[Therapeutic and diagnostic complex in intestinal failure syndrome in patients with closed abdominal trauma]. / Lechebno-diagnosticheskii kompleks pri sindrome kishechnoi nedostatochnosti u patsientov s zakrytoi travmoi zhivota.

Currently, severe combined abdominal trauma ranks third among all causes of mortality In Russia, second only to cardiovascular and oncologic diseases. In the period from 2019 to 2020 in our country, a slight decrease in traumatism is noted due to a decrease in the number of traffic accidents as the main cause of combined and multiple trauma. The number of abdominal injuries from the total number of injuries In Russian regions ranges from 1.5 to 36.5% and is accompanied by a high level of disability (25-80% in combined trauma and 5-8% in isolated trauma). Despite modern medical advances, lethality in combined trauma of abdominal organs varies from 10.7 to 69.7%, with closed abdominal trauma accounting for up to 6% of fatal outcomes. OBJECTIVE: Improving treatment outcomes in patients with closed abdominal trauma through comprehensive diagnosis of SCN and optimization of enteral therapy in patients with closed abdominal trauma. MATERIAL AND METHODS: The study included 40 patients (29 (72.5%) men and 11 (27.5%) women), who underwent examination and treatment at the State Budgetary Institution "Research Institute of SP. Im. N.V. Sklifosovsky Research Institute of St. Petersburg State Medical Center with the diagnosis: Closed abdominal trauma. The age of the patients varied from 25 to 81 years (Mean age was 49.6±13.1). To evaluate the effectiveness of intensive therapy, the patients were divided into 2 groups: the comparison group (n=26) included patients who were treated with complex conservative therapy. Patients of the main group (n=14) conservative therapy was supplemented with the use of ER to restore the functional activity of the intestine under the control of ultrasound and assessment of the degree of intra-abdominal hypertension, as well as with Intestamine to stimulate the intestinal trauma. RESULTS: In the course of the study it was found that, as a result of complex enteral therapy in the patients of the main group, starting from the 7th day of stay in the ORIT, positive dynamics was observed, consisting in a statistically significant decrease in the levels of lactate, ALT, AST, LDH, and CRP. By the 14th day there was also a statistically significant decrease in leukocyte and PCT levels. The lethality in the main group amounted to 7.2%, n=1. At the same time, in patients of the comparison group only by the 7th day there was a decrease in concentration of CRP (p=0.065), by the 10th day - ALT (<0.001) and by the 14th day there was a decrease in leukocytes level (p=0.038). Lethality in this group amounted to 23.1%, n=6. CONCLUSION: Timely initiation of pathogenetic enteral therapy contributes to faster normalization of clinical and laboratory parameters, protection of intestinal barrier function, prevention of complications associated with bacterial translocation and bacterial overgrowth syndrome, increase in immunoresistance of the organism.

The optimal management of blunt aortic injury in the young.

BACKGROUND: Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset. METHODS: Patients (1-19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1-9] and adolescents [ages 10-19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI. RESULTS: Adolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 â€‹%, p â€‹= â€‹0.057) and significantly reduced mortality (2.1 vs 14.4 â€‹%, p â€‹< â€‹0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059-0.324, p â€‹< â€‹0.0001). CONCLUSIONS: BAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.

Complications and failure rate of splenic artery angioembolization following blunt splenic trauma: A systematic review.

BACKGROUND: Over recent decades, splenic angioembolization (SAE) as an adjunct to non-operative management (NOM) has emerged as a prominent intervention for patients with blunt splenic injuries (BSI). SAE improves patient outcomes, salvages the spleen, and averts complications associated with splenectomy. This systematic review aimed to evaluate the failure rate and complications related to SAE in patients with BSI. METHODS: A systematic literature search (PubMed, SCOPUS, and Cochrane Library) focused on studies detailing splenic angioembolization in blunt trauma cases. Articles that fulfilled the predetermined inclusion criteria were included. This review examined the indications, outcomes, failure rate, and complications of SAE. RESULTS: Among 599 identified articles, 33 met the inclusion criteria. These comprised 29 retrospective studies, three prospective studies, and one randomized control trial. The analysis encompassed 25,521 patients admitted with BSI and 3,835 patients who underwent SAE. The overall failure rate of SAE was 5.3 %. Major complications predominantly were rebleeding (4.8 %), infarction (4.6 %), and abscess formation (4 %). Minor complications were fever (18.4 %), pleural effusion (13.1 %), and coil migration (3.9 %). Other complications included splenic atrophy, splenic cyst, hematoma, and access site complications such as splenic/femoral dissection. Overall, post embolization mortality was 0.08 %. CONCLUSION: SAE is a valuable adjunct in managing BSI, with a low failure rate. However, this treatment modality is not without the risk of potentially serious complications.

Treatment Strategies And Outcomes Of Thoracic Aortic Blunt Injuries In Adults: A Systematic Review.

INTRODUCTION: Blunt thoracic aortic injuries (BTAI) once had mortality rates up to 32%, but the advent of thoracic endovascular aortic repair (TEVAR) has significantly improved outcomes. However, concerns persist regarding long-term devicerelated complications, device integrity in aging aortas, and the criteria for selecting patients for endovascular repair. We aimed to assess BTAI treatment strategies based on injury grade and their associated outcomes. METHODS: A systematic search of MedLine and Scopus databases was conducted to identify original articles published after 2013, which provided information on injury characteristics, outcomes, secondary effects, and reinterventions following BTAI. We classified aortic injuries following the SVS Clinical Practice Guidelines. RESULTS: We included 28 studies involving 1888 BTAI patients, including 5 prospective studies. Most patients were under 45 years old (86.4%), and grade III injuries were the most common (901 patients), followed by grades I and II (307 and 291 patients, respectively). TEVAR was performed in 1458 patients, mainly with grade III and IV injuries (1040 patients). Approximately half of the grade I injuries (153 of 307) were treated with TEVAR. Thirty-day mortality rate was 11.2%, primarily due to associated injuries. Aortic-related deaths were reported in 21 studies, with an overall rate of 2.2%, but none occurred beyond the first 30 days. Partial or complete coverage of the left subclavian artery was performed in 522 patients, with 27.9% requiring immediate or delayed revascularization. Aortic reintervention rates were relatively low (3.9%). CONCLUSION: TEVAR effectively treats BTAI grades III and IV, with potential benefit for some grade II injuries with more aggressive early intervention. Despite SVS guidelines suggesting conservative management for grade I injuries, there is a substantial rate of intervention with positive outcomes and low mortality. Long-term follow-up data, extending up to almost 20 years, reveal the durability of grafts, aortic remodeling, and minimal reintervention and complications.

A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury.

BACKGROUND: Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. METHODS: US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001-2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. RESULTS: Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. CONCLUSION: This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Single-Center Long-Term Results of Popliteal Artery Blunt Trauma Management Following Knee Dislocation - A Case Series Study.

BACKGROUND: Injury to the popliteal artery after knee dislocation, if not promptly diagnosed and properly treated, can have devastating results. The purpose of this retrospective study was to describe the diagnostic and the treatment protocol we use, as well as provide long-term outcomes for a series of patients treated in our tertiary hospital, emphasizing on the importance of ankle-brachial index (ABI) measurement as an integral component of the diagnostic approach. METHODS: A retrospective analysis of all admissions to our hospital trauma center between November 1996 and July 2023, with a diagnosis of knee dislocation and the presence or absence of concomitant arterial injury resulting from blunt high-energy trauma, was conducted. Before 2006, digital subtraction angiography (DSA) and/or computed tomography angiography (CTA) were part of the diagnostic approach (group A). After 2006, the ABI was used as a first-line test to diagnose arterial damage (group B). The Tegner and Lysholm scores were chosen to assess patients' postoperative impairment between groups, taking also into account the presence or absence of vascular injury. The Mann-Whitney U test and a univariate analysis of variance were used for the statistical analysis of scores. RESULTS: Overall, 55 patients were identified, and 21 of them (38.2%) had injuries to the popliteal artery, all of which were treated with a reversed great saphenous venous bypass. Out of the 21 patients, 4 (4.3%) developed compartment syndrome, which was treated with fasciotomies, and 1 leg (1.8%) was amputated above the knee. With no patients lost to follow-up, all but one (95%) of the vascular repairs are still patent, and the limbs show no signs of ischemia after a mean follow-up of 6 years. The Tegner and Lysholm score means were similar between groups A and B and independent of the presence of vascular injury and the diagnostic protocol used. Interestingly, an ABI below 0.9 proved to be predictive of arterial injury. CONCLUSIONS: A high level of awareness for the presence of popliteal artery injury should exist and an ABI measurement should be routinely performed in the management of all cases of knee dislocation. This way, fewer patients will undergo unnecessary CTA scanning, and hardly any popliteal artery injuries can go missing, as suggested by our study.

Preperitoneal pelvic packing in isolated severe pelvic fractures is associated with higher mortality and venous thromboembolism: A matched-cohort study.

INTRODUCTION: Preperitoneal pelvic packing (PPP) has been advocated as a damage control procedure for pelvic fracture bleeding, despite of weak evidence. METHODS: Matched cohort study, TQIP database. Patients with isolated severe blunt pelvic fractures (pelvis abbreviated injury score [AIS] â€‹≥ â€‹3, AIS ≤2 in all other body regions) were included. Patients who underwent PPP were matched to patients with no PPP, 1:3 nearest propensity score. Matching was performed based on demographics, vital signs on admission, comorbidities, injury characteristics, type and timing of initiation of VTE prophylaxis, and additional procedures including laparotomy, REBOA, and angioembolization. RESULTS: 64 patients with PPP were matched with 182 patients with No-PPP. PPP patients had higher in-hospital mortality (14.1 â€‹% vs 2.2 â€‹% p â€‹< â€‹0.001) and higher rates of VTE and DVT (VTE: 14.1 â€‹% vs 4.4 â€‹% p â€‹= â€‹0.018, DVT: 10.9 â€‹% vs 2.2 â€‹% p â€‹= â€‹0.008). CONCLUSION: PPP is associated with worse survival outcomes and increased rate of VTE and DVT complications.

Pediatric trauma patients with isolated grade III blunt splenic injuries may be safely managed without intensive care unit admission.

BACKGROUND: Non-operative management is the standard of care for pediatric blunt splenic injury. The American Pediatric Surgical Association recommends intensive care unit monitoring only for grade IV/V blunt splenic injury; however, variation remains regarding this practice. We hypothesized that pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to a non-intensive care unit setting would have similar outcomes to those admitted to the intensive care unit. METHODS: The 2017 to 2019 Trauma Quality Improvement Program database was queried for blunt pediatric trauma patients (≤16 years) with near-isolated grade III blunt splenic injuries. Patients with systolic blood pressure <90 mmHg or heart rate >90 were excluded. Pediatric trauma patients admitted to the intensive care unit were compared to non-intensive care unit admissions. The primary outcome was splenectomy. Bivariate analyses were performed. RESULTS: Of 461 pediatric trauma patients with near-isolated grade III blunt splenic injuries, 186 (40.3%) were admitted to the intensive care unit. Intensive care unit patients were older than their non-intensive care unit counterparts (15 vs 14 years, P = .03). Intensive care unit and non-intensive care unit patients had a similar rate of splenectomy (0.5% vs 0.7%, P = .80) and time to surgery (19.7 vs 19.8 hours, P = .98). Patients admitted to the intensive care unit had a longer length of stay (4 vs 3 days, P < .001). There were no significant complications or deaths in either group. CONCLUSION: This national analysis demonstrated that hemodynamically stable pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to the floor or intensive care unit had a similar rate of splenectomy without complications or deaths. This aligns with American Pediatric Surgical Association recommendations that pediatric trauma patients with grade III blunt splenic injuries be managed in non-intensive care unit settings. Widespread adoption is warranted and should lead to decreased healthcare expenditures.

Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis.

INTRODUCTION: This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries. METHODS: This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival. RESULTS: Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001). CONCLUSIONS: SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries.

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.

Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention.

BACKGROUND: Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. METHODS: A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. RESULTS: Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. CONCLUSION: For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.

Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism.

INTRODUCTION: Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy. METHODS: The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade. RESULTS: The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group. CONCLUSIONS: Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.

Management of Traumatic Diaphragmatic Injuries.

Diaphragm injuries are rarely seen injuries in trauma patients and are difficult to diagnose. With improving technology, computed tomography has become more reliable, but with increasing rates of non-operative management of both penetrating and blunt trauma, the rate of missed diaphragmatic injury has increased. The long-term complications of missed injury include bowel obstruction and perforation, which can carry a mortality rate as high as 85%. When diagnosed, injuries should be repaired to reduce the risk of future complications.

Impact of Trauma Verification Level on Management and Outcomes of Combined Traumatic Brain and Solid Organ Injuries: An NTDB Retrospective Review.

BACKGROUND: Level-I and level-II trauma centers are required to offer equivalent resources since "The Orange Book." This study evaluates differences between level-I and level-II management of solid organ injury (SOI) with traumatic brain injury (TBI). METHODS: We conducted a retrospective review of the National Trauma Data Banks from 2013 to 2021 of adult (≥18 years), blunt trauma patients with both TBI and SOI treated at level-I or level-II trauma centers. RESULTS: 48,479 TBI and SOI patients were identified, 32,611 (67.3%) at level-I centers. Unadjusted incidence of laparotomy was higher at level I (14.5% vs 11.7%, P < 0.001), and angiography rates were similar (3.3% vs 3.4%, P 0.717). Sub-group analysis of stable patients (SBP ≥100) showed an increase in nonoperative management at level II (87.3% vs 88.7%, P < 0.001) and decrease in laparotomy (9.9% vs 8.3%, P < 0.001). On logistic regression (LR), severe TBI, high-grade SOI, and level I trauma status were predictors of laparotomy. Logistic regression showed mild/moderate TBI with high-grade SOI and level II were associated with use of angiography. Unadjusted mortality rates were slightly different (14.8% vs 13.4%, P < 0.001), but there was no association with trauma level on LR. DISCUSSION: Nonoperative management was seen more at level-II centers with laparotomy at level I. Subgroup analysis showed no difference in mortality in trauma levels. Matched patients for level I and II showed no statistical difference in management. Patients were treated similarly at both levels with similar outcomes and mortality.

[Management of Tracheobronchial Injuries due to Brunt Trauma].

BACKGROUND: Tracheobronchial injuries resulting from blunt trauma are relatively rare among chest injuries. However, if these injuries are not managed properly, they can be fatal. The prognosis is intricately linked to the precise diagnosis and treatment. We herein report three cases of tracheobronchial trauma that required surgical intervention. Case 1:A 17-year-old male sustained injuries when his torso became entangled in heavy machinery. The diagnosis revealed a tear in the right main bronchus, which required transportation with left single- lung ventilation. The patient was treated by tracheobronchial reconstruction. Case 2:A 71-year-old male experienced trauma when his car collided with a utility pole. He was transported to the hospital after tracheal intubation due to a laceration of the tracheal membranous area. The site of the injury was closed with sutures. Case 3:A 17-year-old female who had been struck by a train suffered acute respiratory failure and was transported to the hospital after intubation. Veno-venous extracorporeal membrane oxgenation (VV-ECMO) was initiated in response to poor oxygenation. Complete rupture of the right middle bronchial trunk and laceration of the right main bronchial membrane were observed, and bronchoplasty was performed. CONCLUSION: A swift and accurate diagnosis, coupled with timely and judicious therapeutic interventions, play a pivotal role in managing tracheal and bronchial injuries.

Opportunity for Reduction of Intensive Care Unit Resource Utilization in Pediatric Blunt Liver and Spleen Injuries: A National Trauma Data Bank Analysis.

INTRODUCTION: Guidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. METHODS: The National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. RESULTS: 5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). CONCLUSION: Further work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. LEVEL OF EVIDENCE: III.

[Management of Injuries to the Parenchymal Abdominal Organs]. / Management von Verletzungen parenchymatöser Abdominalorgane.

The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma.

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.