Karlijn Julia Patricia van Wessem

Purpose: Comprehensive data on epidemiology, trauma mechanisms, associated injuries, and outcomes of traumatic sternal fractures are scarce. This study analysed nationwide data to improve diagnosis and management within the Dutch healthcare system. Methods: This nationwide retrospective cohort study using the Dutch National Trauma Registry included adult patients admitted with traumatic sternal fractures between 2015 and 2023. Patients with prehospital cardiopulmonary resuscitation or penetrating trauma were excluded. Incidence, patient characteristics, trauma mechanisms, associated injuries, and in-hospital outcomes were analysed. Subgroup analyses evaluated patients with concomitant blunt cardiac injury (BCI). Results: Of 568,399 adult trauma admissions, 4,765 patients (0.84%) sustained traumatic sternal fractures. Median age was 62 years; 60% were male. Motor vehicle accidents (48%) and falls (28%) were the leading mechanisms. 35% were severely injured (ISS ≥ 16). Associated injuries included rib fractures (51%), spinal fractures (36%), and lung contusions (18%). Critical care unit admission was 40%, with median mechanical ventilation duration of 4 days; median hospital stay was 5 days. In-hospital mortality was 5.7%, and 30-day mortality 6.0%. BCI occurred in 9.5% of patients and was associated with a higher number of injuries and increased injury severity, emergency interventions, and critical care admission, but not higher mortality. Conclusion: Traumatic sternal fractures are uncommon, but the incidence in The Netherlands is gradually rising. Sternal fractures frequently occur with severe multisystem injuries. Patients with BCI showed greater injury severity and resource needs. Future research should focus on criteria and clinical significance of BCI, and sternal fracture-specific outcomes and treatment strategies in large patient cohorts.

Objectives: Bilateral transverse thoracosternotomy (“clamshell”) is widely used for (heart-)lung transplantations, but postoperative sternal complications are a significant challenge. The primary objective of this systematic review was to evaluate the prevalence of sternal complications after clamshell surgery in (heart-)lung transplantation patients. Methods: A systematic literature review was conducted. On April 4, 2025, PubMed and Embase databases were searched. Original studies reporting sternal complications after clamshell surgery in adults for bilateral lung or heart-lung transplantation were included. Studies including <10 patients were excluded. Study quality was assessed using the National Institutes of Health assessment tool. The total and range of sternal complication prevalence was provided. Meta-analysis of sternal complication prevalence was not performed due to significant heterogeneity across studies. Results: The database searches yielded 945 eligible articles. Eighteen studies were included, including 828 patients who underwent a total of 830 bilateral lung or heart-lung transplantations through clamshell surgery. All included studies were cohort studies with poor (n = 15), fair (n = 1), or good (n = 2) quality. In total, 286 sternal complications were reported (0.34 event per clamshell surgery; range 0.02 to 1.35 in individual studies) and 90 sternal reoperations were conducted (0.14 reoperation per clamshell surgery; range 0.02 to 0.29 in individual studies). Conclusions: Despite limitations in study quality and heterogeneity, this review highlights the high prevalence and relevance of sternal complications following clamshell surgery for (heart-)lung transplantation. Future studies should focus on patient selection, risk stratification, development of modified sternal closure techniques, and implementation of alternative surgical approaches to (heart-)lung transplantation.

Purpose: A time sequence occurs in pathogens leading to infections in Intensive Care Unit (ICU) patients with a compromised immune system. A similar pattern may also occur in (multi)trauma patients characterized by similar impaired immunological responses. Such immune malfunction might be prolonged and enable hospital-acquired pathogens (selected through antibiotic regimens) to cause infections. This study investigated the timing of infections and associated pathogens in severely injured trauma patients. Methods: A retrospective, single-center cohort study was conducted at a level-1 trauma center. Severely injured trauma patients from 2013 to 2022 with an ICU stay >48 hours were included. Infections compliant with the criteria of the Centers for Disease Control and Prevention and causative pathogens were documented. Timing of infections was scored as days after trauma. Results: 109 out of 572 severely injured trauma patients developed infectious complications. All patients received antibiotics. A time sequence of pathogens that caused infections was observed. Staphylococcus aureus, Enterococcus spp., and CoNS were mainly responsible for infections before day 40 after trauma. From day 60 onward, Klebsiella spp., Candida spp., Enterobacter spp., and Pseudomonas spp. became more frequent. Conclusion: A time sequence in occurrence of pathogens and associated infections was found in severely injured trauma patients. Commensal micro-organisms were predominant in the first weeks after trauma, which shifted toward hospital-acquired microorganisms over time. This observed time sequence is consistent with the hypothesis that a long-term imbalanced innate immune system facilitates infections with these normally non-pathogenic organisms during months after severe trauma. Level of evidence: This was a retrospective cohort study with level III evidence.

Introduction: Resuscitation strategies for severely injured patients have shifted toward reduced crystalloids and increased balanced blood product resuscitation, including Fresh Frozen Plasma (FFP) to reduce organ failure and mortality. However, FFP is associated with higher infection and sepsis risks. This study investigated the impact of resuscitation changes on inflammatory complications and mortality. Methods: This 11-year cohort study included severely injured patients (> 15 years) admitted to a Level-1 Trauma Center ICU. Exclusions included isolated head injuries, drowning, asphyxiation, burns, and deaths < 48 h. Data on demographics, resuscitation, inflammatory complications (MODS, ARDS, infections, thromboembolism), and mortality were collected. Results: Among 585 patients (median age 46,72% male, ISS 29, 94% blunt injuries), 18% developed MODS, 3% ARDS, 45% infections, 9% thromboembolism, and 14% died. Over time, crystalloids ≤ 24 h decreased while FFP ≤ 24 h increased, correlating with reduced ARDS but increased thromboembolic events. Crystalloids ≤ 24 h independently predicted MODS, infections, and mortality, while FFP ≤ 24 h was linked to MODS and thromboembolism. Causes of death other than neurological included MODS (5%), sepsis (3%), and ARDS (1%), with no deaths from thromboembolic complications. Conclusion: Resuscitation evolved toward less crystalloids and more FFP ≤ 24 h, likely reducing ARDS but increasing thromboembolic complications, while other outcomes remained comparable. Low mortality from inflammatory complications suggests these complications were mild. The anti-inflammatory, immune-modulating effect of FFP might have played a role in the attenuation of these complications, supporting current resuscitation strategies. However, improved identification of patients who require FFPs may help reduce thromboembolism. In the future, optimal FFP dosage should be determined to balance coagulopathy correction, blood volume restoration, and management of the inflammatory response following trauma.

Background Nosocomial pneumonia is common in trauma patients and associated with an adverse prognosis. We recently externally validated and recalibrated an existing formula to predict nosocomial pneumonia risk. Identifying more potential predictors could aid in a more accurate prediction of nosocomial pneumonia risk in level-1 trauma patients. This study aims to identify predictors of nosocomial pneumonia in level-1 trauma patients available in the emergency department or shortly after, and examine their added predictive value to an existing prediction model by Croce. Methods This retrospective cohort study included all consecutive trauma patients (≥ 16 years) admitted for > 24 h to our level-1 trauma center in 2017. Excluded were patients with active infection upon admission, transfer from another hospital, or in-hospital mortality < 48 h. Multiple imputations were used for missing values. Multivariable logistic regression analysis and Ridge penalization were performed to assess the association of predictors with nosocomial pneumonia and evaluate predictor stability. The predictive performance in addition to the existing prediction model was evaluated as well. Results The study included 809 patients [median age 51 (IQR 32–68) years, 66.9% male, median ISS 10 (5–17), median GCS score 15 (14–15)]. Pneumonia incidence was 10.6% (n = 86). Age (OR 1.03 per year), ISS (OR 1.10 per point), GCS score (OR 0.91 per point), pulmonary contusion (OR 2.77), male sex (OR 1.36), hypertension (OR 1.86), diabetes (OR 1.20), number of rib fractures (OR 1.05 per fractured rib), and thoracic spine fracture (OR 1.51) were found to be predictors of nosocomial pneumonia. All variables showed added predictive value in addition to the existing model. Conclusion Patient history, injury severity, thoracic trauma, and traumatic brain injury are essential components of nosocomial pneumonia prediction and add to the predictive value of an existing model. Our results further build a basis for more accurate prediction. Level of evidence Level III, prognostic/epidemiological.

Introduction: Advances in trauma care have attributed to a decrease in mortality and change in cause of death. Consequently, exsanguination and traumatic brain injury (TBI) have become the most common causes of death. Exsanguination decreased by early hemorrhage control strategies, whereas TBI has become a global health problem. The aim of this study was to investigate trends in injury severity,physiology, treatment and mortality in the last decade. Methods: In 2014, a prospective cohort study was started including consecutive severely injured trauma patients > 15 years admitted to a Level-1 Trauma Center ICU. Demographics, physiology, resuscitation, and outcome parameters were prospectively collected. Results: Five hundred and seventy-eight severely injured patients with predominantly blunt injuries (94%) were included. Seventy-two percent were male with a median age of 46 (28–61) years, and ISS of 29 (22–38). Overall mortality rate was 18% (106/578) with TBI (66%, 70/106) being the largest cause of death. Less than 1% (5/578) died of exsanguination. Trend analysis of the 10-year period revealed similar mortality rates despite an ISS increase in the last 2 years. No significant differences in demographics,and physiology in ED were noted. Resuscitation strategy changed to less crystalloids and more FFP. Risk factors for mortality were age, brain injury severity, base deficit, hypoxia, and crystalloid resuscitation. Discussion: TBI was the single largest cause of death in severely injured patients in the last decade. With an aging population TBI will increase and become the next epidemic in trauma. Future research should focus on brain injury prevention and decreasing the inflammatory response in brain tissue causing secondary damage, as was previously done in other parts of the body.

Purpose: Trauma triggers a systemic inflammatory cellular response due to tissue damage, potentially leading to a secondary immune deficiency. Trauma severity is quantified by the Injury Severity Score (ISS). Severe Traumatic Brain Injury (TBI) is associated with high ISSs due to high lethality, despite limited tissue damage. Therefore, ISS might overestimate the post-traumatic inflammatory cellular response. This study investigated the effect of TBI on the occurrence of different systemic neutrophil phenotypes as alternative read-out for systemic inflammation. Methods: A single-center retrospective cohort study was conducted at a level-1 trauma center. Patients aged ≥ 18 years, admitted between 01-03-2021–01-11-2022 and providing a diagnostic blood sample were included. Four groups were created: isolated TBI, isolated non-TBI, multitrauma TBI and multitrauma non-TBI. Primary outcome was occurrence of different neutrophil phenotypes determined by automated flow cytometry. Secondary outcome was infectious complications. Results: In total, 404 patients were included. TBI and non-TBI patients demonstrated similar occurrences of different neutrophil phenotypes. However, isolated TBI patients had higher ISSs than their isolated non-TBI controls who suffered similar post-traumatic inflammatory cellular responses. Regardless of the type of injury, patients exhibiting higher systemic inflammation had a high infection risk. Conclusion: When TBI is involved, ISS tends to be higher compared to similar patients in the absence of TBI. However, TBI patients did not demonstrate an increased inflammatory cellular response compared to non-TBI patients. Therefore, TBI does not add much to the inflammatory cellular response in trauma patients. The degree of the inflammatory response was related to the incidence of infectious complications.

Background: The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. Methods: From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. Results: Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). Conclusion: In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.