Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

A pandemic recap: lessons we have learned.

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Damage control in penetrating cardiac trauma.

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

El manejo definitivo de los pacientes hemodinámicamente estables con heridas cardíacas penetrantes continúa siendo controversial con abordajes invasivos versus manejos conservadores. Estas posiciones contrarias se extienden hasta aquellos casos de pacientes hemodinámicamente inestables donde se ha descrito y considerado la cirugía de control de daños como un procedimiento útil y efectivo. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de heridas cardíacas penetrantes con la creación de un algoritmo práctico que incluye los principios básicos del control de daños. Se recomienda que a todos los pacientes con heridas precordiales penetrantes se les debe realizar un ultrasonido torácico como componente integral de la evaluación inicial. Aquellos que presenten un ultrasonido torácico positivo y se encuentren hemodinámicamente estables se les debe realizar una ventana pericárdica con posterior lavado. Se ha demostrado que el 25% de las ventanas pericárdicas positivas no se benefician ni requieren de posteriores abordajes quirúrgicos invasivos. Antes de este concepto, todos los pacientes con ventana pericárdica positiva terminaban en una exploración abierta del tórax y del pericárdico.Los pacientes hemodinámicamente inestables requieren de una cirugía de control de daños para un adecuado y oportuno control del sangrado. Con este propósito, se propone un algoritmo de manejo quirúrgico que incluye todos estos aspectos esenciales en el abordaje de este grupo de pacientes.

Damage control in penetrating cardiac trauma / El control de daños en el trauma cardíaco penetrante

Abstract Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Resumen El manejo definitivo de los pacientes hemodinámicamente estables con heridas cardíacas penetrantes continúa siendo controversial con abordajes invasivos versus manejos conservadores. Estas posiciones contrarias se extienden hasta aquellos casos de pacientes hemodinámicamente inestables donde se ha descrito y considerado la cirugía de control de daños como un procedimiento útil y efectivo. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de heridas cardíacas penetrantes con la creación de un algoritmo práctico que incluye los principios básicos del control de daños. Se recomienda que a todos los pacientes con heridas precordiales penetrantes se les debe realizar un ultrasonido torácico como componente integral de la evaluación inicial. Aquellos que presenten un ultrasonido torácico positivo y se encuentren hemodinámicamente estables se les debe realizar una ventana pericárdica con posterior lavado. Se ha demostrado que el 25% de las ventanas pericárdicas positivas no se benefician ni requieren de posteriores abordajes quirúrgicos invasivos. Antes de este concepto, todos los pacientes con ventana pericárdica positiva terminaban en una exploración abierta del tórax y del pericárdico. Los pacientes hemodinámicamente inestables requieren de una cirugía de control de daños para un adecuado y oportuno control del sangrado. Con este propósito, se propone un algoritmo de manejo quirúrgico que incluye todos estos aspectos esenciales en el abordaje de este grupo de pacientes.

The gap in operative exposure in trauma surgery: quantifying the benefits of an international rotation.

BACKGROUND: International rotations with hands-on experience are commonly cited as a potential supplement to the current experience of surgical trainees in trauma; however, quantification of this experience remains unclear. METHODS: A link to an online survey was distributed by electronic mail to physicians who rotated for any period of time at the Trauma Unit of the Groote-Shuur Hospital of the University of Cape Town from January 1, 2006, to December 2016. RESULTS: Of 160 participants, 75 (47%) completed the survey. A high proportion (45%) had performed less than 25 trauma-related surgical procedures during their previous training. Most (56%) performed ≥ 10 trauma laparotomies and sternotomies/thoracotomies during their rotation, whereas 43% performed ≥ 5 vascular procedures. The level of perceived confidence in managing trauma patients increased significantly from a median of 3/10 to 7/10 (P < .05). CONCLUSION: Rotations at large-volume trauma centers abroad offer the opportunity for a hands-on operative experience and may enhance the confidence of surgical trainees. Further standardization of these opportunities may result in a larger-scale participation of graduate residents and fellows.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011.

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis.

Background: Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs. Methods: We searched electronic databases (March 1966-April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I2 statistics and conducting tests of homogeneity. Results: Of 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9-10.1%; I2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2-0.6%; I2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3-77.7%; I2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0-7.0%; I2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9-10.1%), and back (3.1%; 95% CI = 0-6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3-20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication. Conclusions: SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.

The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis.

BACKGROUND: The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status. METHODS: This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days. RESULTS: A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days. CONCLUSIONS: Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.

Selective nonoperative management of penetrating thoracic injury.

BACKGROUND: Thoracic penetrating injury is a cause for up to one-fifth of all non-natural deaths. The aim of this study was to determine the success of selective nonoperative management (SNOM) of patients presenting with a penetrating thoracic injury (PTI). METHODS: This was a prospective study of patients with PTI who presented to a level 1 Trauma Center between April 2012 and August 2012. RESULTS: A total of 248 patients were included in the study, with 5.7% (n=14) requiring immediate emergency surgery. Overall, five of these 248 patients died, resulting in a mortality rate of 2.0%. Primarily 221 patients (89.1%) were managed with SNOM, of whom 15 (6.8%) failed conservative management. Failure of SNOM was primarily caused by complications of chest tube drainage (n=12) (e.g. retained clot, empyema) and delayed development of cardiac tamponade (n=3). The survival rate in the SNOM group was 100%. CONCLUSION: PTI has a low in-hospital mortality rate. Only 16.5% (41/248) of the patients presenting with PTI will need surgical treatment. The other patients are safe to be treated conservatively according to a protocolized SNOM approach for PTI without any additional mortality. Conservative treatment of patients who were selected for this nonoperative treatment strategy with repeated clinical reassessment was successful in 93.2%.

Comparative assessment of in-hospital trauma mortality at a South African trauma center and matched patients treated in the United States.

BACKGROUND: The unacceptably high rate of death and disability due to injury in Sub-Saharan Africa is alarming. The objective of this work was to compare mortality rates between severely injured trauma patients at a high-volume trauma center in South Africa with matched patients in the United States. METHODS: Clinical databases from the Groote Schuur Hospital for patients treated in Cape Town, South Africa and the American College of Surgeon's National Trauma Databank for patients treated at large academic trauma centers in the United States were used. Coarsened exact matching identified the most comparable patient populations based on sex, age, intent, injury type, injury mechanism, Injury Severity Score, Glasgow Coma Score, and systolic blood pressure. Conditional logistic regression generated odds ratios for mortality among the entire sample and clinically relevant subgroups. RESULTS: Coarsened exact matching matched 97.9% of the Groote Schuur Hospital patient sample, resulting in 3,206 matched-pairs between the Groote Schuur Hospital and National Trauma Databank cohorts. Conditional logistic regression revealed an odds ratio of mortality of 1.67 (95% confidence interval, 1.10-2.52) for patients at Groote Schuur Hospital compared with matched patients from the National Trauma Databank. Subset analyses revealed significantly increased odds of mortality among patients with blunt injuries (odds ratio 3.40, 95% confidence interval, 1.68-6.88) and patients with a Glasgow Coma Score of 8 or lower (odds ratio 4.33, 95% confidence interval, 2.10-8.95). No statistically significant difference was identified among patients with penetrating injuries or with a Glasgow Coma Score >8 (P value .90 and .39, respectively). CONCLUSION: International comparisons of interhospital variation in risk-adjusted outcomes following trauma can identify opportunities for quality improvement and have the potential to measure the impact of any corrective strategy implemented.

Development and validation of a pancreatic injury mortality score (PIMS) based on 473 consecutive patients treated at a level 1 trauma center.

BACKGROUND: This study sought to develop a pancreatic injury mortality score (PIMS) to identify patients at greatest risk of in-hospital mortality after a major pancreatic injury. METHODS: The study used data from a prospective database of 473 patients treated for pancreatic injuries between January 1990 and December 2015. Two thirds of the patients were assigned to the derivation cohort and one third to the validation cohort. Clinical correlates of in-hospital death were identified and considered in stepwise logistic regression analyses that identified the factors included in the risk index. RESULTS: Five variables, age >55, shock on admission, a vascular injury, number of associated injuries and American Association for the Study of Trauma (AAST) pancreatic injury scale correlated with in-hospital death and were used to calculate PIMS. The final score ROC in the derivation dataset was 0.84 (95% CI 0.79-0.89) and in the validation dataset was 0.91 (95% CI 0.84-0.97), which were comparable (p = 0.1). Finally, cut-off scores were used to generate three risk groups and the rate of mortality within the low (PIMS 0-4), medium (PIMS 5-9), and high risk (PIMS 10-20) groups were not significantly different. The scoring system was tested in a validation cohort and showed good calibration and discrimination for in-hospital mortality. CONCLUSIONS: We have derived and validated the PIMS, a novel organ-specific risk prediction score calculated from five variables for in-hospital mortality following major pancreatic trauma. PIMS is simple, quick and easily understandable, increases clinical risk prediction for patients with complex pancreatic and can be used as a benchmark for survival.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification.

AIM: To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries. METHODS: A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied. RESULTS: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. CONCLUSION: This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.

Surgical Management and Outcomes of Combined Pancreaticoduodenal Injuries: Analysis of 75 Consecutive Cases.

BACKGROUND: Combined pancreaticoduodenal injuries (CPDI) are complex and result in significant morbidity and mortality. Survival in CPDI after initial damage-control laparotomy (DCL) and pancreaticoduodenectomy was evaluated in a large cohort treated in a Level I trauma center. We hypothesized that bivariate analyses would accurately identify factors influencing morbidity and mortality. STUDY DESIGN: The records from a prospective database of 453 consecutive patients treated for pancreatic injuries between January 1990 and April 2015 were reviewed to identify those with CPDI. Primary and secondary end points assessed were death and morbidity. RESULTS: Seventy-five patients (69 men, median age 27 years, range 14 to 56 years) with CPDI, underwent 161 operations (range 1 to 9 operations). Twenty-nine patients with complex CPDI underwent a DCL and 46 had definitive treatment during the initial operation. Nineteen had a pancreaticoduodenectomy, either during the initial operation (n = 13) or after the DCL (n = 6). Postoperative complications occurred in 63 (84%) patients. Twenty-one (28%) patients died, including 15 (43%) of 35 patients with associated vascular injuries. Sixteen (84%) of the 19 patients who had a pancreaticoduodenectomy survived. Significantly more complications related to bleeding, disseminated intravascular coagulation, and hypovolemic shock occurred in those patients who eventually died and significantly more abdominal sepsis and fistulas occurred in patients who survived. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.011), and the combination of vascular plus the total number of associated organs injured (p < 0.046). CONCLUSIONS: Despite using DCL in CPDIs, morbidity (84%) and mortality (28%) remain substantial. Careful selection of patients undergoing pancreaticoduodenectomy resulted in 84% survival. Associated vascular injuries, major visceral venous injuries, and combined vascular and associated organs injured influenced outcomes and mortality.

Indications for Use of Damage Control Surgery in Civilian Trauma Patients: A Content Analysis and Expert Appropriateness Rating Study.

OBJECTIVES: To characterize and evaluate indications for use of damage control (DC) surgery in civilian trauma patients. BACKGROUND: Although DC surgery may improve survival in select, severely injured patients, the procedure is associated with significant morbidity, suggesting that it should be used only when appropriately indicated. METHODS: Two investigators used an abbreviated grounded theory method to synthesize indications for DC surgery reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. An international panel of trauma surgery experts (n = 9) then rated the appropriateness (expected benefit-to-harm ratio) of the coded indications for use in surgical practice. RESULTS: The 1107 indications identified in the literature were synthesized into 123 unique pre- (n = 36) and intraoperative (n = 87) indications. The panel assessed 101 (82.1%) of these indications to be appropriate. The indications most commonly reported and assessed to be appropriate included pre- and intraoperative hypothermia (median temperature <34°C), acidosis (median pH <7.2), and/or coagulopathy. Others included 5 different injury patterns, inability to control bleeding by conventional methods, administration of a large volume of packed red blood cells (median >10 units), inability to close the abdominal wall without tension, development of abdominal compartment syndrome during attempted abdominal wall closure, and need to reassess extent of bowel viability. CONCLUSIONS: This study identified a comprehensive list of candidate indications for use of DC surgery. These indications provide a practical foundation to guide surgical practice while studies are conducted to evaluate their impact on patient care and outcomes.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study.

BACKGROUND: The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice. METHODS: Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient. RESULTS: The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11). CONCLUSION: This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

To drain or not to drain? Predictors of tube thoracostomy insertion and outcomes associated with drainage of traumatic hemothoraces.

INTRODUCTION: Historical data suggests that many traumatic hemothoraces (HTX) can be managed expectantly without tube thoracostomy (TT) drainage. The purpose of this study was to identify predictors of TT, including whether the quantity of pleural blood predicted tube placement, and to evaluate outcomes associated with TT versus expected management (EM) of traumatic HTXs. PATIENTS AND METHODS: A retrospective cohort study of all trauma patients with HTXs and an Injury Severity Score (ISS) ≥12 managed at a level I trauma centre between April 1, 2005 and December 31, 2012 was completed. Mixed-effects models with a subject-specific random intercept were used to identify independent risk factors for TT. Logistic and log-linear regression were used to compute odds ratios (ORs) for mortality and empyema and percent increases in length of hospital and intensive care unit stay between patients managed with TT versus EM, respectively. RESULTS: A total of 635 patients with 749 HTXs were included in the study. Overall, 491 (66%) HTXs were drained while 258 (34%) were managed expectantly. Independent predictors of TT placement included concomitant ipsilateral flail chest [OR 3.03; 95% confidence interval (CI) 1.04-8.80; p=0.04] or pneumothorax (OR 6.19; 95% CI 1.79-21.5; p<0.01) and the size of the HTX (OR per 10cc increase 1.12; 95% CI 1.04-1.21; p<0.01). Although the adjusted odds of mortality were not significantly different between groups (OR 3.99; 95% CI 0.87-18.30; p=0.08), TT was associated with a 47.14% (95% CI, 25.57-69.71%; p<0.01) adjusted increase in hospital length of stay. Empyemas (n=29) only occurred among TT patients. CONCLUSIONS: Expectant management of traumatic HTX was associated with a shorter length of hospital stay, no empyemas, and no increase in mortality. Although EM of smaller HTXs may be safe, these findings must be confirmed by a large multi-centre cohort study and randomized controlled trials before they are used to guide practice.

Screening for occult penetrating cardiac injuries.

OBJECTIVE: To determine the sensitivity of emergency department ultrasonography (US) in the diagnosis of occult cardiac injuries. BACKGROUND: Internationally, US has become the investigation of choice in screening patients for a possible cardiac injury after penetrating chest trauma by detecting blood in the pericardial sac. METHODS: Patients presenting with a penetrating chest wound and a possible cardiac injury to the Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 were prospectively evaluated. All patients were hemodynamically stable, had no indication for emergency surgery, and had an US scan followed by subxiphoid pericardial window exploration. RESULTS: There were a total of 172 patients (median age = 26 years; range, 11-65 years). The mechanism of injury was stab wounds in 166 (96%) and gunshot wounds in 6. The sensitivity of US in detecting hemopericardium was 86.7%, with a positive predictive value of 77%. There were 18 false-negatives. Eleven of these false-negatives had an associated hemothorax and 6 had pneumopericardium. A single patient had 2 negative US examinations and returned with delayed cardiac tamponade. CONCLUSIONS: The sensitivity of US to detect hemopericardium in stable patients was only 86.7%. The 2 main factors that limit the screening are the presence of a hemothorax and air in the pericardial sac. A new regimen for screening of occult injuries to make allowance for this is proposed.

Selective nonoperative management in 1106 patients with abdominal gunshot wounds: conclusions on safety, efficacy, and the role of selective CT imaging in a prospective single-center study.

OBJECTIVE: The primary aim of this study was to delineate the role of computed tomography (CT) in patients undergoing NOM for AGSW. BACKGROUND: Nonoperative management (NOM) of abdominal gunshot wounds (AGSWs) remains controversial. METHODS: This prospective study included all patients with abdominal gunshot injuries admitted to our trauma center from April 1, 2004 to September 30, 2009. Exclusion criteria included patients with peritonitis, hemodynamic instability, unreliable physical examination, head and spinal cord injury with an AGSW underwent immediate laparotomy. The remaining patients were selected for NOM. Nonperitonitic stable patients with right-sided thoracoabdominal/right upper quadrant gunshots and/or hematuria underwent mandatory CT with intravenous contrast. CT to detect missile trajectory was optional. The primary outcome measure was failure of NOM. Secondary outcomes were unnecessary laparotomy rates and mortality. RESULTS: A total of 1106 patients with abdominal gunshot injuries were admitted. Of these, 834 (75.4%) underwent immediate laparotomy, whereas 272 (24.6%) were selected for NOM. In the former group, there were 56 (6.7%) deaths and 29 (3.5%) unnecessary laparotomies, whereas in the latter NOM group, 82 (30.1%) patients were managed by serial clinical examination alone, whereas 190 (69.9%) patients underwent abdominal CT scanning, in addition to serial clinical examination. The overall NOM success rate was 95.2%. Of the 13 patients undergoing delayed laparotomy, there were 10 therapeutic, 2 nontherapeutic, and 1 negative laparotomy. CONCLUSIONS: The NOM of appropriately selected patients with AGSW with selective use of CT scanning is feasible, safe, and effective, but largely based on findings from serial clinical examinations.