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.

Massive retroperitoneal hematoma caused by intercostal artery bleeding after blunt trauma: a case report.

BACKGROUND: The occurrence of massive retroperitoneal hematoma caused by intercostal artery bleeding is exceedingly uncommon. CASE PRESENTATION: A middle-aged male presented to the hospital after a fall. Computed tomography scan revealed a massive retroperitoneal hematoma without any evidence of organ or major vessel rupture. The angiogram revealed extravasation from a branch of the twelfth intercostal artery, and successful transcatheter arterial embolization was performed on this specific artery. CONCLUSIONS: The possibility of intercostal artery rupture should be considered in cases of retroperitoneal hematomas, and accurate diagnosis can be achieved through imaging studies. Transcatheter arterial embolization represents an effective treatment modality.

[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.

[Outcomes of Surgical Treatment for Chest Trauma].

BACKGROUND: Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized. METHOD: We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma. RESULTS: All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n= 31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%) had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays. CONCLUSIONS: Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery.

Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report.

We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.

Distinctive Pathology Associated With Focal Stenosis of the Main Pancreatic Duct Secondary to Remote Trauma: A Long-term Complication of Seat Belt Pancreatitis.

The radiologic finding of focal stenosis of the main pancreatic duct is highly suggestive of pancreatic cancer. Even in the absence of a mass lesion, focal duct stenosis can lead to surgical resection of the affected portion of the pancreas. We present four patients with distinctive pathology associated with non-neoplastic focal stenosis of the main pancreatic duct. The pathology included stenosis of the pancreatic duct accompanied by wavy, acellular, serpentine-like fibrosis, chronic inflammation with foreign body-type giant cell reaction, and calcifications. In all cases, the pancreas toward the tail of the gland had obstructive changes including acinar drop-out and interlobular and intralobular fibrosis. Three of the four patients had a remote history of major motor vehicle accidents associated with severe abdominal trauma. These results emphasize that blunt trauma can injure the pancreas and that this injury can result in long-term complications, including focal stenosis of the main pancreatic duct. Pathologists should be aware of the distinct pathology associated with remote trauma and, when the pathology is present, should elicit the appropriate clinical history.

Repeat imaging increases detection of delayed pseudoaneurysms in patients with high-grade solid organ injury following abdominal trauma.

BACKGROUND: Nonoperative management of abdominal trauma can be complicated by the development of delayed pseudoaneurysms. Early intervention reduces the risk of rupture and decreases mortality. The objective of this study is to determine the utility of repeat computed tomography (CT) imaging in detecting delayed pseudoaneurysms in patients with abdominal solid organ injury. METHODS: A retrospective cohort study reviewing Montreal General Hospital registry between 2013 and 2019. Patients with The American Association for the Surgery of Trauma (AAST) grade 3 or higher solid organ injury following abdominal trauma were identified. A chart review was completed, and demographics, mechanism of injury, Injury Severity Score (ISS) score, AAST injury grade, CT imaging reports, and interventions were collected. Descriptive analysis and logistic regression model were completed. RESULTS: We identified 195 patients with 214 solid organ injuries. The average age was 38.6 years; 28.2% were female, 90.3% had blunt trauma, and 9.7% had penetrating trauma. The average ISS score was 25.4 (SD 12.8) in patients without pseudoaneurysms and 19.5 (SD 8.6) in those who subsequently developed pseudoaneurysms. The initial management was nonoperative in 57.0% of the patients; 30.4% had initial angioembolization, and 12.6% went to the operating room. Of the cohort, 11.7% had pseudoaneurysms detected on repeat CT imaging within 72 h. Grade 3 represents the majority of the injuries at 68.0%. The majority of these patients underwent angioembolization. CONCLUSIONS: In patients with high-grade solid organ injury following abdominal trauma, repeat CT imaging within 72 h enabled the detection of delayed development of pseudoaneurysms in 11.7% of injuries. The majority of the patients were asymptomatic.

Hollow viscus perforation in blunt abdominal trauma: A 14-year experience from a trauma center.

BACKGROUND: Isolated perforations of hollow viscus (HV) represent less than 1% of injuries in blunt abdominal trauma (BAT). When they do present, they are generally due to high-impact mechanisms in the segments of the intestine that are fixed. The aim of this study is to determine the incidence of major HV injuries in BAT at the "Dr. Domingo Luciani" General Hospital (HDL), and address the literature gap regarding updated HV perforations following BAT, especially in low-income settings. METHODS: A retrospective review was conducted on the medical records of patients admitted to our trauma center with a diagnosis of complicated BAT with HV perforation over 14 years. RESULTS AND DISCUSSION: Seven hundred sixty-one patients were admitted under the diagnosis of BAT. Of them, 36.79% underwent emergency surgical resolution, and 6.04% had HV perforation as an operative finding. Almost half (44.44%) of these cases presented as a single isolated injury, while the remaining were associated with other intra-abdominal organ injuries. The most common lesions were Grade II-III jejunum and Grade I transverse colon, affecting an equal proportion of patients at 13.33%. In recent years, an increased incidence of HV injuries secondary to BAT has been observed. Despite this, in many cases, the diagnosis is delayed, so even in the presence of negative diagnostic studies, the surgical approach based on the trauma mechanism, hemodynamic status, and systematic reevaluation of the polytraumatized patient should prevail.

Development and validation of a nomogram to predict postsurgical intra-abdominal infection in blunt abdominal trauma patients: A multicenter retrospective study.

BACKGROUND: Intra-abdominal infection is a common complication of blunt abdominal trauma. Early detection and intervention can reduce the incidence of intra-abdominal infection and improve patients' prognoses. This study aims to construct a clinical model predicting postsurgical intra-abdominal infection after blunt abdominal trauma. METHODS: This study is a retrospective analysis of 553 patients with blunt abdominal trauma from the Department of General Surgery of 7 medical centers (2011-2021). A 7:3 ratio was used to assign patients to the derivation and validation cohorts. Patients were divided into 2 groups based on whether intra-abdominal infection occurred after blunt abdominal trauma. Multivariate logistic regression and least absolute shrinkage and selection operator regression were used to select variables to establish a nomogram. The nomogram was evaluated, and the validity of the model was further evaluated by the validation cohort. RESULTS: A total of 113 were diagnosed with intra-abdominal infection (20.4%). Age, prehospital time, C-reactive protein, injury severity score, operation duration, intestinal injury, neutrophils, and antibiotic use were independent risk factors for intra-abdominal infection in blunt abdominal trauma patients (P < .05). The area under the receiver operating curve (area under the curve) of derivation cohort and validation cohort was 0.852 (95% confidence interval, 0.784-0.912) and 0.814 (95% confidence interval, 0.751-0.902). The P value for the Hosmer-Lemeshow test was .135 and .891 in the 2 cohorts. The calibration curve demonstrated that the nomogram had a high consistency between prediction and practical observation. The decision curve analysis also showed that the nomogram had a better potential for clinical application. To facilitate clinical application, we have developed an online at https://nomogramcgz.shinyapps.io/IAIrisk/. CONCLUSION: The nomogram is helpful in predicting the risk of postoperative intra-abdominal infection in patients with blunt abdominal trauma and provides guidance for clinical decision-making and treatment.

When is it safe to start thromboprophylaxis after splenic angioembolization?

BACKGROUND: Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. METHODS: All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. RESULTS: In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]). CONCLUSION: This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.

Stenting for Traumatic Pseudoaneurysms of the Cervical Internal Carotid Artery: Case Report and Systematic Review.

BACKGROUND: The optimal stenting approach for traumatic pseudoaneurysms (PSA) of the extracranial internal carotid artery (ICA) remains underinvestigated. We present a case of a traumatic pseudoaneurysm of the extracranial ICA managed with stenting and review of prior published similar cases. METHODS: The systematic review followed PRISMA-S guidelines and included studies that investigated traumatic pseudoaneurysms of the extracranial ICA managed by stent placement. Statistical analysis assessed the association between the type of injury and stent type, dual antiplatelet therapy (DAPT) duration, and clinical presentation, and the association between stent type and DAPT duration. RESULTS: Our search yielded 82 publications with 135 patients with extracranial ICA PSA treated with stenting. The odds of neck hematoma presentation was 12.2 times greater for patients with penetrating rather than blunt injuries (P = 0.000002). Covered stents had 2.02 times higher odds of use for penetrating rather than blunt injuries compared to bare metal stents. (P = 0.0029). Shorter duration DAPT was seen with bare metal stents having 1.25 higher odds of DAPT duration less than one month compared to covered (P = 0.001). CONCLUSIONS: In traumatic extracranial ICA pseudoaneurysms, covered stents are used more commonly for penetrating injuries compared to blunt injuries. Penetrating injuries are more strongly associated with the presentation of a hematoma compared to blunt injuries. Stent type may influence the recommended DAPT duration. Surgeons should consider these findings when selecting stent type and DAPT duration with patients presenting with traumatic extracranial ICA pseudoaneurysm.

Thoracic Lavage for Traumatic Hemothorax.

This Surgical Innovation discusses thoracic lavage for traumatic hemothorax.

Emergency hybrid surgery for transection of pancreas at the head and neck after blunt abdominal trauma: A case report and review of the literature.

INTRODUCTION: A complete disruption of main pancreatic duct (MPD) presents a significant challenge to the surgeon. Historically, the standard surgical approach for addressing a complete disruption of the MPD involved distal pancreatic resection and pancreaticojejunostomy Roux-en-Y anastomosis. Nevertheless, there have been no reported cases of hybrid surgery being employed for the complete disruption of the MPD. PATIENT CONCERNS: A 63-year-old male patient presented with blunt trauma in the upper abdomen and was transferred to our trauma center 10 hours after injury. Upon arrival at the emergency department, he was conscious, hemodynamically stable, and complained of upper abdominal pain and distention. Physical examination revealed right upper abdominal tenderness and slight abdominal tension. Abdominal contrast-enhanced CT scan revealed a complete transection of pancreatic parenchyma at the junction of the head and neck. DIAGNOSES: Complete transection of pancreatic parenchyma at the junction of the head and neck combined with complete disruption of the MPD, AIS grade IV. INTERVENTIONS: The hybrid surgery was initially utilized for complete MPD disruption, incorporating endoscope-assisted stent placement in the MPD along with primary repair of the pancreatic parenchyma and duct. OUTCOMES: The postoperative period went smoothly, and the patient recovered and was discharged 4 weeks after operation. The MPD stent was removed under endoscope 4 months after operation, and Endoscopic Retrograde Pancreatography examination showed that the MPD was patency and slight MPD stenosis without pancreatic leakage. At the most recent follow-up, the patient had returned to normal life and work without any pancreatic endocrine or exocrine dysfunction. LESSONS: The hybrid surgery, incorporating endoscope-assisted MPD stent placement and primary repair of the pancreatic parenchyma and duct, emerges as a promising alternative for complete MPD disruption in hemodynamically stable patients. The challenge in this hybrid surgery is the precise localization of the distal end of the MPD.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Accuracy of FAST in detecting intraabdominal bleeding in major trauma with pelvic and/or acetabular fractures: a retrospective cohort study.

PURPOSE: The Focused Assessment with Sonography for Trauma (FAST) is a tool to rapidly detect intraabdominal and intrapericardial fluid with point-of-care ultrasound. Previous studies have questioned the role of FAST in patients with pelvic fractures. The aim of the present study was to assess the accuracy of FAST to detect clinically significant intraabdominal hemorrhage in patients with pelvic fractures. METHODS: We included all consecutive patients with pelvic and/or acetabular fractures treated our Level 1 trauma center from 2009-2020. We registered patient and fracture characteristics, FAST investigations and CT descriptions, explorative laparotomy findings, and transfusion needs. We compared FAST to CT and laparotomy findings, and calculated true positive and negative findings, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: We included 389 patients. FAST had a sensitivity of 75%, a specificity of 98%, a PPV of 84%, and a NPV of 96% for clinically significant intraabdominal bleeding. Patients with retroperitoneal hematomas were at increased risk for laparotomy both because of True-negative FAST and False-positive FAST. CONCLUSION: FAST is accurate to identify clinically significant intraabdominal blood in patients with severe pelvic fractures and should be a standard asset in these patients. Retroperitoneal hematomas challenge the FAST interpretation and thus the decision making when applying FAST in patients with pelvic fractures.

Efficacy of direct-to-operating room trauma resuscitation: a systematic review.

BACKGROUND: Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility. METHODS: The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest. RESULTS: We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR. CONCLUSION: Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency.

Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion.

BACKGROUND: Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS: We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS: We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION: These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.

[Complications after conservative vs. operative treatment of severe thoracic trauma]. / Komplikationen nach operativer vs. konservativer Versorgung des schweren Thoraxtraumas.

BACKGROUND: Thoracic trauma is a frequent injury in the routine treatment of injured patients. Due to the increasing demographic changes a further increase is to be expected, especially after low-energy trauma. OBJECTIVE: Expected complications after conservative vs. operative treatment of various injury patterns of thoracic trauma. MATERIAL AND METHODS: Evaluation of a selective literature search regarding possible complications after thoracic trauma and formulation of instructions for action as expert recommendations. CONCLUSION: Both conservative and operative treatment of thoracic trauma have their specific complications, which have to be known to the treating physician. Lung contusions are often underestimated in the initial radiological diagnostics but often lead to relevant problems during the further course of treatment. After conservative treatment of rib fractures persistent pain, functional limitations or even relevant deformities due to secondary dislocation, can remain. There is a significant risk of overlooking or underestimating relevant injuries during the initial diagnostics which then leads to secondary complications. By far the most frequent risk of surgical treatment is an incorrect positioning of chest tubes. Overall, postoperative infections after chest trauma are relatively rare.