Massive Hemorrhage Associated With Upper Cervical Vertebral Fracture Treated Successfully With Transcatheter Arterial Embolization: A Case Report.

Blunt vertebral artery injuries (BVAI) associated with cervical spine fractures are often problematic due to symptoms of occlusion. Denver grade V cases, in which the vertebral artery is transected, are rare but often fatal, and treatment has rarely been reported. We encountered a case of hemorrhagic shock due to an injury to a branch of the vertebral artery associated with an upper cervical spine fracture. Transcatheter arterial embolization was performed successfully to achieve hemostasis, requiring superselective arterial embolization to preserve the main trunk of the vertebral artery. It is important to be aware that vascular injuries to the branch vessels as well as the main trunk can cause complications.

Evaluation of Acute Outcomes and Factors Influencing the Care of Chest Trauma in a District General Hospital in the United Kingdom.

Background The rate of chest trauma admissions under the Queen Hospital Burton Orthopedic team has been steadily increasing, surpassing other hospital trusts. Patients are managed locally by the Orthopedic department, unlike in major trauma centres. Understanding the management outcomes and patient factors in this setting is crucial for enhancing patient safety. Methodology A retrospective analysis of 139 patients with chest trauma referred to the QHB Orthopedic team from October 2017 to May 2021 was conducted using the Meditech-V6 electronic medical records system (Meditech, Westwood, US). This study aims to evaluate the outcomes of patients admitted with chest trauma and improve current practices. The objectives include assessing patient factors influencing outcomes, initiating discussions with a major trauma centre, and enhancing the quality of care for chest trauma patients. Results The mechanism of injury in all cases of chest injuries was blunt trauma, accounting for 100% of the cases. The specific mechanisms of injury observed in the study included falls from standing, falls from height, road traffic collisions, and assault. The study comprised 139 individuals, 128 of whom were diagnosed with rib fractures, and 11 who did not have any rib fractures. In addition, two patients were hospitalized with bilateral rib fractures, both of which were life-threatening. Tragically, one of these cases resulted in the death of the patient. With regard to outcomes, 67% of the patients received a consultation at Royal Stoke Hospital (RSH). Eight individuals were transferred to RSH for further management, while the remaining 131 patients were not transferred. Eighty-seven individuals were discharged from the hospital, indicating successful recovery and readiness for discharge. However, it is noteworthy that nine patients experienced complications during their hospital stay, highlighting the potential challenges and risks associated with chest trauma management. Tragically, seven patients succumbed to their injuries and passed away.  Conclusions The majority of patients in this study were aged 65 and over and presented with multiple comorbidities, indicating the complex medical profile of this population. However, despite the presence of life-threatening injuries and the associated risks, only a minority of patients in the study were transferred to a designated trauma centre. This raises concerns about the adequacy of the current transfer protocols and the potential impact on patient outcomes.

Endovascular Repair of a Traumatic Popliteal Artery Injury.

In patients who sustain a traumatic arterial injury to the lower extremities, timely intervention is key for limb salvage. Traditionally, patients with a popliteal injury have undergone an open surgical bypass but, in recent years, endovascular repair has become more frequent. We present the case of a 46-year-old male who sustained a right tibial/fibular fracture and an associated popliteal artery injury during a pedestrian versus car accident. At presentation, distal signals were not detectable on duplex ultrasonography, and computed tomography confirmed an occlusion of the P3 popliteal artery and proximal anterior tibial and tibioperoneal trunk, as well as a comminuted tibia and fibula fracture. He also had a subdural hematoma without midline shift. He was taken to the operating room emergently and, following external fixation of the tibial/fibular fracture, he underwent angiography of the right leg. There was no thrombus or extravasation but a static column of blood secondary to a flow-limiting intimal flap was present, and an endovascular repair of the popliteal artery with balloon angioplasty and Tack stents (Intact Vascular, Wayne, PA) was pursued. Heparin was not utilized due to the patient's intracranial hemorrhage. On hospital day four, he underwent internal fixation of the tibial/fibular fracture. The subarachnoid/subdural hematoma remained stable and a prophylactic dose of rivaroxaban and aspirin was started. The patient recovered well from these procedures and was discharged 16 days after the accident.

Management of Complex Pelvic Ring and Acetabular Fracture Associated With Open Tibia Fracture in Severe Polytrauma Patient: A Case Report.

With the increase of high energy injuries, acetabular and pelvic ring fractures tend to be a more common part of polytrauma patients. Despite growing incidence, management of these injuries remains one of the most difficult challenges in orthopedic surgery. As these patients are usually multiply injured, it is not only life-threatening trauma in acute settings but also crippling in long time. We present a case of a 40-year-old male who suffered from a dreadful traffic accident following the fractures of pelvic ring and both acetabulum, open fracture of tibia, urinary bladder rupture, and crush syndrome. We discuss the factors which dictated the timing of definitive management of pelvic and associated injuries and compare it with this study. Furthermore, we present patients' final outcomes and management of long-term complications.

Elastic Intramedullary Nails in the Treatment of Multi-Segmental Humeral Fracture in a Polytrauma Patient.

A polytrauma patient with a life-threatening condition is a quite demanding situation due to special considerations regarding the time, the way, and the sequence of the necessary procedures. Elastic intramedullary nails (EIN) could be used under these conditions for adult patients with humeral fractures requiring fixation. Here we present a case of a multi-segmental closed humerus fracture in a polytrauma patient treated by EIN. The general condition of the patient and the need for multiple surgical procedures required the selection of a minimally invasive and time-saving fixation technique. The patient's follow-up was uneventful with complete healing of the humeral fracture; the functional scores results are excellent at five years post operatively. A review of the literature revealed limited published cases of humeral fractures (128 patients) treated by EIN, despite the fact that the results are quite encouraging. Based on our results and the current literature, we believe that EIN could become an effective treatment choice for multi-level humerus fractures, especially in damage control surgery.

The polytrauma patient: Current concepts and evolving care.

Principles of care in the polytraumatized patient have continued to evolve with advancements in technology. Although hemorrhage has remained a primary cause of morbidity and mortality in acute trauma, emerging strategies that can be applied pre-medical facility as well as in-hospital have continued to improve care. Exo-vascular modalities, including the use of devices to address torso hemorrhage and areas not amenable to traditional tourniquets, have revolutionized prehospital treatment. Endovascular advancements including the resuscitative endovascular balloon occlusion of the aorta (REBOA), have led to dramatic improvements in systolic blood pressure, although not without their own unique complications. Although novel treatment options have continued to emerge, so too have concepts regarding optimal time frames for intervention. Though prior care has focused on Injury Severity Score (ISS) as a marker to determine timing of intervention, current consensus contends that unnecessary delays in fracture care should be avoided, while respecting the complex physiology of certain patient groups that may remain at increased risk for complications. Thromboelastography (TEG) has been one technique that focuses on the unique pathophysiology of each patient, providing guidance for resuscitation in addition to providing information in recognizing the at-risk patient for venous thromboembolism. Negative pressure wound therapy (NPWT) has emerged as a therapeutic adjuvant for select trauma patients with significant soft tissue defects and open wounds. With significant advancements in medical technology and improved understanding of patient physiology, the optimal approach to the polytrauma patient continues to evolve.

[Care Management for Polytrauma Patients in a Level-1 Trauma Centre]. / Care Management für Polytrauma-Patientinnen und -Patienten in einem überregionalen Level-1- Traumazentrum.

Care Management for Polytrauma Patients in a Level-1 Trauma Centre Abstract. In our level-1 trauma institution, polytrauma patients with an Injury Severity Score of 16 or higher are facing waiting times for transfer to a rehabilitation facility, causing a negative financial outcome for our institution. The purpose of this study is to stimulate rapid transfer to a rehabilitation facility. In a single-centre case study, care management for (poly)trauma patients was started to ensure time-directed treatment for trauma patients related to Diagnosis-Related Groups (DRG). In the period of 2013-2018 there was an increase in trauma admissions up to 14 % (n = 16 157) with a mean length of hospital stay of 6.4 days, together with a reduction in the number of trauma bed capacity from 50 to 42. In relation to the DRGs, regular trauma patients who were not in need of a stationary rehabilitation facility stayed in line with the expected time of hospital stay. But (poly)trauma patients (n = 1831) with the need of a stationary stay in a rehabilitation centre were faced with waiting times before they could be transferred. The average excess waiting time in relation to DRG for polytrauma patients was 5.1 days. Trauma patients for a rehabilitation centre have a higher Case Mix Index (CMI) compared to those who do not require inpatient rehabilitation (4.22 versus 1.04, p <0.0001). With about 280 trauma patients annually waiting an extra 5.1 days for transfer to a rehabilitation facility, the financial burden for our department amounts to Swiss francs 885,360 without reimbursement. Since no extra bed capacities in rehabilitation facilities are available in our area, it may be advised to set up an early in-hospital trauma rehabilitation program in a level-1 trauma centre in order to reduce financial loss.

[Profile of the child seen in the resuscitation room]. / Perfil del niño atendido en la sala de críticos de Urgencias.

OBJECTIVE: The attention provided to the seriously ill represents a great challenge for health care professionals; familiarity with this profile will allow for the optimal use of resources and will also lead to an improvement in the training of the health professionals. We sought to understand the characteristics of patients seen in the resuscitation room (RR) of a pediatric emergency department (PED), and to determine the risk factors for a poor evolution. METHODS: An observational analytical study was carried out in the PED of a third-level pediatric hospital from September 2016 through August 2017. Included were those patients attended to in the RR; we analyzed their demographic variables, where they were from, how they arrived at the hospital, their reasons for seeking care (medical vs accident), procedures applied, treatments given, diagnoses, and discharge destination. We used logistic regression analysis to determine the independent risk factors for poor evolution. RESULTS: Included were 114 patients. Their median age was 9.9 years (p25-75=4.0-14.7); 65.8% were male. The patients arrived from the street (51.8%) and from home (31.6%); more than two thirds arrived by ambulance (69.3%). Some 42.1% presented with an unstable pediatric assessment triangle (PAT). Some 64.9% were seen for polytrauma (87.8% with stable PAT). Procedures were carried out on 79.8% of the patients. The most frequent diagnoses were polytrauma (64.9%) and convulsive status (14%). The discharge destinations were: home (28.1%), hospital ward (35.1%), intensive care unit (30.7%), and surgery (4.4%); two patients died in the RR. With the univariate study, we identified risk factors for poor outcome: internal medical condition (52.5% vs 21.6%, p=0.001) and age <2 years (55.6% vs 28.1%, p=0.023). In the multivariate study, the medical cause was maintained as an independent risk factor (OR 4 (CI 95% 1.7-9.2), p=0.001). CONCLUSIONS: The profile of the patient seen in the RR is of a school-age child in stable condition, arriving by ambulance for polytrauma. The children seen for internal medical reasons had poorer outcomes.

OBJETIVO: La atención sanitaria a los pacientes gravemente enfermos constituye un reto sanitario; es importante conocer el perfil de estos pacientes, para optimizar los recursos y mejorar la formación de los profesionales. El objetivo del estudio fue conocer las características de los pacientes atendidos en la Sala de Críticos (SC) de un Servicio de Urgencias Pediátricas (SUP) y determinar los factores de riesgo de mala evolución. METODOS: Se realizó un estudio analítico observacional en el SUP de un hospital pediátrico terciario, entre septiembre de 2016 y agosto de 2017. Se incluyeron los pacientes atendidos en la SC, analizando variables demográficas, procedencia, medio de traslado, motivo de consulta (médica o traumática), procedimientos, tratamientos, diagnóstico y destino. Mediante regresión logística se determinaron los factores de riesgo independientes de mala evolución. RESULTADOS: Se incluyeron 114 pacientes. La mediana de edad fue de 9,9 años (p25-75=4,0-14,7), de los que un 65,8% eran varones. Los pacientes llegaban de la vía pública (51,8%) y del domicilio (31,6%), con un 69,3% mediante traslado en ambulancia. El 42,1% presentaba triángulo de evaluación pediátrica (TEP) inestable. El 64,9% fueron atendidos por politraumatismos (87,8% TEP estable). Al 79,8% se les realizó algún procedimiento. Los diagnósticos más frecuentes fueron politraumatismo (64,9%) y "status" convulsivo (14%). El destino de los pacientes fue domicilio (28,1%), planta (35,1%), Unidad de Cuidados Intensivos (30,7%) o quirófano (4,4%). Dos pacientes resultaron éxitus en la SC. En el estudio univariante, se identificaron como factores de riesgo de mala evolución la causa médica (52,5% frente a un 21,6%, p=0,001) y la edad menor a 2 años (55,6% frente a un 28,1%, p=0,023). En el estudio multivariante, la causa médica se mantuvo como factor de riesgo independiente (OR 4 (IC 95% 1,7-9,2), p=0,001). CONCLUSIONES: El perfil del paciente atendido en la SC es un niño estable en edad escolar, que llega en ambulancia y generalmente por politraumatismo. Los niños atendidos por causa médicas tienen mayor riesgo de peor evolución.

Damage Control Resuscitation in polytrauma patient. / Damage Control Resuscitation en el paciente traumático.

Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.

Associated thoracic injury in patients with a clavicle fracture: a retrospective analysis of 1461 polytrauma patients.

PURPOSE: During primary survey the main goal is to ascertain life-threatening injuries. A chest X-ray is recommended in all polytrauma patients as thoracic injury plays an important role in mortality. However, treatment-dictating injuries are often missed on the chest X-ray. In contrast, clavicle fractures should be relatively easy to diagnose on a chest X-ray. We previously showed that clavicle fractures occur in approximately 10 % of all polytrauma patients in our population. The aim was to compare polytrauma patients, with and without a clavicle fracture, to investigate if a clavicle fracture is associated with concomitant thoracic injury. METHODS: A retrospective cohort study of polytrauma patients (ISS ≥ 16) from 2007 until 2011. Thoracic injuries were defined as: ribfracture, pneumothorax, lung contusion, sternum fracture, hemothorax, myocardial contusion, thoracic aorta injury and thoracic spine injury. RESULTS: Of 1461 polytrauma patients in 160 patients a clavicle fracture was diagnosed, and 95 % was diagnosed on chest X-ray. Patients with a clavicle fracture had a higher mean Injury Severity Score (ISS) (29.2 ± 10.1 vs. 24.9 ± 9.1; P < 0.001). Additional thoracic injuries were more prevalent in patients with a clavicle fracture (76 vs. 47 %; OR 3.6; 95 % CI 2.45-5.24) and they had a higher rate of thoracic injury with an AIS ≥ 3 (66 vs. 41 %; OR 2.8; 95 % CI 1.97-3.93). CONCLUSIONS: The clavicle can be seen as the gatekeeper of the thorax. In polytrauma patients, a clavicle fracture is easily diagnosed during primary survey and may indicate underlying thoracic injury, as the rate and extent of concomitant thoracic injury are high.

Assessment of clinical parameters of the polytraumatized patient as predictors of hospital expenditure and of its distribution. / Valoración de parámetros clínicos del paciente politraumatizado como predictores del gasto hospitalario y de su distribución.

INTRODUCTION: Traumatic pathology continues to represent an important socio-health problem. The aim of the study was to assess the clinical predictors of total expenditure, as well as to analyze which components of the cost are modified with each clinical parameter of the polytraumatized patient. MATERIAL AND METHODS: Retrospective study of 131 polytrauma patients registered prospectively. A statistical analysis was carried out to assess the relationship between clinical parameters, the total cost and the cost of various treatment components. RESULTS: The total cost of hospital admission was 3,791,879 euros. The average cost per patient was € 28,945. Age and gender were not predictors of cost. The scales ISS, NISS and PS were predictors of the total cost and of multiple treatment components. The AIS of Skull and Thorax predicted a higher cost of admission to ICU and Total Cost. The AIS of lower limbs was associated with greater spending on facets of treatment related to surgical activity. DISCUSSION: There are clinical parameters that are predictors of the treatment cost of the polytraumatized patient. The study describes how the type of trauma that the patient suffers modifies the type of expenses that will present in their hospital admission. CONCLUSIONS: Polytraumatized patients with severe multisystem injury present increased costs in multiple components of the treatment cost. Patients with TBI or chest trauma present a higher cost for admission to ICU and those with orthopaedic trauma are associated with greater expenditure on surgical activity.

Evaluación de guías de práctica clínica de atención al politraumatizado maxilofacial y trauma maxilofacial grave / Evaluation of clinical practice guidelines for the care of maxillofacial polytrauma and maxillofacial severe trauma patients

Introducción: la guía de práctica clínica es una herramienta que permite resumir la información científica disponible.Objetivo: evaluar dos guías de práctica clínica que abordan la atención en la urgencia de los politraumatizados maxilofaciales y el trauma maxilofacial grave. Métodos: se evaluaron dos guías (una cubana, Guías prácticas de estomatología, y otra extranjera, Manejo del trauma facial: una guía práctica); mediante el instrumento para la evaluación de guías del Appaisal of Guidelines Research and Evaluation. Se conformó el grupo evaluador que fue capacitado en el conocimiento y aprendizaje del instrumento evaluativo. Para el análisis de la información, se trasladaron los datos obtenidos a un modelo Excel y se calculó la puntuación estandarizada por dominio. Resultados: en la guía Manejo del trauma facial, el dominio de Alcance y objetivos obtuvo un resultado catalogado como mejorable, mientras el de claridad de la presentación, con el 22,2 por ciento de puntuación estandarizada, se encontró en el rango de deficiente. En la evaluación globa,l tres de los evaluadores dieron calificación de uno, y otro dio un dos. Los cuatro evaluadores respondieron que no la recomendarían para su uso. En las Guías prácticas de estomatología, los dominios con mejores valores fueron el 6, 2 y 1 con 43,8 por ciento, 22,2 por ciento y 2,8 por ciento, respectivamente, lo cual representó resultados muy mejorables, deficientes y muy deficientes, en ese mismo orden. En la evaluación global, dos evaluadores dieron valores de 3 , otro de 2 y el restante de 1. Al responder a sí recomendarían la guía para su uso, dos respondieron que no y los restantes que si con modificaciones. Conclusiones: las Guías prácticas de estomatología muestran mejores puntuaciones estandarizadas en la mayoría de los dominios que la de Manejo del trauma facial: una guía práctica; aunque los resultados evaluativos no son satisfactorios, los dominios con más bajas evaluaciones resultan, de ...(AU)

Introduction: clinical practice guidelines are tools used to summarize the available scientific information. Objective: evaluate two clinical practice guidelines for emergency care of maxillofacial polytrauma and maxillofacial severe trauma patients.Methods: two guidelines were evaluated: one Cuban (Dental Practice Guidelines) and the other foreign (Management of Facial Trauma: A Practice Guideline), using the guideline evaluation tool Appraisal of Guidelines for Research and Evaluation. An evaluation team was formed who received information about and training in the use of the evaluation tool. For analysis, the data obtained were transferred to an Excel model, and standardized scores were estimated for each domain. Results: in Management of Facial Trauma the scope and objectives domain was classed as improvable, whereas the clarity of presentation domain, with a 22.2 percent standardized score, was classed as poor. In the overall evaluation, three of the evaluators awarded a score of one, and another awarded a two. None of the four evaluators would recommend it for use. In Dental Practice Guidelines, the higher ranking domains were 6, 2 and 1, with 43.8 percent, 22.2 percent and 2.8 percent, respectively, representing very improvable, poor and very poor results, in that order. In the overall evaluation, two evaluators awarded a score of 3, another awarded a 2, and the other a 1. Two evaluators would recommend the guideline for use, two would not, and the remaining ones stated they would recommend it if modified.Conclusions: dental Practice Guidelines obtained higher standardized scores in most domains than Management of Facial Trauma: A Practical Guideline. Although the evaluation results are not satisfactory, the domains with the lowest scores in both tools are rigor in guideline development and applicability(AU)

Evaluación de guías de práctica clínica de atención al politraumatizado maxilofacial y trauma maxilofacial grave / Evaluation of clinical practice guidelines for the care of maxillofacial polytrauma and maxillofacial severe trauma patients

Introducción: la guía de práctica clínica es una herramienta que permite resumir la información científica disponible. Objetivo: evaluar dos guías de práctica clínica que abordan la atención en la urgencia de los politraumatizados maxilofaciales y el trauma maxilofacial grave. Métodos: se evaluaron dos guías (una cubana, Guías prácticas de estomatología, y otra extranjera, Manejo del trauma facial: una guía práctica); mediante el instrumento para la evaluación de guías del Appaisal of Guidelines Research and Evaluation. Se conformó el grupo evaluador que fue capacitado en el conocimiento y aprendizaje del instrumento evaluativo. Para el análisis de la información, se trasladaron los datos obtenidos a un modelo Excel y se calculó la puntuación estandarizada por dominio. Resultados: en la guía Manejo del trauma facial, el dominio de Alcance y objetivos obtuvo un resultado catalogado como mejorable, mientras el de claridad de la presentación, con el 22,2 por ciento de puntuación estandarizada, se encontró en el rango de deficiente. En la evaluación globa,l tres de los evaluadores dieron calificación de uno, y otro dio un dos. Los cuatro evaluadores respondieron que no la recomendarían para su uso. En las Guías prácticas de estomatología, los dominios con mejores valores fueron el 6, 2 y 1 con 43,8 por ciento, 22,2 por ciento y 2,8 por ciento, respectivamente, lo cual representó resultados muy mejorables, deficientes y muy deficientes, en ese mismo orden. En la evaluación global, dos evaluadores dieron valores de 3 , otro de 2 y el restante de 1. Al responder a sí recomendarían la guía para su uso, dos respondieron que no y los restantes que si con modificaciones. Conclusiones: las Guías prácticas de estomatología muestran mejores puntuaciones estandarizadas en la mayoría de los dominios que la de Manejo del trauma facial: una guía práctica; aunque los resultados evaluativos no son satisfactorios, los dominios con más bajas evaluaciones resultan, de forma común, los de Rigor en la elaboración y Aplicabilidad(AU)

Introduction: clinical practice guidelines are tools used to summarize the available scientific information. Objective: evaluate two clinical practice guidelines for emergency care of maxillofacial polytrauma and maxillofacial severe trauma patients. Methods: two guidelines were evaluated: one Cuban (Dental Practice Guidelines) and the other foreign (Management of Facial Trauma: A Practice Guideline), using the guideline evaluation tool Appraisal of Guidelines for Research and Evaluation. An evaluation team was formed who received information about and training in the use of the evaluation tool. For analysis, the data obtained were transferred to an Excel model, and standardized scores were estimated for each domain. Results: in Management of Facial Trauma the scope and objectives domain was classed as improvable, whereas the clarity of presentation domain, with a 22.2 percent standardized score, was classed as poor. In the overall evaluation, three of the evaluators awarded a score of one, and another awarded a two. None of the four evaluators would recommend it for use. In Dental Practice Guidelines, the higher ranking domains were 6, 2 and 1, with 43.8 percent, 22.2 percent and 2.8 percent, respectively, representing very improvable, poor and very poor results, in that order. In the overall evaluation, two evaluators awarded a score of 3, another awarded a 2, and the other a 1. Two evaluators would recommend the guideline for use, two would not, and the remaining ones stated they would recommend it if modified. Conclusions: dental Practice Guidelines obtained higher standardized scores in most domains than Management of Facial Trauma: A Practical Guideline. Although the evaluation results are not satisfactory, the domains with the lowest scores in both tools are rigor in guideline development and applicability(AU)

The Use of Exosomes as Biomarkers for Evaluating and Monitoring Critically Ill Polytrauma Patients with Sepsis.

Regarding genetic biomarkers for early assessment and monitoring the clinical course in polytrauma patients with sepsis, in recent years a remarkable evolution has been highlighted. One of the main representatives is the exosome miRNAs. In this paper, we would like to present in more details the various methods of using exosome miRNAs as a biomarker for monitoring polytrauma patients with sepsis, as well as establishing a belated outcome by aggregating the entire clinical aspects. The use of exosome miRNAs for late evaluating and monitoring the clinical evolution of polytrauma patients can bring significant improvements in current clinical practice through the optimization and modulation of intensive care according to the needs of each patient individually.