Tanya Anand

The provision of nutrition in adult trauma patients requires a detailed and personalized approach to achieve optimal patient outcomes. Initial assessment for malnutrition is required in all patients, as the hypermetabolic state of acute trauma may exacerbate malnutrition risk during the acute phase. Initial assessment in ICU patients includes determination of nutrition risk (high vs. low) using the modified NUTRIC or NRS scores and evaluation for malnutrition. In critically ill trauma patients, indirect calorimetry is most accurate for determination of calorie/protein requirements. Early enteral nutrition is recommended when resuscitation is complete. Continuous gastric feeds are recommended, with postpyloric jejunal feeding for patients at high risk of aspiration. In patients with enteral feeding intolerance and ileus, prokinetic agents should be implemented first, followed by postpyloric feeding tube if persistent feeding intolerance. Parenteral nutrition should be initiated if enteral nutrition is contraindicated (intestinal obstruction, severe ileus, high-output fistula, ischemia), and in patients who cannot achieve goal enteral nutrition. In patients with shock requiring vasopressors, an individualized approach should evaluate the risks and benefits of early enteral nutrition versus the potential risk of nonocclusive mesenteric ischemia. Critically ill geriatric, obese, and cirrhotic trauma patients warrant specialized nutrition care. Immunonutrition, glutamine, and probiotics/prebiotics are not currently recommended for trauma or burn patients.

BACKGROUND: Injured older adults account for nearly 25% of trauma admissions nationwide with increased morbidity and mortality compared with younger adults. Endothelial dysfunction has been associated with poor outcomes in trauma patients. We hypothesized that posttraumatic endothelial changes in older versus younger adult trauma patients will be different with worse outcomes in older adults. METHODS: This is a retrospective secondary analysis of the “Tranexamic Acid (TXA) in Traumatic Brain Injury” prehospital database (2015–2017). We studied patients with admission endothelial biomarkers: intercellular adhesion molecule 1, angiotensin 1, thrombomodulin, vascular cell adhesion molecule 1 (VCAM 1), angiotensin 2, syndecan-1, and thrombospondin. We divided patients into age quartiles and compared the oldest quartile (older age [OA] group) with the three youngest quartiles (younger age [YA] group). In-hospital, discharge, and mortality outcomes were compared. Significance was set at p < 0.05. RESULTS: A total of 436 patients were included. The mean age in OA group was 66 years (55–88 years, n = 108). The YA mean age was 30 years (15–54 years, n = 328). There was no difference between OA and YA in rates of blunt trauma (98.1% vs. 96.3%, p = 0.61), head abbreviated injury scale (mean, 2.83 vs. 2.93; p = 0.582), or Injury Severity Score (mean, 21 vs. 19; p = 0.29). Tranexamic acid dosing was not different between cohorts (p = 0.571). Overall, the OA group had higher thrombomodulin (median, 693.3 vs. 592.9 pg/mL; p = 0.0008), VCAM 1 (median, 70,852 vs. 59,738 pg/mL; p = 0.0015), and angiotensin 2 (median, 165.3 vs. 134.2 pg/mL; p = 0.005). When comparing endothelial biomarkers of OA to each YA age quartile subsets, in the 2g TXA group OA patients had significantly higher syndecan-1 levels from a subset of YA (37 to 54-year-olds, p = 0.034). In the 2g TXA group OA patients had significantly lower plasma thrombomodulin, angiotensin 2, and VCAM 1 (p = 0.00001, p = 0.0032, and p = 0.0002, respectively) than patients in the placebo group. None of the biomarkers were independent predictors of 28-day mortality. CONCLUSION: Despite similar injury patterns, OA presented with higher admission endothelial plasma biomarkers. The OA patients receiving 2 g of TXA had significantly different endothelial biomarker levels versus YA group. These differences suggest that OA patients have a different baseline endothelial function prior to injury and that TXA may have a more pronounced effect on injured OA versus YA endothelium. LEVEL OF EVIDENCE: Therapeutic Care Management; Level IV.

Hemorrhagic shock from traumatic injury results in a massive systemic response with activation of the hypothalamic–pituitary–adrenal (HPA) axis, pro-thrombotic and clot-lysis pathways as well as development of an endotheliopathy. With ongoing hemorrhage, these responses become dysregulated and are associated with worsening coagulopathy, microvascular dysfunction, and increased transfusion requirements. Our transfusion practices as well as our understanding of the molecular response to hemorrhage have undergone significant advancement during war. Currently, resuscitation practices address the benefit of the early recognition and management of acute coagulopathy and advocates for balanced resuscitation with either whole blood or a 1:1 ratio of packed red blood cells to fresh frozen plasma (respectively). However, a significant volume of evidence in the last two decades has recognized the importance of the early modulation of traumatic endotheliopathy and the HPA axis via the early administration of plasma, whole blood, and adjunctive treatments such as tranexamic acid (TXA) and calcium. This evidence compels us to rethink our understanding of ‘balanced resuscitation’ and begin creating a more structured practice to address additional competing priorities beyond coagulopathy. The following manuscript reviews the benefits of addressing the additional interrelated physiologic responses to hemorrhage and seeks to expand beyond our understanding of ‘balanced resuscitation’.

Zangbar and colleagues1 present a timely and essential study comparing medical and combined (combination of medical costs and value of a statistical life) costs associated with fatal geriatric falls to those from fatal firearm injuries. Their findings reveal an increasing incidence and rise in medical costs for geriatric falls over the years, with a marked increase in combined costs for fatal falls among adults aged 45–85 since 2019. The study highlights geriatric falls as a greater economic burden and is a call for immediate prioritization of preventive measures to minimize the incidence of falls.