Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report.

BACKGROUND: Fiberoptic-guided intubation is considered as "gold standard" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist. CASE PRESENTATION: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient's recovery was uneventful, and he was discharged from the hospital one month after the surgery. CONCLUSIONS: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

[Traumatic hemipelvectomy : An uncommon case in trauma surgery]. / Traumatische Hemipelvektomie : Ein nichtalltäglicher Fall in der Unfallchirurgie.

The challenge in treating traumatic hemipelvectomy is the dynamics of the complex and life-threatening consequences of the injury. These include skin and soft tissue defects, osseous, neural and vascular injuries as well as the subsequent hemostatic derangement and organ dysfunction as part of the shock process. The treatment requires rapid and targeted decisions to save the patient's life. In this particular case a 34-year-old farmer was trapped between a wheeled loader and a stationary trailer. Upon arrival at the hospital the patient was in a state of hemorrhagic shock with accompanying acute traumatic coagulopathy and a grade III open pelvic trauma with complete ischemia of the left leg and a bladder injury. After performing emergency surgery and a two-stage approach for pelvic stabilization the patient's condition deteriorated up to multiorgan failure, necessitating left-sided hemipelvectomy as an immediate life-saving salvage procedure. In the further course multiple revision surgeries and plastic reconstructions due to wound infections and the presence of skin and soft tissue damage were required. Due to the rare confrontation with this type of injury in everyday practice and the absence of a universal treatment algorithm, the following case report is intended to contribute to a better understanding of the treatment and to illustrate the coherent interactions of the individual organ systems affected.

Two big bones, one big decision: When to fix bilateral femur fractures.

PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

Peculiarities of treatment of maxillofacial polytrauma during wartime.

OBJECTIVE: Aim: Analyzing of the last-time papers in this subject in organizing, diagnostic and surgery tactic is the aim of this work. PATIENTS AND METHODS: Materials and Methods: The study analyzed the experience of treating patients with maxillofacial polytrauma before and after February 24, 2022. Research methods: bibliographic, systematic, comparative, general clinical, radiological and retrospective analysis. CONCLUSION: Conclusions: Tactic of the multidisciplinal team should based on the principles of damage control, which involves the initial performance of manipulations and surgical interventions that ensure the patient's survival. Modern strategies for infusion-transfusion therapy play a significant role in severe trauma cases. Choosing the rational management of this therapy for severe trauma remains an important issue. Reconstructive surgeries are recommended to be performer deferred, after surgical wound management, neurosurgical interventions and stabilization of the patient common status. Patients with maxillofacial polytrauma needs in specialized medical care at all the levels. Active wound management aimed at creating favorable conditions for healing, comprehensive medical treatment, prevention, early detection and timely treatment of complications.

[Risk of postoperative morbidity and mortality after conversion of osteosynthesis in patients with polytrauma]. / Opredelenie riskov posleoperatsionnykh oslozhnenii i letal'nogo iskhoda posle konversionnogo osteosinteza u patsientov s politravmoi.

OBJECTIVE: To reduce the incidence of postoperative complications and mortality after conversion of external fixation device into various types of submerged osteosynthesis in patients with polytrauma. MATERIAL AND METHODS: A retrospective and prospective analysis of treatment outcomes in 351 patients with polytrauma was divided into 2 stages. At the first stage, we analyzed significant predictors of complications after conversion of osteosynthesis in the 1st group (retrospective analysis). At the second stage, we estimated the efficacy of the developed scale for assessing the risk of complications after conversion of osteosynthesis in a prospective group of patients. RESULTS: According to the complication risk assessment scale for conversion of osteosynthesis, analysis of time to surgical treatment depending on objective criteria in patients with polytrauma can significantly reduce the incidence of postoperative complications by 14% and mortality rate by 1.7%. CONCLUSION: The complication risk assessment scale after conversion of osteosynthesis will personalize the approach to timing and methods of conversion. This measure will eliminate the «second hit¼ in damage control orthopedics and improve the results of treatment.

Modifiability of surgical timing in postinjury multiple organ failure patients.

BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late trauma deaths, with primarily non-modifiable risk factors. Timing of surgery as a potentially modifiable risk factor is frequently proposed, but has not been quantified. We aimed to compare mortality, hospital length of stay (LOS), and ICU LOS between MOF patients who had surgery that preceded MOF with modifiable timings versus those with non-modifiable timings. METHODS: Retrospective analysis of an ongoing 17-year prospective cohort study of ICU polytrauma patients at-risk of MOF. Among MOF patients (Denver score>3), we identified patients who had surgery that preceded MOF, determined whether the timing of these operation(s) were modifiable(M) or non-modifiable (non-M), and evaluated the change in physiological parameters as a result of surgery. RESULTS: Of 716 polytrauma patients at-risk of MOF, 205/716 (29%) developed MOF, and 161/205 (79%) had surgery during their ICU admission. Of the surgical MOF patients, 147/161 (91%) had one or more operation(s) that preceded MOF, and 65/161 (40%) of them had operation(s) with modifiable timings. There were no differences in age (mean (SD) 52 (19) vs 53 (21)years), injury severity score (median (IQR) 34 (26-41)vs34 (25-44)), admission physiological and resuscitation parameters, between M and non-M-patients. M patients had longer ICU LOS (median (IQR) 18 (12-28)versus 11 (8-16)days, p < 0.0001) than non-M-patients, without difference in mortality (14%vs16%, p = 0.7347), or hospital LOS (median (IQR) 32 (18-52)vs27 (17-47)days, p = 0.3418). M-patients had less fluids and transfusions intraoperatively. Surgery did not compromise patient physiology. CONCLUSION: Operations preceding MOF are common in polytrauma and seem to be safe in maintaining physiology. The margin for improvement from optimizing surgical timing is modest, contrary to historical assumptions.

Bilateral intertrochanteric fractures in an elderly patient following high-energy trauma: a case report.

BACKGROUND: Cases of bilateral hip fractures are rare, and even more so are cases of bilateral intertrochanteric fractures. Common causes include trauma, internal diseases, and primary or secondary bone diseases. We report a case of bilateral intertrochanteric fractures in an elderly patient following a severe car accident, a scenario not extensively reported in existing literature. CASE PRESENTATION: We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities. CONCLUSION: Managing bilateral intertrochanteric fractures, particularly in the elderly with severe trauma, is notably challenging due to their rarity. However, a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses.

[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]. / Begleitende Verletzungen von Karpus, distaler Elle und distalem Radioulnargelenk bei distaler Radiusfraktur : Primäre operative Mitversorgung vs. Heilung ohne zusätzliche Therapie.

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis.

INTRODUCTION: There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide. METHODS: We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates. RESULTS: The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34). CONCLUSION: Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The therapeutic value of vacuum external fixation in polytrauma patients with multiple ribs fracture.

BACKGROUND: Multiple displaced rib fractures often result in a poor prognosis. Open reduction and internal fixation has been shown to provide benefits for patients with displaced rib fractures and flail chest. Nevertheless, for patients who are unwilling or unsuitable for surgery, the therapeutic options are limited. We developed a novel plastic vacuum device for rib fractures external stabilization. This study aims to compare the therapeutic efficacy of this device against a traditional chest strap in polytrauma patients with multiple rib fractures. METHODS: A retrospective investigation was conducted on polytrauma patients with multiple rib fractures admitted to our trauma center between March 2020 and March 2023. Patients were categorized into two groups: vacuum external fixation and chest strap. Comparative analysis was conducted on baseline parameters, injury characteristics, and clinical outcomes between the two groups. RESULTS: In this study, 54 patients were included, with 28 receiving chest strap and 26 undergoing vacuum external fixation. Results showed that, at 3 days and 7 days postintervention, the vacuum external fixation group had significantly lower visual analog scale scores during deep breathing and coughing (P < .05). Vacuum external fixation also reduced pleural drainage duration and volume, as well as lowered the risk of pneumonia and other complications (P < .05). Furthermore, the vacuum external fixation group demonstrated notable improvements in vital capacity, tidal volume, blood-gas test results, and a shorter hospital length of stay. CONCLUSIONS: According to the study findings, vacuum external fixation appears to offer benefits to patients with multiple rib fractures, potentially reducing the risk of complications and improving overall clinical outcomes.

Effect of damage control strategy combining pre-hospital emergency treatment with in-hospital treatment on pelvic fracture complicated by multiple injuries.

OBJECTIVE: To analyze the application value of damage control strategies combining pre-hospital emergency treatment with in-hospital treatment for multiple injuries in treating pelvic fracture complicated by multiple injuries. METHODS: 120 patients with pelvic fracture complicated by multiple injuries admitted to our hospital from January 2020 to January 2023 were selected and divided into a damage control group (early temporary reduction after resuscitation, n = 60) and a control group (no reduction and resuscitation only, n = 60) by treatment methods. The control group was treated with conventional methods, while the damage control group was treated with the damage control strategy combining pre-hospital emergency treatment combined with in-hospital treatment in addition to conventional methods. The mortality rate, complication rate, fracture reduction quality, long-term efficacy, and patient satisfaction of the two groups were compared. RESULTS: The mortality rate of the damage control group was lower than that of the control group, and the difference has statistical significance (P<0.05); the incidence of infection, DIC, and MODS of the damage control group were lower than that of the control group, with the difference being statistically significant (P<0.05); the incidence of ARDS in the two groups is not that different (P>0.05); the fracture reduction quality and long-term therapeutic effect of patients in the two groups were statistically different, with the damage control group outperforming the control group in both aspects; the difference between the two groups in terms of patient satisfaction was statistically significant (P<0.05), with the patient satisfaction of the damage control group being higher than that of the control group. CONCLUSION: For patients with pelvic fracture, the application of the damage control strategy combining pre-hospital emergency treatment and in-hospital treatment is a boon to the standardization of the treatment process, the improvement of the treatment success rate and fracture reduction quality and the reduction of complications, and therefore is worth promoting in clinical practice. the early application of external fixation has helped with the definitive reduction at a time when the patuent was stable.

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

BACKGROUND: The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS: In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS: Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). CONCLUSION: Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).

BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Imposter or knight in shining armor? Pelvic circumferential compression devices (PCCD) for severe pelvic injuries in patients with multiple trauma: a trauma-registry analysis.

BACKGROUND: Pelvic Circumferential Compression Devices (PCCD) are standard in hemorrhage-control of unstable pelvic ring fractures (UPF). Controversial data on their usefulness exists. Aim of the study was to investigate whether prehospital application of PCCD can reduce mortality and transfusion requirements in UPF. METHODS: Retrospective cohort study. From 2016 until 2021, 63,371 adult severely injured patients were included into TraumaRegister DGU® of the German Trauma Society (TR-DGU). We analyzed PCCD use over time and compared patients with multiple trauma patients and UPF, who received prehospital PCCD to those who did not (noPCCD). Groups were adjusted for risk of prehospital PCCD application by propensity score matching. Primary endpoints were hospital mortality, standardized mortality rate (SMR) and transfusion requirements. RESULTS: Overall UPF incidence was 9% (N = 5880) and PCCD use increased over time (7.5% to 20.4%). Of all cases with UPF, 40.2% received PCCD and of all cases with PCCD application, 61% had no pelvic injury at all. PCCD patients were more severely injured and had higher rates of shock or transfusion. 24-h.-mortality and hospital mortality were higher with PCCD (10.9% vs. 9.3%; p = 0.033; 17.9% vs. 16.1%, p = 0.070). Hospital mortality with PCCD was 1% lower than predicted. SMR was in favor of PCCD but failed statistical significance (0.95 vs. 1.04, p = 0.101). 1,860 propensity score matched pairs were analyzed: NoPCCD-patients received more often catecholamines (19.6% vs. 18.5%, p = 0.043) but required less surgical pelvic stabilization in the emergency room (28.6% vs. 36.8%, p < 0.001). There was no difference in mortality or transfusion requirements. CONCLUSION: We observed PCCD overuse in general and underuse in UPF. Prehospital PCCD appears to be more a marker of injury severity and less triggered by presence of UPF. We found no salutary effect on survival or transfusion requirements. Inappropriate indication and technical flaw may have biased our results. TR-DGU does not contain data on these aspects. Further studies are necessary. Modular add-on questioners to the registry could offer one possible solution to overcome this limitation. We are concerned that PCCD use may be unfairly discredited by misinterpretation of the available evidence and strongly vote for a prospective trial.

Transcriptomic and Proteomic Characterization of the Immune Response to Elective Spinal Reconstructive Surgery: Impact of Aging and Comparison with Traumatic Injury Response.

BACKGROUND: Major surgery triggers trauma-like stress responses linked to age, surgery duration, and blood loss, resembling polytrauma. This similarity suggests elective surgery as a surrogate model for studying polytrauma immune responses. We investigated stress responses across age groups and compared them with those of polytrauma patients. STUDY DESIGN: Patients undergoing major spinal reconstruction surgery were divided into older (age >65 years, n = 5) and young (age 18 to 39 years, n = 6) groups. A comparison group consisted of matched trauma patients (n = 8). Blood samples were collected before, during, and after surgery. Bone marrow mononuclear cells and peripheral blood mononuclear cells were analyzed using cellular indexing of transcriptomes and epitopes sequencing or single-cell RNA sequencing. Plasma was subjected to dual-platform proteomic analysis (SomaLogic and O-link). RESULTS: Response to polytrauma was highest within 4 hours. By comparison, the response to surgery was highest at 24 hours. Both insults triggered significant changes in cluster of differentiation 14 monocytes, with increased inflammation and lower major histocompatibility complex-class 2 expression. Older patient's cluster of differentiation 14 monocytes displayed higher inflammation and less major histocompatibility complex-class 2 suppression; a trend was also seen in bone marrow mononuclear cells. Although natural killer cells were markedly activated after polytrauma, they were suppressed after surgery, especially in older patients. In plasma, innate immunity proteins dominated at 24 hours, shifting to adaptive immunity proteins by 6 weeks with heightened inflammation in older patients. Senescence-associated secretory phenotype proteins were higher in older patients at baseline and further elevated during and after surgery. CONCLUSIONS: Although both major surgery and polytrauma initiate immune and stress responses, substantial differences exist in timing and cellular profiles, suggesting major elective surgery is not a suitable surrogate for the polytrauma response. Nonetheless, distinct responses in young vs older patients highlight the utility of elective spinal in studying patient-specific factors affecting outcomes after major elective surgery.

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.

Salvage of a severely mangled limb following traumatic injury.

Management of a severely damaged extremity poses a dilemma-whether to perform a primary amputation or attempt limb salvage. A multitude of factors-such as the extent of neurovascular injury, limb ischaemia time, severity of bone and soft tissue loss, physiological reserve of the patient and availability of surgical expertise and resources-influence this decision. The Mangled Extremity Severity Score (MESS) was developed as a predictor of the need for limb amputation, and a MESS of 7 or more is considered a predictor of primary amputation. Here we describe a case where a man in his 20s sustained traumatic avulsion of his right ankle with severe neurovascular damage and multiple tendon injuries onboard a ship at high sea. Despite a MESS of 10, limb ischaemia time of more than 10 hours and injuries to all three extremity vessels (anterior tibial, posterior tibial and peroneal arteries), limb salvage was successfully carried out at a level-II trauma centre.

Outcomes Following Below Knee Arterial Trauma.

INTRODUCTION: Lower extremity vascular injuries have significant implications for trauma patients with regards to morbidity from limb loss. There is limited evidence on outcomes for patients with injuries to tibial arteries. Our study focuses on defining outcomes of traumatic vascular injury to vessels below the knee. METHODS: A retrospective review using ICD-9 and 10 codes of all patients with below knee vascular injuries was performed at a Level 1 trauma center from November 2014 to June 2022. Interventions, outcomes, and complications were assessed. RESULTS: Seventy-six patients were identified fitting inclusion criteria. The mean age was 35.3 +/- 15.2 years and 67 (88%) patients were male. Thirty-nine suffered penetrating trauma, 37 suffered blunt trauma. The most injured artery was posterior tibial artery (40%) followed by anterior tibial artery (36%). Injuries included 51 transections, 22 occlusions and 4 pseudoaneurysms. Forty-five (59%) patients underwent operative intervention. Thirty (67%) operations were performed by trauma surgery. Arterial ligation was performed in 30 cases (67%), arterial bypass in 12 (27%), and 2 (4%) primary amputations. Vascular surgery performed all bypasses. Overall amputation rate was 8% (n = 6) with 3 for mangled extremity and 3 due to failed bypass graft. All amputations were associated with open fracture and amputations for failed bypass had multiple arterial injuries. CONCLUSION: The management of below knee vascular trauma requires a multidisciplinary approach. Patients requiring reconstruction are more likely to have multiple vessel injuries and may have significant risk of graft failure. These patients as well as those with extensive soft tissue injury and/or multi-vessel injuries are at increased risk for amputation.