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1.
Hanish Kataria Robin Kaushik Simrandeep Singh Rajeev Sharma 《Hellēnikē cheirourgikē. Acta chirurgica Hellenica》2017,89(2):121-125
Background
Although blunt abdominal trauma is frequently encountered, isolated duodenal injury is relatively uncommon. The management of such patients is challenging and various surgical procedures are described for their management.Methods
Two patients presented to our emergency department with isolated duodenal injuries (transection and devascularisation) secondary to blunt abdominal trauma.Results
Both patients underwent exploratory laparotomy, revealing transection of the duodenum along with proximal devascularization and detachment of mesentery at duodeno-jejunal junction without any other intra-abdominal injury (especially pancreas, colon, vena cava) for which pancreas-sparing duodenectomy (infra-ampullary) was performed.Conclusion
Pancreas-sparing duodenectomy is a valuable tool in the management of duodenal trauma, allowing the surgeon (and the patient) to avoid the complications of major surgical resections.2.
Antonios Papadomanolakis Eleni Theodoridou Nikistratos Vogiatzis Alexandra Pentheroudaki Despoina Daskalaki Evangelos D. Lolis 《World journal of surgery》2016,40(6):1355-1361
Background
About 50 cases of azygos venous system injuries following civilian trauma have been published in current literature. The purpose of our study was to investigate the incidence of these injuries, the causative mechanism and type of trauma, the co-existing injuries, and the mortality rate in our institution.Methods
We performed a retrospective review of all trauma patients who were admitted to the surgical department of the General Hospital of Rethymno during an 11-year period. Our study included patients arriving at our institution dead or alive with an azygos venous system injury following blunt or penetrating civilian trauma.Results
Seven patients—five men and two women—were identified with azygos venous system injuries. Five had an azygos vein laceration, one suffered from both azygos and hemiazygos vein lacerations, and the last one had sustained hemiazygos and accessory hemiazygos vein injuries. All of them suffered from a blunt trauma. Three arrived at our hospital in extremis, and all died within 24 h despite our resuscitation attempts. All of our patients were polytrauma patients. All of them had co-existing torso injuries which were severe in all but one case, three of them suffered also from serious head injuries, and all but one had at least serious extremity’s injuries.Conclusion
Azygos venous system injuries are rare, although it seems that they are more frequent than current literature would indicate. Blunt trauma mechanism seems to be predominant in civilian trauma setting, and the patients have usually sustained a lot of serious and severe co-existing injuries with high resultant lethality.3.
Manuel Ribeiro da Silva Daniela Linhares Pedro Cacho Rodrigues Eurico Lisboa Monteiro Manuel Santos Carvalho Pedro Negrão Rui Peixoto Pinto Nuno Neves 《International orthopaedics》2016,40(6):1111-1116
Purpose
This observational study aims to describe pediatric C-spine injuries from a level 1 trauma centre through a period of 19 years.Methods
Clinical records of pediatric trauma patients admitted to a level 1 trauma centre between 1991 and 2009 were analyzed. Patients were stratified by age into groups A (8 or less) and B (9 to 16), and in lower (C0-C2) and upper (C3-C7) spine injuries. Several variables were studied.Results
Seventy-five cases of C-spine injuries (nine SCIWORA) were identified. Group A included 23 patients and group B 52. In group A, skeletal injuries at the upper C-spine were more common than injuries at the lower C-spine, whereas in group B, injuries of the lower C-spine were more frequent (p?=?0.035). Motor vehicle accidents were the main cause of injury (44 %); 25.3 % of patients were surgically treated. Thirty-nine patients presented neurologic deficits, 16 of which improved. The overall mortality rate was 18.7 % and significantly higher in patients with neurological damages (p?<?0.001)Conclusions
This study revealed a low incidence of cervical spine injuries in the paediatric population. As in previous reports younger children mainly sustained injuries at the upper C-spine, higher incidence of spinal injuries, and higher risk of death than older children.4.
Algorithm for activation of coagulation support treatment in multiple injured patients––cohort study
Background
Early recognition and management of trauma related coagulopathy improves the outcome. Trauma facilities should implement an algorithm to identify the bleeding trauma patient with coagulopathy.Objective
The scope of the paper is to identify the indicators of early coagulopathy and to optimize the indications for thromboelastometry and coagulation support.Design
Cohort study based on data from trauma registry.Setting
Data of 493 major trauma patients treated in GH Celje from 2006 to 2014 were included into The TraumaRegister DGU® (TR-DGU).Patients
Patients were selected for inclusion into TR-DGU according to the following criteria: polytraumatized patients with Injury severity score (ISS) ≥ 18, patients with injuries to single region with AIS 5, patients with major injuries to a single region and abnormal vital signs. All patients that were dead on arrival to hospital, patients presented to hospital >24 h after the injury, and head injuries that occurred with a low energy mechanism in patients on anticoagulation drugs were excluded.Measurements
Two groups were formed (with or without coagulopathy). Mortality, morbidity, length of mechanical ventilation, ICU and hospital stay were used as outcome and compared between the groups. A coagulopathy prediction model (CPM) was developed to identify the patients who were at high risk of coagulopathy.Results
Coagulopathy was present in 51 % of patients. Severe injuries to the torso and limbs, infusion of >1000 ml of fluids in the prehospital settings, and hypotension were included into CPM. If all three criteria were present, the sensitivity of the model to predict coagulopathy was 93 %. By adding the blood gas analysis (BE ≤ ?5), the specificity increased to 81.7 %.Limitations
Shortcomings of our analysis are mainly related to the quality of data in the registry that may not be comparable to a clinical trial where data are collected specifically to address a given issue.Conclusions
The Criteria for activation of coagulation support treatment remain centre dependent. In our settings the CPM is the tool to select patients for ROTEM® analysis. By adding data from blood gas analysis, treatment of coagulopathy is justifiable before complete test results are available.5.
6.
Purpose of Review
Renal embolization (RE) is a minimally invasive endovascular procedure performed primarily by interventional radiology that can be used to treat a variety of urologic conditions including malignant renal tumors, angiomyolipomas, renal trauma, and complications following biopsy. The following review examines renal embolization indications, technique, and potential complications.Recent Findings
Renal embolization is a versatile therapeutic and adjunctive tool for many acute and chronic urologic conditions. RE has become a first-line therapy for renal trauma in lower grade injuries and increasing in prevalence for higher grade injuries. Additionally, the safety and efficacy of chemoembolization for primary treatment of renal cell carcinoma is under evaluation.Summary
A multidisciplinary approach between urology and interventional radiology should be pursued for all patients undergoing renal embolization regardless of indication. Preprocedural planning and careful monitoring of complications should be performed to optimize clinical outcomes.7.
U. Bakal M. Sarac T. Tartar E. B. Cigsar A. Kazez 《European journal of trauma and emergency surgery》2016,42(5):599-603
Purpose
The aim of this study was to review our 20 years of experience determining the common mechanisms of perineal trauma and initial management to evaluate the effects of classification for treatment.Methods
A total of 75 children with perineal injuries were reviewed retrospectively, including patient demographics, mechanism of injury, associated injuries, injury severity score, presenting symptoms and methods of diagnosis and treatment.Results
Amongst the 75 children (55 females and 20 males; mean age, 8 years), fall from height, followed by motor vehicle crash and sexual abuse were the most common reasons for injury. The most common symptom on presentation was bleeding, followed by abdominopelvic pain and tenderness. Eleven patients were allowed to heal secondarily, and 64 were examined under general anaesthesia. The affected area was repaired in 48, further diagnostic tools were needed in 20 and 11 cystoscopic, 10 rectoscopic, and 5 vaginoscopic evaluations were performed. Six patients with full-thickness injuries that extended to the peritoneum were treated with colostomy, and all were victims of motor vehicle crashes.Conclusion
The genital injury score is a useful genital trauma scale for predicting anogenital injury severity. Identifying the mechanism and severity of perineal and associated injuries under general anaesthesia may facilitate appropriate classification and management.8.
Purpose
Spinal immobilization is a standard procedure in emergency medicine. Increasing awareness of complications associated with immobilization of trauma patients leads to controversial discussions in the literature. Current guidelines require to include considerations of accident mechanism, an assessment of the patient’s condition and an examination of the spine in the decision-making process if immobilization of the spine should be performed. This requires sound knowledge of assessing these parameters. The aim of the current study is to analyze German paramedics’ subjective uncertainty in terms of their prehospital assessment and treatment of patients suffering from spine injuries.Methods
Over a period of 17 months participants in a trauma course were asked to complete a standardized anonymous questionnaire about subjective uncertainty of prehospital assessment and management of spinal trauma before participation in that course. Questions about the frequency of application of different immobilization tools and skills training on spinal immobilization were also asked.Results
A total of 465 paramedics were surveyed. The participants did not indicate any uncertainty about the prehospital diagnosis and treatment of spinal injuries. The feeling of confidence was significantly greater in participants who had already attended another course on structured trauma care before. The participants agreed with the statements that standardized algorithms facilitate teamwork and that there is a need for a protocol for the prehospital treatment of spinal injuries.Conclusions
Paramedics do not feel uncertain about the prehospital assessment and treatment of spinal injuries. The feeling of confidence in participants who had already attended a course on the treatment of trauma patients before was significantly higher.9.
10.
Importance
In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care.Objective
To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients.Design
We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention.Setting
The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi.Participants
All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014).Intervention
Lay people were trained to take and record vital signs.Main outcomes and measures
The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis.Results
Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded.Conclusions and relevance
The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.11.
Introduction
The objective of this study was to review the trauma workload and operative exposure in a major South African trauma center and provide a comparison with contemporary experience from major military conflict.Materials and methods
All patients admitted to the PMTS following trauma were identified from the HEMR. Basic demographic data including mechanism of injury and body region injured were reviewed. All operative procedures were categorized. The total operative volume was compared with those available from contemporary literature documenting experience from military conflict in Afghanistan. Operative volume was converted to number of cases per year for comparison.Results
During the 4-year study period, 11,548 patients were admitted to our trauma center. Eighty-four percent were male and the mean age was 29 years. There were 4974 cases of penetrating trauma, of which 3820 (77%) were stab wounds (SWs), 1006 (20%) gunshot wounds (GSWs) and the remaining 148 (3%) were animal injuries. There were 6574 cases of blunt trauma. The mechanism of injuries was as follows: assaults 2956, road traffic accidents 2674, falls 664, hangings 67, animal injuries 42, sports injury 29 and other injuries 142. A total of 4207 operations were performed. The volumes per year were equivalent to those reported from the military surgical literature.Conclusion
South Africa has sufficient burden of trauma to train combat surgeons. Each index case as identified from the military surgery literature has a sufficient volume in our center. Based on our work load, a 6-month rotation should be sufficient to provide exposure to almost all the major traumatic conditions likely to be encountered on the modern battlefield.12.
Background
Prior to the advent of whole body computed tomography, injuries of the adrenal gland were almost exclusively identified on postmortem examinations and were associated with severe injury. Recent literature has continued to identify an association between adrenal injuries and high ISS. The purpose of this study was to assess the influence of adrenal trauma on ISS and mortality while controlling for potential confounding factors.Methods
A 15-year retrospective review for all adrenal gland injuries from a Level 1 Trauma Center’s Trauma Registry was performed. Based on the characteristics of that patient population, the same Trauma Registry was then queried for case-matched patients, and the two groups compared to assess the influence of adrenal gland injuries on mortality.Results
Seventy-two patients with adrenal injuries were identified and compared to 1026 case-matched patients. The adrenal gland injury was not a contributing factor in any of the study group mortalities. The mean ISS for the adrenal gland injured group was higher than the overall Registry ISS (18.7 vs 10.6) but almost identical to the ISS of patients case matched for abdominal injuries.Conclusion
Case-matched analysis based on multiple clinical variables demonstrates that the ISS of patients with adrenal gland injuries were similar to the ISS of patients with other injuries to the abdominal region and were in fact associated with a 0.02% decrease in mortality.13.
Alexander R. Vaccaro Gregory D. Schroeder Christopher K. Kepler F. Cumhur Oner Luiz R. Vialle Frank Kandziora John D. Koerner Mark F. Kurd Max Reinhold Klaus J. Schnake Jens Chapman Bizhan Aarabi Michael G. Fehlings Marcel F. Dvorak 《European spine journal》2016,25(4):1087-1094
Purpose
The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system.Methods
A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed.Results
The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30 % of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70 % of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five.Conclusion
The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.14.
P. Störmann S. Wutzler K. Sommer I. Marzi F. Walcher T. Lustenberger 《Notfall & Rettungsmedizin》2016,19(6):442-450
Background
Injury severity following penetrating trauma may range from simple soft tissue injuries to complex and life-threatening multiple organ lesions. The purpose of this article is to offer basic guidelines in the management of patients with penetrating trauma.Method
Research and analysis of the current literature.Results and conclusions
The emergency room management is structured according to the ATLS® (Advanced Trauma Life Support) and S3 Polytrauma Guidelines. Life-threatening injuries have to be diagnosed early to minimize the time delay to operative intervention, in particular in the hemodynamically unstable patient. The clinical examination is the basis for further diagnostic studies and therapy and includes inspection of the penetrating wound as well as a “full-body examination” to exclude other injuries. With the sonographic examination according to the FAST (“focussed assessment with sonography for trauma”) protocol, free intraabdominal and pericardial fluid can be detected. Subsequent diagnostic examinations are based on the hemodynamic status of the patient. In case of hemodynamic instability, damage control procedures such as emergency room thoracotomy or emergency room laparotomies may be performed.15.
Background
Despite improvements in prevention and rescue, mortality rates after severe blunt trauma continue to be a problem. The present study analyses mortality patterns in a representative blunt trauma population, specifically the influence of demographic, injury pattern, location and timing of death.Methods
Patients that died between 1 January 2004 and 31 December 2005 were subjected to a standardised autopsy. Inclusion criteria: death from blunt trauma due to road traffic injuries (Injury Severity Score ≥ 16), patients from a defined geographical area and death on scene or in hospital. Exclusion criteria: suicide, homicide, penetrating trauma and monotrauma including isolated head injury. Statistical analyses included Student’s t test (parametric), Mann–Whitney U test (nonparametric) or Chi-square test.Results
A total of 277 consecutive injured patients were included in this study (mean age 46.1 ± 23 years; 67.5% males), 40.5% of which had an ISS of 75. A unimodal distribution of mortality was observed in blunt trauma patients. The most frequently injured body regions with the highest severity were the head (38.6%), chest (26.7%), or both head and chest (11.0%). The cumulative analysis of mortality showed that several factors, such as injury pattern and regional location of collisions, also affected the pattern of mortality.Conclusions
The majority of patients died on scene from severe head and thoracic injuries. A homogenous distribution of death was observed after an initial peak of death on scene. Moreover, several factors such as injury pattern and regional location of collisions may also affect the pattern of mortality.16.
Background
Tibial plateau fractures represent 1–2?% of all human fractures. Complex fractures affecting the tibial joint surface and accompanying injuries of the soft tissue covering can be a special challenge for surgeons. This paper provides the current state of treatment options.Classification
In German-speaking countries the classification of the Working Group for Osteosynthesis (Arbeitsgemeinschaft für Osteosynthesefragen, AO) is accepted as the gold standard but in English-speaking countries the classification by Schatzker is preferred.Diagnostics
The severity of the soft tissue injury is the main factor for determining the time of operation and for perioperative decision making. The gold standards in imaging diagnostics are conventional x-ray photographs in two planes and computed tomography plus 3D reconstruction. Magnetic resonance imaging plays the most important role in evaluating concomitant injuries of ligaments and menisci.Therapy
One of the main goals is to avoid posttraumatic arthritis of the knee joint. Time and fracture management depend on the so-called personality of the fracture. Screws and locking plates are most commonly used as implants. The importance of arthroscopically assisted surgery is increasing. For filling bone defects artificial bone graft substitutes are inserted more frequently.Conclusion
The long-term outcome of surgically treated younger patients with low energy trauma seems to be good. Poorer results can be expected in cases with high energy trauma and higher degrees of destruction of the tibial joint surface. The ongoing research on operation techniques, implants and bone graft substitutes aims at improving the results in the future.17.
Jörg Bayer Rolf Lefering Sylvia Reinhardt Jan Kühle Jörn Zwingmann Norbert P. Südkamp Thorsten Hammer TraumaRegister DGU 《World journal of emergency surgery : WJES》2017,12(1):43
Background
Thoracic trauma is a relevant source of comorbidity throughout multiply-injured patient care. We aim to determine a measurable influence of chest trauma’s severity on early resuscitation, intensive care therapy, and mortality in severely injured patients.Methods
Patients documented between 2002 and 2012 in the TraumaRegister DGU®, aged ≥?16 years, injury severity score (ISS) ≥ 16 are analyzed. Isolated brain injury and severe head injury led to exclusion. Subgroups are formed using the Abbreviated Injury ScaleThorax.Results
Twenty-two thousand five hundred sixty-five patients were predominantly male (74%) with mean age of 45.7 years (SD 19.3), blunt trauma (95%), mean ISS 25.6 (SD 9.6). Overall mean intubation period was 5.6 days (SD 10.7). Surviving patients were discharged from the ICU after a mean of about 5 days following extubation. Thoracic trauma severity (AISThorax ≥ 4) and fractures to the thoracic cage significantly prolonged the ventilation period. Additionally, fractures extended the ICU stay significantly. Suffering from more than one thoracic injury was associated with a mean of 1–2 days longer intubation period and longer ICU stay. Highest rates of sepsis, respiratory, and multiple organ failure occurred in patients with critical compared to lesser thoracic trauma severity.Conclusion
Thoracic trauma severity in multiply-injured patients has a measurable impact on rates of respiratory and multiple organ failure, sepsis, mortality, time of mechanical ventilation, and ICU stay.18.
Amin Madani Nicolò Pecorelli Tarek Razek Jonathan Spicer Lorenzo E. Ferri David S. Mulder 《World journal of surgery》2016,40(11):2658-2666
Background
Injuries to the airway in the neck and thorax are uncommon, but may be potentially life threatening. The objective of this study is to determine the clinical characteristics and outcomes for patients with airway injury.Methods
From 1974 to 2014, a prospectively entered trauma database at a Level 1 trauma center was accessed to identify patients with injuries to the larynx, cervical trachea, or thoracic airway. Hospital charts were reviewed to obtain data on demographics, presentation, injury management, in-hospital and long-term morbidity and in-hospital mortality. Multivariate logistic regression was used to estimate predictors of mortality and long-term vocal cord morbidity. Data are expressed as N (%).Results
One hundred and twenty patients were included (median injury severity score: 19 [interquartile range: 10–27]). There were 65 (54 %) blunt and 55 (46 %) penetrating injuries, with 90 (75 %) suffering multiple injuries. Sixteen (13 %) patients died from associated injuries (7: in ER; 9: after admission). Injuries were located in the cervical airway [101 (84 %)], thoracic airway [21 (18 %)], or both [2 (2 %)]. Eighty-six (72 %) patients were managed surgically. Predictors of in-hospital mortality included hemodynamic instability (OR 6.54, 95 % CI 1.11–37.14), GCS < 8 upon presentation (OR 4.35, 95 % CI 3.24–5.41), and head trauma (OR 4.10, 95 % CI 1.91–6.30). Fracture of cricoid or thyroid cartilages was a strong predictor of long-term vocal cord injury (OR 3.93, 95 % CI 1.25–12.59).Conclusions
Airway trauma remains a major challenge for early diagnosis, airway control, and management of both acute life-threatening injury and long-term morbidity.19.
Introduction
Establishing a definitive airway in order to ensure adequate ventilation and oxygenation is an important aspect of resuscitation of the polytrauma patient .Aim
To review the relevant literature that compares the different drugs used for rapid sequence intubation (RSI) of trauma patients, specifically reviewing: premedication, induction agents and neuromuscular blocking agents across the prehospital, emergency department and operating room setting, and to present the best practices based on the reviewed evidence.Method
A literature review of rapid sequence intubation in the trauma population was carried out, specifically comparison of the drugs used (induction agent, neuromuscular blocking drugs and adjuncts).Discussion
Studies involving the comparison of drugs used in RSI in, specifically, the trauma patient are sparse. The majority of studies have compared induction agents, etomidate, ketamine and propofol, as well as the neuromuscular blocking agents, succinylcholine and rocuronium.Conclusion
There currently exists great variation in the practice of RSI; however, in trauma the RSI armamentarium is limited to agents that maintain hemodynamic stability, provide adequate intubating conditions in the shortest time period and do not have detrimental effects on cerebral perfusion pressure. Further, multicenter randomized controlled studies to confirm the benefits of the currently used agents in trauma are required.20.
K. Gelse 《Trauma und Berufskrankheit》2018,20(1):41-46