Pre- and post-implementation protocol for non-operative management of grade III-V splenic injuries: An observational study.

Background: Grade (III-V) blunt splenic injuries (BSI) in hemodynamically stable patients represent clinical challenges for successful non-operative management (NOM). In 2014, Our institution proposed a treatment protocol requiring splenic angiography and embolization for stable, intermediate, and high-grade BSI. It also included a follow-up CT scan for grade III BSI. We sought to assess the success rate of NOM in treating intermediate and high-grade BSI, following a standardized treatment protocol at a level 1 trauma center. Methods: An observational retrospective study was conducted. Data of patients with BSI from June 2011 to September 2019 were reviewed using the Qatar National Trauma Registry. Patients' demographics, CT scan and angiographic findings, grade of splenic injuries, and outcomes were analyzed. The pre- and post-implementation of treatment protocol periods were compared. Results: During the study period, a total of 552 hemodynamically stable patients with BSI were admitted, of which 240 had BSI with grade III to V. Eighty-one patients (33.8%) were admitted in the pre-protocol implementation period and 159 (66.2%) in the post-protocol implementation period. The NOM rate increased from 50.6% in the pre-protocol group to 65.6% in the post-protocol group (p = 0.02). In addition, failure of the conservative treatment did not significantly differ in the two periods, while the requirement for blood transfusion dropped from 64.2% to 45.9% (p = 0.007). The frequency of CT scan follow-up (55.3% vs. 16.3%, p = 0.001) and splenic arterial embolization (32.7% vs. 2.5%, p = 0.001) in NOM patients increased significantly in the post-protocol group compared to the pre-protocol group. Overall mortality was similar between the two periods. However, hospital and ICU length of stay and ventilatory days were higher in the post-protocol group. Conclusions: NOM is an effective and safe treatment option for grade III-V BSI patients. Using standardized treatment guidelines for intermediate-to high-grade splenic injuries could increase the success rate for NOM and limit unnecessary laparotomy. Moreover, angioembolization is a crucial adjunct to NOM that could improve the success rate.

A multidisciplinary approach to rescue a full-term pregnant and her fetus after blunt abdominal trauma: A case report and literature review.

Blunt abdominal trauma due to motor vehicle crash is one of the leading causes of mortality during pregnancy. Though the trauma team plays a critical role in the initial management, a multidisciplinary contribution is essential to ensure the safety of the mother and her fetus. This case report followed the multidisciplinary approach for the management of a 32-year-old female during the last week of pregnancy. She sustained blunt trauma causing maternal and fetal distress due to abruption of the placenta with a large intrauterine and retroplacental hemorrhage, retro-hepatic and retroperitoneal hemorrhage, pseudoaneurysm of uterine arteries leading to postpartum hemorrhage. Immediate intervention and management at a Level 1 trauma center led to survival of both the mother and infant.

Adipsic Hypernatremia With Neurologic Manifestations in a Patient With Severe COVID-19 Pneumonia.

This report describes a case of a 50-year-old man with hypertension who was admitted with a history of fever, chills, and shortness of breath and tested positive for COVID-19. Shortly after resolving his acute respiratory distress syndrome (ARDS), he developed adipsic hypernatremia with associated confusion, lethargy, and weakness. COVID-19 is a serious disease that mainly targets the respiratory system; however, we must not overlook its effects on other organ systems. When the etiology of hypernatremia is unclear, it requires extensive workup and monitoring, and the lack of rapid correction can cause serious and irreversible neurological damage.

Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center.

BACKGROUND: Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients. METHODS: A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF). RESULTS: A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062-16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157-1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance. CONCLUSION: The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03846973.

Late development of giant hepatic artery pseudoaneurysm following abdominal trauma due to tire blast: case report and literature review.

Giant hepatic artery pseudoaneurysm is rare but could have a significant implication. A 35-year-old male was severely injured by a truck tire explosion and presented with hypotension and positive focused assessment with sonography in trauma scan. After resuscitation, abdomen computed tomography (CT) scan showed a Grade 4 liver injury. The patient was admitted to the intensive care unit, and the liver injury was treated conservatively. Seventeen days later, he developed abdominal pain with deep epigastric tenderness. Repeated abdomen CT scan detected a giant hepatic artery pseudoaneurysm. Embolization was achieved using gel foam with the placement of six microcoils. The patient had an uneventful recovery. Late development of giant hepatic artery pseudoaneurysm is a rare complication of hepatic trauma and could be life-threatening. Timely identification and treatment with endovascular intervention are crucial. We recommend, especially when dealing with trauma related to blast injury, follow-up images for patients who develop symptoms suggestive of hepatic injury.

The use of Indocyanine green fluorescent in patients with abdominal trauma for better intraoperative decision-making and less bowel anastomosis leak: case series.

Despite technological advances in the management of blunt abdominal trauma, the rate of bowel anastomotic leakage (AL) remains high. The etiology of AL is multifactorial, but insufficient blood perfusion is considered to play a substantial role in the pathogenesis. In recent years, angiography with Indocyanine green (ICG), a fluorescent dye, has been introduced in the clinical practice to assess organ perfusion in several conditions. Given the scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy that may facilitate intraoperative decisions and limit the extent of bowel resection, we presented the utility of intraoperative ICG fluorescent in abdominal trauma patients in a level 1 trauma center. The use of ICG fluoroscopy in patients with abdominal trauma is feasible and useful; however, large prospective studies in trauma patients are warranted.

Patterns and Effects of Admission Hyperglycemia and Inflammatory Response in Trauma Patients: A Prospective Clinical Study.

BACKGROUND: The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients. METHODS: A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups [non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)]. The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson's correlation test and logistic regression analysis were also performed. RESULTS: During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p = 0.005), lower Trauma Injury Severity Score (p = 0.01) and lower GCS (p = 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%; p = 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39-33.68) points was found more in hyperglycemia than normoglycemia group (p = 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (r = 0.40, p = 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076-5.447, p = 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion. CONCLUSIONS: In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment. TRIAL REGISTRATION: This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016. https://clinicaltrials.gov/ct2/show/NCT02999386 .

Relationship of Optic Nerve Sheath Diameter and Intracranial Hypertension in Patients with Traumatic Brain Injury.

BACKGROUND: to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury. PATIENTS AND METHODS: A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality. RESULTS: A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement (r = 0.21, P = 0.04). Patients who developed ICH were more likely to have higher mean ONSD (P = 0.01) and subarachnoid hemorrhage (SAH) (P = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (ß = 0.21, 95% confidence interval 0.25-5.08, P = 0.03). CONCLUSIONS: ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.

Occult Pneumothorax in Patients Presenting with Blunt Chest Trauma: An Observational Analysis.

Background: We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Methods: Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Results: Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Conclusions: Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.

Postoperative complications of intestinal anastomosis after blunt abdominal trauma.

BACKGROUND: Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma. METHOD: We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications. RESULTS: A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications. CONCLUSION: Repair of traumatic blunt bowel injury remains a surgical challenge.

Shock index in patients with traumatic solid organ injury as a predictor of massive blood transfusion protocol activation.

PURPOSE: We aimed to assess the utility of shock index (SI) to predict the need for massive transfusion protocol (MTP) in patients with solid organ injury (SOI) in a Level 1 Trauma center. METHODS: We conducted a retrospective analysis for patients with SOI between 2011 and 2014. Patients were categorized according to on-admission SI into low (< 0.8) and high SI (≥0.8) group. RESULTS: A total of 4500 patients were admitted with trauma, of them 572 sustained SOIs (289 patients had SI ≥0.8). In comparison to low SI, patients with high SI were younger, had higher injury severity scores (ISS) and lower Trauma and Injury Severity Score (TRISS); (p < 0.001). The proportion of exploratory laparotomy (EXLap), blood transfusion (BT), MTP activation, sepsis and hospital mortality were significantly higher in patients with high SI. Serum lactate (r = 0.34), hematocrit (r = - 0.34), ABC score (r = 0.62), ISS (r = 0.35), and amount of transfused blood (r = 0.22) were significantly correlated with SI. On multivariable regression analysis using 9 relevant variables (age, sex, ISS, ED GCS, serum lactate, hematocrit, Abdomen AIS and Focused assessment with sonography in trauma (FAST) and SI), SI ≥ 0.8 was an independent predictor of BT (OR 2.80; 95%CI 1.56-4.95) and MTP (OR 2.81;95% CI 1.09-7.21) . CONCLUSIONS: In patients with SOI, SI is a simple bedside predictor for BT and MTP activation. Further prospective studies are needed to support our findings.

Bicycle-related traumatic injury hospitalizations: six years descriptive analysis in Qatar.

BACKGROUND: Bicycle riding is a widely practiced mode of transportation, commuting, competition, fitness and recreation. We aimed to describe the incidence, risk factors and outcomes of Bicycle-Related Traumatic Injury (BRTI) in a Middle Eastern country. METHODS: Data were extracted from a prospectively collected trauma registry over a period of six years (2010- 2015) from the national trauma center. Demographics and clinical characteristics of patients, and outcomes were analyzed. RESULTS: There were 150 patients with a mean age of 27.2±16.6 years, 98% were males, 86.6% were hit by a car and 8.7% died. The average annual incidence of BRTIs was 1.3 per 100,000 populations. The mean Glasgow Coma Score (GCS) and injury severity score (ISS) were12.7±4.0 and 13.6±9.8; respectively. Almost one-third of cases had an ISS of 9-15. The most commonly injured region was the head (47%) followed by a lower extremity (30%), chest (25%), upper extremity (21.3%), spine (20.7%), abdomen (18.7%) and (7%) pelvis. CONCLUSIONS: BRTI is relatively uncommon in Qatar; however, it is characterized by a distinct epidemiology with a considerable mortality. Young male nationals, recreational cyclists and expatriate young commuter cyclists comprise the majority of victims and should be the focus of primary prevention efforts. Complementary prevention should aim at enforcing helmet laws to reduce fatal head injuries, and educating motorists of safer practices around cyclists.

Traumatic sternal injury in patients with rib fracture: A single-center experience.

PURPOSE: We aimed to assess the pattern and impact of sternal injury with rib fracture in a Level 1 trauma center. PATIENTS AND METHODS: We conducted a retrospective review of trauma registry data to identify patients who presented with sternal fracture between 2010 and 2017. Data were analyzed and compared in patients with and without rib fracture. RESULTS: We identified 212 patients with traumatic sternal injury, of them 119 (56%) had associated rib fractures. In comparison to those who had no rib fracture, patients with rib fractures were older (40.1 ± 13.6 vs. 37.8 ± 14.5), were frequently involved in traffic accidents (75% vs. 71%), had higher chest abbreviated injury scale (AIS 2.8 ± 0.6 vs. 2.2 ± 0.5) and Injury Severity Score ( ISS 17.5 ± 8.6 vs. 13.3 ± 9.6), were more likely to be intubated (33% vs. 19%), required chest tube insertion (13.4% vs. 4.3%), and received blood transfusion (29% vs. 17%). Rates of spine fracture, head injury, and solid organ injury were comparable in the two groups. Manubrium, clavicular and scapular fractures, lung contusion, hemothorax, and pneumothorax were significantly more evident in those who had rib fractures. Hospital length of stay was prolonged in patients with rib fractures (P = 0.008). The overall mortality was higher but not statistically significant in patients with rib fractures (5.0% vs. 3.2%). CONCLUSIONS: Sternal fractures are rare, and detection of associated injuries requires a high index of suspicion. Combined sternal and rib fractures are more evident in relatively older patients after chest trauma. This combination has certain clinical implications that necessitate further prospective studies.

Clinical Significance and Prognostic Implications of Quantifying Pulmonary Contusion Volume in Patients with Blunt Chest Trauma.

BACKGROUND Pulmonary contusion (PC) is the most frequent blunt chest injury which could be used to identify patients at high-risk of clinical deterioration. We aimed to investigate the clinical correlation between PC volume and outcome in patients with blunt chest trauma (BCT). MATERIAL AND METHODS BCT patients with PC were identified retrospectively from the prospectively collected trauma registry database over a 2-year period. Contusion volume was measured and expressed as percentage of total lung (CTCV) volume using three-dimensional reconstruction of thoracic CT images on admission. Data included patients' demographics, mechanism of injury (MOI) and injury severity, associated injuries, CTCV, mechanical ventilation, complications, and mortality. RESULTS A total of 226 BCT patients were identified to have PC with a mean age of 35.2 years. Motor vehicle crash (54.4%) and falls (16.4%) were the most frequent MOIs. Bilateral PC (61.5%) was more prevalent than right-sided (19.5%) and left-sided PC (19%). CTCV had a significant positive correlation with ISS; whereas, age and PaO2/FiO2 ratio showed a negative correlation (p<0.05 for all). The median CTCV was significantly higher in patients who developed in-hospital complications (p=0.02). A CTCV >20% was associated with increasedrisk of acute respiratory distress syndrome (ARDS), blood transfusion and prolonged mechanical ventilation. However, multiple linear regression analysis showed that CTCV alone was not an independent predictor of in-hospital outcomes. Presence of chest infection, CTCV, and Injury Severity Scores were predictors of ARDS. CONCLUSIONS Quantifying pulmonary contusion volume could allow identification of patients at high-risk of ARDS. CTCV has a significant correlation with injury severity in patients with BCT. Further prospective studies are needed to address the validity of CTCV in the patients care.

Bispectral index as a predictor of unsalvageable traumatic brain injury.

PRIMARY OBJECTIVE: We aimed to assess the utility of bispectral index (BIS) monitoring to diagnose brain death (BD) in patients with severe traumatic brain injury (TBI). RESEARCH DESIGN AND METHODS: A prospective observational study was conducted for patients with severe TBI between 2012 and 2014. MAIN OUTCOMES AND RESULTS: This study included 62 patients with a mean age of 32.5 ± 10.5 years. Nine patients had BD on admission with a sustainable BIS value of 0. Fifty-three patients were not initially diagnosed with BD with BIS values of 2-56. Forty-four patients deteriorated to BD, and their respective BIS values progressively decreased to 0. Nine patients with mean BIS of 39.2 ± 9.0 recovered and were transferred to a specialized high dependency unit. BIS values showed positive correlation with the Glasgow Coma Score (GCS) on admission (r = 0.43, p = 0.001). Survivors had higher BIS values than those who were initially declared BD or those who died during the hospitalization course (p = 0.001). CONCLUSION: BIS values have a significant correlation with initial GCS and can assist in the early detection of BD in patients with severe acute TBI. Further larger studies are needed to support our findings.

Troponin T in Patients with Traumatic Chest Injuries with and without Cardiac Involvement: Insights from an Observational Study.

BACKGROUND: Serum troponin T (TnT) is a common marker of myocardial injury. However, its implication in the absence of clinical evidence of cardiac reason is not well established. AIMS: The aim of this study was to identify the implications of positive TnT in traumatic chest injury (TCI) patients regardless of the cardiac involvement. MATERIALS AND METHODS: We conducted a retrospective analysis of all TCI patients admitted to level 1 trauma center between 2008 and 2011. Patients who underwent TnT testing were divided into two groups: Group 1 (positive TnT) and Group 2 (negative TnT). The two groups were analyzed and compared, and multivariate regression analyses were performed to identify predictors of TnT positivity and mortality. RESULTS: Out of 993 blunt TCI patients, 19.3% had positive TnT (Group 1). On comparison to Group 2, patients in Group 1 were 5 years younger and more likely to have head, cardiac, hepatic, splenic, and pelvic injuries, in addition to lung contusion. Positive TnT was associated with higher Injury Severity Score (ISS) (P = 0.001), higher chest Abbreviated Injury Score (AIS) (P = 0.001), and longer hospital stay (P = 0.03). In addition, Group 1 patients were more likely to undergo chest tube insertion, exploratory laparotomy, mechanical ventilation, and tracheostomy. Twenty patients had cardiac involvement, and of them 14 had positive TnT. Among 973 patients who showed no evidence of cardiac involvement, 178 had positive TnT (18.3%). There were 104 deaths (60% in Group 1). On multivariate regression analysis, the predictors of hospital mortality were positive TnT, head injury, and high ISS, whereas, the predictors of TnT positivity were cardiac, hepatic, and pelvic injuries; higher ISS; and age. CONCLUSIONS: Positive TnT in blunt TCI patients is a common challenge, particularly in polytrauma cases. Patients with positive TnT tend to have the worst outcome even in the absence of clinical evidence of acute cardiac involvement. Positive TnT is also a reflection of the severity of chest or extrathoracic injuries; however, further prospective studies are warranted.

Early high ratio platelet transfusion in trauma resuscitation and its outcomes.

INTRODUCTION: The optimal ratio of platelets (PLTs) to packed red blood cell (PRBC) in trauma patients requiring massive transfusion protocol (MTP) is still controversial. This report aims to describe the effect of attaining a high PLT:PRBC ratio (≥1:1.5) within 4 h postinjury on the outcomes of trauma patients receiving MTP. METHODS: Over a 24-month period, records of all adult patients with traumatic injury who received MTP were retrospectively reviewed. Data were analyzed with respect to PLT:PRBC ratio ([high-MTP ≥1:1.5] [HMTP] vs. [low-MTP <1:1.5] [LMTP]) given within the first 4 h postinjury and also between (>4 and 24 h). Baseline demographic, clinical characteristics, complications, and outcomes were compared according to HMTP and LMTP. RESULTS: Of the total 3244 trauma patients, PLT:PRBC ratio was attainable in 58 (1.2%) patients who fulfilled the inclusion criteria. The mean age was 32.3 ± 10.7 years; the majority were males (89.6%) with high mean Injury Severity Score (ISS): 31.9 ± 11.5 and Revise Trauma Score (RTS): 5.1 ± 2.2. There was no significant association between age, gender, type of injury, presenting hemoglobin, International Normalized Ratio, ISS, and RTS. The rate of ventilator-associated pneumonia (38.9% vs. 10.8%; P = 0.02) and wound infection (50% vs. 10.8%; P = 0.002) were significantly higher in the HMTP group. However, HMTP was associated with lower rate of multiple organ failure (MOF) (42.1% vs. 87.2%, P = 0.001) and mortality (36.8% vs. 84.6%, P = 0.001) within the first 30 days postinjury. CONCLUSIONS: Our study revealed that early attainment of high PLT/PRBC ratio within 4 h postinjury is significantly associated with lower MOF and mortality in trauma patients.

Outcome of concurrent occult hemothorax and pneumothorax in trauma patients who required assisted ventilation.

Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy. Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded. Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group. Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise.

Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm?

INTRODUCTION: The clinical significance of extended Focused Assessment with Sonography for Trauma (EFAST) for diagnosis of pneumothorax is not well defined. OBJECTIVES: To investigate the utility of EFAST in blunt chest trauma (BCT) patients. STUDY DESIGN: A single blinded, prospective study. PARTICIPANTS: All patients admitted with BCT (2011-2013). SETTINGS: Level 1 trauma center in Qatar. PROCEDURES AND OUTCOME MEASURES: Patients were screened by EFAST and results were compared to the clinical examination (CE) and chest X-ray (CXR). Chest-computed tomography (CT) scoring system was used to confirm and measure the pneumothorax. Diagnostic accuracy of diagnostic modalities of pneumothorax was measured using sensitivity, specificity, predictive values (PVs), and likelihood ratio. RESULTS: A total of 305 BCT patients were included with median age of 34 (18-75). Chest CT was positive for pneumothorax in 75 (24.6 %) cases; of which 11 % had bilateral pneumothorax. Chest CT confirmed the diagnosis of pneumothorax in 43, 41, and 11 % of those who were initially diagnosed by EFAST, CE, and CXR, respectively. EFAST was positive in 42 hemithoraces and its sensitivity (43 %) was higher in comparison to CXR (11 %). Positive and negative PVs of EFAST were 76 and 92 %, respectively. The frequency of missed cases by CXR was higher in comparison to EFAST and CE. The lowest median score of missed pneumothorax was observed by EFAST. CONCLUSION: EFAST can be used as an efficient triaging tool in BCT patients to rule out pneumothorax. Based on our analysis, we would recommend EFAST as an adjunct in ATLS algorithm.