Transarterial embolization to treat hemodynamically unstable trauma patients with splenic injuries: A retrospective multicenter observational study.

PURPOSE: We described clinical outcomes for patients with blunt splenic injuries treated with transarterial embolization (TAE) based on their hemodynamic status. MATERIALS AND METHODS: This is a retrospective two-center study of adult patients with splenic injuries who underwent emergency TAE between January 2011 and December 2022. Patients were divided into two groups; hemodynamically unstable (HDU) and hemodynamically stable (HDS) patients. HDU patients were defined as transient- or non-responders to fluid resuscitation and HDS as responders. When immediate laparotomy was not possible for HDU patients, angiography and embolization were performed. The primary outcome was the survival discharge rate. Rebleeding and splenectomy rate was also investigated. RESULTS: Of 38 patients underwent emergency TAE for splenic trauma, 17 were HDU patients and 21 were HDS patients. The survival discharge rate was 88.2 % (15/17) in the HDU- and 100 % in HDS patients (p = 0.193). Rebleeding rate was 23.5 % (4/17) in HDU- and 5.0 % (1/21) in HDS patients (p = 0.15). Splenectomy was required for one HDU patient (5.9 %) for rebleeding. CONCLUSION: The survival discharge rate of TAE for splenic trauma in HDU patients was acceptable with a low rate of splenectomy. Further comparative studies of TAE versus operative management in HDU patients are needed to prove the usefulness of TAE.

Pelvic packing or endovascular interventions: Which should be given priority in managing hemodynamically unstable pelvic fractures? A systematic review and a meta-analysis.

Background: Pelvic fractures in trauma patients can be associated with substantial massive hemorrhage. Hemostasis interventions mainly consist of pelvic packing (PP) and endovascular intervention (EI), such as angiography-embolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA). Whether PP or EI should be prioritized for the management of hemodynamic unstable patients with pelvic fractures remains under debate. This meta-analysis aimed to establish the evidence-based recommendations for the management of hemodynamic unstable patients. Materials and methods: PubMed, CENTRAL, and EMBASE databases were searched for articles published from January 1, 2000 to January 31, 2023. Eligible studies, such as retrospective cohort studies, propensity score matching studies, prospective cohort studies, observational cohort studies, quasi-randomized clinical trials evaluating PP and EI (AE or REBOA) for the management of patients with hemodynamically unstable pelvic fractures, were included. Mean Difference (MD), relative risk (RR), and 95 % confidence intervals (CI) were calculated using fixed- or random-effects models depending on the heterogeneity of included trials. We compared the effectiveness of the two methods in terms of mortality, unstable fracture pattens, injury severity score (ISS), systolic blood pressure (SBP), lactate (LA), base deficiency (BE), hemoglobin preoperatively, blood transfusion requirement, the time to and of operation, complications. Results: Overall, 15 trials enrolling 1136 patients were analyzed, showing a total mortality rate of 28.4 % (323/1136). No effect of PP preference on the ISS (PP 36.4 ± 10.4 vs. EI 34.5 ± 12.7), SBP (PP 81.1 ± 24.3 mmHg vs. EI 94.2 ± 32.4 mmHg), LA (PP 4.66 ± 2.72 mmol/L vs. 4.85 ± 3.45 mmol/L), BE (PP 8.14 ± 5.64 mmol/L vs. 6.66 ± 5.68 mmol/L), and unstable fracture patterns (RR = 1.10, 95 % CI [0.63, 1.92]) was observed. PP application was associated with lower preoperative hemoglobin level (PP 8.11 ± 2.28 g/dL vs. EI 8.43 ± 2.43 g/dL, p < 0.05), more preoperative transfusion (MD = 2.53, 95 % CI [0.01, 5.06]), less postoperative transfusion within the first 24 h (MD = -1.09, 95 % CI [-1.96, -0.22]), shorter waiting time to intervention (MD = -0.93, 95 % CI [-1.54, -0.31]), and shorter operation time of intervention (MD = -0.41, 95 % CI [-0.52, -0.30]). PP had lower mortality rate owing to uncontrolled hemorrhage in the acute phase (RR = 0.41, 95 % CI [0.22, 0.79]). There was neither difference in mortality due to other complications (RR = 1.60, 95 % CI [0.79, 3.24]), nor in total mortality (RR = 0.92, 95%CI [0.49, 1.74]) (p > 0.05). Conclusions: PP showed advantages of reducing the amount of postoperative transfusion, shortening the time of waiting and operating, and decreasing mortality due to uncontrolled hemorrhage in the acute phase without raising the odds of mortality due to complications. PP, a reliable hemostatic method, should be prioritized for resuscitating most pelvic fractures with hemodynamically unstable, especially in case of bleeding from veins and fracture sites, as well as inadequate EI.

Experience of Sustained Low-Efficiency Dialysis (SLED) in an Intensive Care Unit of a Quaternary Care Hospital.

BACKGROUND: In critically ill patients, sustained low-efficiency dialysis (SLED) has become a viable option for treating acute kidney injury (AKI) instead of continuous renal replacement therapy (CRRT). This study aimed to evaluate clinical outcomes in critically ill patients receiving SLED. MATERIAL AND METHODS: In our ICU, we performed a retrospective cohort study on hemodynamically unstable patients requiring dialysis in the form of SLED. Demographics, clinical, and biochemical variables were analyzed. RESULTS: A total of 58 patients were enrolled in the study. The mean age was 48.58 ± 15 with a male-to-female ratio of 3:1. Higher APACHE II score, high international normalized ratio, thrombocytopenia, and septic shock were found to be poor prognostic markers, with an overall observed mortality of 56.9%. CONCLUSION: SLED can be considered as an alternative to CCRT for selected hemodynamically unstable patients requiring renal replacement therapy.

Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND: Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial. PURPOSE: To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients. METHODS: This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes. RESULTS: Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points. CONCLUSION: Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.

Extraperitoneal pelvic packing versus angiographic embolization for hemodynamically unstable pelvic fractures: a retrospective single-center analysis.

OBJECTIVE: To retrospectively analyze the clinical data and treatment procedures of angiographic embolization (AE) and extraperitoneal pelvic packing (EPP) for traumatic pelvic fractures in our center for the purpose of providing recommendations on the selection of treatment protocols. METHODS: We analyzed 110 patients with traumatic pelvic fractures treated with AE and EPP from January 2015 to May 2023. The patients were divided into the AE group (69 men, 41 women) and the EPP group (20 men, 12 women). The primary outcomes were the mortality rate and incidence of complications. RESULTS: The mortality rate was slightly lower in the AE than EPP group (7.3% vs. 9.4%). The overall blood transfusion volume was lower and the length of hospital stay was shorter in the AE than EPP group (7.79 ± 12.04 vs. 9.14 ± 14.21 units and 20.48 ± 11.32 vs. 22.14 ± 10.47 days). CONCLUSIONS: Both AE and EPP have good treatment effects. AE is preferred for patients in stable condition with severe hemorrhage. This study suggests that EPP should be the primary treatment and that AE should serve as a complementary treatment for critical patients.

Nonoperative management with angioembolization for blunt abdominal solid organ trauma in hemodynamically unstable patients: a systematic review and meta-analysis.

PURPOSE: The objective of the present study is to provide a comprehensive review of the literature on associated outcomes of angioembolization in blunt abdominal solid organ traumas. METHODS: The databases of Medline, Embase, and Cochrane Library were explored until 24 September 2021. All studies with data on the efficacy or safety of angioembolization in patients suffering from hemodynamically unstable blunt abdominal solid organ trauma were included. The primary outcomes were clinical success rate and mortality. Pooled event rates were calculated using a double arcsine transformation to stabilize the variance of the original proportion. RESULTS: In total, 13 reports of 12 studies were included in the systematic review. According to the current meta-analysis, the angioembolization for blunt abdominal solid organ trauma in hemodynamically unstable patients had a high clinical success rate [0.97 (95% CI 0.93-0.99)] and low mortality [0.03 (95% CI 0.01-0.07)]. Furthermore, no statistically significant difference was found between the various injured solid organs for either of these parameters. In addition, the technique-associated adverse events were seldom and tolerable. CONCLUSIONS: For blunt abdominal solid organ trauma in hemodynamically unstable patients, this review shows that angioembolization exhibited a high clinical success rate, low mortality, and tolerable technique-related adverse events. Furthermore, the top possible indication for angioembolization in hemodynamically unstable patients is an individual who responds to rapid fluid resuscitation. However, high-quality and large-scale trials are needed to confirm these results and determine the selection criteria for appropriate patients in this setting.

Abdominal and thoracic wall closure: damage control surgery's cinderella.

Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

Los principios de la cirugía de control de daños consisten en realizar procedimientos abreviados que permiten diferir el manejo de la lesión traumática para lograr una resucitación metabólica temprana en pacientes severamente comprometidos en su fisiología. Sin embargo, la respuesta fisiológica inicial al trauma y a la cirugía, junto con los esfuerzos de resucitación hemostática, pueden generar edema en los órganos abdominales o torácicos, aumento de la presión en la cavidad visceral y repercusiones hemodinámicas. En consecuencia, con el paso de los años se han desarrollado técnicas para el cierre diferido de la cavidad; aunque, existen controversias sobre la técnica más adecuada para el cierre quirúrgico tanto del abdomen, como del tórax. El objetivo de este artículo es presentar las indicaciones y técnicas quirúrgicas para el cierre diferido del abdomen y tórax respecto a la cirugía de control de daños del paciente con trauma severo, a partir de la experiencia del grupo de cirugía de Trauma y Emergencias de Cali, Colombia. Se recomienda el uso de los sistemas de presión negativa como la estrategia ideal para el cierre diferido de la pared abdominal o torácica, que se asocia con una mayor tasa de cierre definitivo, una menor tasa de complicaciones y mejores resultados clínicos.

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach.

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

El trauma penetrante del torso representa la segunda causa de muerte de origen traumático después del trauma craneoencefálico. En países desarrollados existe mayor prevalencia de trauma cerrado, asociado principalmente a accidentes de tránsito o caídas de grandes alturas. Mientas, que en países en vía de desarrollo el trauma penetrante es más prevalente con heridas por arma de fuego o por arma blanca asociado a la violencia y las desigualdades sociales. El trauma penetrante torácico y abdominal pueden presentar altas tasas de mortalidad en la escena del trauma si se comprometen estructuras importantes como el corazón, los grandes vasos o el hígado. Actualmente, existen controversias sobre el adecuado abordaje quirúrgico con la implementación o no de dispositivos endovasculares como el balón de resucitación endovascular de oclusión aórtica (Resuscitative Endovascular Balloon Oclussion of the Aorta - REBOA) y la realización de ayudas imagenológicas. El objetivo de este artículo es presentar el conocimiento sobre este tema, basado en la experiencia adquirida durante los últimos 30 años con el manejo del trauma, cirugía general y cuidado crítico. Sostenemos que en un paciente hemodinámicamente inestable se debe realizar una temprana oclusión aórtica endovascular o abierta con el objetivo de evitar el desarrollo o propagación del rombo de la muerte. Con este propósito, presentamos una guía práctica y sencilla sobre el abordaje quirúrgico del paciente hemodinámicamente inestable con trauma penetrante del torso.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses.

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses / Control de daños del trauma vascular periférico - No le tema a la fosa axilar o poplítea

Abstract Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

Resumen El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

Abdominal and thoracic wall closure: damage control surgery's cinderella / El cierre de la pared abdominal y torácica: La cenicienta en la cirugía control de daños

Abstract Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach / Guía práctica para el abordaje quirúrgico del trauma penetrante del torso en paciente hemodinámicamente inestable

Abstract Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

Resumen El trauma penetrante del torso representa la segunda causa de muerte de origen traumático después del trauma craneoencefálico. En países desarrollados existe mayor prevalencia de trauma cerrado, asociado principalmente a accidentes de tránsito o caídas de grandes alturas. Mientas, que en países en vía de desarrollo el trauma penetrante es más prevalente con heridas por arma de fuego o por arma blanca asociado a la violencia y las desigualdades sociales. El trauma penetrante torácico y abdominal pueden presentar altas tasas de mortalidad en la escena del trauma si se comprometen estructuras importantes como el corazón, los grandes vasos o el hígado. Actualmente, existen controversias sobre el adecuado abordaje quirúrgico con la implementación o no de dispositivos endovasculares como el balón de resucitación endovascular de oclusión aórtica (Resuscitative Endovascular Balloon Oclussion of the Aorta - REBOA) y la realización de ayudas imagenológicas. El objetivo de este artículo es presentar el conocimiento sobre este tema, basado en la experiencia adquirida durante los últimos 30 años con el manejo del trauma, cirugía general y cuidado crítico. Sostenemos que en un paciente hemodinámicamente inestable se debe realizar una temprana oclusión aórtica endovascular o abierta con el objetivo de evitar el desarrollo o propagación del rombo de la muerte. Con este propósito, presentamos una guía práctica y sencilla sobre el abordaje quirúrgico del paciente hemodinámicamente inestable con trauma penetrante del torso.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses / Control de daños del trauma vascular periférico - No le tema a la fosa axilar o poplítea

Abstract Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

Resumen El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients / El REBOA como nuevo actor en el control de daños del paciente hemodinámicamente inestable con hemorragia no compresible del torso

Abstract Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.

Resumen La hemorragia no compresible del torso es una de las principales causas de muerte prevenibles alrededor del mundo. Una evaluación eficiente y apropiada del paciente traumatizado con hemorragia activa es la esencia para evitar el desarrollo del rombo de la muerte (hipotermia, coagulopatía, hipocalcemia y acidosis). Actualmente, las estrategias de manejo inicial incluyen hipotensión permisiva, resucitación hemostática y cirugía de control de daños. Sin embargo, los recientes avances tecnológicos han abierto las puertas a una amplia variedad de técnicas endovasculares que logran esos objetivos con una morbilidad mínima y un acceso limitado. Un ejemplo de estos avances ha sido la introducción del balón de resucitación de oclusión aortica; REBOA ( Resuscitative Endovascular Balloon Occlusion of the Aorta , por sus sigla en inglés ), el cual, ha tenido gran provecho entre los cirujanos de trauma alrededor del mundo debido a su potencial y versatilidad en áreas como trauma, ginecología y obstetricia, y gastroenterología. El objetivo de este artículo es describir la experiencia lograda en el uso del REBOA en pacientes con hemorragia no compresible del torso. Nuestros resultados muestran que el REBOA puede usarse como un nuevo actor en la resucitación de control de daños del paciente con trauma severo, para este fin, nosotros proponemos dos nuevos algoritmos para el manejo de pacientes hemodinámicamente inestables: uno para trauma cerrado y otro para trauma penetrante. Se reconoce que el REBOA tiene sus limitaciones, las cuales incluye un periodo de aprendizaje, su costo inherente y la disponibilidad. A pesar de esto, para lograr los mejores resultados con esta nueva tecnología, el REBOA debe ser usado en el momento correcto, por el cirujano correcto con el entrenamiento y el paciente correcto.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown / Control de Daños en Trauma Hepático Penetrante: El Miedo a Lo Desconocido

Abstract The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Resumen El hígado es el órgano solido más comúnmente lesionado en casos de trauma abdominal. El manejo del trauma penetrante hepático es un dilema para los cirujanos. Sin embargo, con la introducción del concepto de la cirugía de control de daños y los avances tecnológicos en imagenología y técnicas endovasculares han permitido que el enfoque del tratamiento cambie. La disponibilidad inmediata de la tomografía computarizada permite estadificar el grado de la lesión e incrementar la posibilidad de un manejo conservador en pacientes hemodinámicamente estables con trauma hepático. El trauma hepático severo que se asocia con inestabilidad hemodinámica tiene una alta mortalidad debido a la hemorragia activa. El objetivo de este artículo es proponer un algoritmo de manejo producto de un consenso de expertos acerca del abordaje de los pacientes hemodinámicamente inestables con trauma hepático penetrante. El manejo debe ser por parte de un equipo multidisciplinario que comienza desde la evaluación inicial de los pacientes, la activación temprana de protocolo de transfusión masiva y el control temprano de la hemorragia, siendo estos aspectos esenciales para disminuir la mortalidad. El miedo a lo desconocido es el dilema quirúrgico donde existen pocas opciones y es imperante decisiones rápidas y oportunas; por esta razón, se propone dar una luz de guía sobre lo desconocido respecto al manejo del paciente con trauma hepático severo.

Hemodynamically unstable pelvic fracture: A damage control surgical algorithm that fits your reality / Trauma pélvico e inestabilidad hemodinámica: Un algoritmo quirúrgico de control de daños que se adapta con su realidad

Abstract Pelvic fractures occur in up to 25% of all severely injured trauma patients and its mortality is markedly high despite advances in resuscitation and modernization of surgical techniques due to its inherent blood loss and associated extra-pelvic injuries. Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery). This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons. We propose two different management algorithms that specifically address the availability of qualified staff and existing infrastructure: one for the fully equipped trauma center and another for the very common limited resource center.

Resumen Las fracturas de pelvis ocurren en más del 25% de los pacientes con trauma severo y su mortalidad es alta, a pesar de los avances en la resucitación hemodinámica y las técnicas quirúrgicas. Esta mortalidad se explica por la hemorragia inherente y las lesiones extra pélvicas asociadas, las fracturas o las disrupciones ligamentarias de la pelvis aumentan el volumen del espacio pélvico, y conlleva a que la hemorragia pélvica se acumule en el espacio retroperitoneal. En poco tiempo, esto conduce a la inestabilidad hemodinámica y el rombo de la muerte. La hemorragia pélvica es un 80% venosa proveniente de los plexos pre-sacro / pre-peritoneal. El restante 20% es arterial por sangrado de las ramas de la arteria iliaca interna. Esta realidad podría ser cambiada a través de un manejo secuencial enfocado según la disposición de recursos del centro de atención y de un trabajo colaborativo entre ortopedistas, cirujanos de trauma e intensivistas. Este articulo propone dos algoritmos de manejo que están enfocados según la disponibilidad de un equipo calificado e infraestructura existente: uno para un centro de trauma totalmente equipado, y el otro para un centro con recursos limitados.

Association between Young-Burgess pelvic ring injury classification and concomitant injuries requiring urgent intervention.

BACKGROUND: Young-Burgess classification (YB) is a mechanistic system which classifies pelvic ring injuries into anterior-posterior compression (APC), lateral compression (LC), vertical shear (VS) injuries, and combined mechanism (CM). The objective of this study was to identify associated injuries which require urgent operative intervention by YB classification. We hypothesize that YB classification is associated with 1) need for urgent intervention for pelvic fracture-related hemorrhage and 2) patterns of injury complexes requiring surgery. METHODS: This is a retrospective study of severely injured trauma patients with pelvic ring injuries who presented to an urban Level-1 trauma center from 2007 to 2017. Associated injuries and procedures were determined by Abbreviated Injury Scale (AIS) and ICD-9/10 codes. YB classes were compared, followed by a cluster analysis to identify injury patterns and association with YB classifications. RESULTS: Overall, 135 patients were included. 98 (72%) of patients presented with LC, 16 (12%) with APC, 8 (6%) with VS, and 13 (10%) with CM. VS and APC groups had higher rates of REBOA use compared to LC and CM groups (38% and 31% versus 11% and 0%, respectively, p = 0.01). The CM group, compared to LC, APC, and VS, had higher rates of urgent operative intervention for bleeding control (69% versus 32%, 50% and 43%, respectively, p = 0.01). 39 (29%) patients had a concomitant injury which was identified by CT scan in initial trauma work up and altered management, 46% which merited urgent intervention. On cluster analysis, there were no distinct injury complexes which required urgent operative intervention by YB class. CONCLUSIONS: These data failed to identify unique injury complexes which merit urgent operative intervention by YB class. Nearly one in four patients had injuries identified by initial CT imaging which altered initial management, demonstrating the importance of early, full body CT imaging in severely injured patients with pelvic ring injuries.

Gastrointestinal anastomosis (GIA) stapler as a safe and efficacious damage control tool for high-grade liver injury in hemodynamically unstable patient- A case report.

INTRODUCTION: Liver injury occurs in approximately 5% of all trauma admissions. There are many traditional ways of controlling hemorrhage from the liver and here we report a case in which a GIA 75 stapler was successfully used to manage Grade IV liver injury in a hemodynamically unstable patient. PRESENTATION OF CASE: 45 years old policeman presented in the emergency, after sustaining a gunshot injury to his abdomen. At presentation, he was hemodynamically unstable and had a single entry wound in the epigastrium. He was rushed to the operating room (OR) for exploratory laparotomy which revealed a shattered left lobe of the liver. Gastrointestinal anastomosis 75 stapler device was used for non-anatomical left segmentectomy (segments I and II). Perihepatic packing was done and the patient shifted to the surgical intensive care unit (SICU). He was re-explored within 24 h. No active bleeding was seen after the packs were removed and the abdomen was closed. The next day he was moved out of SICU and was discharged on the 10th day of admission. DISCUSSION: The concept of damage control surgery rests on quick control of life-threatening bleeding and a GIA stapler can be effectively used for rapid non-anatomical resection of the liver in trauma. This can prevent the depletion of physiological reserves and the life-threatening death triad. CONCLUSION: GIA stapler device is an effective, safe, and rapidly deployable tool for managing high-grade liver injury in a hemodynamically unstable patient.

Initial experience with the T-Clamp for temporary fixation of mechanically and hemodynamically unstable pelvic ring injuries.

In polytrauma patients with unstable pelvic ring injuries, pelvic binders interfere with femoral arterial access and are frequently removed for emergent endovascular and abdominal procedures. The 'trochanteric C-clamp' (T-clamp) is a novel technique described for rapid stabilization of the pelvis without fluoroscopic imaging, while ensuring adequate access to the groin. This case series reports the feasibility and safety following T-clamp application for unstable pelvic ring injuries in patients requiring simultaneous endovascular intervention. Between May 2018 - May 2019, seventeen patients with unstable pelvic ring injuries were treated with a T-clamp in conjunction with other emergent endovascular or intra-abdominal procedures. Nine presented with unstable APC injuries, seven with unstable LC injuries and one with a vertical shear pattern. Complications related to the T-clamp were prospectively collected. Following T-clamp application, there were two cases of intraoperative over-reduction, one of which required exchange for an anterior external fixator. This was the result of a concomitant acetabulum fracture leading to iatrogenic acetabular protrusion secondary to the T-clamp. Twelve cases maintained the T-clamp fixation postoperatively ranging from 1-3 days. One postoperative loss of reduction was noted and required exchange for anterior external fixator. In hemodynamically unstable patients who require emergent endovascular procedures, such as pelvic angiography and REBOA, T-clamp application offers a reasonably safe and effective method for expeditious stabilization of the pelvis while allowing unimpeded access to the abdomen, groin and pelvis. Caution should also be applied in patients with concomitant acetabulum fracture for risk of malreduction. Additionally, its prolonged postoperative use should be limited to patients who are not immediately suitable for fixation of the pelvis.

Management of Hemodynamically Unstable Pelvic Ring Fractures.

Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm.