Morbidity and mortality after distal pancreatectomy for trauma: A critical appraisal of 107 consecutive patients undergoing resection at a Level 1 Trauma Centre

Background

This study evaluated 30-day morbidity and mortality and assessed pancreas-specific complications in patients with major pancreatic injuries who underwent a distal pancreatectomy.

Study design

Records of 107 consecutive patients who underwent a distal pancreatectomy at a Level 1 Trauma Centre in Cape Town between January 1982 and December 2011 were reviewed. Primary endpoints were postoperative morbidity and death. Complications were graded according to the Clavien–Dindo severity classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions.

Results

A total of 107 patients [94 men, median age 26, median RTS 7.8, 69 penetrating injuries (63 gunshot wounds, 6 stabs wounds), 38 blunt injuries] underwent distal pancreatectomy. Overall mortality was 12%, 16% for gunshot injuries, 8% for blunt trauma and 0% in patients who had stab wounds. Eighty patients had a post-operative complication. A pancreatic leak (n = 26) was the most common pancreatic related complication. Median postoperative stay in 28 patients with no or grade I complications was 9 days; in 11 patients with grade II complications was 18 days; in 14 grade IIIa, 31 days; in 19 grade IIIb, 38 days; in 8 grade IVa, 33 days in 14 grade IVb, and in 13 grade V the duration of postoperative stay was 14 ± 39.4 days.

Conclusions

Overall mortality for distal pancreatectomy was 12%. Pancreatic leak was a common cause of morbidity. Length of hospitalisation increased with increasing Clavien–Dindo severity grading. There was a significant difference in the duration of hospitalisation in patients with no or grade I complications compared to those with grade II–IV injuries (p < 0.05).     

Penetrating trauma in urban women: patterns of injury and violence

Background

Penetrating trauma is known to occur with less frequency in women than in men, and this difference has resulted in a lack of characterization of penetrating injury patterns involving women. We hypothesized that the nature of penetrating injury differs significantly by gender and that these injuries in women are associated with important psychosocial and environmental factors.

Materials and methods

A level 1 urban trauma center registry was queried for all patients with penetrating injuries from 2002–2010. Patient and injury variables (demographics and mechanism of injury) were abstracted and compared between genders; additional social and psychiatric histories and perpetrator information were collected from the records of admitted female patients.

Results

Injured women were more likely to be Caucasian, suffer stab wounds instead of gunshot wounds, and present with a higher blood alcohol level than men. Compared with women with gunshot wounds, those with stab wounds were three times more likely to report a psychiatric or intimate partner violence history. Women with self-inflicted injuries had a significantly greater incidence of prior penetrating injury and psychiatric and criminal history. Male perpetrators outnumbered female perpetrators; patients frequently not only knew their perpetrator but also were their intimate partners. Intimate partner violence and random cross-fire incidents each accounted for about a quarter of injuries observed.

Conclusions

Penetrating injuries in women represent a nonnegligible subset of injuries seen in urban trauma centers. Psychiatric and social risk factors for violence play important roles in these cases, particularly when self-infliction is suspected. Resources allocated for urban violence prevention should proportionately reflect the particular patterns of violence observed in injured women.     

Erfolgreiche präklinische Notfallthorakotomie nach stumpfem Thoraxtrauma

Background

The European Resuscitation Council guidelines for resuscitation in patients with traumatic cardiac arrest recommend the immediate treatment of all reversible causes, if necessary even prior to continuous chest compression. In the case of cardiac tamponade immediate emergency thoracotomy should also be considered.

Objective

The authors report the case of a 23-year-old male patient with multiple injuries including blunt thoracic trauma, which caused a witnessed cardiac arrest. He successfully underwent prehospital emergency resuscitative thoracotomy. The lessons learned from this case on internal and external quality measures are discussed in detail.

Results

After 60?min of technical rescue, extensive trauma life support including intubation, chest decompression and bleeding control was carried out. The cardiovascular insufficiency progressively deteriorated and under the suspicion of a cardiac tamponade a prehospital emergency thoracotomy was carried out. After successful resuscitative thoracotomy and return of spontaneous circulation (ROSC) the patient was airlifted to the next level 1 trauma center for damage control surgery (DCS). The patient could be discharged 59 days after the accident and now 2 years later is living a normal life without neurological or cardiopulmonary limitations. Airway management, chest decompression including resuscitative thoracotomy, fluid resuscitation and blood products were the key components to ensure that the patient achieved ROSC. Advanced Trauma Life Support® as well as structural prerequisites made these measures and good results for the patient possible.

     

The evolution of the diagnostic work-up for stab wounds to the back and flank

Background

Stab wounds to the back and flank infrequently cause injuries requiring operative treatment. Triple-contrast CT scan (3CT) has essentially replaced diagnostic peritoneal lavage (DPL) as the primary means of identifying patients who require operative intervention. This study aims to review the evolution of the diagnostic work-up for stab wounds to the back and flank.

Methods

We performed a retrospective review of haemodynamically stable patients with stab wound to the back or flank treated at a single Level 1 trauma centre over a 10-year period. Diagnostic accuracy of DPL and 3CT screening tests were evaluated against the patient's subsequent clinical course. The elapsed time between emergency department (ED) presentation and test results was recorded and compared.

Results

A total of 177 patients were identified. 76 patients had stab wounds isolated to the back, 90 had stab wounds isolated to the flank and 11 had wounds in both locations. CT ultimately became the predominant initial diagnostic test during the study period. Although less frequently used over time, DPL retained good sensitivity and specificity for injuries requiring operative intervention (92% and 83%, respectively). 3CT identified all injuries requiring laparotomy (100% sensitivity) and had a specificity of 96%. 3CT was a more time-consuming process, with results available at a median of 3:31 h after arrival to the ED, as compared to 1:03 h for DPL (p < 0.01).

Conclusions

3CT diagnosed all injuries requiring operative intervention, and its use was associated with a lower rate of non-therapeutic laparotomies. However, average time to diagnosis by 3CT was prolonged compared to DPL. Although 3CT has become the predominant diagnostic test when evaluating patients with stab wounds to the back and flank at our institution, efforts to further expedite the diagnostic work-up are necessary.     

Schuss- und Stichverletzungen in Deutschland – Epidemiologie und Outcome

Background

The management of gunshot wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. Penetrating injuries occur with an incidence of 5% in Germany. They are caused by gunshots or more commonly by knives or other objects, for example during accidents. Since even the number of patients who are treated at level 1 trauma centres is limited by the low incidence, the objective of this study was to assess the epidemiology and outcome of gunshot and stab wounds in Germany.

Material and methods

Since 2009, the trauma registry of the German Trauma Society (TraumaRegister DGU®) has been used to assess not only whether a trauma was penetrating but also whether it was caused by a gunshot or a stabbing. On the basis of this registry, we identified relevant cases and defined the observation period. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2011. We did not specify exclusion criteria in order to obtain as comprehensive a picture as possible of the trauma entities investigated in this study. As a result of the high incidence of gunshot wounds to the head and the implications of this type of injury for the entire group, a subgroup of patients without head injuries was analysed.

Results

From 2009 to 2011, there were 305 patients with gunshot wounds and 871 patients with stab wounds. The high proportion of suicide-related gunshot wounds to the head resulted in a cumulative mortality rate of 39.7%. Stab wounds were associated with a lower mortality rate (6.2%). Every fourth patient with a gunshot or stab wound presented with haemorrhagic shock, which was considerably more frequently seen during the prehospital phase than during the inhospital phase of patient management. Of the patients with gunshot wounds, 26.9% required transfusions. This percentage was three times higher than that for patients with blunt trauma.

Conclusion

In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicide. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required which can provide the basis for an evaluation of the long-term quality of the management of patients with stab or gunshot wounds.     

Selective non-operative management of civilian gunshot wounds to the abdomen: A systematic review of the evidence

Background

Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds.

Methods

A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed.

Results

Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n = 6072) of patients were initially managed non-operatively and 15.5% (n = 943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay.

Conclusions

SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.     

Emergent pancreaticoduodenectomy: a dual institution experience and review of the literature

Background

Emergent pancreaticoduodenectomy (EPD) is an uncommon surgical procedure performed to treat patients with acute pancreaticoduodenal trauma, bleeding, or perforation. This study presents the experience of two university hospitals with EPD.

Methods

Clinical data on EPD in trauma and nontrauma patients from 2002–2012 were extracted from the hepatopancreatobiliary surgery databases at Thomas Jefferson University and Kaunas Medical University Hospitals. Data on indications, perioperative variables, morbidity, and mortality rates were evaluated.

Results

Ten single-stage EPD patients were identified. Five underwent a classic Whipple resection, whereas five had pylorus preservation. Seven patients had traumatic indications for pancreaticoduodenectomy: three from gunshot wounds to the abdomen and four from blunt high-energy injuries (two sustained injuries by falling from height and two by direct assaults on the abdomen). Three cases of nontrauma patients had EPD surgery for massive gastrointestinal hemorrhage. The median age of the EPD cohort was 46 y (range, 19–67 y). All 10 patients were recovered and were discharged from the hospital with a median postoperative length of stay of 24 d (range, 8–69 d). There were no perioperative mortalities.

Conclusions

Despite a high morbidity rate and prolonged recovery, this dual institutional review suggests that EPD can serve as a lifesaving procedure in both the trauma and the urgent nontrauma settings.     

Optimiser la réanimation des arrêts cardiaques traumatiques préhospitaliers : l’expérience d’un registre prospectif

Objectives

Describe the epidemiology and the survival of patients with traumatic cardiac arrest (CA), and compare them to those with nontraumatic CA. Highlight the weaknesses in their care and consider ways to improve their survival.

Method

Traumatic and nontraumatic CA are described using the Utstein style in the “réseau nord-alpin des urgences” registry. Regarding the traumatic CA, we focus on circumstances, types of injuries and specific resuscitation techniques used.

Results

From 1st January 2004 to 31st December 2005, prehospital medical teams provided care to 1552 victims of CA, 129 of whom were trauma patients (8.3%). Average age was 47.1 years; 74.4% were males. Blunt trauma occurred in 94.6%. None of the patients had chest tube insertion or thoracotomy on the scene. A return of spontaneous circulation was observed in 24.8%, the survival after 24 h was of 3.9%, and 0.8% of patients remained alive 1 year following the accident. The topography of lesions responsible for the CA as well as the fact that these lesions are limited or multiorgan influence the survival.

Conclusion

The survival of patients with prehospital traumatic CA is catastrophic and it is worse than that of patients with nontraumatic CA. However, a specific earlier and more adapted prehospital resuscitation could help improve this survival.     

Epidemiology of trauma: A population-based study of geographical risk factors for injury deaths in the working-age population of Norway

Introduction

Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality.

Methods

All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16–66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates.

Results

The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths.

Conclusion

Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.     

Intérêts des manœuvres de réanimation à thorax ouvert en France ?

Objective

To expose and clarify indications, techniques, results, complications and cost for open chest cardiopulmonary resuscitation manoeuvres (OCCRM) in traumatic or nontraumatic cardiac arrest.

Data sources

References were obtained from Pubmed data bank using the following keywords: “emergency thoracotomy”, “resuscitative thoracotomy”.

Study selection

We focused on publications in English language, from 2000 to 2007.

Data synthesis

OCCRM are useful especially in case of traumatic cardiac arrest, penetrating trauma, but also in blunt trauma. Time between cardiac arrest and realisation of the thoracotomy seems to be the most important factor for the prognosis.

Conclusion

According to the French “physician in ambulance” prehospital system, OCCRM might be promising in France, because this system favours the fastness of care and therefore would minimize the time factor.     

Can We Train Military Surgeons in a Civilian Trauma Center?

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.

     

Is pre-hospital thoracotomy necessary in the military environment?

Introduction

Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest ‘on-scene’ thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries?

Methods

Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome.

Results

Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities—7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring.

Discussion

Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury.

Conclusion

As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.     

Anatomic Location and Mechanism of Injury Correlating with Prehospital Deaths in Sub-Saharan Africa

Introduction

Trauma is a large contributor to morbidity and mortality in developing countries. We sought to determine which anatomic injury locations and mechanisms of injury predispose to prehospital mortality in Malawi to help target preventive and therapeutic interventions. We hypothesized that head injury would result in the highest prehospital mortality.

Methods

This was a retrospective analysis of all trauma patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from 2008 to 2015. Independent variables included baseline characteristics, anatomic location of primary injury, mechanism of injury, and severity of secondary injuries. Multivariable logistic regression was used to assess the effect of primary injury location and injury mechanism on prehospital death, after adjusting for confounders. Effect measure modification of the primary injury site/prehospital death relationship by injury mechanism (stratified into intentional and unintentional injury) was assessed.

Results

Of 85,806 patients, 701 died in transit (0.8%). Five hundred and five (72%) of these patients sustained a primary head injury. After adjustment, head injury was the anatomic location most associated with prehospital death (OR 11.81 (95% CI 6.96–20.06, p?<?0.0001). The mechanisms of injury most associated with prehospital death were gunshot wounds (OR 38.23, 95% CI 17.66–87.78, p?<?0.0001) and pedestrian hit by vehicle (OR 2.62, 95% CI 1.92–3.55, p?<?0.0001). Among head injury patients, the odds of prehospital mortality were higher with unintentional injuries.

Conclusions

Head injuries are the most common causes of prehospital death in Malawi, while pedestrians hit by vehicles are the most common mechanisms. In a resource-poor setting, preventive measures are critical in averting mortality.

     

A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients

Background

The objective of this systematic review and meta-analysis was to determine the effect of REBOA, compared to resuscitative thoracotomy, on mortality and among non-compressible torso hemorrhage trauma patients.

Methods

Relevant articles were identified by a literature search in MEDLINE and EMBASE. We included studies involving trauma patients suffering non-compressible torso hemorrhage. Studies were eligible if they evaluated REBOA and compared it to resuscitative thoracotomy. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. We conducted meta-analysis using random effect models.

Results

We included three studies in our systematic review. These studies included a total of 1276 patients. An initial analysis found that although lower in REBOA-treated patients, the odds of mortality did not differ between the compared groups (OR 0.42; 95% CI 0.17–1.03). Sensitivity analysis showed that the risk of mortality was significantly lower among patients who underwent REBOA, compared to those who underwent resuscitative thoracotomy (RT) (RR 0.81; 95% CI 0.68–0.97).

Conclusion

Our meta-analysis, mainly from observational data, suggests a positive effect of REBOA on mortality among non-compressible torso hemorrhage patients. However, these results deserve further investigation.

     

Impact de la mise en place d’un réseau de soins en traumatologie sur la mortalité des patients traumatisés graves du bassin

Aim

To evaluate the impact of a regional trauma network on intra-hospital mortality rates of patients admitted with severe pelvic trauma.

Study

Retrospective observational study.

Patients

Sixty-five trauma patients with serious pelvic fracture (pelvic abbreviated injury scale [AIS] score of 3 or more).

Methods

Demographic, physiologic and biological parameters were recorded. Observed mortality rates were compared to predicted mortality according to the Trauma Revised Injury Severity Score methodology adjusted by a case mix variation model.

Results

Twenty-nine patients were admitted in a level I trauma centre (reference centre) and 36 in level II trauma centres (centres with interventional radiology facility and/or neurosurgery). Patients from the level I trauma centre were more severely injured than those who were admitted at the level II trauma centres (Injury Severity Score [ISS]: 30 [13–75] vs 22 [9–59]; P < 0.01). Time from trauma to hospital admission was also longer in level I trauma centre (115 [50–290] min vs 90 [28–240] min, P < 0.01). Observed mortality rates (14%; 95% confidence interval, 95% CI, [1–26%]) were lower than the predicted mortality (29%; 95% CI [13–44%]) in the level I trauma centre. No difference in mortality rates was found in the level II trauma centres.

Conclusion

The regional trauma network could screen the most severely injured patients with pelvic trauma to admit them at a level I trauma centre. The observed mortality of these patients was lower than the predicted mortality despite increased time from trauma to admission.     

Management of comminuted but continuous mandible defects after gunshot injuries

Introduction

Firearm injuries continue as a major public health problem, contributing significant morbidity, mortality, and expense to our society. There are four main steps in the management of patients with gunshot wounds to the face: securing an airway, controlling haemorrhage, identifying other injuries and definitive repair of the traumatic facial deformities. The objective of this study was to determine late outcome of two treatment options by open reduction and internal fixation versus closed reduction and maxillomandibular fixation (MMF) in the treatment of gunshot injuries of the mandible.

Methods

Sixty patients of gunshot injury were randomly allocated in two groups. In group A, 30 patients were treated by open reduction and internal fixation and in group B, 30 patients were treated by closed reduction and maxillomandibular fixation. Patients were discharged as the treatment completed and recalled for follow up. Up to 3 months after injury, fortnightly complications like infection, malocclusion, malunion of fractured fragments, facial asymmetry, sequestration of bone and exposed plates were evaluated and the differences between two groups were assessed. The follow-up period ranged from 3 months to 10 months.

Results

Patients treated by open reduction tended to have less complications as compared to closed reduction.

Conclusion

Based on this study open reduction and internal fixation is the best available method for the treatment of gunshot mandible fractures without continuity defect.     

Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation?

BACKGROUND: Documented prehospital asystole justifies termination of resuscitation, but recently it has been proposed to extend this policy to patients in the field with pulseless electrical activity. Consequently, we questioned whether resuscitative thoracotomy is warranted in the critically injured patient who fails to respond to prehospital CPR. STUDY DESIGN: A prospective database of all emergency department resuscitative thoracotomies (EDT) performed at our Level I trauma center has been maintained since January 1977. These registry data were augmented by a review of prehospital paramedic records for all survivors of EDT to verify length of CPR. RESULTS: During the 26-year study period, 959 patients underwent EDT. Of the 62 patients who survived to leave the hospital, 26 (42%) required prehospital CPR. The injury mechanism in these 26 patients was stab wounds in 18 (69%), gunshot wounds in 4 (15%), and blunt trauma in 4 (15%). The duration of prehospital CPR ranged from 3 to 15 minutes and in 7 patients CPR exceeded 10 minutes. Five survivors had asystole documented at the time of EDT; four of these patients had good functional outcomes at discharge. Each of these patients had pericardial tamponade from ventricular stab wounds. Patients with blunt trauma had uniformly dismal neurologic outcomes. CONCLUSIONS: EDT after prehospital CPR can be used to salvage select critically injured patients. Based on these data, we propose that resuscitative thoracotomy is futile care in patients with blunt trauma requiring prehospital CPR longer than 5 minutes, and in patients with penetrating trauma with more than 15 minutes of prehospital CPR. EDT is warranted in those patients with penetrating trauma with less than 15 minutes of prehospital CPR, and should be performed despite documented asystole on arrival if pericardial tamponade is the proximate event.     

The UK military experience of thoracic injury in the wars in Iraq and Afghanistan

Introduction

Thoracic injury during warfare is associated with a high incidence of morbidity and mortality. This study examines the pattern and mortality of thoracic wounding in the counter-insurgency conflicts of Iraq and Afghanistan, and outlines the operative and decision making skills required by the modern military surgeon in the deployed hospital setting to manage these injuries.

Methods

The UK Joint Theatre Trauma Registry was searched between 2003 and 2011 to identify all patients who sustained battle-related thoracic injuries admitted to a UK Field Hospital (Role 3). All UK soldiers, coalition forces and local civilians were included.

Results

During the study period 7856 patients were admitted because of trauma, 826 (10.5%) of whom had thoracic injury. Thoracic injury-related mortality was 118/826 (14.3%). There were no differences in gender, age, coalition status and mechanism of injury between survivors and non-survivors. Survivors had a significantly higher GCS, Revised Trauma Score and systolic blood pressure on admission to a Role 3 facility. Multivariable regression analysis identified admission systolic blood pressure less than 90, severe head or abdominal injury and cardiac arrest as independent predictors of mortality.

Conclusions

Blast is the main mechanism of thoracic wounding in the recent conflicts in Iraq and Afghanistan. Thoracic trauma in association with severe head or abdominal injuries are predictors of mortality, rather than thoracic injury alone. Deploying surgeons require training in thoracic surgery in order to be able to manage patients appropriately at Role 3.     

Violent trauma recidivism: Does all violence escalate?

Purpose

Rates of trauma patients presenting with history of prior trauma range from 25 to 44%. Outcomes involving recidivists in the setting of intentional trauma, especially penetrating trauma, are conflicting. We hypothesized that if violence does escalate with successive incidence, then injuries due to successive violence should escalate or become increasingly severe with successive admissions.

Methods

The trauma registry from an urban level I adult and pediatric trauma center was queried for injuries due to blunt assault, stabbing, and firearm injury. Primary outcome measures were mortality, injury mechanism, and injury severity for each successive trauma admission.

Results

Victims of blunt assault and stabbing were more likely to become recidivists than victims of gun violence (OR 1.53, p?<?0.001 and OR 1.57, p?<?0.001). Violent re-injury became increasingly severe only in victims of repeated gun violence. Patients with gunshot as the mechanism at every admission are at highest risk for mortality (OR 13.48, p?<?0.001). All but one mortality (95.8%) in the recidivist population occurred within 180 days of discharge from a prior injury.

Conclusion

Recidivism for interpersonal violence results in a significant number of admissions to trauma centers. In our patient cohort, injury associated with successive blunt assaults did not worsen with subsequent admissions. Recidivism for gunshot wounds tends to be more severe and have a worse prognosis with each successive admission compared to outcomes associated with repeated stab wounds. Focused efforts should include rehabilitation efforts early in the post-injury period, especially in patients with a history of gunshot wounds.