Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service.

BACKGROUND: The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. METHODS: From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. RESULTS: Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). CONCLUSION: In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.

Management of pediatric blunt abdominal trauma in a Dutch level one trauma center.

PURPOSE: Most children with intra-abdominal injuries can be managed non-operatively. However, in Europe, there are many different healthcare systems for the treatment of pediatric trauma patients. Therefore, the aim of this study was to describe the management strategies and outcomes of all pediatric patients with blunt intra-abdominal injuries in our unique dedicated pediatric trauma center with a pediatric trauma surgeon. METHODS: We performed a retrospective, single-center, cohort study to investigate the management of pediatric patients with blunt abdominal trauma. From the National Trauma Registration database, we retrospectively identified pediatric (≤ 18 years) patients with blunt abdominal injuries admitted to the UMCU from January 2012 till January 2018. RESULTS: A total of 121 pediatric patients were included in the study. The median [interquartile range (IQR)] age of patients was 12 (8-16) years, and the median ISS was 16 (9-25). High-grade liver injuries were found in 12 patients. Three patients had a pancreas injury grade V. Furthermore, 2 (1.6%) patients had urethra injuries and 10 (8.2%) hollow viscus injuries were found. Eighteen (14.9%) patients required a laparotomy and 4 (3.3%) patients underwent angiographic embolization. In 6 (5.0%) patients, complications were found and in 4 (3.3%) children intervention was needed for their complication. No mortality was seen in patients treated non-operatively. One patient died in the operative management group. CONCLUSIONS: In conclusion, it is safe to treat most children with blunt abdominal injuries non-operatively if monitoring is adequate. These decisions should be made by the clinicians operating on these children, who should be an integral part of the entire group of treating physicians. Surgical interventions are only needed in case of hemodynamic instability or specific injuries such as bowel perforation.

Long-term follow-up after rib fixation for flail chest and multiple rib fractures.

PURPOSE: Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures. METHODS: All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone. RESULTS: Of the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal. CONCLUSIONS: We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.

Leg crossing, muscle tensing, squatting, and the crash position are effective against vasovagal reactions solely through increases in cardiac output.

Tensing of lower body muscles without or with leg crossing (LBMT, LCMT), whole body tensing (WBT), squatting, and sitting with the head bent between the knees ("crash position", HBK) are believed to abort vasovagal reactions. The underlying mechanisms are unknown. To study these interventions in patients with a clinical history of vasovagal syncope and a vasovagal reaction during routine tilt table testing, we measured blood pressure (BP) continuously with Finapres and derived heart rate, stroke volume, cardiac output (CO), and total peripheral resistance using Modelflow. In series A (n = 12) we compared LBMT to LCMT. In series B (n = 9), WBT was compared with LCMT. In series C (n = 14) and D (n = 9), we tested squatting and HBK. All maneuvers caused an increase in BP, varying from a systolic rise from 77 +/- 8 to 104 +/- 18 mmHg (P < 0.05) in series A during LBMT to a rise from 70 +/- 10 to 123 +/- 9 mmHg (P < 0.05) in series B during LCMT. In each maneuver, the BP increase started within 3-5 s from start of the maneuver. In all maneuvers, there was an increase in CO varying from 54 +/- 12% of baseline to 94 +/- 21% in WBT to a rise from 65 +/- 17% to 110 +/- 22% in LCMT in series A. No maneuver caused significant change in total peripheral resistance. We conclude that the mechanism underlying the effects of these maneuvers is exclusively an increase in CO.

Hemodynamic effects of leg crossing and skeletal muscle tensing during free standing in patients with vasovagal syncope.

Physical maneuvers can be applied to abort or delay an impending vasovagal faint. These countermaneuvers would be more beneficial if applied as a preventive measure. We hypothesized that, in patients with recurrent vasovagal syncope, leg crossing produces a rise in cardiac output (CO) and thereby in blood pressure (BP) with an additional rise in BP by muscle tensing. We analyzed the age and gender effect on the BP response. To confirm that, during the maneuvers, Modelflow CO changes in proportion to actual CO, 10 healthy subjects performed the study protocol with CO evaluated simultaneously by Modelflow and by inert gas rebreathing. Changes in Modelflow CO were similar in direction and magnitude to inert gas rebreathing-determined CO changes. Eighty-eight patients diagnosed with vasovagal syncope applied leg crossing after a 5-min free-standing period. Fifty-four of these patients also applied tensing of leg and abdominal muscles. Leg crossing produced a significant rise in CO (+9.5%; P < 0.01) and thereby in mean arterial pressure (+3.3%; P < 0.01). Muscle tensing produced an additional increase in CO (+8.3%; P < 0.01) and mean arterial pressure (+7.8%; P < 0.01). The rise in BP during leg crossing was larger in the elderly.