Timing of male urethral injury treatment in patients with polytrauma: A retrospective study.

INTRODUCTION: Male urethral injuries are uncommon, and the ideal timing of the definitive treatment remains controversial. This study aimed to compare the outcomes of early and delayed interventions (1 month or more after the injury) for male urethral injuries. PATIENT AND METHODS: We conducted a retrospective review of the medical records of 67 male patients with urethral injuries treated at our institution between 2011 and 2020. We examined patient age, injury severity score (ISS), abbreviated injury scale, mechanism, location and severity of injury, presence of pelvic fractures, surgical interventions, timing of treatment, and complications. We analysed factors associated with urinary complications based on the location of urethral injury. Additionally, we performed a subset analysis of patients with severe injuries (ISS≥16) to assess the impact of delayed surgery. RESULTS: Overall, 47 %, 37 %, and 27 % of patients in the delayed treatment group (N = 30) had urethral stricture (US), erectile dysfunction (ED), and/or urinary incontinence (UI). These rates were greater than the 22 % US, 3 % ED, and 11 % UI rates in the early treatment group (N = 37). The subgroup analysis revealed that patients with anterior urethral injury (AUI) who underwent delayed treatment (N = 18) tended to be more severely injured (ISS, 19 vs 9, p = 0.003) and exhibited higher rates of US (44% vs 21 %, p = 0.193) and ED (39% vs 0 %, p = 0.002) than those who received early treatment (N = 24). In the case of posterior urethral injury (PUI), the delayed treatment group (N = 13) had higher rates of US (50% vs 23 %, p = 0.326), ED (33% vs 8 %, p = 0.272), and UI (42% vs 0 %, p = 0.030) than the early treatment group. Regarding study limitations, more than 45 % of the enrolled patients were severely injured (ISS≥16), which may have potentially influenced the timing of urethral injury repair. CONCLUSIONS: The treatment of male urethral injuries may be delayed due to concurrent polytrauma and other associated injuries. However, delayed treatment is associated with higher rates of urinary complications. Early treatment of urethral injuries may be beneficial to male patients with urethral trauma, even in cases of severe injury.

Conventional herniorrhaphy followed by laparoscopic appendectomy for a variant of Amyand's hernia: a case report.

BACKGROUND: Amyand's hernia (AH) is an appendix (with or without acute inflammation) trapped within an inguinal hernia. Most AH with acute appendicitis had a preexisting appendix within the hernia sac. We herein report a variant of AH that has never been described before. An inflamed appendix that was managed conservatively was found to have migrated and trapped in the sac of a previously unrecognized right inguinal hernia 6 weeks after the index admission, resulting in a secondary Amyand's hernia. CASE PRESENTATION: A 25-year-old healthy Taiwanese woman had persistent right lower abdominal pain for 1 week and was diagnosed with perforated appendicitis with a localized abscess by abdominal computed tomography (CT). No inguinal hernia was noted at that time. Although the inflamed appendix along with the abscess was deeply surrounded by bowel loops so that percutaneous drainage was not feasible, it was treated successfully with antibiotics. However, she was rehospitalized 6 weeks later for having a painful right inguinal bulging mass for a week. Abdominal CT revealed an inflamed appendix with abscess formation in an indirect inguinal hernia raising the question of a Amyand's hernia with a perforated appendicitis. Via a typical inguinal herniorrhaphy incision, surgical exploration confirmed the diagnosis, and it was managed by opening the hernial sac to drain the abscess and reducing the appendix into the peritoneal cavity, followed by conventional tissue-based herniorrhaphy and a laparoscopic appendectomy. She was then discharged uneventfully and remained well for 11 months. CONCLUSIONS: Unlike the traditional definition of Amyand's hernia, where the appendix is initially in the hernia sac, the current case demonstrated that Amyand's hernia could be a type of delayed presentation following initial medical treatment of acute appendicitis. However, it can still be managed successfully by a conventional tissue-based herniorrhaphy followed by laparoscopic appendectomy.

Deep Learning for Automated Detection and Localization of Traumatic Abdominal Solid Organ Injuries on CT Scans.

Computed tomography (CT) is the most commonly used diagnostic modality for blunt abdominal trauma (BAT), significantly influencing management approaches. Deep learning models (DLMs) have shown great promise in enhancing various aspects of clinical practice. There is limited literature available on the use of DLMs specifically for trauma image evaluation. In this study, we developed a DLM aimed at detecting solid organ injuries to assist medical professionals in rapidly identifying life-threatening injuries. The study enrolled patients from a single trauma center who received abdominal CT scans between 2008 and 2017. Patients with spleen, liver, or kidney injury were categorized as the solid organ injury group, while others were considered negative cases. Only images acquired from the trauma center were enrolled. A subset of images acquired in the last year was designated as the test set, and the remaining images were utilized to train and validate the detection models. The performance of each model was assessed using metrics such as the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, and negative predictive value based on the best Youden index operating point. The study developed the models using 1302 (87%) scans for training and tested them on 194 (13%) scans. The spleen injury model demonstrated an accuracy of 0.938 and a specificity of 0.952. The accuracy and specificity of the liver injury model were reported as 0.820 and 0.847, respectively. The kidney injury model showed an accuracy of 0.959 and a specificity of 0.989. We developed a DLM that can automate the detection of solid organ injuries by abdominal CT scans with acceptable diagnostic accuracy. It cannot replace the role of clinicians, but we can expect it to be a potential tool to accelerate the process of therapeutic decisions for trauma care.

Does a collecting system injury with grade iv renal blunt trauma always need urinary intervention?

PURPOSE: This study aimed to identify the characteristics associated with the need for urinary intervention for a blunt renal injury with collection system involvement using a computed tomography (CT) protocol for trauma. MATERIALS AND METHODS: Abdominal CT images of patients with blunt renal injuries from 2016 to 2020 were reviewed. Patients with low-grade renal trauma, non-collecting system involvement, American Association for the Surgery of Trauma grade V shattered kidney, and emergent nephrectomy were excluded. The largest perinephric mass thickness was measured in the axial view using CT, and a cutoff value was obtained using a receiver-operating characteristic curve analysis. Risk factors for further urinary intervention were analyzed. RESULTS: Among the 70 patients included in this study, those with perinephric mass thicknesses < 25 mm (n = 36) had a significantly lower rate of urinary intervention than those with perinephric mass thicknesses ≥ 25 mm (0 vs. 5; p = 0.023). There was no significant difference in the follow-up durations of the groups (19 days vs. 38 days; p = 0.198). More than 90% of the perinephric mass in the < 25 mm group resolved within a median follow-up duration of 38 days, whereas nearly half of the ≥ 25 mm group had a residual perinephric mass during a median follow-up duration of 19 days. CONCLUSION: The initial CT protocol for trauma was useful for predicting the need for further urinary interventions for collecting system injuries. A perinephric mass thickness < 25 mm is predictive of a low likelihood of requiring urinary intervention.

Evaluation of Concomitant Facial Fracture in Traumatic Brain Injury Patients-Simplification and External Validation of a Prediction Model.

BACKGROUND: Patients with traumatic brain injuries (TBIs) often experience concurrent facial bone fractures. In 2021, a prediction model with 10 variables was published and precisely predicted concomitant facial fractures in TBI patients. Herein, external validation and simplification of this model was performed. METHODS: Traumatic brain injury patients treated at a major referral trauma center were retrospectively reviewed for 1 year. The original prediction model (published in 2021), which was developed from a rural level II trauma center, was applied for external validation. A new and simplified model from our level I trauma center was developed and backwardly validated by rural level II trauma center data. RESULTS: In total, 313 TBI patients were enrolled; 101 (32.3%) had concomitant facial fractures. When the previous prediction model was applied to the validation cohort, it achieved acceptable discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.713 and good precision, with a Brier score of 0.083. A new and simplified model with 6 variables (age, tooth rupture, epistaxis, facial lesion, eye injury, and intracranial hemorrhage) was created with excellent discrimination (AUC = 0.836) and good precision (Brier score of 0.055). The backward validation of this new model also showed excellent discrimination in the cohort used to develop the original model (AUC = 0.875). CONCLUSION: The original model provides an acceptable and reproducible prediction of concomitant facial fractures among TBI patients. A simplified model with fewer variables and the same accuracy could be applied in the emergency department and at higher- and lower-level trauma centers.

The effect of transarterial embolization and nephrectomy on acute kidney injury in patients with blunt renal trauma: An American College of Surgeons - Trauma Quality Improvement Program analysis.

INTRODUCTION: Transarterial embolization (TAE) or nephrectomy for patients with blunt renal trauma might result in acute kidney injury (AKI). Thus, we analyzed the American College of Surgeons - Trauma Quality Improvement Program (TQIP) to validate this. We hypothesized that nephrectomy, and not TAE, would be a risk factor for AKI in patients with blunt renal trauma. MATERIAL AND METHODS: Adult patients with blunt injuries from the TQIP between 2017 and 2019 were eligible for inclusion. The patients were divided into three treatment groups: conservative treatment, TAE, and nephrectomy. Multivariable logistic regression was used to clarify the AKI predictors. RESULTS: The study included 12,843 patients, wherein 12,373 (96.3 %), 229 (1.8 %), and 241 (1.9 %) patients were in the conservative, TAE, and nephrectomy groups, respectively. A total of 269 (2.2 %), 20 (8.7 %), and 29 (12.0 %) patients had AKI in the three groups, respectively. Both TAE (odds ratio [OR], 2.367; 95 % confidence interval [CI], 1.372-3.900; p = 0.001) and Nephrectomy (OR, 2.745; 95 % CI, 1.629-4.528; p < 0.001) were a statistically significant predictor for AKI in the multivariable logistic regression. CONCLUSIONS: TAE and nephrectomy were statistically associated with AKI in patients with blunt renal trauma. This result differs from our previous research findings that nephrectomy, but not TAE, was a risk factor for AKI in patients with blunt renal trauma. Further prospective and well-designed research may be needed.

Speeding pelvic fracture fixation: CT scan with simultaneous 3-D pelvic reconstruction in the emergency department.

INTRODUCTION: Contrast-enhanced computed tomography (CT) scans are usually needed in the emergency department (ED) to evaluate intra-abdominal injuries associated with pelvic fractures. Three-dimensional (3-D) images for pelvis reconstruction are also needed for planning surgical fixation after admission. This study investigates the advantages integrating a one-stage computed tomography (CT) scan with these two diagnostic modalities simultaneously to reduce the time to surgery and improve the outcomes of pelvic fracture fixation. METHODS: A retrospective cohort study (2018-2021) of patients with pelvic fractures was performed. Patients were categorized into the one-stage CT group or the two-stage CT group, and propensity score matching was used to address biases. The outcome measures included time to surgical fixation, time to CT scan for 3-D pelvis reconstruction, and overall length of hospital stay. RESULTS: Four hundred forty-four pelvic fracture patients who underwent definite surgical fixation were identified. Of those, 320 underwent a one-stage CT scan, while the remaining 124 underwent a two-stage CT scan. After well-balanced matching, those in the one-stage CT group had a significantly shorter time to surgical fixation than those in the two-stage CT group (4.6 vs. 6.8 days, p < 0.001). Even among critically ill patients necessitating intensive care unit (ICU) admission, the one-stage CT scan group had a shorter time to definitive surgical fixation (5.5 vs. 7.2 days, p = 0.002) and a shorter hospital stay (19.0 vs. 32.7 days, p = 0.006). CONCLUSION: A one-stage contrast-enhanced CT scan combined with simultaneous 3-D pelvis reconstruction is promising for expediting surgical fixation in pelvic fracture patients. This innovative strategy may improve patient outcomes by facilitating timely surgical interventions and minimizing delays associated with additional CT scans.

The Role of Diagnostic Laparoscopy in the Evaluation of Abdominal Trauma Patients: A Trauma Quality Improvement Program Study.

PURPOSE: We aimed to identify factors related to delayed intervention in abdominal trauma patients who underwent diagnostic laparoscopy using a nationwide databank. METHODS: From 2017 to 2019, abdominal trauma patients who underwent diagnostic laparoscopy were retrospectively evaluated using the Trauma Quality Improvement Program. Patients who underwent delayed interventions after a primary diagnostic laparoscopy were compared with those who did not. Factors associated with poor outcomes that are usually correlated with overlooked injuries and delayed interventions were also analyzed. RESULTS: Of the 5221 studied patients, 4682 (89.7%) underwent inspection without any intervention. Only 48 (0.9%) patients underwent delayed interventions after primary laparoscopy. Compared with patients receiving immediate interventions during primary diagnostic laparoscopy, patients receiving delayed interventions were more likely to have small intestine injuries (58.3% vs. 28.3%, p < 0.001). Among patients with hollow viscus injuries, a significantly higher probability of overlooked injuries that required delayed intervention was observed in patients with small intestine injuries (small intestine injury: 16.8%; gastric injury: 2.5%; large intestine injury: 5.2%). However, delayed small intestine repair did not significantly affect the risk of surgical site infection (SSI) (p = 0.249), acute kidney injury (AKI) (p = 0.998), or hospital length of stay (LOS) (p = 0.053). In contrast, significantly positive relationships between delayed large intestine repair and poor outcomes were observed (SSI, odds ratio = 19.544, p = 0.021; AKI, odds ratio = 27.368, p < 0.001; LOS, ß = 13.541, p < 0.001). CONCLUSIONS: Most examinations and interventions (near 90%) were successful during primary laparoscopy for abdominal trauma patients. Small intestine injuries were easily overlooked. Delayed small intestine repair-related poor outcomes were not observed.

Effect of multiple-digit replantation in patients with amputated digits.

PURPOSE: The replantation of multiple amputated digits is a technically challenging procedure for reconstructive surgeons that requires more time than the replantation of a single digit. We evaluated the effect of multiple-digit replantation on the success of digital replantation. METHODS: Patients who experienced digital amputation and underwent digital replantation from January 2018 to December 2021 were studied retrospectively. Patients who experienced successful and failed replantation were compared, as were digits that survived or became necrotic after replantation. A multivariate logistic regression (MLR) analysis was performed to evaluate the independent factors of replanted digit survival. RESULTS: There were 378 patients with 497 amputated digits who underwent digital replantation. Of all 378 patients, 298 underwent single-digit replantation, and the other 80 patients underwent multiple-digit replantation. A total of 83.3% of the replanted digits survived (414 of 497). Compared with patients with surviving replanted digits, significantly more patients with necrotic replanted digits underwent multiple-digit replantation (37.7% vs. 17.5%, p < 0.001). On the other hand, a digit that developed necrosis after replantation was more likely to have been involved in the replantation of three or more digits (16% vs. 29%, p = 0.005). The subsequent MLR analysis revealed that the likelihood of necrosis was 2.355 (p = 0.003) times higher in the replantation of three or more digits than in the replantation of one or two digits. CONCLUSION: Patients who underwent multiple-digit replantation exhibited a higher incidence of necrosis in the replanted digits. In cases involving patients with multiple-digit amputation, it is crucial to prioritize and perform selective replantation based on the amputated digits.

Sarcopenia provides extra value outside the PULP score for predicting mortality in older patients with perforated peptic ulcers.

BACKGROUND: Perforated peptic ulcer (PPU) remains challenging surgically due to its high mortality, especially in older individuals. Computed tomography (CT)-measured skeletal muscle mass is a effective predictor of the surgical outcomes in older patients with abdominal emergencies. The purpose of this study is to assess whether a low CT-measured skeletal muscle mass can provide extra value in predicting PPU mortality. METHODS: This retrospective study enrolled older (aged ≥ 65 years) patients who underwent PPU surgery. Cross-sectional skeletal muscle areas and densities were measured by CT at L3 and patient-height adjusted to obtain the L3 skeletal muscle gauge (SMG). Thirty-day mortality was determined with univariate, multivariate and Kaplan-Meier analysis. RESULTS: From 2011 to 2016, 141 older patients were included; 54.8% had sarcopenia. They were further categorized into the PULP score ≤ 7 (n=64) or PULP score > 7 group (n=82). In the former, there was no significant difference in 30-day mortality between sarcopenic (2.9%) and nonsarcopenic patients (0%; p=1.000). However, in the PULP score > 7 group, sarcopenic patients had a significantly higher 30-day mortality (25.5% vs. 3.2%, p=0.009) and serious complication rate (37.3% vs. 12.9%, p=0.017) than nonsarcopenic patients. Multivariate analysis showed that sarcopenia was an independent risk factor for 30-day mortality in patients in the PULP score > 7 group (OR: 11.05, CI: 1.03-118.7). CONCLUSION: CT scans can diagnose PPU and provide physiological measurements. Sarcopenia, defined as a low CT-measured SMG, provides extra value in predicting mortality in older PPU patients.

Timely surgical fixation confers beneficial outcomes in patients' concomitant flail chest with mild-to-moderate traumatic brain injury: a trauma quality improvement project analysis - a cohort study.

BACKGROUND: Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. RESEARCH QUESTION: Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? STUDY DESIGN AND METHODS: Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. RESULTS: Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p <0.001), a longer length of stay (coefficient ß , 4.664; SE, 0.789; p <0.001), longer ventilator days (coefficient ß , 2.020; SE, 0.528; p <0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p <0.001). INTERPRETATION: Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury.

The three-dimensional weakly supervised deep learning algorithm for traumatic splenic injury detection and sequential localization: an experimental study.

BACKGROUND: Splenic injury is the most common solid visceral injury in blunt abdominal trauma, and high-resolution abdominal computed tomography (CT) can adequately detect the injury. However, these lethal injuries sometimes have been overlooked in current practice. Deep learning (DL) algorithms have proven their capabilities in detecting abnormal findings in medical images. The aim of this study is to develop a three-dimensional, weakly supervised DL algorithm for detecting splenic injury on abdominal CT using a sequential localization and classification approach. MATERIAL AND METHODS: The dataset was collected in a tertiary trauma center on 600 patients who underwent abdominal CT between 2008 and 2018, half of whom had splenic injuries. The images were split into development and test datasets at a 4 : 1 ratio. A two-step DL algorithm, including localization and classification models, was constructed to identify the splenic injury. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Grad-CAM (Gradient-weighted Class Activation Mapping) heatmaps from the test set were visually assessed. To validate the algorithm, we also collected images from another hospital to serve as external validation data. RESULTS: A total of 480 patients, 50% of whom had spleen injuries, were included in the development dataset, and the rest were included in the test dataset. All patients underwent contrast-enhanced abdominal CT in the emergency room. The automatic two-step EfficientNet model detected splenic injury with an AUROC of 0.901 (95% CI: 0.836-0.953). At the maximum Youden index, the accuracy, sensitivity, specificity, PPV, and NPV were 0.88, 0.81, 0.92, 0.91, and 0.83, respectively. The heatmap identified 96.3% of splenic injury sites in true positive cases. The algorithm achieved a sensitivity of 0.92 for detecting trauma in the external validation cohort, with an acceptable accuracy of 0.80. CONCLUSIONS: The DL model can identify splenic injury on CT, and further application in trauma scenarios is possible.

A Simple Scoring Model for Evaluation of Concomitant Vascular Injuries in Patients with Lower Extremity Open Fractures.

BACKGROUND: Timely diagnosis and management of concomitant vascular injuries is usually needed for the management of lower extremity open fractures. In the current study, a prediction model and simplified scoring system of vascular injuries were developed for the primary evaluation of patients with lower extremity open fractures. METHODS: Patients with lower extremity open fractures were retrospectively reviewed from 2017 to 2020. Multivariate logistic regression analysis was used to evaluate independent risk factors for concomitant vascular injuries in these patients using data collected from 2017 through 2019 and a prediction scoring model was created accordingly. Model performance was validated with data from 2020. RESULTS: In total, 949 patients with lower extremity open fractures (development cohort, 705 patients, 2017 through 2019; validation cohort, 244 patients, 2020) were enrolled. Concomitant vascular injuries occurred in 44 patients in the development cohort (6.2%). Three clinical variables were identified for a prediction scoring model with weighted points, including hard or soft vascular signs (3 points), segmental fractures (2 points), and degloving soft-tissue injury (1 point). The model showed good discrimination (area under the receiver operating characteristic curve, 0.928), calibration (Hosmer-Lemeshow test, P = 0.661), and precision (Brier score, 0.041). Subsequent management regarding different aspects (observation only, further imaging study, or direct surgical exploration) can thus be decided. The model also demonstrated good discrimination (area under the receiver operating characteristic curve, 0.949), good calibration (Hosmer-Lemeshow test, P = 0.174), and good precision (Brier score, 0.042) in the validation cohort. CONCLUSION: This model may guide the subsequent management of vascular injuries associated with lower extremity open fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Is It Beneficial to Optimize Vital Signs Before Embolization for Pelvic Fractures? A Dilemma Between Resuscitation and Hemostasis.

PURPOSE: Adequate resuscitation and definitive hemostasis are both important in the management of hemorrhage related to pelvic fracture. The goal of this study was to analyze the relationship between the amount of blood transfused before transcatheter arterial embolization (TAE) and the clinical outcome later in the disease course. METHODS: Patients with pelvic fractures who underwent TAE for hemostasis from January 2018 to December 2019 were studied. The characteristics of patients who received blood transfusions of >2 U (1000 mL) and ≤2 U before TAE were compared. The mortality rate, blood transfusion-related complications, and length of stay were compared between these two groups. RESULTS: Among the 75 studied patients, 39 (52.0%) received blood transfusions of ≤2 U before TAE, and the other 36 (48.0%) patients received blood transfusions of >2 U before TAE. The incidence rates of systemic inflammatory response syndrome, sepsis, and coagulopathy were significantly higher in the >2 U group (97.2% vs 81.1%, P = .027; 50.0% vs 27.0%, P = .045; and 44.4% vs 5.4%, P < .01, respectively). After nonsurvivors were excluded, the >2 U group had a significantly higher proportion (43.8% vs 14.7%, P < .001) of prolonged intensive care unit (ICU) length of stay (7 days or more) and a longer hospital length of stay (33.8 ± 15.1 vs 21.9 ± 94.0, P < .01) than the ≤2 U group. Pre-TAE blood transfusion >2 U serves as an independent risk factor for prolonged ICU length of stay and increased hospital length of stay. CONCLUSION: Early hemostasis for pelvic fracture-related hemorrhage is suggested to prevent pre-TAE blood transfusion-associated adverse effects of blood transfusion.

Spleen size greater than 9.76 cm may impact the treatment strategy for blunt splenic injury in adults - A retrospective analysis of experience at a tertiary trauma center in Taiwan.

BACKGROUND/OBJECTIVE: The present study investigated the impact of splenomegaly on the treatment outcomes of blunt splenic injury patients. METHODS: All blunt splenic injury patients were enrolled between 2010 and 2018. The exclusion criteria were age less than 18 years, missing data, and splenectomy performed at another hospital. The patients were divided into two groups based on the presence of splenomegaly, defined as a spleen length over 9.76 cm on axial computed tomography. The primary outcome was the need for hemostatic interventions. RESULTS: A total of 535 patients were included. Patients with splenomegaly had more high-grade splenic injuries (p = 0.007). Hemostatic treatments (p < 0.001) and transarterial embolization (p = 0.003) were more frequently required for patients with splenomegaly. Multivariate analysis showed that male sex (p = 0.023), more packed red blood cell transfusions (p = 0.001), splenomegaly (p = 0.019) and grade 3-5 splenic injury (p < 0.001) were predictors of hemostatic treatment. The failure rate of transarterial embolization was not significantly different between the two groups (p = 0.180). The sensitivity and specificity for splenomegaly in predicting hemostatic procedures were 48.8% and 66.5%, respectively. The positive and negative predictive values were 62.8% and 52.9%, respectively. The overall mortality rate was 3.7%. CONCLUSION: Splenomegaly is an independent predictor for the requirement of hemostatic treatments in blunt splenic injury patients, especially transarterial embolization. Transarterial embolization is as effective for blunt splenic injury patients with splenomegaly as it is for those with a normal spleen.

Could video-assisted thoracoscopic surgery be feasible for blunt trauma patients with massive haemothorax?

INTRODUCTION: The study reviewed the experience of video-assisted thoracoscopic surgery (VATS) for the treatment of massive haemothorax (MHT). MATERIALS AND METHODS: All adult patients who sustained blunt trauma with a diagnosis of traumatic haemothorax or pneumothorax (ICD9 860; ICD10 S27.0-2), injury to the heart and lungs (ICD9 861; ICD10 S26, S27.3-9), and injury to the blood vessels of the thorax (ICD9 901; ICD10 S25) were queried from the trauma registry between 2014 and 2018. Patients who had chest tube drainage amounts meeting the criteria for MHT and who underwent subsequent operations were eligible for analyses. The patients were divided into VATS or thoracotomy groups based on the surgical modalities. Descriptions and analyses of the two groups were made. RESULTS: Thirty-eight patients were enroled in the study, including 8 females (21%) and 30 males. The median age was 47.0 (first quartile (Q1) 25.5 and third quartile (Q3) 59.3) years. Twenty-three patients were in the VATS group, six (26%) of whom were converted to thoracotomy. There were no obvious differences in age, sex, pulse rate, or systolic pressure on arrival to the ED or after resuscitation between the two groups. The laboratory data were worse amongst the thoracotomy group, especially the arterial blood gas analysis (ABG) results: pH 7.2 (7.1, 7.3) vs. 7.4 (7.2, 7.4); HCO3 14.6 (12.4, 18.7) vs. 19.7 (16.1, 23.9) mEq/L; base excess (BE) -12.6 (-15.8, -7.8) vs. -5.2 (-11.1, -0.9) mEq/L. The PaO2/FiO2 ratio was lower in the thoracotomy group (91.4 (68.5, 193.3) vs. 245.3 (95.7, 398.0) mmHg). The thoracotomy group had coagulopathy (INR 1.6 (1.2, 1.9) vs. 1.3 (1.1, 1.4)) and required more blood transfusions (WB and PRBC 36.0 (16.0, 48.0) vs. 12.0 (4.0, 24.0) units; FFP 20.0 (6.0, 50.0) vs. 6.0 (2.0, 20.0) unit). No factors associated with VATS conversion to thoracotomy could be identified. CONCLUSIONS: VATS could be applied to selected blunt trauma patients with MHT. The major differences between the VATS and thoracotomy groups were coagulopathy, acidosis, PaO2/FiO2 ratio < 200 mmHg, or a persistent need for blood transfusion.

Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS.

BACKGROUND: This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE). METHODS: We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE. RESULTS: In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate. CONCLUSIONS: Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.

Does Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Increase the Probability of Delayed Intra-abdominal Hemorrhage in Patients With Concomitant Blunt Abdominal Trauma?

PURPOSE: Most blunt thoracic aortic injuries (BTAIs) may be treated using thoracic endovascular aortic repair (TEVAR), and most blunt abdominal traumas (BATs) are managed conservatively. We hypothesized that severe trauma that needs TEVAR may increase the risk of delayed intra-abdominal hemorrhage in patients with concomitant BTAI and BAT because of the potential hemorrhagic shock, disseminated intravascular coagulopathy, blood loss, consequent need for blood transfusion, and procedure-associated heparinization. MATERIALS AND METHODS: From 2015 to 2019, blunt trauma patients with concomitant severe chest trauma and abdominal trauma who could be managed conservatively were studied. The probability of delayed intra-abdominal hemorrhage was compared between patients with concomitant BTAI who received or did not undergo TEVAR. Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and multivariate logistic regression (MLR) were used to eliminate discrepancies between these 2 groups. RESULTS: Among the 341 studied patients, there were 26 patients with BTAI, and 19 of them underwent TEVAR. Delayed intra-abdominal hemorrhage was observed in 4 patients (21.1%, 4/19) who underwent TEVAR. Both PSM and IPTW showed that patients who underwent TEVAR for concomitant BTAI had a greater delayed need for blood transfusions and a larger proportion of delayed intra-abdominal hemorrhage than patients who did not undergo the procedure. The MLR analysis showed that TEVAR for BTAI was an independent risk factor for delayed intra-abdominal hemorrhage (odds ratio: 10.534, 95%, p<0.001). CONCLUSION: An increased probability of delayed intra-abdominal hemorrhage in patients with BAT (who could be managed conservatively) was observed in patients who underwent TEVAR for concomitant BTAI. CLINICAL IMPACT: More attention should be give in patients with high grade aortic injuries and concomitant abdominal trauma.

Temporary or Permanent? A Clinical Challenge in the Evaluation of Traumatic Brain Injury Patients with Unconsciousness and Normal Initial Head CT.

BACKGROUND: Traumatic brain injury (TBI) patients with unconsciousness and normal initial head computed tomography (CT) present a clinical dilemma for physicians and neurosurgeons in the emergency department (ED). We recorded how long it took for patients to regain consciousness and evaluated the patients' characteristics. METHODS: From 2018 to 2020, TBI patients with unconsciousness and normal initial head CT [Glasgow coma scale (GCS) score < 13, negative CT scan and normal laboratory test results] were evaluated. Patients who regained consciousness were analyzed. Multivariate logistic regression (MLR) analyses were used to evaluate independent factors for regaining consciousness. RESULTS: A total of 77 patients were included in this study. Fifty-eight (75.3%) patients regained consciousness, most within one day (43.1%). Nineteen (24.7%) patients never regained consciousness. MLR analysis showed that initial GCS score (odds 1.85, p = 0.017), early airway protection in ED (odds 25.02, p = 0.018) and 72-h GCS score improvement by two points (odds 0.02, p = 0.001) were independent factors for regaining consciousness. Overall, 94.1% of patients who received early airway protection and improved 2 points in 72-h GCS score regained consciousness. The association between days to M5 status and days to M6 status (consciousness) was highly significant. Fewer days to M5 status were highly associated with needing fewer days to regain consciousness. CONCLUSIONS: For TBI patients with unconsciousness and normal initial head CT, a higher probability of regaining consciousness was observed in those who underwent early airway protection and who improved 2 points in 72-h GCS score. Regaining consciousness within a short period could be expected in patients with M5 status.