 241.5 ± 171.6 to 583.8 ± 620.9 nM/ml (p = 0.036)). In MT, DAGs and TAGs show significant increases after fracture and remain elevated for 4 h: (148.9 ± 63.6 (B) to 211,7 ± 77.7 nM/ml (2 h) (p \ 0.01) and (366.4 ± 207.8 (B) to 552,8 ± 343.3 nM/l (2 h) (p = 0.01)) SR and NO showed significant (p \ 0.05) increase of circulating DAGs and TAGs after intervention in most groups (MT/MT ? PT), while RIA did not. Conclusions: Our data clearly suggests significant changes to circulating lipid composition after trauma and treatment. Furthermore, we showed a significant decrease of intravasation of DAGs and TAGs by using RIA. Lipidomic analysis in our standardized porcine polytrauma model help understand the role of lipids in acute trauma and treatment. Collation with data from the clinical setting is needed.

Optimizing the use of advanced bleeding control techniques in military environments: a Delphi consensus study S. Vrancken 1,2 , B. Borger van der Burg 1 , J. Dubose 3 , J. Glaser 4, 5 Leiden University Medical Centre, Department of Surgery, Leiden, Netherlands Introduction: Truncal and junctional hemorrhage are the most common causes of potentially survivable deaths in combat casualties. The use of advanced bleeding control techniques in combat zones has the potential to improve the outcome of these patients. This study aimed to establish consensus on the optimal use of advanced bleeding control techniques in military environments. Material & methods: An international expert panel of military physicians was selected to complete a three-round Delphi survey. Consensus was reached with C 70% agreement and a response rate of at least 70%. Results: Thirty-two experts from 10 different nations participated in the Delphi process. They reached consensus on the preferred contents of a standard bleeding control toolbox and the locations where it should be available, which providers should be allowed to use invasive and non-invasive bleeding control techniques and their training requirements, and on certain indications and contraindications for resuscitative endovascular balloon occlusion of the aorta (REBOA) in military environments. There was no consensus on the indications for REBOA in military settings in patients with chest injuries, axillary injuries or penetrating neck injuries in combination with thoracoabdominal injuries. The panel agreed that there should be international registries and guidelines on bleeding control care in military environments. Conclusions: Consensus was reached on the contents of a standard bleeding control toolbox, where it should be available, providers allowed to use advanced bleeding control techniques and their training requirements, potential indications for REBOA in military environments, and the need for international registries and guidelines.

Do we need to repeat CT in mild brain-injured patients on blood thinners?

J. Pinto 1 , J. Pinheiro 1 , D. Gaspar 1 , B. Barbosa 1 , J. Pereira 1 , C. Casimiro 1 1 Centro Hospitalar Tondela-Viseu, Serviço de Cirurgia, Viseu, Portugal Introduction: Mild head injury is a common reason for admission to the ED. CT is liberally used, mainly on high-risk patients. In our Hospital, a 12 h CT is used to identify the onset of a secondary brain hemorrhage on patients under antiaggregating or anticoagulation therapy. Most of these CT come normal. This study aims to evaluate the need for control CT in this subset of high-risk patients.

Material & methods: This is a prospective observational study of patients with mild head trauma (GCS 14-15) admitted to our emergency department between January and June 2018. Results: A total of 343 patients were included in the study, 149 (43.4%) were under blood thinners therapy, and 194 (56.6%) were not (control). There were no differences between the groups regarding the existence of traumatic brain injury on admission CT. A total of 10 patients (6.1%) exhibited intracranial lesions in control CT without the need for surgery. On subgroup analysis, despite the higher prevalence of traumatic brain injuries in the first or control CT in patients on antiaggregating (36.6%, 12.3%), the difference to the patients under anticoagulation (32.7%, 5.7%) was not statistically significant. On multiple logistic regression, GCS at admission, age, Charlson Comorbidity Index, amnesia, and headaches were associated with secondary bleeding as seen on control CT. Conclusions: The incidence of secondary bleeding in patients on blood thinners is rare. These results do not support the need for a control CT in this group of high-risk patients. The use of this surveillance method should be reconsidered and further studied. Amsterdam UMC location VUmc, Emergency Medicine, Amsterdam, Netherlands examines the in-hospital trauma resuscitation times in a Dutch level-1 academic trauma center.

A prospective observational double cohort study was conducted three months before and after placing a visible clock in the trauma resuscitation room. Trauma patients above 15 years old presented at the trauma resuscitation room during weekdays between 9.00 AM and 9.00 PM were included. Time until diagnostics (chest X-Ray, FAST, or CT scan), time until therapeutic intervention, and total resuscitation time were measured manually with a stopwatch. Patient characteristics and information regarding trauma-and injury type were collected. Times before and after trauma clock implementation were compared. Results: In total, 100 patients were included. Median time until diagnostics was 8.1 min (IQR 2.4) before vs. 7.5 min (IQR 2.0) after clock implementation (p = 0.064). Median time until CT scan and mean total resuscitation rime (including CT scan) were 25. Introduction: Polyrauma patient with additional SARS-CoV 2 infection may be associated with increased complication rate. Both factors alone are known for a large number of complications. It was our interest to find out whether the combination of both factors has an impact on the inpatient course. The main goal of this study was to analyze the clinical course of trauma patients with COVID infection and a positive CT finding. Material & methods: This is a retrospective in-hospital study. Data were collected by a review of medical records. Monotrauma and polytrauma patient with positive infection of SARS-CoV 2 were include into our analysis. Radiological changes associated with SARS-CoV 2 were screened. The outcome parameters were: pulmonary complication during admission, pulmonary embolism, pleural fluid, pneumonia, mortality, length of stay and readmission \ 30 days. Results: In total 48 patient were included. Trauma patients in the ageadjusted matched-pair analysis with SARS-CoV-2 typical changes in CT findings showed significantly more pulmonary complications in general and significantly more pneumonia (complications: 56% vs. 11%, p = 0.046/pneumonia 44% vs. 0%, p = 0.023). in addition. Similarly, polytrauma patients with SARS-CoV-2 infection showed a significantly higher rate of pulmonary embolism than monotrauma patients (20% vs. 3%, p = 0.049) Conclusions: The results of our study show that the changes in CT findings of trauma patients with SARS-CoV-2 infection is a good indicator of further inpatient outcome. Similarly, polytrauma patients with SARS-CoV-2 infection are shown to be at significantly increased risk for pulmonary embolism. Introduction: Medical errors are among the 5 most frequent causes of death. However, although potential risks are well-known by healthprofessionals, especially in stressful situation, they remain undiscovered and uncorrected due to impaired situational awareness. A ''room of error'' is an innovative possibility to train situational awareness. It is a simulation room prepared as a clinical room containing hidden errors and potential risks which have to be discovered by health professionals. During the pandemic, simulation training was highly reduced due to hygienic and other restraints. The aim of the present work was to develop a Virtual Reality (VR) based serious game targeted on improving the situational awareness of health-professionals in surgery and emergency medicine. Material & methods: Four different rooms (operation room, emergency room, intensive care room, normal ward) were designed in VR with its complete interior. In each room, 10 errors were implemented representing the different categories of medical errors defined in the taxonomy of incident types by the world health organization, and further, representing frequent errors. Health-professionals were trained in the room of error. Each had 10 min in each room to identify the hidden errors. Afterwards a questionnaire was administered. Results: By now, a total of 45 health-professionals (11 physicians, 18 nurses, 16 medical students) completed the questionnaire. All evaluated the room of error as highly realistic and easy to use. They judged the hidden errors to be relevant for their daily work and rated to be better prepared in identifying potential errors and risks in their future work. Conclusions: The VR room of error represents a practical, lowthreshold possibility to train health professionals identifying hazards of patient safety, teach their power of observation and situational awareness. In comparison to a simulated room of error, VR is more realistic due to its high level of immersion. Furthermore, it is independent of room capacities, pandemic restrictions and can be used 24/7. Introduction: Laparoscopic subtotal cholecystectomy (LSC) for acute cholecystitis (AC) is nowadays accepted as an effective surgical strategy when the Calot's triangle cannot be adequately dissected due to severe fibrosis or inflammation. Several surgical techniques have been developed with heterogeneous results. The use of a laparoscopic stapler seems a promising approach, particularly in emergency settings, but data on technical feasibility and postoperative outcome are currently lacking. Material & methods: Retrospective analysis of prevalence and morbidity of urgent stapler-LSC (S-LSC) for AC, performed in five Italian Centers between 2010-2020. Results: During the study period, 5516 urgent laparoscopic cholecystectomies were performed for AC. Among these 125 (2.3%) were LSC, comprising 32 (25.6%) S-LSC. In the analyzed group, the median patient age was 62 years [IQR 54-78] and median time interval between symptoms onset and surgery was 5 days [3] [4] [5] [6] [7] [8] [9] . At intraoperative exploration, AC presented as AAST grade [ 2 in 37.5% and [ 3 in 21.9%. The median operative time was 147 min and no cases of biliary or vascular injuries were recorded. The median postoperative length of stay was 8 days [5] [6] [7] [8] [9] [10] [11] [12] , with no 30-days mortality. Reoperation was never required, only three patients (9.4%) underwent percutaneous drainage of intrabdominal abscesses, while for the others only Clavien-Dindo B 2 complications occurred. No cases of biliary leak were recorded. At a median follow up of 24 months , none of the patients developed any episode of pancreatitis, obstructive biliary complication or remnant AC. Conclusions: In addition to the techniques already described by Strasberg et al., S-LSC seems a feasible, effective and safe surgical approach with good short-and long-term outcomes.

Laparoscopic approach for the treatment of acute small bowel obstruction: how to predict safety, feasibility and outcomes Introduction: Acute intestinal obstruction is one of the most common surgical emergencies. The small bowel obstruction (SBO) is the most common cause (76%) and adhesions represent the most frequent etiology (65%) in literature. Laparoscopy still has no defined and validated role as surgical treatment.

Material & methods: We reviewed medical records of patients with intestinal obstruction and, within these ones, patients with SBO undergoing NOM vs operative treatment, and in particular laparoscopy, in the last 5 years. Data obtained included demographics, clinical and radiologic presentations, intraoperative outcomes, and postoperative course. Results: During the observation period (January 2016-March 2021) 207 patients were admitted for SBO. NOM was performed in 53 (25.6%) of patients. 154 patients underwent surgery and 49 were successfully treated laparoscopically. Conversion to laparotomy rate was 41%. The median postoperative stay was significantly different between patients who underwent laparoscopic approach and those ones who underwent laparotomy: 6 days (IQR 4-9) in the first group vs 8.5 days (IQR 6-13) in the second one (t = 3.305, p = 0.019). No statistically significant difference in the length of hospital stay between laparotomies ab initio vs converted cases was found. In order to find a predictive model of successful laparoscopy, we analyzed, in cases who underwent conversion to laparotomy, if any statistical variable (previous laparoscopies or laparotomies, number of previous operations, etiology, history of peritonitis and/or intestinal obstruction) was predictive of failure of the laparoscopic attempt. Previous surgery for peritonitis and/or intestinal obstruction significantly related with conversion rate (X 2 = 4,509, p = 0,034). Conclusions: Laparoscopy is safe and feasible in the management of acute SBO in selected patients. We need further prospective and randomized studies to identify a predictive model for effective laparoscopic treatment of SBO. Introduction: Small bowel obstruction (SBO) is a common surgical emergency. Thirty years have passed since the first reported case of laparoscopic adhesiolysis were done by Bastug DF. However widespread acceptance of laparoscopy in the management of SBO was limited due to the lack of supporting evidence of its superiority over an open approach and concerns regarding its real benefits. Currently laparotomy is accepted as the standard surgical intervention for SBO, although laparotomy itself is an independent risk factor for SBO. The aim of this study is to compare laparoscopy and laparotomy for the treatment of not extensive adhesive small bowel obstruction with a special focus on the incidence of recurrence of the disease and the quality of life in the long-term. Material & methods: A retrospective analysis of patients treated for adhesive SBO at our institution between January 2012 and December 2016 was made by a comprehensive search of a prospectively maintained database of emergency procedures. Open adhesiolysis were compared with laparoscopic adhesiolysis. Morbidity and mortality, operative time, length of stay and subsequent re-admission to hospital and re-operation were compared between groups. A longterm follow-up of this cohort of patients was performed: Gastrointestinal Quality of Life Index (GIQLI) questionnaire has been used to assess the quality of life of the patients. Results: A cohort of 365 patients with adhesive SBO was identified: patients with dense/matted adhesions and patients who required bowel resection were excluded from the study. Of the 172 remaining patients fifty one were lost to follow-up, the minimum follow-up period was 4 years (median 6,4 years). The patients that completed the follow-up were 121: 74 (61%) underwent open procedure and 47 (39%) underwent laparoscopic procedure. Within the laparoscopic group 5 (10%) underwent conversion to open procedure. The mean operative time was shorter for laparoscopic group (94 min vs. 97 min, p = 0,35) as mean length of stay (7 days vs 10 days, p = 0,066). The overall complication rate was significantly lower in the laparoscopic group (p \ 0,005), in particular for severe complications (Clavien-Dindo 3 or higher). At very long-term follow-up we found a significant higher re-admission and re-operation rate for small bowel obstruction in the patients treated with open procedure (4,7% vs 12,6%, p \ 0,005). Moreover GIQLI scores at follow-up were markedly worse in patients treated with laparotomy (p \ 0,005), in particular for the subscales of GI symptoms and emotional status, while there were no differences for physical and social subscales. Conclusions: In a significant proportion of patients treated with laparotomy adhesive disease could relapse leading to the need for reinterventions and affecting the quality of life with a variety of chronic symptoms such as abdominal distension, pain and nausea. Laparoscopy could limit adhesions formation. Our study support the benefit of minimally invasive management of SBO in the long-term. Introduction: Abdominal emergency surgery (ES) in elderly is associated with high mortality and long hospital stay. Moreover, data regarding maintenance of autonomy following ES admission among older adults are lacking. The aim of this study was to compare the outcomes of elderly patients following explorative laparotomy or multiple abdominal intervention.

Materials & methods: Patients aged 65 years and over following emergency laparotomy (EL) between 1.1.2017 to 31.12.2019 were included. The primary outcome of interest was in-hospital mortality and discharge home. Data collected included preoperative diagnosis, number of laparotomies, facility where patient initially presented with surgical pathology (emergency department, surgical floor, internal medicine facility, etc.), discharge destination and mortality. Patients underwent single laparotomy were compared to group with multiple interventions. Results: Overall, 200 patients underwent EL, of whom 59 patients (30%) needed more than one abdominal intervention. The median age was 78 (65-101) years and 40% (79 pts) were C 80. The indication for EL were bowel obstruction (91; 46%), ischemic bowel (32; 16%), hollow viscous perforation (46; 23%) and other (31; 15%). 59 patients (30%) died at their index admission. 37 patients (63%) presented not from emergency department or surgical ward required multiple interventions. The mortality rate at multiple interventions group was 58% (N = 34). Only 14 patients (24%) in this group were discharge home, in contrast to the 95 (67%) from the single laparotomy group (p = 0.0018). Patients with ischemic bowel had the highest mortality (22 of 32 patients; 69%). Conclusions: Elderly patients that underwent single EL are more likely to be discharge home. Elderly patients who present from nonsurgical departments with ES pathology and require EL had dismal outcome. This study provides important information to support and help improve the planning for care of older patients who present with intra-abdominal emergencies. Introduction: Posttraumatic release of pro-inflammatory mediators is a one of the factors developing systemic inflammatory response that increases comorbidities and mortality of severe traumatized patients. Lipidomics is a new research method analyzing specific lipids, that has revealed new lipid-based inflammatory mechanisms responsible for several pathophysiological conditions [1] . However, only a few studies using this technology have been reported yet in the field of trauma. In the current study, we investigated the posttraumatic changes of 233 specific lipids in circulation of porcine polytrauma model. Material & methods: 54 male pigs were split in polytrauma (PT), monotrauma (MT) and sham group. PT received a combined injury of blunt chest trauma, a liver laceration, controlled hemorrhagic shock, and femoral shaft fracture. MT received an isolated femoral shaft fracture. After 60 min animals received resuscitation and fracture stabilization. Venous blood was taken regularly from baseline until 6 h post trauma. 233 specific lipids were analyzed using mass spectrometry.

Results: Acylcarnitines showed a significant increase at resuscitation phase only in PT. Three subgroups (Diacylglyceroles, Triacylglycerols, and Phosphatidylethanolamines) increased significantly in MT after trauma and in PT 2 h after trauma. Conclusions: Our results suggest that circulating lipid composition was significantly changed after trauma and treatment. Corresponding factors might be the posttraumatic intravasation of lipids from bone Abstracts marrow and damaged tissue, a response to posttraumatic cytokine storm or the onset of a hypermetabolic state. Individual pathways have yet to be investigated and collation with clinical data is needed. Introduction: The innate immune system in trauma patients is in a precarious state. Neutrophils, the most abundant cells of the white blood cell pool, are affected by tissue injury. At homeostasis there is a homogeneous pool of circulating neutrophils patrolling the body for danger-and pathogen associated signals. However, trauma directly changes this situation and additional neutrophil subsets appear in the bloodstream. These subsets can be discriminated based on their surface markers: CD16 and CD62L. These subsets showed differences in functionality, thus they might play a role in the occurrence of infectious complications in multi-trauma patients. Therefore it is necessary to know how this subset profile develops over time and how the subsets function against pathogens.

Material & methods: Multi-trauma patients were included who were admitted to the trauma bay of the UMC Utrecht. Patients were 18-80 years of age, were not pre-existing immunocompromised and were expected to stay on the ICU for [ 48 h. Blood was drawn right after admission (day 0), at day 3, 6, 10 and 15. Flow cytometry was used to analyze blood neutrophils. A panel with antibodies against surface markers (e.g. CD16 and CD62L) was used. Additional functional analyses were performed with the blood neutrophils. Results: A specific pattern of occurrence and disappearance of neutrophil subsets in the circulation occurred over time after injury. During the first day, neutrophils low in CD16 appeared, thought of as younger neutrophils. Those CD16low neutrophils disappeared from the circulation during the first days. At day 10 there was a noteworthy rise in CD62Llow neutrophils, that have been associated with a higher activation status. Also, the antibacterial function of CD62Llow neutrophils was lacking. Conclusions: These results of neutrophil kinetics in trauma patients are very relevant in order to understand the occurrence of inflammatory and infectious complications in vulnerable multi-trauma patients.

Pelvic ring fractures treated with the Illuminoss patient conforming implant system M. Guijt 1 1 Elkerliek Hospital, traumasurgery, Helmond, Netherlands Introduction: Evaluation of the first 40 patients with an anterior pelvic ring fracture treated with the IlluminOssÒ system.

Material & methods: 40 patients were included in this single center retrospective observational study, all treated with the IlluminOssÒ polymeric rod. The implant is introduced through a 4 cm incision over the os pubis and positioned in the rames superior up to the acetabular dome across the fracture. 10 patients also had a sacral fracture. Median age age 76 years (46-96 yr). 85% female. 29 patients had a fall from standard height.5 unknown.4 multi-trauma and 2 due to metastatic bone disease. All patients had a pre-operative CT scan. 18 patients a concomitant sacral fracture. Rommens classification: 1 ab -14. 2 bc -17. 3 c -4. nonunions 3. MBD 1. acetabular fracture 1. 50% ASA 2. 50% ASA3. Average stay in hospital 11 days (1-25 days) Results: VAS score dropped 50% at the first post-operative day (mean pre-op 3.4 to 1.7 post-op). All patients were able to mobileze on day one after surgery. 21 patientst were discharded to their homes, 19 patients went to rehabilitation center. 26 patients returned to pretrauma ambulation and ADL. Conclusions:

The IlluminOssÒ system appears to be a promising surgical technigue for the treaatment of fragility fractures of the pelvic ring in the elderly patient Introduction: Opportunistic screening for bone mineral density (BMD) of the first lumbar vertebra (L1) using computed tomography (CT) is increasingly used to identify patients at risk for osteoporosis. An extensive study in the United States has suggested sex-specific normative values of CT-based BMD across all ages. The aim was to validate North American references bone mineral density (BMD) values for the Dutch trauma population. Material & methods: All trauma patients aged 16 or older, admitted to our level-1 trauma center during 2017, who underwent a CT scan of the chest or abdomen at 120kVp within 7 days of hospital admission, were retrospectively included. BMD measurements in HU were performed manually in L1 or an adjacent vertebra. Student''s t-tests were performed to compare the Dutch mean BMD value per age group to the North American reference values. Linear regression analysis and Pearson''s correlation rho (q) were performed to assess the correlation between BMD and age. Results: In total, 624 patients were included (68.4% men, aged 16-95). Mean BMD decreased linearly with 2.4 HU per year of age (q = -0.77). Sex-specific analysis showed that BMD of Abstracts premenopausal women was higher than BMD of men at these ages. Dutch mean BMD values in the age groups over 35 years were significantly lower than the North American reference values. Conclusions: Our findings indicate that using North American BMD thresholds in Dutch clinical practice would result in overdiagnosis of osteoporosis and osteopenia. Dutch guidelines may benefit from population-specific thresholds.

Healthcare utilization and satisfaction with treatment before and after direct discharge from the Emergency Department of simple stable musculoskeletal injuries in the Netherlands Introduction: To evaluate healthcare utilization and satisfaction with treatment before and after implementing direct discharge (DD) from the Emergency Department (ED) of patients with simple, stable musculoskeletal injuries.

Material & methods: Patients with simple, stable musculoskeletal injuries were included in two Dutch hospitals: OLVG and Sint Antonius (SA), before (pre-DD-cohort) and after implementing DD (DD-cohort). With DD, no routine follow-up appointments are scheduled after the ED visit, supported by information leaflets, a smartphone application and a telephone helpline. Outcomes included: secondary healthcare-utilization (follow-up appointments and X-ray/ CT/MRI); satisfaction with treatment (scale 1-10); primary healthcare-utilization (general practitioner (GP) or physiotherapist visited, yes/no). Linear regression was used to compare secondary healthcareutilization for all patients and per injury. Satisfaction and primary healthcare-utilization were analysed descriptively. Results: A total of 2,033 (OLVG = 1,686; SA = 347) and 1,616 (OLVG = 1,396; SA = 220) patients were included in the pre-DDcohort and DD-cohort. After DD, the mean number of follow-up appointments per patient reduced by 1.06 (1.13-0.99; p \ 0.001) in OLVG and 1.07 (1.02-0.93; p \ 0.001) in SA. Follow-up appointments reduced significantly for all injury subgroups. Mean number of follow-up X-rays per patient reduced by 0.17 in OLVG (p \ 0.001) and 0.18 in SA (p \ 0.001). Numbers of CT/MRI-scans were low and comparable. In OLVG, mean satisfaction with treatment was 8.1 (pre-DD-cohort) versus 7.95 (DD-cohort), versus 7.75 in SA (DD-cohort only). In OLVG, 23.6% of pre-DD-cohort patients visited their GP, versus 26.1% in the DD-cohort, versus 13.3% in SA (DD-cohort only). Conclusions: This study performed in a large population and additional hospital confirms earlier pilot results, i.e. that DD has the potential to effectively reduce healthcare utilization, while maintaining high levels of satisfaction. Introduction: Anterior knee pain is common after tibial nailing and its origin is poorly understood. Literature suggests it may be related to infrapatellar nerve injury. The aim of this study was to compare the effect of a transverse (potentially infrapatellar nerve sparing) incision for insertion of a tibia nail versus a longitudinal incision on anterior knee pain. Material & methods: Adult patients with a tibial shaft fracture to be treated with an intramedullary nail were randomized to a transverse (n = 68) or longitudinal incision (n = 68) in multiple centers. The primary outcome measure was kneeling pain based on a Numeric Rating Scale (NRS). Secondary outcome measures included knee pain during daily activities, functional outcome (Short Musculoskeletal Function Assessment (SMFA) and Lower Extremity Functional Scale (LEFS)), quality of life (Euro-QoL-5D, EQ-5D), activity resumption, complications, reoperations, and direct and indirect costs until one year after trauma. Results: At 12 months the estimated marginal mean for kneeling pain was 2.4 (95% CI 1. 6-3.2) in the transverse incision group and 3.7 (95% CI 3.0-4.5) in the longitudinal group. Regression analysis showed no significant difference between both groups over time (P = 0.239 at 12 months). Knee pain scores for daily activities, functional outcome scores, and quality of life were also comparable between the groups. Signs of infrapatellar nerve injury were found less often after a transverse incision (16% versus 53%; P \ 0.001). The total (direct and indirect) costs per patient were €10,468 in the transverse incision group and €11,066 in the longitudinal incision group. Loss of productivity accounted for 67% and 52% of the total costs, respectively. Conclusions: In this multicenter randomized controlled trial with 12 months follow-up, we found no significant relation between a transverse and longitudinal incision for insertion of a tibia nail and the occurrence of anterior knee pain. Knee pain during daily activities, functional outcome, quality of life, activity resumption and number of complications and reoperations were also similar. Loss of productivity was the main cost driver for patients treated with an intramedullary nail. Use of a transverse instead of a longitudinal incision for tibial nailing is advised to avoid iatrogenic injury to the infrapatellar nerve. Introduction: Review the results after primary pantalar arthrodesis with Intramedullary Nailing for severely tibial pilon fractures, nonreconstructibles according to articular fractures treatment principles. Assess time-to-heal and fuse (fracture and arthrodesis) and intra and postoperative complications. Materials & methods: The retrospective study was performed on 47 pilon fractures operated at UCL Hospital Brussels, (October 2011-Abstracts January 2020) out of which 42 had open reduction and internal fixation and 5, with severe comminution of the articular surface received primary pantalar arthrodesis with an intramedullary nail. These were reviewed, regarding age, sex, injury type, previous musculo-skeletal conditions, need for temporary external fixation, time to second surgery (nailing), arthrodesis type (open/arthroscopic), bone grafting/additional soft tissue reconstruction, complications, time to bone healing, need for revision surgery, radiological alignment of the hindfoot. The average period of follow up was m 12 months (6.5-22) Out of the 5 patients with primary arthrodesis, 1 had high-energy (good bone stock) and 4 low energy trauma (poor bone quality). Provisional external fixation was needed in 4 cases. 1 case with severe post-traumatic soft tissue loss needed a free flap 2 cases had arthroscopic tibio-talar arthrodesis, 3 were operated with an open technique. 1 autograft from iliac crest and 1 allograft were used. All fixations were performed with an intramedullary nail. Results: No intraoperative problems were recorded, 1 delayed healing of surgical wound was encountered. No postoperative infection was recorded. Average time to bone healing was wee 21 weeks (19-24). No revision surgery or additional procedures were needed to obtain healing of tibio-talar joint and fracture itself, one revision of subtalar joint (postero-lateral approach, autologus bone graft and additional screw fixation) was needed Conclusions: Primary pantalar arthrodesis with fracture reduction and stabilisation is a valuable option for selected cases (severely comminution of joint surface in pilon fractures, poor bone stock), when failure of anatomic reduction and stable internal fixation is highly predictable. Achieving an anatomical reduction using a standard anterolateral approach is impossible. Therefore, we present four atypical cases where PLQD was irreducible because of an entrapment of the popliteal tendon. Material & methods: We performed a retrospective single center cohort review at our trauma unit. During a period of 10 years we performed surgery on 555 proximal tibia fractures (AO 41) while we only stated 4 cases of an irreducible PLQD with entrapment of the popliteal tendon (0.7%). The mean age was 52.3 years, two female patients with a partial intraarticular fracture (AO 41-B3) and two male patients with a complete intraarticular fracture (AO 41-C3).

Computertomography images were used to classify the fracture types after initial stabilization with a knee bridging external fixator. In all cases we performed open reduction and internal fixation with locking compression plates (LCP) using a transfibular approach. Intraoperatively the interposition of the popliteal tendon was located, looped with a rubber band and with tension on the tendon the fragment could be reduced anatomically. Results: In all four cases an anatomical restoration of the joint line was possible after releasing the entrapped popliteal tendon. Clinical and x-ray follow-up was done at six and twelve weeks and one year after surgery in the outpatient department. No complications like infection, re-operation or non-union were recorded. One patient was lost to follow up one year postoperatively, the remaining 3 patients presented with a healed fracture and no limitation in range motion. Conclusions: PLQD is often challenging to reduce anatomically. As these cases have shown, we recommend reducing these fractures through a transfibular approach to have visual insight into the fracture zone for releasing the entrapped popliteal tendon. Thus, an awareness of this fracture pattern such as we reported in the present cases, is important for all surgeons treating proximal tibial fractures. Introduction: The measurement of intracompartmental pressures is used to evaluate the indication for surgical treatment of the chronic exertional compartment syndrome. Recently, the commonly used Stryker device became unavailable in Europe, forcing physicians to look for alternatives. The aim of this study was to compare the accuracy of manometers and needles available for intracompartmental pressure measurement. Materials & methods: An experimental compartment simulation model was developed to compare four different terminal devices (Compass manometer, Stryker device, Meritrans transducer, and arterial line) and 22 needle types (Fig. 1) . First, all possible device/ needle combinations were introduced in rubber ports at the bottom of a water column. The water column was gradually drained three times for each device/needle combination and pressures were recorded by two researchers. This procedure was repeated after placement of a sample of homogenous porcine gluteal muscle tissue. Statistical analyses were performed using the water height as reference pressure. Results: When measuring the fluid column only, all Intraclass Correlation Coefficients were found to be C 0.980, indicating good Abstracts resemblance to the reference pressure (table 1). After addition of muscle tissue to the experimental set up, the accuracy of the Stryker device and arterial line remained the same. The accuracy of the Compass manometer and Meritrans transducer became less. Excellent reliability was only found for 7 out of 22 needles when combined with the Stryker device and for 3 out of 22 needles when combined with the arterial line. Conclusions: The four terminal devices tested were all accurate when measuring pressure in a water column, however only the Stryker device and an arterial line were accurate when measuring pressure in a porcine gluteal muscle model and only in combination with some of the tested needles. Netherlands  TABLE 1 Overview of the reliability for all terminal devices when installed with the different types of needles in the fluid column without and with a sample of porcine gluteal muscle after calculating the Intraclass Correlation Coefficient (ICC) and the respective confidence interval (CI). Excellent reliability with CI [ 0.900 is represented in green, good reliability with CI 0.900-0.750 in yellow, moderate reliability with CI 0.750-0.500 in orange, and poor reliability with CI \ 0.500 in red. Introduction: The indication for surgical treatment of the chronic exertional compartment syndrome is evaluated by measuring intracompartmental pressures (ICP). The validity of these invasive ICP measurements are increasingly questioned in the absence of a standardized test protocol and uniform cut-off values. The aim of the current study was to aid in standardization of the test protocol of ICP measurements, thereby supporting the physician''s choice in the selection of appropriate manometers and needles. Materials & methods: A compartment syndrome was simulated in embalmed above-knee cadaveric leg specimen. Four different terminal devices (Compass manometer, Stryker device, Meritrans transduce, and arterial line) were tested with 22 different needle types. Legs were pressurized after introduction of the four terminal devices in the anterior compartment, using the same needle type (Fig. 1) . Pressure was recorded at a 30-s interval for 11 min in total. Before and after pressurization the intravenous bag of saline was weighed. Results: A compartment syndrome was simulated successfully in all 22 legs, with ICP values exceeding 100 mmHg in 17 of the 22 legs (77%). In the other five legs, a smaller built up of pressure was seen, although maximum ICP was in between 70 and 100 mmHg. The Intraclass Correlation Coefficient was above 0.700 for all possible needle types (table 1) . Excellent to good reliability was seen in 16 out of 22 instrumental setups (73%). The mean volume of saline infusion required in runs that exceeded 100 mmHg (309 ± 116 ml) was significantly lower compared to the legs in which 100 mmHg was not achieved (451 ± 148 ml; p = 0.04). Conclusions: The ICP recordings of the four terminal devices were comparable, when tested with a standardized pressurization model in a human cadaver model. None of the included terminal devices or needle types were found to be superior. The results provide evidence for more divers material selection when logistic choices for ICP measurement devices are warranted. Introduction: As soon as a fracture occurs, a fracture hematoma (fxh) is formed. fxh plays an important role in fracture healing and, under normal circumstances, aids in generating an environment in which a variety of cells orchestrate processes inducing fracture healing. MicroRNAs (miRNAs) may influence these processes. The aim of this study was therefore to determine the miRNA signature of human fxh in normal fracture healing and examine potential influences of clinical parameters on those miRNA expression levels.

Material & methods: fxh was harvested during fracture surgery of long bones. miRNAs were isolated, transcribed, analyzed by means of qPCR arrays, and validated in the study population. Qiagen fibrosisand inflammation qPCR arrays were used based on a broad literature study on fracture healing and osteogenesis. Subsequently, possible targets of regulated ([ twofold) miRNAs were determined using Qiagen Ingenuity Pathway Analysis. Results: In total, fxh was harvested from 61 patients (mean age 52 ± 19; 32$). From the array data, a selection of twenty most regulated miRNAs, 10 up-and 10 down-regulated, was validated in the study population. Expression levels of seven out of these 20 miRNAs correlated to several clinical parameters (Fig. 1) . The time interval between trauma and surgery influenced the expression of three miR-NAs, other three miRNAs were expressed in a patient age dependent manner and one based on the severity of trauma. In silico target analysis revealed 260 mRNA targets for 14 out of the 20 validated miRNAs. Conclusions: This study portrayed the regulatory role and importance of miRNAs in human fxh, linked to key processes in fracture healing. The expression levels of seven validated miRNAs correlated with several clinical parameters and showed to be involved in multiple processes that are important in the fracture healing cascade, such as, angiogenesis mineralization. These data broaden our view on potential therapeutic implications of miRNAs in fracture healing. FIGURE 1 In silico target analysis, performed with Qiagen Ingenuity Pathway Analysis (IPA) software, of 7 miRNAs whose expression was dependent on the time interval between trauma and surgery, patient age, or severity of trauma. Green color represents upregulated miRNA expression, References: Results: The shooting of 2093 people at 45 separate events were described. Most common injury locations being: extremity 27.3% (197/722) followed by chest 23.0% (166/722) and abdomen 20.6% (149/722). The median number of operations and operated patients per event was 14 (IQR 10-86) and 9 (7-30), respectively. The median use of blood products was 277 units (IQR 256-280) per event. Vascular injuries ranged from 8%-29%, extremity vascular injury being most common. A total of 899 deaths were reported. The dominating causes of death were head injury in 29.4%, thoracic injury in 29.4%, and haemorrhagic shock or vascular trauma in 23.5% from 9 separate events. 8.2%-10% of all deaths involved specific vascular injuries; thoracic aorta (18%) followed by carotid (6%) and abdominal aorta (5%). Conclusions: Mass casualty shooting injuries are mainly located to the torso followed by the extremity. Vascular injuries vary from different events but about one quarter of deaths is related to haemorrhage involving central large vessel injuries. The data is sparse but further understanding of these injuries may improve outcome. Introduction: The injury severity score (ISS) continues to represent a key factor in assessing anatomic injury severity scoring and is based on the abbreviated injury scale (AIS). The advantages and disadvantages of the ISS and the AIS have been assessed in several studies. Thus, the aim of this work was to assess inter-observer variability of the AIS as well as the surgical priority and expected outcome of polytraumatized patients based on the rated AIS. Material & methods: A web-based survey using SurveyMonkeyÒ consisting of 35 questions related to the scoring of patients with multiple injuries was shared via E-Mail to members of the European Society of Trauma and Emergency Surgery (ESTES) between 28th of February 2018 and 28th of July 2019. Participants were asked for demographics age, sex, level of specialty training, trauma case load, working experience, surgical specialty and were then asked to rate the AIS of 10 fictive injured patients. Furthermore, participants were asked to rate the surgical priorities of the assessed body regions. Out of 10 presented cases in the survey, we picked the two most frequently answered cases for further analysis. Results: 102 participants (82% male) participated in this survey. 79.8% (79) of the participants were trauma surgeons. 46 Residents, 44 Attendings and 10 times a Head of department undertook the survey (N = 100). The mean work experience in years was 11.8 and the mean case load of polytraumatized patients per month was 11.9. 80% of the participants stated, that they were working in a level-1-trauma center. Out of 10 presented cases in the survey, the two most frequently answered cases were further analyzed. In case 1, 63% of the ratings differed from the pre-defined score according to AIS 2015Ò (68% in case 2). Trauma surgeons had a significant smaller number of wrong answers compared to their orthopaedic colleagues in case 1 (p = 0.038), but not in case 2 (p = 0.730). In both cases, no correlation between working experience or trauma case load and correct AISratings was seen. The mean calculated ISS in case 1 was 59.5 (SD 14.0), whereas the pre-defined ISS was 66. In case 2 the mean calculated ISS was 49.8 (SD 14.2), whereas the pre-defined ISS was 57. All respondents identified the displayed patients as polytraumatized. Conclusions: AIS and the directly connected ISS are overly rater dependent scoring tools with only questionable adequacy as classifiers for summarizing injury severity. However, inter-rater variability for the surgical priorities were relatively low and a relatively high agreement on injury severity and expected outcome was seen.

Trauma scores for decision making in polytrauma: one might not fit all. Introduction: Trauma is one of the leading causes of mortality and morbidity worldwide. Trauma scores allow to compare different trauma populations. They can also be valid allies in decision making and therefore should be selected carefully for our purpose. Scores have been shown to perform differently in relation to different outcomes [1] , and to be influenced by patients' age [2] . Some suggest the need for a score covering multiple physiological systems [3] such as the recently introduced Clinical Grading System (CGS). In our study, we compared ISS, NISS, CGS RTS, TRISS predictivity of mortality and morbidity in different age groups. Material & methods: This was a retrospective study on 369 polytrauma patients. We used Receiver operator Characteristic (ROC) curves for the prediction of Mortality, Hospitalization, Prolonged Hospitalization and ICU for each score through four age groups. Results: TRISS and RTS were the best predictors of mortality (AUC 0,973 and 0,930). Hospitalization was best predicted by NISS and ISS (AUC 0,864 and 0,862). ISS performed best in predicting ICU (AUC 0,902) and NISS in predicting long hospitalization (AUC 0,773). Predictivity decreased over 80 years of age for mortality, over 65 years of age for morbidity. CGS showed the best ability to predict ICU over 65 years (AUC 0,798). Conclusions: TRISS and RTS predict mortality better while morbidity is better predicted by anatomical scores. CGS is especially suited to predict ICU allocation in elderly patients. Introduction: The electric scooter is increasingly becoming a popular mode of transportation, especially in the central areas of large cities. Despite its use has been rising rapidly and many rental programs has been implemented, in Rome there are still no regulations for their use. The aim of this study is to analyze the types of injuries associated with the use of electric scooters, their incidence and its trend over time.

Material & methods: A retrospective analysis of patients presented to the emergency department for injuries associated with electric scooter between September 2019 and September 2021 was done. Results: During 24 months a total of 186 patients were admitted in the emergency department due to electric scooter associated injuries: 151 (81,2%) were riders of the scooter and 35 (18,8%) were nonriders. Mean age was 31 years (range 16-69), 109 were males and 77 were female. Interestingly there is a constant increase of cases over time: the number of cases was 46 in the first 12 months of the study and 140 in the following 12 months (an increase of more than three times in one year). Usually patients presented to the emergency department in the evening: 94% of patients arrived between 6.00 p.m. and 1.00 a.m. with a plateau around 10.00 p.m. The large majority of patients did not use helmet. The mean Injury Severity Score (ISS) was 4,1 (range 2-50) because the majority of patients had contusions/abrasions, minor wounds and/ or minor head injuries and has been discharged home within 12 h, thirty nine patients (20,9%) had ISS [ 9. The most frequent injuries involved the head (45,1%), the face (26,8%) and the upper limbs (43%), lower limbs (21,5%), chest (10,7%) and abdomen (8%) are involved less frequently. 42 Patients (22,5%) required admission in the hospital (5 in intensive care unit), 36 required an operation. There have been no mortality but 4 patients had permanent disability at discharge. Factors with higher likelihood of hospital admission included presentation to the hospital in the late evening/night (after 11 p.m.) (OR 2.17, p \ 0,05), loss of consciousness (OR 1.75 p \ 0,01), transport to the hospital by helicopter (OR 4.12, p \ 0,05) and use of anticoagulant or antiplatelet drugs (OR 5.17, p \ 0, 01) . Conclusions: The increasing popularity of electric scooter has been rising the rate of injuries associated with this mode of transportation: Abstracts the number of injuries and the types of injuries (with head injuries representing the main form of injury) show the urgent need for regulation of this mode of transport Introduction: Unlike many other types of weapons, firearms are of special interest due to their high lethality and criminal value. There is lacking data on the epidemiology of gunshot wounds in Central Europe in a clinical context and especially the clinical (resuscitation) management as well as the outcome of victims with sustained firearm injuries. Thus, the aim of this study was to review the current legal frameworks on firearms in Germany, Austria and Switzerland and secondly to retrospectively analyze the epidemiology of gunshot wounds, prehospital and clinical management as well as the outcome. Material & methods: All patients with sustained gunshot injury in the period from 1st January 2009 to 31st December 2019 who were transferred to a level 1 or 2 trauma center in Germany, Switzerland and Austria were analyzed retrospectively regarding trauma mechanism, injury severity, injured body region and mortality, using data from the TraumaRegister DGUÒ (TR-DGU). Results: In total, there were 111 gunshot victims in Austria (A), 102 in Switzerland (S) and 1099 in Germany (G) during the respected time period. The mean injury severity score (ISS) was 25 (A), 31.5 (S) and 23.4 (G). Almost 60% of all patients with gunshot wounds died in Austria, 52% in Switzerland and 42% in Germany. Overall, more than 50% of the gunshot injuries were due to suspected violent crime in the age group of 0 to 40 years. The incidence of suspected suicide increased rapidly from the age of 40 to up to 93.6% in patients aged above 80 years. Accidental gunshot wounds had a peak in patients aged \ 20 years (27.3%) and showed a steady decline with advanced age. The highest mortality in accidental gunshot wounds was seen in Austria (25%) followed by Switzerland (14.3%) and

Germany (11.2%), whereas death in suspected suicide occurred most often in Switzerland (82.1%), followed by Austria (75.3%) and Germany (63.7%). Most of the gunshots to the head were due to suspected suicide (83.4%), whereas gunshots to the body stem and the extremities were mainly due to suspected crime (51.3%-73.6%). Conclusions: Overall, gunshot wounds are rare, but there is evidence that gun laws may have an impact on gunshot wounds with suicidal intent.

Resuscitative endovascular balloon occlusion of the aorta with distal resuscitation (reboa-dr)-proof of concept for a novel resuscitative technique Introduction: Ischemia-reperfusion injury (IRI) following Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) remains the major determinant for maximal duration of aortic occlusion. Techniques for mitigating this IRI including partial or intermittent balloon deflation, and partial pREBOA catheter under development, remain predicated on acceptable physiological hemodynamics above the balloon prior to any deflation. We describe a novel technique using REBOA with Distal Resuscitation (REBOA-DR) and hypothesize that this can be utilized to infuse resuscitative fluids into the distal aorta during complete occlusion to potentially mitigate distal ischemia and aid in earlier identification of major vascular injury. Material & methods: Six (6) Yorkshire pigs weighing approx. 70 kg underwent an exploratory laparotomy and splenectomy, followed by hemorrhage of 25% estimated total blood volume to induce hemorrhagic shock. A [ 50% circumference injury was created in the iliac artery. A REBOA catheter was deployed in Zone I of the aorta through a 7-french sheath in the femoral artery contralateral to the injury to assess effects of extravasation and perfusion distal to this injury. Resuscitative crystalloid solution and contrast were infused alongside REBOA catheter through the single sheath in a pressurized retrograde fashion via a rapid infuser connected to sheath side-port. Results: Fluoroscopic images and videos showed proof-of-concept evidence for REBOA-DR where resuscitative solution is infused alongside a REBOA catheter via a single femoral arterial sheath. Infused contrast-laden resuscitative solution is noted to reach the renal and celiac vessels below the inflated REBOA balloon in zone 1 of the occluded aorta ( Fig. 1) . At the site of the iliac artery injury, evidence of flow is noted in the artery distal to injury despite extravasation of contrast (Fig. 2) . Conclusions: REBOA-DR provides an opportunity to perfuse distal organs during aortic occlusion without a need for additional arterial access. Resuscitative solution extravasation can potentially aid in localization of major vascular injury in the abdomen while affording partial limb perfusion. Application of REBOA-DR technique for reducing IRI and earlier intraoperative identification of injuries with limb perfusion await elucidation. 

A severe isolated injury is a high-risk entity for resource use and mortality: A Dutch national observational study Introduction: The Berlin polytrauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD, even though, they concern approximately 50% of patients with an injury severity score (ISS) C 16. Objectives: This study aims to describe the characteristics, resource use and outcome of patients with SII according to their injured body region, as well as the prevalence of physiological risk factors and their association with mortality. Furthermore, to adjudicate whether it is justified to exclude SII patients from trauma definitions like the BPD.

Material & methods: This retrospective observational study includes data from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score C 4 in one body region, with at most minor additional injuries (AIS B 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs. Finally, the association between the PRFs described in the BPD and mortality was analyzed.

Results: A total of 10.344 SII patients were included; 47.8% were admitted to the ICU, and the overall mortality was 19.5%. Compared to all other body regions the adjusted risk of death was highest for external (2.6, ) and for head SII (2.0, . Patients with SII to the abdomen (2.3, CI 1.9-2.7) and thorax (2.0, CI 1.8-2.3) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.1, CI 8. 1-12.6) .

The presence of C 1 PRFs was associated with a mortality rate of at least 15% for thoracic SII, 17% for spine SII, 22% for head SII and 49% for external SII. Conclusions: A severe isolated injury is a high-risk entity and should be recognized and treated as such. Injuries in the external region, head, spine, and thorax have a high impact on medical resources and pose a significant risk of death. The addition of PRFs to the anatomical injury criteria improves the identification of patients with SII at risk of worse outcomes. Table 1 Patient characteristics of patients with severe isolated injuries to the anatomical region of the head, thorax, spine, abdomen, extremity or external. Figure 1 Mortality of severe isolated injury patients who sustained injuries in the region of the head, thorax, abdomen, or extremities versus the presence of PRFs Secondary objective: to measure the predictive capacity of the new triage model in relation to patient outcome with respect to the Revised Trauma Score (RTS) and Injury Severity Score (ISS). Assumption: The COVID-19 pandemic has dramatically re-proposed the need to have a triage system capable of dividing patients into priority and urgency categories in maxi-emergency. To date, the most widely used international systems in the event of a traumatic event are the START and SIEVE algorithms. WHO and ICRC have recently proposed a new primary triage model, targeting low-resource systems. Material & methods: During a MACSIM training event (MAss Casualty SIMulation) aimed at 77 Emergency Medicine residents (MEU), training was offered on the 3 triage methods under study and on the MACSIM simulation system. The doctors, randomly divided into two groups (n1: 40, n2: 37), had the task of performing primary triage, simulating being at the gates of the PS, using the SIEVE algorithm (group 1) and WHO-ICRC (group 2) on 40 MACSIM patient cards, projected consecutively for a time of 20 s. The 40 MACSIM patients had already been previously assessed using the START triage model (20R, 9G, 11 V) and the RTS and ISS scores, used as a reference for the study. Participants in the study carried out their triage assessment using suitably prepared cards. In the end, they were also asked for subjective feedback, regarding the ease of use of the triage system they used compared to START triage (triage faster, more accurate, easier to learn, easier to apply). Results: SIEVE and WHO-ICRC were very consistent with the START model with respect to the primary assessment. In the study in question, there was a slight tendency of the SIEVE model to overestimate all degrees of priority. The WHO-ICRC model occasionally underestimated the GREEN code (p3). As for the feedback, the participants reported a greater accuracy of the WHO-ICRC model than the START but found the SIEVE easier to learn, to apply and faster to execute. Conclusions: WHO-ICRC is a valid alternative to international algorithms. It should be noted that this protocol provides for the assignment of the BLUE CODE, as opposed to the SIEVE and START models. Therefore, for statistical purposes, it was considered as RED (p1). Furthermore, the WHO-ICRC triage is designed for a reality setting with limited resources, difficult to apply to the European reality. Another consideration to be made is that the participants in the study were all doctors: this could have led to a tendency to make ''diagnoses'' and therefore give an incorrect value to the primary triage. It is interesting, in the future, to repeat the study with nurses and paramedics.

Pediatric burns from 2015-2019 at OUS-scalding still a common issue L. M. Svendsen 1 1 University of Oslo, Klinikk for hode, hals og rekonstruktiv kirurgi, Oslo, Norway.

Introduction: The goal of this study was to create an overview of pediatric burn injuries, with a special focus on scald burns among children \ 18 years of age. By examining the mechanisms of significant scald burns, the aim was to discover insight into prevention strategies.

Material & methods: Medical records for children \ 18 years of age, who were admitted with burn injuries between January 2015 and December 2019, were identified through the Oslo universitetssykehus (OUS), DIPS system. Demographic data and details of the circumstances and mechanism of injury were some of the variables extracted from the medical records. Results: 370 admissions to OUS during the 5-year study periode involved children with burn injuries. 271 were B 3-years of age and a majority (57.2%) of these children were males. Injuries typically occur during the winter months, in the child''s home with the mother present. The most common mechanism of injury was scald burns (78.9%) in both age groups B 3-years (88.2%) and [ 3-years of age (53.5%). First aid was initiated at the site of injury in 65.9% of the reported cases. Few patients were transferred to Haukeland universitetssykehus (HUS). 22.2% of the children were given DormicumÒ or KetalarÒ when arriving at OUS for assessment of the depth and extent of the burn, and wound cleaning. The mean TBSA expressed as % was 4.73 and 69.8% had TBSA B 5%. 64.1% of the children had superficial dermal IIa burn injuries mainly on their torso, 11.4% was in need of a partial thickness skin graft and 27.0% received antibiotics primarily because of a wound infection. Average hospital stay was 13 days and a little over 1/3 of the children had a follow-up session and the majority of these children had superficial, small burns. Conclusions: Current prevention strategies don''t adequately address the most common mechanism of scald injury requiring hospitalization. Many of the incidents could have been avoided. An objective of this study was to provide information to potentially target scald prevention programs or strategies. Prevention programs are important to improve awareness and decrease the incident of pediatric scald burns. The information can for example be incorporated into the «Helsestasjonsprogrammet 0-5 år» to make parents and caregivers more aware. This study aims to increase knowledge about scald injuries, what devastating effects they can have, how to avoid them, first aid, and how the treatment takes place at the hospital. Objective: This study of stable patients with AASW compared CECT based SNOM and diagnostic laparoscopy. Introduction: Penetrating abdominal trauma was traditionally managed by mandatory exploration which led to high rates of nontherapeutic surgery. Diagnostic Laparoscopy is less invasive, however general anesthesia is required, and risk of iatrogenic injuries persists. Image guided selective non-operative management avoids surgery altogether.

Material & methods: This prospective two-armed randomized study was conducted between April 2019 and February 2021. Hemodynamically stable patients with AASW were randomized to diagnostic laparoscopy (DL) and CECT based management. Exclusion criteria included hemodynamically unstable patients, evisceration or peritonitis, gunshot injuries, concomitant injuries requiring surgery. Primary outcome was length of hospital stay. Secondary outcomes were rate of non-therapeutic surgery, length of ICU stay and rate of complications. Results: One hundred six patients were randomized: 52 patients in DL group and 54 patients in CECT group. Demographics and clinical parameter were comparable. Mean length of stay was similar in both groups (3.5 days vs 3 days, p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (17.4% vs 65.4%, p = 0.0001). NOM based on CECT findings was successful in 93.8% of patients, 2 patients required delayed surgery. Conclusions: This study did not find any difference in length of hospital stay in patients undergoing DL or CECT. However, there was a significant reduction in non-therapeutic surgery by using CECT to evaluate these patients. Use of CECT as a screening tool did not lead to significant increase in missed injuries. Introduction: Renal injury is the most frequently encountered urogenital trauma, mainly caused by blunt trauma mechanism. Nonoperative management (NOM) for blunt low-grade renal trauma results in high success rates. However, no consensus exists on the management of high-grade renal injuries. The presence of urinary extravasation from the collecting system might be considered essential for decision making. We hypothesize that patients with minimal Abstracts urinary extravasation and retroperitoneal confinement can be treated without the need for open surgical intervention, or even percutaneous or endoscopic procedures. Material & methods: All patients with renal injury presented to our level one trauma center from 01-2007 to 12-2018 were retrospectively included. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on renal injury and the type of management. Interventions consisted of renal angio-embolization, JJstenting, percutaneous nephrostomy catheter, laparotomy with packing, or nephrectomy. Results: A total of 293 patients with renal injury were included with a median age of 32 years (20-55) and a median ISS of 20 (13-29). From the 293 included patients, 29 patients (10%) were admitted with a high grade renal injury. A total of 277 patients received non-interventional treatment without the need for interventions. Initially, 16 patients required immediate intervention for their renal injury (group B, of which 12 had a high grade injury). Six patients were treated primarily with angio-embolization for active hemorrhage on imaging. Furthermore, 15 patients showed urinary leakage on CT-scan with retroperitoneal confinement in 13 out of 15 patients, of which ten patients were treated without an intervention (C) and 5 patients with urinary leakage (D) underwent immediate intervention. In 2 out of the 10 patients without primary intervention for their urinary leakage, secondary procedures were needed. Conclusions: Hemodynamic stability dictates treatment in terms of laparotomy, angio-embolization or non-operative management. In hemodynamic stable patients with urinary leakage, retroperitoneal confinement dictates treatment in terms non-interventional management, which comes with satisfying success rates of 80%. Noninterventional management in hemodynamic stable patients with renal injuries results in a high renal salvage rate, regardless of renal injury severity. 

Introduction: Splenic injury is prevalent in trauma. Although splenectomy was the previous mainstay of management, there has been a shift non-operative management (NOM)1 including embolization. The formation of pseudoaneurysms (PSA), delayed bleeding and delayed rupture can all lead to failure of NOM2. Interventional Radiology (IR) embolization is now an integrated part of the NOM reducing the risks mentioned above. The aim of this study was to look at the incidence and management of PSAs at our institution and whether PSA is associated with failure of NOM. Materials & methods: This was a single centre retrospective study from a Major Trauma Centre. All adult trauma patients (blunt and penetrating) who sustained a splenic injury between January 2014 and September 2019. Results: 226 patients with splenic injury were identified. Of these, 169 were managed non-operatively, with 41 receiving IR embolisation. NOM was successful in 98.8% of cases. Overall, there were 19 cases of PSA (8.4%) in our cohort, with a median time of diagnosis of 2.4 days from injury. 3 patients with PSA underwent splenectomy. 11 patients with PSA underwent IR embolization, with no complications reported. Persistent PSA, defined as PSA seen on imaging post IR, was seen in 6 patients. One of these patients required further IR intervention, 3 had resolution of PSA on follow up and 2 did not have further imaging but remained clinically well. 5 patients with PSA were managed conservatively. Of these, half had follow up imaging, with all imaging confirming PSA resolution. Conclusions: NOM was successful in 98.8% of cases (compared to 80% success rate in the literature). Embolisation of PSA is associated with immediate thrombosis in only 58% of patients. However, PSAs may also auto-thrombose with time. Aggressive pursuit of PSAs in our institution is associated with a highly successful rate of NOM in splenic injury. Introduction: Damage control surgery (DCS) has been successfully applied in major intra-abdominal trauma and abdominal catastrophe. Previous studies using direct peritoneal resuscitation (DPR) as an adjunct to management of patients undergoing DCS have shown Abstracts promising results. The aim of this study was to report our initial experience in patients managed with DPR as adjunct technique in patients that underwent DCS. Material & methods: We studied 29 patients between August 2020 and July 2021 in our institution. DPR consisting of peritoneal lavage with DIANEAL PD-2 D 2.5% was used, and the patient outcomes were evaluated. Results: The median (interquartile range: IQR) age was 63 (55.5-71.5) years; 69% were male, and median (IQR) body mass index was 30. 1 (25.4-38.6 ) kg/m2. The majority (62%) of patients required DCS due to peritonitis or septic abdomen. Median (IQR) APACHE IV score was 46.5 (32-60.8) and Acute Physiology Score (APS) was 34 (25-50.5) on DPR initiation. Median (IQR) duration of DPR was 5 (2-8) days and primary abdominal closure was achieved in 25 patients (86%). The most frequent complication was surgical site infection recorded in 8 patients (27.6%). Frequency distribution of other complications and outcomes are presented in Table 1 . Overall, 21 (72.4%) patients were either discharged home or transferred to rehab center/nursing home. Overall postoperative mortality was 27.6%. Conclusions: In this study of 29 patients, we achieved an 86% rate of definitive abdominal closure at the index hospitalization. Further well designed, and controlled multi-institutional investigations are needed to confirm the efficacy of DPR. Introduction: Mild traumatic brain injury (mTBI) occupies one of the first places in children injuries. Among all brain networks at the resting state, the Default Mode Network (DMN) is the most widely studied network. The aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mTBI using rsfmRI. Material & methods: 34 MR negative participants were studied in age from 12 to 17 years (mean age-14.5 years). Group of patients consisted of 17 children with mild traumatic brain injury in acute stage. 17 age-matched healthy volunteers comprised control group. All studies were performed at Phillips Achieva 3.0 T MRI scanner using 32-channel head coil. fMRI data were processed using functional connectivity toolbox CONN. Seed-based analysis was performed in order to reveal disturbances in functional connectivity.Statistical processing was performed using Statistica 12. Results: DTI analysis didn't show any changes in values of apparent diffusion coefficient (ADC) and fractional anisotropy (FA) between two groups. No statistically significant differences in correlation strength between DMN parts were observed in two groups. Intergroup seed-based analysis revealed statistically significant (p \ 0,05) difference in neural correlations between DMN parts and flocculus (cerebellum structural part): positive link in control group and negative link in group of patients. Conclusions: One of the most common symptoms of mTBI is dizziness as a result of impaired movements coordination. Flocculus as an essential cerebellum part plays an important role in the vestibulo-ocular system which is involved in the learning of basic motor skills in the brain. Flocculus aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together. Our results show that mTBI appears to be a possible reason of connectivity malfunction in normal-appearing vermis.

The effects of patient age on treatment intensity and mortality in Traumatic Brain Injury (TBI) O. Skaansar 1 , C. Tverdal 1 , P. Rønning 1 , K. Skogen 1 , T. Brommeland 1 , O. Røise 1 , M. Aarhus 1 , N. Andelic 1 , E. Helseth 1 1 Oslo University Hospital, Neurosurgery, Oslo, Norway Introduction: Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a selffulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI. Materials & methods: Included in this study was patients consecutively admitted to Oslo University Hospital with TBI, aged C 15 years, with a cerebral CT showing intracranial signs of trauma, during [2015] [2016] [2017] [2018] . As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Main outcome variable was 30-day mortality. Results: A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years, 70% were men, and 39% were C 65 years. Head injury severity was mild in 45%, moderate in 28%, and severe in 27%. Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score C 3, and low management intensity. Conclusions: The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of a selffulfilling prophecy. Skaansar et al., Traumatic brain injury-the effects of patient age on treatment intensity and mortality BMC Neurology (2020) Background: In recent years ''new'' direct oral anticoagulants (DOAC) gradually replaced other antithrombotic therapies. International literature agrees on an increased mortality for traumatic brain injury (TBI) patients using vitamin K antagonists (VKA), but there isn''t sufficient data on the influence of DOAC on the outcome of TBI. Methods: We retrospectively analyzed data from patients who presented with head trauma using antithrombotic therapy. Outcome parameters were presence of pathologies on the initial CT, occurrence of delayed intracranial hemorrhage, surgical intervention and death. Results: In total we reviewed data of 1169 patients. 92.7% had a mild TBI, 5.7% moderate TBI and 1.5% severe TBI. 456 patients used DOAC and 713 patients used VKA, antiplatelet therapy or prophylactic doses of low molecular weight heparin at the time of trauma. The groups showed no significant differences in age, injury mechanisms or GCS at presentation. Patients with head trauma and DOAC therapy without other antithrombotic medication had pathological findings on CT in 4.9%, patients with VKA in 4.8% and patients with antiplatelet therapy in 10.6%. There was a statistically significant difference in occurrence of CT pathologies between DOAC alone compared to ASS (4.9 vs. 10.5%, p = 0.04). Delayed intracranial hemorrhage after an initial negative CT during in-house observation occurred in 0.2% of the DOAC group, 0.9% in the VKA group and 0.9% in the antiplatelet group. Head trauma related surgery was performed in 0.7% of the DOAC group, 0.9% of the VKA group and 1.3% in the antiplatelet group. Death due to the head trauma occurred in 0.7% of the DOAC group compared to 0.4% of the VKA group and 0.2% of the antiplatelet group. Conclusions: Our data suggests a comparable risk for pathological CT findings, delayed intracranial hemorrhage, surgical interventions and death after blunt head trauma for patients with DOAC compared to VKA but a lower risk for pathological CT findings compared to platelet inhibitors. It is known that VKA increase mortality, so our data suggests that similar caution should be used when treating patients with head trauma and DOAC.

The value of metabolites, lipoproteins, and vitamins in the assessment of nutritional status in severely injured patients during Intensive Care Unit admission Introduction: Objective measurement of the nutritional status is a major challenge, especially in severely injured patients (SIP). This observational prospective study aimed to identify metabolites, lipoproteins and vitamins that can be used to assess nutritional status of SIP during ICU admission.

Material & methods: In 27 SIP, plasma metabolite and lipoprotein concentrations were analyzed in relation to the diagnosis of malnutrition (Subjective Global Assessment (SGA) B 5) through partial least squares discriminant analysis. Metabolites and lipoproteins with a Variable Importance in Projection (VIP) score C 1.5 were considered potentially useful for discrimination between well-nourished and malnourished SIP at day 5 of ICU admission. In the 10 SIP that developed malnutrition during ICU admission, the mean metabolite and lipoprotein levels on day 1-3 were compared to mean concentrations in the first days malnutrition was diagnosed (paired samples T-test). Mean Vitamin D levels and the amount of samples with insufficient vitamin D levels (\ 50 nmol/L) were also compared between the well-nourished and malnourished SIP (resp. Independent samples T-test and Fisher''s exact test). Results: An increase of VLDL, LDL and IDL, and a decrease of HDL particle levels were related to malnutrition (VIP C 1.5). Increased total cholesterol and creatine concentrations were associated with malnutrition in the 10 patients \ 55 years, and decreased concentrations of both metabolites were associated with malnutrition in the 8 patients C 55 years. In both age groups, several amino acids (alanine, glycine, leucine, lysine, and valine), 2-hydroxybutyric acid, and succinic acid were increased, and tyrosine and glucose were decreased in case of malnutrition. Vitamin D was not found to be related to malnutrition. Conclusions: Several lipoproteins and metabolites seem to be associated with malnutrition in SIP and show potential for serving as an objective parameter for malnutrition in trauma patients. Figure 1 : Metabolites potentially associated with malnutrition in critically ill patients based on currently available literature [1, 2] Introduction: The Swedish National Trauma Triage Criteria (SNTTC) [1] , implemented in 2017, is divided into three levels; Trauma Alert, Trauma Response or Cautions. The SNTTC have previously been examined for under-and overtriage [2] but not for accuracy of the criteria. The aim of the study was to evaluate the SNTTC with regard to its accuracy in predicting a severely injured patient or a patient in need for an emergency intervention. Material & methods: Data was collected from six hospitals in Sweden via the Swedish Trauma Registry. The analyzed population consisted of 626 patients examined with regard to the New Injury Severity Score (NISS), performed emergency interventions and the criterion used to initiate the trauma call. Sensitivity, specificity, positive predictive value (PPV) and positive likelihood ratio (LR ?) were calculated, as well as undertriage and overtriage. Results: The SNTTC as a whole had a sensitivity [ 80% for a severely injured patient. The Trauma Alert Criteria had the highest accuracy (AUC 0.724), higher LR ? (3.5 vs all criteria 1.4), specificity (82.3 vs 39.1%) and PPV (55.4 vs 37.6%) but a lower sensitivity of 62.6%. With the physiological criteria alone, LR ? (6.7), specificity (93.3%) and PPV (70.2%) improved compared to Trauma Alert Criteria, however, sensitivity (44.8%) and accuracy (AUC 0.690) decreased. Conclusions: Severely injured patients and patients in need for an emergency intervention are efficiently identified by the SNTTC, which also exhibits the best sensitivity compared to other examined combinations. No additional criterion was found to improve the protocol enough to promote a change. 

Introduction: Traumatic cardiac arrest (TCA) is a severe and lifethreatening situation that mandates urgent action. Outcomes after onscene treatment of TCA in the Netherlands are currently unknown.

The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS). Material & methods: A retrospective cohort study was performed including patients C 18 years with TCA for which the Dutch HEMS were dispatched between January 1st 2014 and December 31st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge. Results: Nine-hundred-fifteen patients with confirmed TCA were included (table 1) . ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age \ 70 years (0.7% vs. 5.2%; p = 0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p \ 0.001) were associated with increased odds of survival (table 2) . Conclusions: Neurologic intact survival is possible after prehospital traumatic cardiac arrest. Younger patients and patients with a shockable ECG rhythm have higher survival rates after TCA. Introduction: Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. [1] [2] [3] As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. [4] [5] [6] [7] [8] This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients.

Material & methods: All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS C 3 with an AIS B 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0,1,2,3, C 4) and inhospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. Results: 259,399 patients met the study''s inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI): 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI): 1.17 (1.05-1.31), p = 0.004], and RCRI C 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.46 (1.11-1.90) , p = 0.006], compared to RCRI 0. Conclusions: An elevated RCRI C 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population. The Injury Prevention and Outcomes following Trauma (IPOT) project: a nationwide registry-based study in Norway Introduction: Traumatic injuries constitute a major cause of mortality and morbidity. Still, the public health burden of trauma in Norway has not previously been characterized by the use of nationwide registry data. The aim of the project is to establish a comprehensive research database, where the Norwegian National Trauma Registry (NTR) will be merged with several data sources to pursue three main research topics: 1) the public health burden of trauma (e.g. excess mortality, disability-adjusted life-years), 2) trauma aetiology (e.g. socioeconomic factors, comorbidity, drug use), and 3) trauma survivorship (e.g. survival, drug use, use of welfare benefits, work ability, education, income). Material & methods: Trauma patients included in the NTR from 01.01.2015 to 31.12.2018 will be coupled with data from Statistics Norway, the Norwegian Patient Registry, the Cause of Death Registry, the Registry of Primary Health Care, and the Norwegian Prescription Database. To quantify the public health burden, DALYs will be calculated from the NTR. To address trauma aetiology, we will conduct nested case-control studies with trauma-free controls (drawn from the National Population Register) matched to each trauma case on birth year, sex and index date. Conditional logistic regression models will be used to estimate trauma risk according to relevant exposures. To address trauma survivorship, we will use cohort and matched cohort designs and time-to-event analyses to examine various post-trauma outcomes. Results: A total of 26,652 trauma patients were included in the analysis and coupled with 265,620 trauma-free controls drawn from the National Population register. All variables in the data set included one year before trauma (2014) until two years after (2020). The data set consists of more than 500 million datapoints. The protocol has been published [1] . Conclusions: Coupled registry data is a potential solution as more knowledge is warranted on trauma risk factors and long-term outcomes. Establishment of a Norwegian prospective nationwide registry coupled with central health registries is feasible, and analyses addressing the main research topics will follow. Introduction: Prehospital identification of major injuries is essential for decision-making, but even expert clinicians may be inaccurate. The degree to which clinician uncertainty affects accuracy is unknown. We aim to determine the diagnostic accuracy of prehospital clinical assessment to identify major injuries, determine the effect of clinician uncertainty on accuracy, and analyse factors associated with inaccuracy.

Material & methods: Retrospective evaluation of diagnostic performance of prehospital trauma clinicians compared to in-hospital diagnosis. Patients included all adults (C 16 years) injured in 2019-2020, assessed by London's Air Ambulance and conveyed to the Royal London Hospital. Diagnostic accuracy was calculated for 22 major injuries, and 9 abbreviated injury scale (AIS) regions. Subgroup analyses were conducted based on clinician certainty of injuries. Multivariate logistical regression analyses were conducted for each AIS region, with inaccuracy as the dependent variable, and patient, clinician, and environmental factors as independent variables. Results: 921 patients met inclusion criteria for the study. Overall accuracy of prehospital clinical assessment was 92%, sensitivity 43%, specificity 96%, positive predictive value 51%, and negative predictive value 95%. Clinicians were more uncertain of head and torso injuries (range 25%-40%) than extremity injuries (6-10%). Overall accuracy when clinicians were certain was 93%, reducing to 39% when clinicians were uncertain (Fig. 1) . The risk of inaccuracy increased when the patient was multiply injured (odds ratios (OR) and 95% confidence intervals (CI) ranged from 1.84 (1.02-3.32) to 7.29 (1.94-47.8)), and the clinician was uncertain (OR 3.8 (95% CI 0.96-12.8) to 311 (89.1-1567)). Conclusions: The impact of clinician uncertainty on prehospital diagnostic accuracy of injuries is profound. These data will help inform solutions for improving prehospital diagnostic accuracy and reducing uncertainty, such as diagnostic adjuncts and clinical decision support. Introduction: Failure to identify serious injury may lead to delayed diagnostics and lifesaving interventions. Trauma team activation (TTA) is based on specific criteria (i.e. physiologic, anatomic, mechanism of injury and other) to ensure rapid therapeutic interventions upon hospital admission. Severely injured patients not by trauma team is often referred to as undertriage [1] . The aim of this study was to assess if undertriaged trauma patients were eligible for TTA based on pre-hospital documentation. Results: The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018 (Fig. 1) . During this period on average 70% of these patients were directly admitted to a TC (range 63-74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS (Fig. 2) , than those directly transported to a NTC. Conclusions: Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving prehospital triage, to facilitate swift transfer of the right patient to the right hospital. Introduction: The seasonal variability in major trauma injuries and presentation is a well-known phenomenon. However, the COVID-19 pandemic and the associated UK nationwide lockdown led to an unprecedented change in societal behaviours and opportunities for harm that ultimately led to the well reported decreases in admissions of major injured patients. It is not known whether this new variation in patterns and demographics of injuries seen during the lockdown would be temporary or an enduring phenomenon post-covid.

Material & methods: This prospective cohort study included all patients admitted following major trauma injuries during the 10-weeks of 9th March-18th May 2020 (lockdown cohort), compared with those patients admitted during the 10-weeks from the 4th July 2020-12th September 2020 (post-lockdown cohort) at our Major Trauma Centres in the United Kingdom. The outcomes of interest were volume, spectrum and mechanism of injuries presenting to the major trauma centre during lockdown and post-lockdown and the associated risk of 30-day mortality. Results: A total of 692 major trauma admissions were included in this analysis. Of these, 237 patients were admitted during the lockdown and 455 patients admitted post-lockdown. This represented a twofold increase in trauma admission between the two periods. Characteristically, both cohorts had a higher proportion of male patients (73.84% male in lockdown, 72.5% male post-lockdown). There was a noted shift in age groups between both cohorts with an overall more elderly population during lockdown (p = 0.0292), There was a significant difference in mechanisms of injury between the two cohorts. The 3-commonest mechanisms during the lockdown period were: Road traffic accidents-31.22%, Falls of less than 2 m-26.58% and falls greater than 2 m causing 22.78% of major trauma admissions. However, in the post-lockdown period Road traffic accidents represented 46.15% of all trauma admissions with falls greater than 2 m causing 17.80% and falls less than 2 m causing 15.16% of major trauma injuries. With falls in the elderly associated with an increased risk of 30-day mortality. Conclusions: The lifting of lockdown restrictions resulted in a twofold increase in major trauma admissions that was also associated with significant changes in both the demographic and patterns of injuries with Road traffic accidents contributing almost half of all injury presentations. Trial registration: This study was classed as service evaluation and registered with the local audit department, registration number: 20-177C.

The association of radiologic body composition parameters with clinical outcomes in level-1 trauma patients-A retrospective cohort study Introduction: The present study aims to assess whether CT-measured muscle mass, muscle density and visceral adipose tissue are associated with complications and other clinical outcomes in trauma patients.

Material & methods: A retrospective cohort study was conducted on adult patients admitted to the University Medical Center Utrecht following a trauma between January 1 st and December 31 st , 2017. Trauma patients aged 16 years or older without severe neurological injuries, who underwent a CT that included the abdomen within 7 days of admission, were included. An artificial intelligence (AI) algorithm was used to retrieve muscle areas to calculate the psoas muscle index (PMI) and to retrieve psoas muscle density (PMD) and visceral adipose tissue (VAT) area from axial CT images. Multivariable logistic and linear regression analyses were performed to assess associations between body composition parameters and outcomes.

Results: A total of 404 patients were included for analysis. The median age was 49 (interquartile range [IQR] 30-64), and 66.6% were male. Severe comorbidities (ASA 3-4) were seen in 10.9%, and the median ISS was 9 (IQR 5-14). PMI was not independently associated with complications. There were independent associations between PMI and an unfavorable Glasgow Outcome Scale (GOS Conclusions: In level-1 trauma patients without severe neurological injuries, psoas muscle density was associated with complications, whereas psoas muscle area was not. Visceral adipose tissue was associated with delirium. Automatically retrieved body composition parameters are able to identify patients at risk for complications and other adverse outcomes. Introduction: Calcium is an essential part of the major haemorrhage protocol (MHP) in major trauma. It minimize the exacerbation of transfusion related coagulopathies due to the citrate preservative in transfused blood binding to ionised calcium in plasma leading to a further reduction in plasma calcium and thus is unable to participate in the coagulation cascade as an essential co-factor. Up to 50% of trauma patients may present with hypocalcaemia prior to transfusion and especially in patients with a shock index [ 1, this leads to the risk of exacerbated coagulopathies (1) . Given the importance of the issue we were surprised at the sparse guideline and exact protocol for calcium administration in the MHP. An audit was completed at Nottingham University Hospital in 2019, analysing the percentage of patients who received calcium as part of a massive transfusion and the incidence of hypocalcaemia. Our initial quality improvement project in 2019 showed 75% of patients received calcium supplementation, with only 10% of patients achieving a corrected serum calcium. The implementation of this audit lead to a change to the MHP transfusion guidelines, making it mandatory to consider calcium administration. A second closed loop was performed in 2021 to review the effects of this change in guideline. Material & methods: Retrospective review of patients with activated MHP between May and July 2021. Documentation was reviewed whether calcium was administrated as part of the major transfusion guideline.In absence of a current exact standard we recommend that 100% of all massive transfusion should have received calcium. A massive transfusion was defined as 10 red blood cells units or more in 24 h, 3 within an hour or any 4 blood products within 30 min. Data was collected using the Trauma Audit and Research Network (TARN) database and our digital health records (DHR). Results: Of the 52 patients in which the MHP was activated, 46 patients were included in the audit due to lack of documentation in 6 patients. Comparing the initial loop in 2019 to the new loop in 2021 there was 3.8 fold increase in patients who received the MHP. Out of these 10/12 (75%) received calcium and on average after 6.4 units of blood products in the first loop. In the second loop 23/46 (50%) received calcium supplementation and on average sooner, after 4 units Abstracts of blood products. 1/10 (10%) of patients had their calcium corrected to normal range in the first loop compared to 18/23 (78.3%) in the second loop. Conclusions: We have achieved to create an effective amendment to the MHP guideline within our trust recommending that all patients with activated MHP transfusion protocol should receive supplementary calcium as to avoid exacerbated coagulopathy. The implemented change has led to a significant improvement in corrected serum calcium levels in patients who received major transfusions. There still are avenues to improve the calcium administration in our trauma centre. We recommend placing the new adapted MHP guideline into the into the major haemorrhage packs. This leaves us with the bigger question, should we give prophylactic calcium to all our trauma patients who are bleeding? The References: 1. Vasudeva, M., Mathew, J.K., Fitzgerald, J.K., Hypocalcaemia and traumatic coagulopathy: an obvservation al analysis, Voc Sanguinis Impact of preinjury antithrombotic therapy on 30-day mortality in older patients hospitalized with traumatic brain injury (TBI) in the era of antithrombotic reversal protocols. Oslo University Hospital, Neurosurgery, Oslo, Norway Introduction: Antithrombotic therapy, comprising antiplatelet and anticoagulant drugs, is frequently used in the elderly population. Although antithrombotic therapy reduces the risk of ischemic events in patients with cardiovascular disease, atrial fibrillation, and venous thromboembolism, they are associated with an increased risk of spontaneous and traumatic intracranial bleeding. Nevertheless, the effect of these drugs on survival and functional outcome after traumatic brain injury (TBI) is unclear. Contemporary TBI series after the introduction of direct oral anticoagulants (DOACs) are needed to evaluate the current risk of preinjury antithrombotic use in TBI patients from centers that have implemented protocols for reversal of antithrombotic drugs. Material & methods: This retrospective study included patients C 65 years admitted to a Norwegian Level 1 trauma center with TBI identified on cerebral computed tomography (cerebral-CT) during 2014-2019. The primary outcome was 30-day mortality. Uni-and multivariate logistic regression analyses estimated the association between the use of antithrombotic drugs and mortality. A reversal protocol for antithrombotics was used throughout the study period. Results: The study includes 832 consecutive TBI patients C 65 years. The median age was 76 years, 58% were males, and 50% had moderate/severe TBI. Preinjury use of antithrombotics was registered in 471/832 (55.6%) patients; antiplatelet therapy alone in 268, anticoagulant therapy alone in 172, and combined antiplatelet and anticoagulant therapy in 31. Combined use of antiplatelet and anticoagulant therapy was significantly associated with 30-day mortality, while preinjury antiplatelet or anticoagulation treatment alone was not. No difference in 30-day mortality between patients using vitamin K antagonists (VKAs), DOACs, and low molecular weight heparins (LMWH) was encountered. Conclusions: In this cohort, neither antiplatelet nor anticoagulant therapy alone was associated with increased 30-days mortality. Combined antiplatelet and anticoagulant therapy posed increased risk of 30-days mortality. Introduction: Multiple injured patients may continue to exhibit hemodynamic instability after bleeding control has been attempted by operative or endovascular interventions, this instability may be due to unrecognized persistent bleeding or severe inflammatory response syndrome (SIRS). Our objective was to determine which is the best marker for early identification of persistent bleeding in unstable trauma patients. Material & methods: Severe trauma patients were prospectively enrolled from 3/2016 to 5/2019. Definitive interventions for hemorrhage were recorded and defined as ongoing need for transfusion; use of vasoactive drugs and need for surgical/angio-embolization for definitive bleeding control. At the 8th hour of arrival hemodynamic status was re-evaluated and patients with hypotension (\ 90 mmHg), tachycardia ([ 100 bpm) or in vasopressor support were considered hemodynamically unstable. Two groups were defined: ''Persistent bleeding'' (PB) (patients who needed at least one definitive intervention) and ''Systemic Inflammatory response'' (SIR) (who didn''t need any). Resuscitation markers were evaluated and ROTEM results were classified in 5 phenotypes, according to the degree of abnormality observed (0 = normal; 1 = fibrinogen deficiency; 2 = hypocoagulability; 3 = platelet deficiency; 4 = global deficiency; 5 = global deficiency hyperfibrinolysis). Results: A total of 66 consecutive patients were included: Mean age 42 years (SD 15), male 80%, median ISS 25.5 (IQR 8-68) and mortality 18.2%. Nine patients were excluded (3 patients died \ 8th hour and 6 died of severe head trauma). IR. p \ 0,05. Persistent hemodynamic instability was found in 40 patients; 25 were found to have persistent bleeding (18 needed blood cell transfusion, 6 needed surgery and 3 needed embolization for bleeding control) and 15 had SIRS. ROTEM in patients with persistent bleeding group 3-4-5 ([ 3) were statistically significant different when compared with ROTEM in SIRS patients ROTEM groups 0-1-2 versus (p = 0,026). Conclusions: An abnormal ROTEM phenotype higher or equal to 3 found 8 h after trauma was associated with clinically relevant persistent bleeding. Figure 1 : Table comparing mean values of statistically significative variables between persistent bleeding and inflamatory response Introduction: In this study, we investigated the effects of antithrombin III administration on the prognosis of severe trauma patients with disseminated intravascular coagulation. Material & methods: From January 2012 to December 2019, 140 patients with DIC were enrolled among severe trauma patients with an ISS score of 16 or higher who were admitted to the trauma-ICU during the period. These patients were classified into antithrombin IIIadministered and non-antithrombin III-administered groups. And their clinical data including laboratory finding, trauma and ICU related severity score, prognosis include length of stay of hospital, and needs of organ supports were collected retrospectively. Through statistical analysis of the collected clinical information, the effect of antithorombin III administration for severe trauma patient with DIC was analyzed. Results: Of the 140 enrolled patients, 61 were treated with anthrombin III and 79 were not administered with anthrombin III. When comparing the two groups, there was no statistically significant difference in the baseline characteristics of the two groups in initial laboratory result, initial vital sign, and trauma related severity score (AIS, ISS, RTS) ( Table 1) . As a prognostic marker, changes of SOFA score of two groups were compared. The improvement of SOFA score (Delta SOFA) was statistically significantly greater in the administered group. (P = 0.009) (Fig. 1 ). In addition, it was confirmed that the larger the improvement of the SOFA score, the greater the proportion of the antithrombin-administered group than the non-administered group. (P = 0.002) (Fig. 2) . However, there was no statistical difference between two groups in the frequency or duration of organ support treatments such as renal replacement therapy and mechanical ventilation. (Table 2 ) And mortality (28 days, Overall) length of stay (ICU, total hospital) did not show a significant difference (Table 3) . Conclusions: Administration of antithrombin III to severe trauma patients with DIC features showed improvement in SOFA score, and it helps in recovery from multi organ dysfunction. And if appropriate indications are studied in the future, it will be possible to maximize the improvement effect of this drug in patients with severe trauma. Introduction: Tissue injury (TI) and hemorrhagic shock (HS) are major drivers of trauma induced coagulopathy (TIC). Injured patients with TIC typically have combined TI and HS. We developed a large animal model to isolate TI and HS and characterize the mechanisms of these individual insults on TIC. We hypothesized that both HS and TS decreased clot strength, but only HS increased hyperfibrinolysis.

Material & methods: 50 kg Yorkshire swine were randomized into 3 groups: isolated TI (bilateral chest wall and femur fractures), isolated HS (bleeding to a base deficit of 10 mEq/l followed by resuscitation with shed blood) or Controls (no injury). Viscoelastic coagulation assays, PAI-1, TAFI, protein-C, and histones were analyzed at preselected timepoints. Linear mixed models for repeated measures were used to compare HS vs TI vs Controls over time; p-values were FDR adjusted for pairwise comparisons.

Results: The temporal trends were significantly different across study groups for PAI-1 (p = 0.046), calcium (p = 0.001) and clot strength (p = 0.004). TAFI and protein-C levels were stable for all groups. PAI-1 increased significantly in HS and was higher than in TI and Controls after resuscitation ( Fig. 1:A) . Calcium decreased immediately postinjury in HS but improved during resuscitation ( Fig. 1:B) . Clot strength decreased significantly immediately after injury in HS, and improved with resuscitation ( Fig. 1:C) . PAI-1, calcium and MA stayed stable in TI and Controls. Fibrinolysis was higher in the HS group, but the differences did not reach significance. The TI group showed a significant increase in histones at 120 min (p = 0.02) then declined to baseline levels.

Conclusions: These results suggest that resuscitation of HS induces an increase in PAI-1, which has been shown to be associated with decreased fibrinolysis. The HS-induced hypocalcemia with diminished clot strength did respond to resuscitation. Isolated TI leads to early histone release, but this was not associated with TIC. Introduction: Early identification of casualties at risk of developing trauma-induced coagulopathy (TIC) is necessary to guide strategic decisions in trauma care, such as a damage control approach to resuscitation and surgery. An artificial intelligence (AI) risk prediction system has been developed to support decision-making following civilian trauma but was not validated in military casualties Objectives: We aimed to update and validate the AI prediction system for military trauma casualties Material & methods: Data was obtained from the UK Joint Theatre Trauma Registry, comprising UK military personnel injured in Afghanistan between 2009-2014 with laboratory testing of coagulation on arrival at a Medical Treatment Facility. Literature and experts were used to inform the updating of the model structure. The parameters of the variables were learned from data. The parameters of latent variables were learned from a combination of rules-based classification and data clustering, followed by expert review of discrepancies. Internal tenfold cross-validation was conducted to test the model's performance in terms of discrimination, calibration, and accuracy Results: Our development cohort included 678 combat casualties with median age 24 (18-55) years. 675 (99.6%) were male, with a median Injury Severity Score of 9 (Interquartile range 4-20). Overall mortality was 2.9%. The incidence of TIC was 9.5%. The updated model structure included new variables such as blast mechanism, injuries characteristic of military trauma, and estimated blood loss per injury. Calibration was good (intercept -0.023, slope 1.3) and discrimination was excellent (Area under the receiver operator curve 0.95 (95% CI 0.92-0.97). Accuracy was 0.91, with Brier score 0.06 and Brier skill score 0.50 Conclusions: An updated and recalibrated AI risk prediction system for TIC has excellent performance in military casualties. This performance is equivalent to that seen with the previous model in civilian patients. Being able to prognosticate risk of TIC from information Abstracts gathered only at initial clinical assessment will enable earlier treatment decisions tailored to individual needs

Responder and Non-responder to resuscitation show different lipidomic courses in porcine poly trauma model Lipidomics is a new research method analyzing specific lipids, that has revealed new lipid-based inflammatory mechanisms responsible for several pathophysiological conditions [1] . We hypothesized that lipids may also contributes to the systemic physiological process during resuscitation and recovery after trauma. In the current study, we investigated the relation between responsiveness to resuscitation and lipidomic changes after trauma in poly trauma pig model Material & methods: 25 male pigs received a combined injury of blunt chest trauma, a liver laceration, controlled hemorrhagic shock, and femoral shaft fracture. After 60 min animals received resuscitation and fracture stabilization. Venous blood was taken regularly from baseline until 6 h post trauma. Animals were divided into two groups based on serum lactate level at the end point (\ 2 mmol/L; Responder (R), ] 2 mmol/L; Non responder (NR)) and lipidomic analysis was performed retrospectively Results: Eighteen animals were assigned to R group and 7 to NR group. Five lipid subgroups (Diacylglyceroles, Triacylglycerols, Phosphatidylethanolamines, Ceramides, and Phosphatidylglycerols) showed a significant increase only in R group 2 h after trauma compared with BL. Acylcarnitines showed a significant increase after trauma in both groups Conclusions: Five lipid groups increased only in R group. This result indicates that changes of these lipid sub groups were related to responsiveness to resuscitation. Whereas, Acylcarnitines increased in both groups, suggesting possibility to become a biomarker for trauma. Individual pathways have yet to be investigated and collation with clinical data is needed References: Introduction: Occult hypoperfusion (OH) and persistent lactat acidosis may be continuously present after resuscitation in severe trauma and hemorrhage. Systemic vital parameters might be normalized after resuscitation, however, the microcirculation is still impaired. This study was performed in order to assess the effect of occult hypoperfusion on local and systemic inflammation Materials & methods: Male Swiss landrace pigs went under general anaesthesia and served as a standardized polytrauma model. This included a femur shaft fracture, liver laceration, blunt chest trauma, and mean arterial pressure (MAP) controlled hemorrhagic shock. One hour after trauma resuscitation included retrograde femoral nailing, inserting a chest tube if necessary, volume controlled fluid therapy and liver packing. For a total of 6 h after trauma, blood gas analysis (BGA) was taken every hour, and the local perfusion at the femoral fracture was measured utilizing oxygen to see (O2C) device. Perifracture local soft tissue (fatty tissue, and muscle) was taken 6 h after trauma and analyzed for interleukines via PCR. Results were compared 6 h after trauma Results: This study included 24 animals, 5 (20.8%) had persistent lactic acidosis ([ 2 mmol after 6 h) and fulfilled the criteria for occult hypoperfusion (OH). Group OH had significantly higher pCO2 levels, and significantly lower pH values when compared with the control (p \ 0.05). The local oxygenation was significantly lower in Group OH (60.4 versus 75.8, p = 0.049). The local hemoglobin amount was significantly lower in Group OH (39.4 vs. 63.9, p = 0.031). The perifracture local inflammation of fatty tissue was significantly higher in Group OH for IL8 (442.9 vs 72.3, p = 0.05) and for IL6 (318.3 vs. 73.9, p = 0.03) Conclusions: Persistent lactic acidosis serves as an indicator for local occult hypoperfusion. The increased local inflammation might impair local healing and increase the risk for further complications and should be taken into consideration during polytrauma management

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach. Open Access Maced

Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values

Medical Response to Major Incidents

A consensus-based gold standard for the evaluation of mass casualty triage systems

Major incident triage and the implementation of a new triage tool, the MPTT-24

Metabolites Associated With Malnutrition in the Intensive Care Unit Are Also Associated With 28-Day Mortality

Rapid decreases of key antioxidant molecules in critically ill patients: A personalized approach

1-palmitoyl-glycerophosphoethanolamine; 2-HB, 2-Hydroxybutyrate; 3-HB, 3-Hydroxybutyrate; 3-HIBA, 3-Hydroxyisobutyrate

Ace, Acetate; Ala, Alanine; Arg, Arginine; AS, Argininosuccinate; a-KG, a-ketoglutarate

Bet, Betaine; Car, Carnitine

Glutamate-1-semialdehyde

3-(4-hydroxyphenyl)lactate

Impact of Preinjury Antithrombotic Therapy on 30-Day Mortality in Older Patients Hospitalized With Traumatic Brain Injury (TBI). Front Neurol

Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes

A meta-analysis to determine the effect of anticoagulation on mortality in patients with blunt head trauma

A meta-analysis to determine the effect of preinjury antiplatelet agents on mortality in patients with blunt head trauma

Impact of antithrombotic agents on radiological lesion progression in acute traumatic brain injury: A CENTER-TBI propensity-matched cohort analysis

The novel oral anticoagulants (NOACs) have worse outcomes compared with warfarin in patients with intracranial hemorrhage after TBI

Antithrombin supplementation and risk of bleeding in patients with sepsis-associated disseminated intravascular coagulation

A randomized, controlled, multicenter trial of the effects of antithrombin on disseminated intravascular coagulation in patients with sepsis

Efficacy and safety of anticoagulant therapy in three specific populations with sepsis: a meta-analysis of randomized controlled trials

High-dose antithrombin III in the treatment of severe sepsis in patients with a high risk of death: efficacy and safety

Antithrombin Supplementation and Mortality in Sepsis-Induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study

Abstracts