"Zooming" in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé?

SUMMARY OBJECTIVE: Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days. METHODS: This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy. RESULTS: The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected. CONCLUSIONS: Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment.

"Zooming" in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé?

OBJECTIVE: Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days. METHODS: This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy. RESULTS: The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected. CONCLUSIONS: Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Damage Control for renal trauma: the more conservative the surgeon, better for the kidney.

Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management.

El trauma renal y de las vías urinarias se presenta con relativa frecuencia en pacientes con trauma penetrante. El estándar actual de manejo es realizar una evaluación imagenológica, por medio de tomografía computarizada y un abordaje vascular, a través de técnicas de angiografía/embolización. Sin embargo, el manejo de un paciente hemodinámicamente inestable con criterios de laparotomía de emergencia, con hallazgos de trauma renal o de vías urinarias es aún tema de discusión. El siguiente articulo presenta el consenso del grupo de Cirugía de Trauma y Emergencias (CTE) de Cali respecto al manejo del trauma penetrante renal y de vías urinarias mediante cirugía de control de daños. Las características intra quirúrgicas del hematoma perirrenal tales como si es expansivo o si tiene signos de sangrado activo, son puntos de referencia para decidir entre un abordaje conservador, por estudios imagenológicos posteriores. En cambio, si existe la sospecha de un trauma renal severo, se debe realizar exploración quirúrgica con alta probabilidad de una nefrectomía. El manejo de control de daños de las vías urinarias debe ser conservador y diferido, la lesión de estos órganos no representa un riesgo en el manejo agudo del trauma.

Damage Control for renal trauma: the more conservative the surgeon, better for the kidney / Control de daños renal: entr e más conservador sea el cirujano mejor para el riñón

Abstract Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management.

Resumen El trauma renal y de las vías urinarias se presenta con relativa frecuencia en pacientes con trauma penetrante. El estándar actual de manejo es realizar una evaluación imagenológica, por medio de tomografía computarizada y un abordaje vascular, a través de técnicas de angiografía/embolización. Sin embargo, el manejo de un paciente hemodinámicamente inestable con criterios de laparotomía de emergencia, con hallazgos de trauma renal o de vías urinarias es aún tema de discusión. El siguiente articulo presenta el consenso del grupo de Cirugía de Trauma y Emergencias (CTE) de Cali respecto al manejo del trauma penetrante renal y de vías urinarias mediante cirugía de control de daños. Las características intra quirúrgicas del hematoma perirrenal tales como si es expansivo o si tiene signos de sangrado activo, son puntos de referencia para decidir entre un abordaje conservador, por estudios imagenológicos posteriores. En cambio, si existe la sospecha de un trauma renal severo, se debe realizar exploración quirúrgica con alta probabilidad de una nefrectomía. El manejo de control de daños de las vías urinarias debe ser conservador y diferido, la lesión de estos órganos no representa un riesgo en el manejo agudo del trauma.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent? / Cirugía de control de daños en lesiones combinadas de intestino delgado y colon en trauma penetrante: ¿Es pertinente el uso de ostomías?

Abstract Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Laparoscopic versus open approach for diffuse peritonitis from appendicitis ethiology: a subgroup analysis from the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study.

Diffuse peritonitis represents a life-threatening complication of acute appendicitis (AA). Whether laparoscopy is a safe procedure and presents similar results compared with laparotomy in case of complicated AA is still a matter of debate. The objective of this study is to compare laparoscopic (LA) and open appendectomy (OA) for the management of diffuse peritonitis caused by AA. This is a prospective multicenter cohort study, including 223 patients with diffuse peritonitis from perforated AA, enrolled in the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study from February to May 2018. Two groups were created: LA = 78 patients, mean age 42.51 ± 22.14 years and OA = 145 patients, mean age 38.44 ± 20.95 years. LA was employed in 34.98% of cases. There was no statically significant difference between LA and OA groups in terms of intra-abdominal abscess, postoperative peritonitis, rate of reoperation, and mortality. The wound infection rate was higher in the OA group (OR 21.63; 95% CI 3.46-895.47; P = 0.00). The mean postoperative hospital stay in the LA group was shorter than in the OA group (6.40 ± 4.29 days versus 7.8 ± 5.30 days; P = 0.032). Although LA was only used in one-third of cases, it is a safe procedure and should be considered in the management of patients with diffuse peritonitis caused by AA, respecting its indications.

Management of Appendicitis Globally Based on Income of Countries (MAGIC) Study.

BACKGROUND: Our aim is to compare the management approaches and clinical outcomes of acute appendicitis according to annual Gross National Income per Capita (GNI/Capita) of countries. METHODS: Consecutive patients who were diagnosed to have acute appendicitis from 116 centers of 44 countries were prospectively studied over a 6-month period (April-September 2016). Studied variables included demography, Alvarado score, comorbidities, radiological and surgical management, histopathology, and clinical outcome. Data were divided into three groups depending on the GNI/Capita. RESULTS: A total of 4271 patients having a mean (SD) age of 33.4 (17.3) years were studied. Fifty-five percent were males. Two hundred and eighty patients were from lower-middle-income (LMI) countries, 1756 were from upper-middle-income (UMI) countries, and 2235 were from high-income (HI) countries. Patients in LMI countries were significantly younger (p < 0.0001) and included more males (p < 0.0001). CT scan was done in less than 8% of cases in LMI countries, 23% in UMI countries, and 38% in HI countries. Laparoscopy was performed in 73% of the cases in the HI countries, while open appendectomy was done in more than 60% of cases in both LMI and UMI countries (p < 0.0001). The longest mean hospital stay was in the UMI group (4.84 days). There was no significant difference in the complication or death rates between the three groups. The overall death rate was 3 per 1000 patients. CONCLUSIONS: There is great variation in the presentation, severity of disease, radiological workup, and surgical management of patients having acute appendicitis that is related to country income. A global effort is needed to address this variation. Individual socioeconomic status could be more important than global country socioeconomic status in predicting clinical outcome.

Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.