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.

Occult Perforation of the Esophagus during Removal of an Enteral Feeding Tube: A Case Report and Literature Review.

Background. The use of oral or nasal route for enteral feeding is a standard practice in intensive care patients with a safe profile in general. However, complications associated with the insertion of a nasogastric (NGT) or orogastric tube (OGT) are common in the medical literature compared to the removal of such tubes. Case presentation. We presented a 38-year-old male who was involved in a motor-vehicle collision and found with low Glasgow Coma Scale outside his vehicle. He had polytrauma and was intubated-and commenced on enteral feeding via an OGT. Esophageal bezoar developed within a few days around the feeding tube, resulting in significant force being required to remove it, which was complicated by esophageal perforation. The esophageal injury was treated conservatively with uneventful recovery. Discussion and conclusions. Although limited case reports of esophageal enteral feeding bezoar formation do exist in the literature, we believe that this is the first case report of esophageal perforation due to the forceful removal of a wedged OGT secondary to esophageal bezoar formation. Morbidity associated with OGT/NGT is not common and may require a high index of suspicion to be identified. This is especially true if resistance is appreciated while removing the NGT/OGT. Gastroenterology consultation is recommended as early as possible to detect and manage any complications, however, their role was very limited in such stable case. In addition, early computed tomography (CT) can be considered for timely recognition of esophageal perforation. Non-operative management may be considered in stable patients, especially if the leak is in the cervical portion of the esophagus. Finally, prevention is better than cure, so being diligent in confirming NGT/OGT position, both radiologically and by measuring the tube length at the nostril/mouth, is the key to avoid misplacement and complication. This case raises the awareness of physician for such preventable iatrogenic event.

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 .

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.