Prevalence of intra-abdominal injury among patients with seatbelt signs, a systematic review and meta-analysis.

INTRODUCTION: The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention. METHODS: PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity. RESULTS: The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I2 = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I2 = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I2 = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I2 = 89%. CONCLUSION: This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results.

Serum lactate normalization time associated with prolonged postoperative ileus after surgical management of the small bowel and/or mesenteric injuries.

BACK GROUND: Determining the optimal timing of postoperative oral feeding in trauma patients who have undergone abdominal surgery with small bowel and/or mesenteric injuries is challenging. The aim of this study is to investigate serum lactate as a factor that can predict oral feeding tolerance and prolonged postoperative ileus (PPOI) in patients who underwent surgery for small bowel and/or mesenteric injury due to trauma. METHODS: The single center retrospective observational study was conducted on 367 patients who underwent surgery for small bowel and/or mesenteric injury between January 2013 and July 2021. The patient group was divided into two groups based on whether the peak serum lactate was over 2mmol/L (18 mg/dL). In the group of lactate > 2mmol/L, it was divided into prolonged postoperative ileus (PPOI) groups and groups rather than PPOI. RESULTS: Patients in the peak serum lactate > 2 group had tendency to use vasopressors, lower initial systolic blood pressure, larger number of packed red blood cells for 24 h, higher injury severity score, higher PPOI incidence, and a tendency for delayed oral intake tolerance. In peak serum lactate greater than 2 mmol/L group, the lactate normalization time (OR 1.699, p = 0.04), quantity of FFP transfusion for 24 h (OR 1.145, p = 0.012), and creatine kinase (OR 1.001, p = 0.023) were related to PPOI. The lactate normalization time had the highest correlation. CONCLUSION: In patients undergoing surgical management for small bowel and/or mesenteric injury after trauma, serum lactate normalization time affects oral intake tolerance and prolongs postoperative ileus.

Single centre analysis of factors influencing surgical treatment of splenic trauma in children.

OBJECTIVE: This study aims to investigate determinants impacting the surgical management of splenic trauma in paediatric patients by scrutinizing age distribution, etiological factors and concomitant injuries. The analysis seeks to establish a foundation for delineating optimal operative timing. METHODS: A cohort of 262 paediatric cases presenting with splenic trauma at our institution from January 2011 to December 2021 underwent categorization into either the conservative or operative group. RESULTS: Significantly disparate attributes between the two groups included age, time of presentation, blood pressure, haemoglobin levels, blood transfusion requirements, thermal absorption, American Association for the Surgery of Trauma (AAST) classification and associated injuries. Logistic regression analysis revealed age, haemoglobin levels, AAST classification and blood transfusion as autonomous influencers of surgical intervention (OR = 1.024, 95% CI: 1.011-1.037; OR = 1.067, 95% CI: 1.01-1.127; OR = 0.2760, 95% CI: 0.087-0.875; OR = 7.873, 95% CI: 2.442-25.382; OR = 0.016, 95% CI: 0.002-0.153). The AAST type and age demonstrated areas under the receiver operating characteristic (ROC) curve of 0.782 and 0.618, respectively. CONCLUSION: Age, haemoglobin levels, AAST classification and blood transfusion independently influence the decision for surgical intervention in paediatric patients with splenic trauma. Age and AAST classification emerge as viable parameters for assessing and prognosticating the likelihood of surgical intervention in this patient cohort.

Validation of the predictive model for operative intervention after blunt abdominal trauma in children with equivocal computed tomography findings: a multi-institutional study.

BACKGROUND: We recently developed a preliminary predictive model identifying clinical and radiologic factors associated with the need for surgery following blunt abdominal trauma (BAT) in children. Our aim in this study was to further validate the factors in this predictive model in a multi-institutional study. METHODS: A retrospective chart review of pediatric patients from five pediatric trauma centers who experienced BAT between 2011 and 2020 was performed. Patients under 18 years of age who had BAT and computed tomography (CT) abdomen imaging were included. Children with evidence of pneumoperitoneum, and hemodynamic instability were excluded. Fisher's exact test was used for statistical analysis of the association between the following risk factors and need for laparotomy: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture (TLF), presence of free fluid (FF), presence of solid organ injury (SOI). A predictive logistic regression model was then estimated employing these factors. FINDINGS: Seven hundred thirty-four patients were identified in this multi-institutional dataset with BAT and abdominal CT imaging, and 726 were included. Of those, 59 underwent surgical intervention (8.8%). Univariate analysis of association between the studied factors and need for surgical management showed that the presence of TLF (p < 0.01), APT (p < 0.01), FF (p < 0.01), and SOI (p < 0.01) were significantly associated. A predictive model was created using the 5 factors resulting in an area under the curve (AUC) of 0.80. For the motor vehicle collisions (MVC) group, only FF, SOI, and TLF are significantly associated with the need for surgical intervention. The AUC for the MVC group was 0.87. CONCLUSIONS: A clinical and radiologic prediction rule was validated using a large multi-institutional dataset of pediatric BAT patients, demonstrating a high degree of accuracy in identifying children who underwent surgery. FF, SOI, and TLF are the most important factors associated with the need for surgical intervention. LEVEL OF EVIDENCE: Level III.

Patterns and outcomes of patients with abdominal injury: a multicenter study from Iran.

BACKGROUND: Injury is one of the leading causes of death worldwide, and the abdomen is the most common area of trauma after the head and extremities. Abdominal injury is often divided into two categories: blunt and penetrating injuries. This study aims to determine the epidemiological and clinical characteristics of these two types of abdominal injuries in patients registered with the National Trauma Registry of Iran (NTRI). METHODS: This multicenter cross-sectional study was conducted with data from the NTRI from July 24, 2016, to May 21, 2023. All abdominal trauma patients defined by the International Classification of Diseases; 10th Revision (ICD-10) codes were enrolled in this study. The inclusion criteria were one of the following: hospital length of stay (LOS) of more than 24 h, fatal injuries, and trauma patients transferred from the ICU of other hospitals. RESULTS: Among 532 patients with abdominal injuries, 420 (78.9%) had a blunt injury, and 435 (81.7%) of the victims were men. The most injured organs in blunt trauma were the spleen, with 200 (47.6%) and the liver, with 171 (40.7%) cases, respectively. Also, the colon and small intestine, with 42 (37.5%) cases, had the highest number of injuries in penetrating injuries. Blood was transfused in 103 (23.5%) of blunt injured victims and 17 (15.2%) of penetrating traumas (p = 0.03). ICU admission was significantly varied between the two groups, with 266 (63.6%) patients in the blunt group and 47 (42%) in penetrating (p < 0.001). Negative laparotomies were 21 (28%) in penetrating trauma and only 11 (7.7%) in blunt group (p < 0.001). In the multiple logistic regression model after adjusting, ISS ≥ 16 increased the chance of ICU admission 3.13 times relative to the ISS 1-8 [OR: 3.13, 95% CI (1.56 to 6.28), P = 0.001]. Another predictor was NOM, which increased ICU chance 1.75 times more than OM [OR: 1.75, 95% CI (1.17 to 2.61), p = 0.006]. Additionally, GCS 3-8 had 5.43 times more ICU admission odds than the GCS 13-15 [OR:5.43, 95%CI (1.81 to 16.25), P = 0.002] respectively. CONCLUSION: This study found that the liver and spleen are mostly damaged in blunt injuries. Also, in most cases of penetrating injuries, the colon and small intestine had the highest frequency of injuries compared to other organs. Blunt abdominal injuries caused more blood transfusions and ICU admissions. Higher ISS, lower GCS, and NOM were predictors of ICU admission in abdominal injury victims.

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department.

OBJECTIVES: Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period. METHODS: We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death. RESULTS: We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported. CONCLUSION: The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Traumatic Injury in Pregnancy: A Propensity Score-Matched Analysis.

INTRODUCTION: Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG. MATERIALS AND METHODS: The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications. RESULTS: A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs. CONCLUSIONS: After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs.

Surgical approaches for core abdominal injuries: a review of the Abdominal Core Health Quality Collaborative database.

INTRODUCTION: Core abdominal injury (CAI) is a broad term that describes injuries resulting from repetitive loading of the pubis that leads to inflammation, rupture, or destabilization of the core muscles from the pubic bone. There is no clear recommendation on the surgical approach to CAI. We aimed to describe how hernia surgeons within the Abdominal Core Health Quality Collaborative (ACHQC) address this problem surgically and the short-term outcomes. METHODS: We queried the ACHQC registry for patients undergoing surgery for isolated CAI and concomitant inguinal hernias (IH) and CAI. Operative approach and quality of life (using EuraHS survey scores) was abstracted. RESULTS: A total of 29,451 patients underwent surgery for IHs, CAIs, or both within the registry. Twenty patients underwent surgery for isolated CAI (median age 29, 90% males). Eleven patients (55%) underwent surgery with mesh (four Lichtenstein, three TAPP, and four TEP). Nine patients (45%) underwent tissue-based repairs (four closure of floor, one Bassini, one McVay, one Shouldice, one femoral exploration, and one laparoscopic-to-open conversion). There were no postoperative complications or reoperations within 30 days. EuraHS scores showed improvement at 30 days from baseline (median 29 [6.75-41.75] from 42 [29.42-57.61]). Sixty patients had both IHs and CAIs (median age 31, 97% males). All patients received mesh. Thirty-one patients (52%) underwent open surgery (23 Lichtenstein, 1 plug, 7 TREPP) and 29 underwent minimally invasive repairs (23 TAPP, 6 TEP). There was one seroma at 30 days. EuraHS scores showed improvement at 30 days from baseline (median 16 [5.17-27.33] from 37.5 [26.44-46.58]). CONCLUSIONS: Despite technical variability, CAIs with or without concomitant IH generally undergo operations commonly used for IH repairs. Within our series, there was inconsistency with approach and mesh placement. Future work should be focused on standardizing the approach to CAI and capturing long-term data within the ACHQC.

A Rare Secondary Dysmenorrhea Resulted from Separation of Corpus Uteri from Cervix: A Case Report and Literature Review.

Secondary dysmenorrhea is a pain associated with disease such as endometriosis, pelvic inflammatory disease, leiomyomas, and interstitial cystitis. Treatment of secondary dysmenorrhea always focuses on the causative pelvic pathology or medical condition. Here, we found a rare case with secondary dysmenorrhea that resulted from traumatic separation of the uterine corpus from the cervix. In this case, the patient experienced a childhood blunt trauma of the pelvic crush and was successfully diagnosed by magnetic resonance imaging and 3-dimensional ultrasonography. Moreover, laparoscopic anastomosis could be a minimally invasive way to resolve this problem.

Surgical management of colorectal injury in war.

The rate of colorectal trauma is 5-10 % in modern war conflicts. The most common causes include gunshots or shrapnel injuries; the contusion-laceration mechanism occurs in sporadic cases in the war zone. Despite modern surgical procedures, however, it is associated with a high rate of morbidity, especially if it is not diagnosed and treated in time. Surgical management is specified by simple scoring schemes - the colon injury scale, rectal injury scale and the Flint grading system. Colonic resection with primary or delayed anastomosis is not associated with a higher risk of complicated healing and is nowadays preferred over the construction of terminal stomas. These are indicated only for cases with severe hemodynamic instability in traumatic-hemorrhagic or septic shock with severe diffuse peritonitis. Trauma to the intraperitoneal segment of the rectum is treated in the same way as trauma to the colon. An extraperitoneal rectal injury without soft tissue devastation can be treated with or without a transanal suture. On the contrary, devastating injuries to the rectum including the pelvic soft tissues should be primarily controlled with a stoma with delayed reconstruction. Presacral drainage or rectal stump lavage are no longer recommended.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study.

Non-operative management for abdominal solidorgan injuries: A literature review.

The philosophy of abdominal injury management is currently changing from mandatory exploration to selective non-operative management (NOM). The patient with hemodynamic stability and absence of peritonitis should be managed non-operatively. NOM has an overall success rate of 80%-90%. It also can reduce the rate of non-therapeutic abdominal exploration, preserve organ function, and has been defined as the safest choice in experienced centers. However, NOM carries a risk of missed injury such as hollow organ injury, diaphragm injury, and delayed hemorrhage. Adjunct therapies such as angiography with embolization, endoscopic retrograde cholangiopancreatography with stenting, and percutaneous drainage could increase the chances of successful NOM. This article aims to describe the evolution of NOM and define its place in specific abdominal solid organ injury for the practitioner who faces this problem.

Thoracic vertebrae fracture: Is it an indicator of abdominal injury?

PURPOSE: Traumatic vertebral fracture accounts for 10-15% of trauma related admissions. While the correlation between lumbar vertebral fractures and abdominal injuries is well established, the relationship between thoracic vertebral fractures (TVF) and abdominal injuries is comparatively less well elucidated. Using a large national trauma database, we aimed to examine the incidence and severity of associated abdominal injuries in blunt trauma patients suffering from TVF. METHODS: A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic vertebrae spine fractures following blunt mechanisms of trauma between 1997 and 2018 were examined, comparing the incidence and severity of associated intraabdominal organs injuries with and without TVF. Demographics and outcomes between the two cohorts were compared. RESULTS: From 362,924 blunt trauma patients, 4967 (1.37%) had isolated TVF. Mean age was 49.8 years and 61.9% were males. The most common mechanism of injury was fall following by MVC. The patients with TVF had significantly higher rates of increased ISS score (ISS > 16, 28.45% vs. 10.42%, p < 0.001) and higher mortality rate (3.5% vs. 2%, p < 0.0001). Patients with TVF had 2-3 times more intraabdominal organ injuries (p < 0.001). The most commonly injured organ was spleen (3.28%); followed by liver (2.64%) and kidney (1.47%). An analysis of non-isolated thoracic spine fractures showed same distribution in age, ISS, mechanisms, patterns of intra-abdominal injury, mortality rate and laparotomy rate. CONCLUSION: Clinicians should have an elevated suspicion for intra-abdominal injuries when a thoracic spine fracture is identified, which may necessitate further evaluation.

Role of hydrogen peroxide injection for penetrating abdominal injury in creating CT Tractogram.

Penetrating abdominal trauma is responsible for approximately 35% of patients admitted to urban trauma centers, and up to 12% of those admitted in suburban or rural centers in the United States. Current protocol relies heavily on CT imaging as the diagnostic tool in evaluating for peritoneal violation in hemodynamically stable patients, however it is associated with false negative rates. In addition, visualization of the fascia of the rectus abdominis, the transversalis fascia, and the peritoneum cannot be reliably identified with CT. Studies have probed into the use of injecting IV contrast dyes prior to imaging to establish a CT tractography. We present a case of a 31-year-old male presenting to the emergency department for evaluation of stab wounds following an altercation. On exam, a 1 cm penetrating wound to the LUQ of his abdomen was noted. A CT scan of the abdomen and pelvis was performed with 91 mL of Omnipaque-350 intravenous contrast. Prior to imaging, 30 mL of hydrogen peroxide was injected directly into the opening site of the stab wound to amplify the wound tract. The result was a well-visualized intact peritoneum. We propose hydrogen peroxide as an alternative method to liquid contrast in reestablishing the stab wound tract. This method creates a negative contrast level to augment the ability of CT imaging to determine peritoneal penetration. Key Words: Penetrating Abdominal Injury, CT Tractography, Abdominal Trauma, Hydrogen Peroxide, Trauma Management.

Blunt abdominal injury resulting in a belly full of candy after a motocross accident, a case report.

BACKGROUND: Blunt traumatic gastric perforations in children are rare. Delayed diagnosis will lead to abdominal contamination and may result in morbidity and even mortality. We present a case of an adolescent who sustained blunt abdominal injury in a motocross accident and presented with remarkable hyperdense spherical shaped structures on the computed tomography (CT). CASE PRESENTATION: A 15-year-old boy arrived at the emergency room with an acute abdomen after a motocross accident. A CT scan of the abdomen demonstrated free air and hyperdense round structures in the stomach, pelvic cavity and right paracolic gutter. During emergency laparotomy a traumatic gastric perforation was sutured, a splenic rupture was treated with a vicryl mesh and multiple spherical food scraps were removed from the abdomen. After surgery, the boy clarified that he had eaten a whole bag of colorful and spherical shaped candy just before the accident. CONCLUSIONS: Traumatic gastric rupture in children is rare but physicians should be aware of this diagnosis in case of blunt abdominal trauma with free air on the CT scan. Gastric contents, in this case candy, can present as hyperdense shaped structures in the abdominal cavity on the CT scan.

First Russian experience with endovascular balloon occlusion of the aorta in a zone of combat operations. / Pervyi otechestvennyi opyt primeneniia éndovaskuliarnoi ballonnoi okkliuzii aorty v zone boevykh deistvii.

Resuscitative endovascular balloon occlusion of the aorta has increasingly been used all the world over for arresting ongoing intraabdominal and intrapelvic bleeding accompanied by unstable haemodynamics. However, the use of resuscitative endovascular balloon occlusion of the aorta in a zone of military operations has been limited to sporadic cases only. This article deals with 3 clinical case reports regarding rendering medical care for the wounded presenting with extremely unstable haemodynamics and/or a terminal state in a field hospital, where insertion of a balloon into the aorta made it possible to stabilize the condition, to perform the basic scope of diagnosis, and to finally control the continuing bleeding: in one case - intraabdominal (due to splenic rupture) and in 2 cases - intrapelvic (unstable fractures of pelvic bones). In two cases, despite low readings of blood pressure, puncture of the femoral artery was performed 'blindly' and in one case - in an open fashion. The balloons used were the 7 Fr Rescue Balloon (Japan) and 10 Fr balloons manufactured by the Limited Liability Company 'Minimally Invasive Technologies' (Russia). The balloons were positioned in the aorta also 'blindly' and only in one case we managed to perform an X-ray examination confirming the correct position of the balloon. The mean time of occlusion of the thoracic aorta in the survivors amounted to 20 minutes. The operations were accompanied by intensive therapy and massive haemotransfusion. The introducers were removed using the fascia suture technique (without closure of the arterial wall). Two of the three wounded were saved, to be evacuated to a central hospital and discharged 170 and 75 days thereafter, which was due to long-term treatment of severe concomitant fractures of pelvic bones and lower extremities. No complications on the background of resuscitative endovascular balloon occlusion of the aorta were revealed. Two years after surgery both men continue serving in the Armed Forces, with no significant functional impairments. Our third injured patient delivered in a condition of clinical death, despite restoration of the rhythm after inflation of the balloon unfortunately died. Our case reports demonstrate high efficacy of resuscitative endovascular balloon occlusion of the aorta in unstable haemodynamics induced by combat injury to the abdomen and pelvis. The technique of this method makes it possible not only to stabilize haemodynamics, to improve perfusion of the vital organs but also to staunch continuing haemorrhage, hence allowing additional time to carry out haemotransfusion. In future, resuscitative endovascular balloon occlusion of the aorta may become one of the methods of the extended protocol of prehospital care.

Clinical Significance of the Seat Belt Sign as Evidence of a Compromised Occupant-Seat Belt Relationship.

BACKGROUND: Seat belt marks are seen frequently on occupants after motor vehicle accidents. Over the years, the clinical significance of these marks has changed as restraint systems have evolved. With modern restraint systems, signs of a compromised occupant-restraint relationship are an important and easily identified bedside finding. OBJECTIVES: We sought to learn to recognize seat belt marks that demonstrate an abnormal occupant-restraint system relationship and to cultivate an understanding of significant soft tissue biomechanical loading associated with marks caused by a compromised occupant-restraint relationship. DISCUSSION: A review of case studies from the literature combined with forensic work demonstrate a strong correlation between significant injury and improper seatbelt use. When evidence of a compromised occupant-restraint relationship exists, incorporating computed tomography angiography and observation may be clinically indicated. CONCLUSION: The recognition of seat belt marks made by a compromised occupant-restraint relationship is an important finding that allows risk stratification of the patient at the bedside. Further investigation with a prospective trial at a trauma center is warranted.

Splenic Embolization After Trauma: An Opportunity to Improve Best Immunization Practices.

BACKGROUND: The spleen is the second most commonly injured solid organ during blunt abdominal trauma. Although total splenectomy is frequently performed for injury, splenic rupture can also be managed by splenic embolization. For these patients, current Advisory Committee on Immunization Practices (ACIP) recommendations indicate that if 50% or more of the splenic mass is lost, patients should be treated as though they are asplenic. We have previously demonstrated that compliance with ACIP guidelines regarding immunization after splenectomy is poor. Compliance with vaccination in the setting of splenic embolization for trauma is unknown and we hypothesized patients would not receive the recommended immunizations. MATERIALS AND METHODS: All admissions at our level 1 trauma center requiring splenic embolization secondary to traumatic injury between January 1, 2010, and November 1, 2015, were reviewed. Demographic and injury data, dates and imaging of splenic embolizations, immunization documentation, subsequent vaccination boosters received, and outcomes were collected from the medical record. The proportion of spleen embolized was estimated by review of angiographic imaging using an established method. RESULTS: Nine thousand nine hundred sixty-five trauma patients were admitted during the period studied. Nineteen patients met inclusion and exclusion criteria. Median age of the patient population was 35 y, 85% were male, and median injury severity score was 28. Of these, 15 patients underwent a splenic embolization, in which 50% or more of their splenic mass was lost through embolization. Eight patients received at least one immunization before discharge. Six received initial immunizations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, while three received only the initial immunization against S pneumoniae. None of the 15 patients received any ACIP-recommended booster. Of the four patients having less than 50% of their spleen embolized, three wrongly received immunization against encapsulated organisms before hospital discharge. CONCLUSIONS: Trauma patients undergoing splenic embolization at our institution receive postsplenectomy immunizations incorrectly and had no recorded booster vaccines. We speculate that this is common among the U.S. trauma centers. Review of immunization practices in our trauma and nontrauma patient populations is underway in our health system to improve the care of these patients, and our experience may serve as a guide for other centers to reduce complications associated with asplenia.

Interventional treatment experience in multiple injury with major abdominal or pelvic injuries: 160 cases analysis.

PURPOSE: To observe the therapeutic effect of interventional embolization and haemorrhage control in multiple trauma patients with a major abdominal or pelvic injury. METHODS: Data of 160 multiple trauma patients with a major abdominal or pelvic injury were retrospectively analyzed. They were admitted into the Department of Emergency of the First Affiliated Hospital of Zunyi Medical College from October 2013 to April 2016. Eighty-seven patients who received emergent intervention for embolization and haemorrhage control were set as group A, including 72 males and 15 females, with an average age of (39.32 ± 14.0) years. Patients underwent emergent intervention for embolization and hemostasis. The other 73 patients who received traditional surgeries were set as group B, including 62 males and 11 females, with an average age of (38.48 ± 13.12) years. The time from admission to emergency intervention, the time of interventional embolization, transfusion during hospitalization, length of stay and prognosis were observed. The whole treatment and prognosis were compared between group A and group B. RESULTS: In group A, the average time from admission to intervention exploration was (132.05 ± 86.80) min, the average operation time was (149 ± 49.69) min, the average hospitalization time was (18.37 ± 4.71) days, the average amount of RBC transfusion during hospitalization was (7.2 ± 4.33) units, and the mortality was 4.60% (4 patients died). The corresponding data in group B were respectively (138.95 ± 82.49) min, (183 ± 52.39) min, (22.72 ± 6.63) days, (12.23 ± 5.43) units, and 9.59% (7 cases died). There was no statistical difference in the time from admission to operation between the two groups (p > 0.05), but there was statistical difference in operation time, RBC transfusion, hospitalization time, prognosis, and mortality between the two groups (all p < 0.05). CONCLUSION: The emergent intervention for embolization and haemorrhage control of multiple trauma patients with a major abdominal or pelvic injury and visceral organ haemorrhage has the advantages of less trauma, shorter operation time, shorter hospital stay, less blood transfusion in comparison to the traditional emergency surgeries.

Suicide by self-disembowelment in prison.

Self-inflicted abdominal injuries are uncommon. Fatal self-inflicted abdominal injury is a rare occurrence, especially as a custodial death. A prisoner under-trial for attempted suicide was in judicial custody and was found unconscious in a pool of blood in the bathroom with cut open abdomen and exposed coils of intestine. The bathroom was found locked from inside and had to be forcibly opened. In spite of immediate hospitalisation and appropriate emergency surgical treatment, he succumbed on the same day. As the person had previously made several futile attempts to commit suicide and was in fact under trial for the crime of attempted suicide (section 309 of Indian Penal Code), the prison authorities had already taken good precautions to prevent access to any type of weapon, instrument, or material that could rekindle the thought of another attempt. In spite of all this, he successfully committed suicide with an apparently innocuous object, a disposable razor. This case is reported for the rarity of occurrence of this type of suicide, and it highlights the importance of utmost precautions to be taken in dealing with prisoners having suicidal tendencies.