Diagnostic pathways in major trauma patients admitted to Italian hospitals: survey and discussion points from the trauma update 2019.

BACKGROUND: Major trauma is a leading cause of mortality, morbidity, and disability. Severe trauma patients are taken to hospital with multiple suspected injuries and need urgent diagnosis in order to achieve focused and lifesaving interventions. The primary endpoint of this survey was to evaluate the intrahospital diagnostic paths that trauma patients undergo in Italian hospitals. Thus, during the 14th Italian Trauma Network Congress (Trauma UpDate, Bologna, February 2019), we collected and discussed data from Italian hospitals regarding the usual diagnostic pathway for major trauma patients. METHODS: Three sets of multiple closed questions, designed to measure the structure, protocols, and habits of Italian hospitals were sent prior to the congress. The questionnaire was developed on the basis of the available literature and expert opinion, regarding: (1) the role of E-FAST, chest and pelvis radiographs in stable major trauma patients; (2) diagnostic pathways after the first-level imaging in major trauma patients, focused on a number of clinical scenarios; (3) diffusion and knowledge of trauma-specific computed tomography (CT) protocols and fast radiologic reporting. RESULTS: We obtained a total of 232 responses to our survey. A remarkable heterogeneity was found between hub and spoke hospitals regarding the indications to the first- and second-level diagnostics, and their use before centralization to trauma centers of patients admitted to peripheral hospitals. CONCLUSION: Italian hospitals show a high heterogeneity in the diagnostic pathways proposed to major trauma victims, an interdisciplinary revision of local protocols taking into account hospital capabilities, new evidence, and emergency system geographical distribution is strongly recommended.

Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma.

BACKGROUND: since 2005, we refined the technique of perihepatic packing including complete mobilization of the right lobe and packing around the posterior paracaval surface, lateral right side, and anterior and posteroinferior surfaces. METHODS: two groups of patients with grade IV/V liver trauma underwent perihepatic packing before and after 2005. The study group included 12 patients treated with the new technique. The control group included 23 patients treated with the old technique. RESULTS: all 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P < .02); the liver-related mortality was 8.3% versus 34.8% (P = not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P = not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P = not significant). The overall (81.8% vs 100%, P = not significant) and liver-related morbidity rate (18.2% vs 41.7%, P = not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P = not significant) decreased. CONCLUSIONS: our refined technique of perihepatic packing seems to be safe and effective.

CEUS in abdominal trauma: multi-center study.

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.