Definitive Repair of Injuries to the Liver During Initial Trauma Laparotomy.

INTRODUCTION: Numerous surgical approaches and hemostatic techniques are used and have been described when operating on the traumatized liver. Despite a substantial decline in operative liver trauma, there still remains a debate on the optimal surgical approach, and goals, during the initial trauma laparotomy. Hepatic resection during the first operation, including the damage control settings, is advocated and practiced in only a select few institutions and remains highly controversial. Here, we describe our success with hepatic resection, repair, and/or hepatic vascular repair, during the trauma laparotomy with our emphasis on the collaboration between the trauma and hepatobiliary surgical teams. CASE SERIES: From 207 patients with liver injuries during the study period, 7 patients had definitive liver resection or repair during the initial trauma laparotomy. One had hepatic tissue repair, 1 had hepatic vein repair, and 5 had liver resections. All the operations involved a hepatobiliary surgeon together with the trauma team. There were no fatalities in the liver operation group, no sepsis, or need for emergent angiography because of hemorrhage. Four patients needed endoscopic retrograde cholangiopancreatography (ERCP) and stenting because of biliary leak. Three patients were discharged home and 4 to rehabilitation. DISCUSSION: Hepatic resection, and/or definitive hepatic repair, may be safe and beneficial to the patients during the initial operation even in a damage control setting when the patients' overall condition allows. We emphasize the benefit of collaboration with experienced and trained liver surgery, especially in lower volume trauma centers. ERCP is commonly needed for postoperative biliary leak and should be readily utilized.

Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention.

Importance: Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion. Objective: To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention. Design, Setting, and Participants: Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015. Main Outcomes and Measures: Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score. Results: Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P < .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P < .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores. Conclusions and Relevance: Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.

Incidence and injury characteristics of traumatic brain injury: Comparison between children, adults and seniors in Israel.

AIM: To assess the incidence and injury characteristics of hospitalized trauma patients diagnosed with TBI. METHODS: A retrospective study of all injured hospitalized patients recorded in the National Trauma Registry at 19 trauma centres in Israel between 2002-2011. Incidence and injury characteristics were examined among children, adults and seniors. RESULTS: The annual incidence rate of hospitalized TBI for the Israeli population in 2011 was 31.8/100,000. Age-specific incidence was highest among seniors with a dramatic decrease in TBI-related mortality rate among them. Adults, in comparison to children and seniors, had higher rates of severe TBI, severe and critical injuries, more admission to the intensive care unit, underwent surgery, were hospitalization for more than 2 weeks and were discharged to rehabilitation. After adjusting for age, gender, ethnicity, mechanism of injury and injury severity score, TBI-related in-hospital mortality was higher among seniors and adults compared to children. CONCLUSION: Seniors are at high risk for TBI-related in-hospital mortality, although adults had more severe and critical injuries and utilized more hospital resources. However, seniors showed the most significant reduction in mortality rate during the study period. Appropriate intervention programmes should be designed and implemented, targeted to reduce TBI among high risk groups.

The ins and outs of terrorist bus explosions: injury profiles of on-board explosions versus explosions occurring adjacent to a bus.

BACKGROUND: Terrorist explosions occurring in varying settings have been shown to lead to significantly different injury patterns among the victims, with more severe injuries generally arising in confined space attacks. Increasing numbers of terrorist attacks have been targeted at civilian buses, yet most studies focus on events in which the bomb was detonated within the bus. This study focuses on the injury patterns and hospital utilisation among casualties from explosive terrorist bus attacks with the bomb detonated either within a bus or adjacent to a bus. METHODS: All patients hospitalised at six level I trauma centres and four large regional trauma centres following terrorist explosions that occurred in and adjacent to buses in Israel between November 2000 and August 2004 were reviewed. Injury severity scores (ISS) were used to assess severity. Hospital utilisation data included length of hospital stay, surgical procedures performed, and intensive care unit (ICU) admission. RESULTS: The study included 262 victims of 22 terrorist attacks targeted at civilian bus passengers and drivers; 171 victims were injured by an explosion within a bus (IB), and 91 were injured by an explosion adjacent to a bus (AB). Significant differences were noted between the groups, with the IB population having higher ISS scores, more primary blast injury, more urgent surgical procedures performed, and greater ICU utilisation. Both groups had percentages of nearly 20% for burn injury, had high percentages of injuries to the head/neck, and high percentages of surgical wound and burn care. CONCLUSIONS: Explosive terrorist attacks detonated within a bus generate more severe injuries among the casualties and require more urgent surgical and intensive level care than attacks occurring adjacent to a bus. The comparison and description of the outcomes to these terrorist attacks should aid in the preparation and response to such devastating events.

Trauma system configurations in other countries: the Israeli model.

Israel is a small country with a unique trauma system that was developed from the experience gained in peace and in war. That trauma system was designed to fit the state's current health system, which is different from the European and American systems. This article describes the infrastructure of both prehospital and in-hospital trauma management, as well as the main cornerstones of their development. The experience that was gained from multiple mass casualty incidents is discussed. The protocols of mass casualty management in the prehospital and in-hospital setup are described.

[Post-operative delirium of the elderly patient--an iceberg?].

Post-operative delirium is common, and has an incidence of 37-74% as reported in different publications. The growing rates of the elderly among surgical patients makes that condition more relevant than ever, since these populations are highly susceptible to develop this condition. Contrary to the common assumption, delirium is not a unique complication of the elderly alone. Trauma and young surgical patients may also present its manifestations after major and complicated surgery in the different intensive care units. Post-operative delirium was shown to precede long term complications such as dementia. Many of the patients that develop delirium will be sent to long and complicated rehabilitation units, after being reLeased from hospitalization, thus increasing the economic burden on the medical system. Furthermore, the once recognized "ICU Psychoses" are no longer exclusive to intensive care units alone, and nowadays, infiltrate to all surgical departments. Simple, bedside clinical tools were developed, for rapid diagnoses of post-operative delirium. Adequate and on time diagnosis of this condition is crucial in the surgical patient, as it may be the only sign that predicts other severe surgical complications. This review exposes aspects of post-operative delirium in the elderly patient. Diagnostic modalities, as well as current management recommendations are discussed.

Morbidity associated with MDMA (ecstasy) abuse: a survey of emergency department admissions.

METHODS: We conducted a prospective, representative-sample nationwide study on morbidity related to 3,4, methylenedioxymethamphetamine (MDMA; 'ecstasy') as determined from admissions to 5 geographically representative emergency departments (EDs) and from data from the poison information center (PIC). MDMArelated ED admissions were analyzed over a 7-month period and the records of all PIC calls were reviewed. RESULTS: There were 52 (age 15-44 years, 32 males) ecstasy-related ED admissions during the study period. Most (68%) admissions presented to the ED at night, 52% on weekends and 44% consumed the drug at clubs and parties. Forty-six percent of the patients took between 1/2 to 3 tablets and 29 patients (56%) had taken ecstasy before. Twenty-two subjects (42%) reported poly-drug use. Fifteen subjects (29%) required hospitalization, six of them (11%) to the intensive care unit. The most common manifestations were restlessness, agitation, disorientation, shaking, high blood pressure, headache and loss of consciousness. More serious complications were hyperthermia, hyponatremia, rhabdomyolysis, brain edema and coma. CONCLUSION: The image of ecstasy as a safe party drug is spurious. The results of this study confirm that the drug bears real danger of physical harm and of behavioral, psychological and psychiatric disturbances.

Prophylactic fluconazole does not improve outcome in patients with purulent and fecal peritonitis due to lower gastrointestinal perforation.

The benefit of anticandida treatment in addition to standard antibiotic therapy in the presence of perforation/leakage of the lower gastrointestinal tract (LGIT) is still controversial. We retrospectively assessed the clinical effects of empiric anticandida treatment in patients with LGIT perforation who had undergone exploratory laparotomy due to perforated/leaking bowel or appendix between 1999 and 2004, including generalized fecal/purulent peritonitis. Two groups of patients emerged: those receiving empiric anticandida treatment (fluconazole, n = 24) and those who did not (n = 77). All the fluconazole-treated and 40/77 nonfluconazole-treated patients required intensive care unit care and were the subject of this assessment. Postoperative candida infection and mortality rates were similar in the critically-ill fluconazole-treated and nontreated patients (4% vs 7%, 21% vs 22.5%, respectively, P = NS); resistant candidiasis rates were also similar. Hospital and intensive care unit stays were longer in the treated group, however not reaching statistical difference (26.5 +/- 18 vs 21.4 +/- 18.3 days, 14.8 +/- 14.2 vs 9.3 +/- 14.1 days, respectively). The rates of morbidity, pneumonia, and multiorgan failure were significantly higher (P < 0.05) in the treated patients (87% vs 63%, 37% vs 7.5%, and 58% vs 35%, respectively). Empiric fluconazole in patients with peritonitis associated with LGIT perforation did not improve patients' outcome compared with those without empiric treatment.

Proximal Splenic Artery Embolization In Blunt Splenic Trauma.

BACKGROUND: Proximal embolization of the splenic artery (PSAE) has recently been reported for traumatic splenic injury. The suggested mechanism of action entails a decrease in the splenic blood pressure without ischemia due to collateral blood supply. The main complications of selective embolization are continuous bleeding, splenic infarcts and splenic abscesses. The main complications of observation alone are continuous bleeding and formation of splenic pseudoaneurysms. Our aim was to assess the efficacy of PSAE in the cessation of bleeding without formation of pseudoaneurysms, and the outcome of the spleen after such intervention. METHODS: A prospective observational study of all patients undergoing PSAE for traumatic splenic injury in our institution over a 33-month period. Clinical and Doppler sonographic examinations were performed to assess cessation of bleeding, splenic blood flow, and formation of splenic pseudoaneurysms, infarcts or abscesses. RESULTS: During 33 months, 11 patients with blunt abdominal trauma and tomographic evidence of either high grade or actively bleeding splenic injuries were treated by PSAE. During follow-up, no patient underwent surgery or repeated embolization. Preserved blood flow was found on Doppler sonography in 82% of the patients and no pseudoaneurysms were demonstrated. A perisplenic collection was found in one patient and responded well to percutaneous drainage. CONCLUSIONS: Proximal embolization of the splenic artery for severe splenic injury is highly successful in cessation of bleeding while preserving splenic architecture. There were minimal complications in this series demonstrated by clinical and Doppler examinations.

Low probability of Significant Intra-Abdominal Injury in Stable Patients with Abdominal ''Seat Belt Sign''.

STUDY OBJECTIVE: Our aim was to determine the diagnostic significance of the association between the abdominal skin bruise from a seat belt and the presence of intraabdominal injury. METHODS: This was an observational analysis of prospectively collected data on 45 patients who presented with an abdominal seat belt sign to a level 1 trauma center following a motor vehicle accident between July 2004 and December 2007. The patients were evaluated by computed tomography (CT) scans or ultrasonography (FAST), depending on their hemodynamic stability. They were then hospitalized for treatment or observation. RESULTS: Forty-five patients [23 males (51.1%) and 22 females (48.9%)], with a mean age of 32.2 years (range 16-80 years), fulfilled entry criteria and were enrolled. Of these, 44 (97.8%) underwent CT, and one (2.2%) underwent FAST due to hemodynamic instability. two patients (4.4%) had intraabdominal injuries: one required surgery for bowel injury, and the other had a minor liver laceration, which was managed expectantly. Sixteen patients (35.5%) had concomitant injuries. The length of hospital stay ranged from 1-23 days (median 2.2 days). CONCLUSIONS: Despite the widely accepted view that patients with an abdominal seat belt sign are more likely to have serious intraabdominal injuries, the results of our investigation showed no such association in a group of hemodynamically stable patients.

An interventional study to improve the quality of analgesia in the emergency department.

OBJECTIVE: We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention. METHODS: We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol. RESULTS: Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%-68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively). CONCLUSION: Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.

Usage of blood products in multiple-casualty incidents: the experience of a level I trauma center in Israel.

OBJECTIVE: To predict how much blood will be needed based on the number of injured patients arriving after a multiple-casualty incident. DESIGN: A retrospective study evaluating data collected in 18 consecutive terrorist attacks in the city of Tel Aviv between January 1997 and February 2005. SETTING: A large, urban trauma center. PATIENTS: A total of 986 patients in 18 events. MAIN OUTCOME MEASURES: Number of packed red blood cell (PRBC) units transfused per patient. RESULTS: A total of 332 U of PRBCs were transfused. Half of the PRBC units were administered as massive transfusions to 4.7% of the patients. The number of PRBC units transfused per patient index (PPI) was related to incident size (mean [SD], 0.70 [1.60] to 1.50 [1.60]). The most frequent major blood group transfused was type O (50%). Half of the units of PRBCs were supplied during the first 2 hours. CONCLUSIONS: One unit of blood per evacuated victim is sufficient in a small multiple-casualty incident and 2 U is sufficient in a large multiple-casualty incident. Half of the PRBC units should be blood group O.

Reliability of cardiac output calculation by the fick principle and central venous oxygen saturation in emergency conditions.

BACKGROUND: For many years thermodilution has been the gold standard for determining cardiac output in the critically ill patients. Less invasive methods have recently been introduced. This study aimed at evaluating the agreement between cardiac output (CO) measured by a new Fick method, using central venous saturation (Scvo(2)), and that measured by the classic thermodilution technique, in patients requiring emergent CO evaluation. SETTINGS: Prospective clinical study in a university-affiliated, tertiary hospital, at surgical and general intensive care units. PATIENTS AND METHODS: Fifteen mechanically ventilated patients arriving in the emergency department in hemodynamic shock, had immediately a pulmonary artery catheter introduced under fluoroscopy upon arrival into the ICU. Cardiac output (CO) was obtained in each patient via both thermodilution and the Fick method, using oxygen consumption, SpO(2) and Scvo(2). RESULTS: COs ranged between 2 and 2.3 (in the Fick and thermodilution methods, respectively) and 19 or 19.5 l/min (respectively). Mean thermodilution-derived CO was 6.2 +/- 4.2 l/min whereas the Fick's was 7.0 +/- 4.3 l/min. There was statistical significant correlation between the two modalities of measurements, with an r (2) = 0.9 (P < 0.001). CONCLUSIONS: The new method of Fick assessed emergent CO as reliably as the thermodilution, regardless of whether it was low or high. The use of Scvo(2) allows for prompt bedside calculation for most emergency patients.

How can trauma surgeons maintain their operative skills?

BACKGROUND: The operative experience of the dedicated trauma surgeon is declining. Much attention has focused on the operative workload of trauma surgeons as it is critical in both maintaining operative skills and promoting the interest of surgical residents in trauma careers. We examined the operative experience of our surgical service which includes trauma, emergency general surgery, and elective general surgery to analyze changes occurring over the past decade. METHODS: A retrospective study was performed by extracting data from the operative database at our Level I trauma center from January 1995 to December 2005. The cases were classified as trauma, emergency general surgery, or elective general surgery. Data were analyzed using weighted linear regression to analyze statistical significance. RESULTS: Although the total number of cases performed by the trauma service remained constant, the proportion of initial operative trauma cases (<24 hours from arrival to operation) decreased from 14% to 8% (r2 = 0.91, p < 0.001) over the study period. In contrast, emergency general surgery cases increased over this time period (r2 = 0.57, p < 0.01). Elective case volume was unchanged. The majority of the waning of trauma cases was due to decreased surgery on the liver and spleen and fewer neck explorations. CONCLUSIONS: Trauma operative experience decreased but emergency general surgery increased over a decade at our trauma center. It appears possible to maintain a busy operative trauma service by the inclusion of emergency general surgery consultations.