Hepatic artery pseudoaneurysm rupture: A case report.

Hepatic artery pseudoaneurysms are an uncommon complication of blunt hepatic trauma typically presenting in a delayed fashion. A 40-year-old male presented to a trauma centre after a 6-metre fall from a construction site with multiple injuries including a grade IV liver laceration centred around the porta hepatis. This liver injury was managed non-operatively. On day sixteen of admission, he had a sudden cardiac arrest from haemorrhagic shock with a subsequent CT demonstrating a ruptured extrahepatic proper hepatic artery pseudoaneurysm. Despite laparotomy and vessel repair, he died from pulmonary complications of aspiration pneumonia and acute lung injury associated with massive transfusion. The literature demonstrates conflicting views regarding the utility of repeat CT to detect a pseudoaneurysm in asymptomatic, non-operatively managed patients with blunt hepatic trauma. In particular, the literature does not distinguish the utility of repeat routine CT for intrahepatic and extrahepatic hepatic artery pseudoaneurysm, the latter if which is rarer. Current guidelines recommend against it, but there are observational studies suggesting utility, particularly in high grade (≥IV) liver injury. In patients with a high-grade injury extending to the porta hepatis, repeat imaging should be considered to detect possible pseudoaneurysm.

Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention.

BACKGROUND: To evaluate risk factors (treatment-related, comorbidities, and lifestyle) for breast cancer-related lymphedema (BCRL) within the context of a Prospective Surveillance and Early Intervention (PSEI) model of care for subclinical BCRL. METHODS: The parent randomized clinical trial assigned patients newly diagnosed with breast cancer to PSEI with either bioimpedance spectroscopy (BIS) or tape measurement (TM). Surgical, systemic and radiation treatments, comorbidities, and lifestyle factors were recorded. Detection of subclinical BCRL (change from baseline of either BIS L-Dex ≥6.5 or tape volume ≥ 5% and < 10%) triggered an intervention with compression therapy. Volume change from baseline ≥10% indicated progression to chronic lymphedema and need for complex decongestive physiotherapy. In this secondary analysis, multinomial logistic regressions including main and interaction effects of the study group and risk factors were used to test for factor associations with outcomes (no lymphedema, subclinical lymphedema, progression to chronic lymphedema after intervention, progression to chronic lymphedema without intervention). Post hoc tests of significant interaction effects were conducted using Bonferroni-corrected alphas of .008; otherwise, an alpha of .05 was used for statistical significance. RESULTS: The sample (n = 918; TM = 457; BIS = 461) was female with a median age of 58.4 years. Factors associated with BCRL risk included axillary lymph node dissection (ALND) (p < .001), taxane-based chemotherapy (p < .001), regional nodal irradiation (RNI) (p ≤ .001), body mass index >30 (p = .002), and rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not associated with BCRL risk. CONCLUSIONS: Within the context of 3 years of PSEI for subclinical lymphedema, variables of ALND, taxane-based chemotherapy, RNI, body mass index >30, and rurality increased risk.

Blunt thoracic aortic injury resulting in free rupture into the pleural space and cardiac arrest, managed successfully with endovascular stenting.

Blunt thoracic aortic injury (BTAI) is an uncommon yet serious diagnosis in trauma patients, with high on-scene mortality. BTAI typically occurs from rapid deceleration such as in motor vehicle collisions or high-altitude falls shearing the aorta just proximal to the ligamentum arteriosum. We report a case of a man in his 50s falling from a height of 15 m who presented hypotensive with retrosternal chest pain. Mobile chest X-ray showed a widened mediastinum with left-sided haemothorax. CT revealed a contained free aortic rupture just inferior to the origin of the left subclavian artery with bleeding into the mediastinum and left pleural space. The patient underwent urgent thoracic endovascular aortic repair (TEVAR) but arrested on-table due to a left-sided tension haemothorax requiring chest-drain decompression and haemostatic resuscitation. After return of spontaneous circulation, TEVAR was successfully performed. BTAI is a dynamic process; hence, timely imaging and minimally invasive surgical treatment are key to patients surviving grade III and IV aortic injuries.

Utility of venous blood gases for the assessment of traumatic shock: a prospective observational study.

BACKGROUND: ABG samples are often obtained in trauma patients to assess shock severity. Venous blood gas (VBG) sampling, which is less invasive, has been widely used to assess other forms of shock. The study aim was to determine the agreement between VBG and ABG measurements in trauma. METHODS: Patients were enrolled at an Australian trauma centre between October 2016 and October 2018. Bland-Altman limits of agreement (LOA) between paired blood gas samples taken <30 min apart were used to quantify the extent of agreement. The impact of using only VBG measurements was considered using an a priori plan. Cases where venous sampling failed to detect 'concerning levels' were flagged using evidence-based cut-offs: pH ≤7.2, base deficit (BD) ≤-6, bicarbonate <21 and lactate ≥4. Case summaries of these patients were assessed by independent trauma clinicians as to whether an ABG would change expected management. RESULTS: During the study period 176 major trauma patients had valid paired blood gas samples available for analysis. The median time difference between paired measurements was 11 min (IQR 6-17). There was a predominance of men (81.8%) and blunt trauma (92.0%). Median Injury Severity Score was 13 (range 1-75) and inpatient mortality was 6.3%. Mean difference (ABG-VBG) and LOA between paired arterial and venous measurements were 0.036 (LOA -0.048 to 0.120) for pH, -1.27 mmol/L (LOA -4.35 to 1.81) for BD, -0.64 mmol/L (LOA -1.86 to 0.57) for lactate and -1.97 mmol/L (LOA -5.49 to 1.55) for bicarbonate. Independent assessment of the VBG 'false negative' cases (n=20) suggested an ABG would change circulatory management in two cases. CONCLUSIONS: In trauma patients VBG and ABG parameters displayed suboptimal agreement. However, in cases flagged as VBG 'false negative' independent review indicated that the availability of an ABG was unlikely to change management.

The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures.

Management of haemodynamically unstable pelvic ring injuries has been simplified into treatment algorithms to streamline care and emergent decision making in order to improve patient outcomes whilst decreasing mortality and morbidity. Pelvic ring injuries are most commonly a result of high-velocity and energy forces that exert trauma to the pelvic bones causing not only damage to the bone but the surrounding soft-tissue, organs, and other structures and are usually accompanied by injuries to other parts of the body resulting in a polytraumatised patient. Open pelvic fractures are a rare subset of pelvic ring fractures that are on the more severe end of the pelvic fracture continuum and usually produce uncontrolled haemorrhage from fractured bone, retroperitoneal haematomas, intraabdominal bleeding from bowel injury, soft tissue injuries to the anus, perineum, and genitals, fractures of the pelvic bones, causing bleeding from cancellous bone, venous, and arterial injuries combined with bleeding from concomitant injuries. This is a very complex and challenging clinical situation and timely and appropriate decisions and action are paramount for a positive outcome. Consequently, open pelvic fractures have an extremely high rate of mortality and morbidity and outcomes remain poor, despite evidence-based improvements in treatment, knowledge, and identification of haemorrhage; in the pre-hospital, critical care, and operative settings. In the future utilisation of haemostatic drugs, dressings, devices, and procedures may aid in the time to haemorrhage control.

Process measure aimed at reducing time to haemorrhage control: outcomes associated with Code Crimson activation in exsanguinating truncal trauma.

BACKGROUND: Major trauma activation is a process that mobilizes personnel and resources required to care for severely injured patients. Exsanguinating truncal trauma patients require an additional response beyond major trauma activation aimed at expediting haemorrhage control. To address this requirement, 'Code Crimson' (CC) activation was developed. Our aim was to examine the performance of CC activation as a process measure in the identification and management of patients with exsanguinating truncal trauma. METHODS: Retrospective cohort study (2010-2015) of all adult patients who underwent operative intervention within 6 h of arrival for truncal trauma was performed. Patients were classified into: (i) major haemorrhage (assessment of blood consumption score ≥2, base deficit ≥5 and/or transfusion ≥5 U of red blood cells pre-/intra-operatively), or (ii) no major haemorrhage. We evaluated the proportion of patients with/without major haemorrhage in which a CC was activated as well as time to operating theatre across groups. RESULTS: A total of 210 patients were included with a median Injury Severity Score of 20 (interquartile range (IQR) 9-29) and overall mortality of 13%. Eighty-nine patients were classified as major haemorrhage and 61 patients underwent CC activation. The majority of CC activations (92%) fulfilled major haemorrhage criteria (sensitivity 63%, specificity 96%). Time to theatre was lower in those with CC activation with median time of 23 min (IQR 15-39.5) versus non-CC with median of 95 min (IQR 43-180, P < 0.001). CONCLUSION: CC was primarily activated in patients with major haemorrhage and led to a decrease in time to theatre for patients with operative truncal trauma.

The swing shift: Opportunity to enhance trauma training in Australia.

BACKGROUND: Training in trauma forms a fundamental component of general surgical training in Australia. It faces a number of challenges, including the limitations of working hours and increasing use of non-operative management techniques. Adjustment of rosters to encompass a "swing shift" (12pm-midnight) is one proposed solution to maximise exposure of junior surgical doctors to trauma. This proposal prompted a review of the timing of major trauma presentations and interventions at a Level 1 trauma centre. METHODS: A retrospective observational study was performed of all major trauma presentations to Westmead Hospital, Australia over ten-years (2008-2017). Trauma operative procedures and major resuscitations were reviewed across three potential shifts: day shift (0730-1930), night shift (1930-0730) and "swing shift" (1200-midnight). Operative interventions included: laparotomy, thoracotomy/sternotomy, re-look laparotomy, rib fixation and tracheostomy. Descriptive statistics were obtained for between-shift comparisons. RESULTS: Over the ten-years there were 3745 full trauma team activations (FTTAs). The "swing shift" had the highest number of FTTAs, patients with injury severity scores >15, patients requiring resuscitation and emergency operations (laparotomies, sternotomies/thoracotomies). CONCLUSIONS: More major trauma calls, laparotomies and thoracotomies occurred during a theoretical "swing shift" rather than the standard day and night shifts. Changing trauma rostering for junior doctors to reflect this peak in clinical and operative demand could change exposure to trauma training.

Donor white blood cell survival and cytokine profiles following red blood cell transfusion in Australian major trauma patients.

BACKGROUND: The potential for the co-existence of genetically disparate cells (microchimerism) and associated cytokine profiles following red blood cell (RBC) transfusion in trauma patients has not been well characterized to date. This study investigated the incidence of surviving donor white blood cells (known as transfused-associated microchimerism (TAM)) and cytokine changes following blood transfusion in trauma patients. STUDY DESIGN AND METHODS: Trauma patients with an injury severity score (ISS) >12 who had been transfused between 2012-2016 with at least 5 units of RBC units over a 4 h period were recruited. Trauma patients with ISS > 12 who did not require blood transfusion were recruited as controls. The incidence of TAM was determined using a panel of insertion/deletion (InDel) bi-allelic polymorphisms. Selected pro- and anti-inflammatory cytokine profiles were analyzed using cytometric bead array. RESULTS: The transfused cohort (n = 40) had median ISS of 28 [12-66], received a median of 11 RBC units [4-114] and had median hospital length of stay of 35 days [1-152]. Only 11 (27.5%) patients returned for follow-up blood sampling after discharge. Of these, one patient showed an InDel pattern indicating the presence of TAM. No patients in the control cohort (n = 49) showed TAM. Cytokines IL-10 and IL-6 were found to be elevated in the transfused trauma patients. CONCLUSION: In this cohort, TAM was found to occur in one patient of the 11 who received a blood transfusion. Elevated IL-6 and IL-10 cytokines were detected in those patients who were transfused. However, the incidence of TAM could not be correlated with the elevated cytokine profiles for this cohort.

Lean psoas area does not correlate with clinical outcomes in moderately to severely injured older people.

OBJECTIVE: Frailty has been associated with worse outcomes in older trauma patients. Specifically, the utility of lean cross-sectional psoas muscle area (LPA) was examined as a potentially simple objective measure of frailty. METHODS: Five hundred and fifty-four patients over the age of 65 were admitted with trauma between 2011 and 2014. Two hundred and twenty-five of these had adequate computed tomography imaging available for analysis. Cross-sectional area of the psoas muscle at the inferior endplate of L4 was quantified. RESULTS: Multivariate regression analysis showed no significant correlation between LPA and outcomes of mortality (P = 0.82) or inpatient complications (P = 0.22). Injury Severity Score (ISS) had a strong association with both mortality (odds ratio (OR) 9.5; 95% confidence interval (CI) 2.9-30.9) and inpatient complications (OR 9.9; 95% CI 3.5-27.7). Age also had an association with mortality (OR 1.09; 95% CI 1.03-1.16) and inpatient complications (OR 1.06; 95% CI 1.01-1.12). CONCLUSION: Lean psoas area was not an independent predictor of mortality or complications in a cohort of injured older patients.

Digital health technology and trauma: development of an app to standardize care.

BACKGROUND: Standardized practice results in less variation, therefore reducing errors and improving outcome. Optimal trauma care is achieved through standardization, as is evidenced by the widespread adoption of the Advanced Trauma Life Support approach. The challenge for an individual institution is how does one educate and promulgate these standardized processes widely and efficiently? In today's world, digital health technology must be considered in the process. AIM: The aim of this study was to describe the process of developing an app, which includes standardized trauma algorithms. The objective of the app was to allow easy, real-time access to trauma algorithms, and therefore reduce omissions/errors. METHOD: A set of trauma algorithms, relevant to the local setting, was derived from the best available evidence. After obtaining grant funding, a collaborative endeavour was undertaken with an external specialist app developing company. RESULTS: The process required 6 months to translate the existing trauma algorithms into an app. The app contains 32 separate trauma algorithms, formatted as a single-page flow diagram. It utilizes specific smartphone features such as 'pinch to zoom', jump-words and pop-ups to allow rapid access to the desired information. CONCLUSION: Improvements in trauma care outcomes result from reducing variation. By incorporating digital health technology, a trauma app has been developed, allowing easy and intuitive access to evidenced-based algorithms.

Leukodepleted blood components do not remove the potential for long-term transfusion-associated microchimerism in Australian major trauma patients.

Despite the introduction of leukodepleted blood components, it has been shown that donor leukocyte engraftment (microchimerism) remains a long-term consequence of red blood cell (RBC) transfusion. The incidence of microchimerism may be affected by international disparities in blood processing methods or variations in transfusion practices. This study was conducted to determine the prevalence of microchimerism in Australian trauma patients. A secondary aim was to examine whether any patient complications correlated to the incidence of microchimerism. Australian trauma patients (n = 86) who had been transfused with red blood cell (RBC) units between 2000 and 2012 with an injury severity score (ISS) of greater than 15 were recruited. The prevalence of microchimerism was determined using genetic screening with a panel of insertion/deletion biallelic polymorphisms. The mean storage age of the transfused RBC units was 20 ± 8 days and the mean length of stay (LOS) in hospital was 40 ± 39 days. There were no significant associations in this study sample to bias for patient age, gender, number of transfused RBC units or ISS. Nine of the 55 (16.3%) patients transfused with non-leukodepleted blood components displayed an incidence of microchimerism. Of the 31 patients transfused with leukodepleted RBC units, 3 (9.6%) displayed an incidence of microchimerism. Therefore, despite the universal introduction of leukodepleted blood components in Australia, the prevalence of transfusion-associated microchimerism was found to be unchanged. Furthermore, half of the patients exhibiting microchimerism were recorded to have had splenic injury or required splenectomy at the time of transfusion.

Damage control in the injured patient.

The damage control concept is an essential component in the management of severely injured patients. The principles in sequence are as follows: (1) abbreviated surgical procedures limited to haemorrhage and contamination control; (2) correction of physiological derangements; (3) definitive surgical procedures. Although originally described in the management of major abdominal injuries, the concept has been extended to include thoracic, vascular, orthopedic, and neurosurgical procedures, as well as anesthesia and resuscitative strategies.

The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: experience of an Australian major trauma service.

UNLABELLED: Focused assessment with sonography for trauma (FAST) is a method for detecting haemoperitoneum in trauma patients on initial assessment in the Emergency Department. The aim of this paper is to present an Australian trauma centre's experience with FAST as a tool to screen for intraabdominal free fluid in patient's sustaining blunt truncal trauma. METHOD: Over a 63-month period, FAST scans were prospectively studied and compared with findings from a gold-standard investigation, either computed tomography (CT) or laparotomy. RESULTS: 463 FAST results were collected prospectively from 463 patients. 53 scans were excluded due to lack of a corresponding confirmatory gold-standard test. Overall sensitivity, specificity, positive and negative predictive values for FAST in detecting free fluid were 78%, 97%, 91%, 93%, respectively. Analysis of the credentialed operators demonstrated an improvement in accuracy (sensitivity 80%, specificity 100%, positive predictive value 100%, negative predictive value 94%). These findings are comparable with documented international experience. CONCLUSION: The study demonstrates that the use of non-radiologist performed FAST in the detection of free fluid is safe and accurate within an Australian Trauma Centre.

Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging.

OBJECTIVE: The aim of the study was to determine a clinical diagnostic pathway for the imaging of the thoracolumbar spine in blunt trauma patients. METHOD: A literature review was undertaken to determine the factors important in the detection of thoracolumbar injury and also to produce a trial protocol, which could be tested retrospectively. Two hundred patients admitted between 1998 and 2000 were reviewed retrospectively to form a database of the relevant clinical features. The diagnostic pathway protocol was tested retrospectively in two groups; one hundred with known thoracolumbar fractures and one hundred undifferentiated multi-trauma patients. Sensitivity and specificity indices were determined using the chi-squared test of association. RESULTS: Falls and motor vehicle crashes were the most common mechanism of injury causing thoracolumbar fractures. No significant association could be found between mechanism of injury (MOI) and presence of thoracolumbar fracture. Clinical signs found to be associated with thoracolumbar fracture include: (1) back pain/midline tenderness (Sens 62.1% Spec 91.5%), (2) palpable midline step (Sens 13.8% Spec 100%), (3) back bruising (Sens 6.9% Spec 98.6%), (4) abnormal neurological signs (Sens 41.4% Spec 95.8%). Cervical level fractures were also found to be associated with an increased incidence of thoracolumbar fractures. Factors found to influence the detection of back pain/midline tenderness include: (1) GCS<15, (2) ETOH/drug intoxication, (3) major distracting injury. The proposed diagnostic pathway would have led to 92% of patients receiving TL imaging in group 2 (multi-trauma) with a sensitivity of 100%, specificity of 11.3% and a negative predictive value of 100%. CONCLUSION: From the literature and the results of the study, we propose that imaging of the thoracolumbar spine is required in those patients suffering from a high force mechanism of injury if any of the following are present: (1) back pain/midline tenderness, (2) local signs of thoracolumbar injury, (3) abnormal neurological signs, (4) cervical spine fracture, (5) GCS<15, (6) major distracting injury, (7) ETOH/ drug intoxication. An evidence based diagnostic pathway has been shown to be highly sensitive in determining the presence of TL fracture in a retrospective study of blunt trauma patients.