Presentations and management of hospitalized patients with upper extremity fractures at a level 1 trauma center: a 5-year observational study.

BACKGROUND: Upper extremity injuries (UEIs) are common in the emergency departments, yet they are under-reported in developing countries. This study examined the frequency, injury characteristics, and treatment approaches of upper extremity fractures (UEFs) among hospitalized trauma patients in a nationally representative population. METHODS: We conducted a retrospective, observational study including all the hospitalized patients with UEFs in the only level 1 trauma center in Qatar between July 2015 and August 2020. Comparative analyses were performed according to injury mechanisms, severity, and management approach. RESULTS: A total of 2,023 patients sustained UEIs with an average age of 34.4 ± 12.9 years, and 92% were males. Motor vehicle crashes (MVCs; 42.3%) were the primary cause of shoulder girdle injuries in 48.3% of cases. Fractures of the radius, ulna, and hands occurred in 30.8, 16.5 and 14.5%, respectively. Young adults were more involved in MVCs and motorcycle crashes (MCCs), while pedestrians who were typically older had a higher rate of humerus fractures. Patients with MCCs had a higher rate of clavicle and ulna fractures. Pedestrians were at risk of serious injuries, with a higher mean injury severity score and lower Glasgow Coma Scale. CONCLUSION: Most UEFs patients were young males and mainly affected by MVCs. Shoulder girdle, particularly clavicle and scapula/glenoid fractures, emerged as common injury sites. The study highlighted the potential risk of pedestrian injuries, as reflected in higher injury severity, concomitant injuries, and higher mortality. Future studies are needed to optimize preventive measures by incorporating insights into specific injury mechanisms and patterns of UEIs.

Traumatic Kidney Injury: An Observational Descriptive Study.

BACKGROUND: Trauma is a major cause of death and disability worldwide. Renal injuries account for 8-10% of abdominal trauma. We aimed to describe the incidence, presentation, and management of traumatic kidney injury in our institution. METHODS: This is a retrospective analysis of all patients admitted with traumatic kidney injury at a level 1 trauma center between January 2014 and December 2017. RESULTS: During a period of 3 years, a total of 152 patients with blunt renal trauma were admitted to a level 1 trauma center; 91% of these were males, with a mean age of 32.8 ± 13.7 years. Motor vehicle crashes accounted for 68% of cases, followed by fall from height (23%). Seventy-one percent of patients had associated chest injuries, 38% had pelvis injuries, and 32% had head injury. Associated abdominal injuries included the liver (35%) and spleen (26%). The mean abdominal abbreviated injury scale was 2.8 ± 1.0; and for those with severe renal injury, it was 3.9 ± 0.9. The mean injury severity score was 24.9 ± 13.7 (31.8 ± 14.2 with renal vs. 21.9 ± 12.9 without renal injury, p = 0.004). Most of the patients were treated conservatively (93%), including severe renal injuries (grades IV and V), and 7% had surgical exploration, mainly those with severe injuries (grades IV and V). The mortality rate was 11%. CONCLUSIONS: High-grade renal injuries in hemodynamically stable patients can be managed conservatively. A multidisciplinary approach coordinated by trauma, urology, and radiology services facilitates the care of these patients in our trauma center.

Blunt liver trauma: a descriptive analysis from a level I trauma center.

BACKGROUND: We aimed to review liver injury experience in a level 1 trauma center; namely clinical presentation, grading, management approach and clinical outcomes. METHODS: It is a retrospective analysis to include all blunt liver injury patients who were admitted at the Level 1 trauma center over a 3-year period. Data were compared and analyzed based on the liver injury grades and management approaches. RESULTS: Blunt liver injury accounted for 38% of the total blunt abdominal trauma cases with a mean age of 31 ± 13 years. Liver injury grade II (44.7%) was most common followed by grade I (28.8%), grade III (19.1%), grade IV (7.0%) and grade V (0.4%). Blood transfusion was more frequently required in patients with grade IV (p = 0.04). Out of 257 patients with blunt liver trauma, 198 were initially treated conservatively, that was successful in 192 (97%), whereas it failed in 6 (3%) patients due to delayed bleeding from hepatic hematoma, associated splenic rupture and small bowel injury which mandate surgical intervention. Fifty-nine patients (23%) underwent emergent surgery in terms of packing, resection debridement, left lobe hepatectomy and splenectomy. Hepatic complications included biloma, pseudoaneurysm and massive liver necrosis. Subanalysis of data using the World Society of Emergency Surgery (WSES) classification revealed 19 patients were categorized as a WSES grade IV who needed surgical intervention without having an initial computerized tomography scanning. The overall mortality was 7.8% which was comparable among the conservative and operative group. CONCLUSIONS: In our center, low grade liver injury in young males prevails. NOM is successful even for high graded injuries. All conservatively treated patients with high-grade liver injuries should be closely monitored for signs of failure of the non-operative management. Introducing the new WSES classification makes clear how is important the hemodynamic status of the patients despite the lesion. However, further larger prospective and multicenter studies are needed to support our findings.

Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm?

INTRODUCTION: The clinical significance of extended Focused Assessment with Sonography for Trauma (EFAST) for diagnosis of pneumothorax is not well defined. OBJECTIVES: To investigate the utility of EFAST in blunt chest trauma (BCT) patients. STUDY DESIGN: A single blinded, prospective study. PARTICIPANTS: All patients admitted with BCT (2011-2013). SETTINGS: Level 1 trauma center in Qatar. PROCEDURES AND OUTCOME MEASURES: Patients were screened by EFAST and results were compared to the clinical examination (CE) and chest X-ray (CXR). Chest-computed tomography (CT) scoring system was used to confirm and measure the pneumothorax. Diagnostic accuracy of diagnostic modalities of pneumothorax was measured using sensitivity, specificity, predictive values (PVs), and likelihood ratio. RESULTS: A total of 305 BCT patients were included with median age of 34 (18-75). Chest CT was positive for pneumothorax in 75 (24.6 %) cases; of which 11 % had bilateral pneumothorax. Chest CT confirmed the diagnosis of pneumothorax in 43, 41, and 11 % of those who were initially diagnosed by EFAST, CE, and CXR, respectively. EFAST was positive in 42 hemithoraces and its sensitivity (43 %) was higher in comparison to CXR (11 %). Positive and negative PVs of EFAST were 76 and 92 %, respectively. The frequency of missed cases by CXR was higher in comparison to EFAST and CE. The lowest median score of missed pneumothorax was observed by EFAST. CONCLUSION: EFAST can be used as an efficient triaging tool in BCT patients to rule out pneumothorax. Based on our analysis, we would recommend EFAST as an adjunct in ATLS algorithm.

Clinical patterns and outcomes of hospitalized patients with grinder-related neurovascular injuries: A decade of experience from a Level I Trauma center.

BACKGROUND: Occupational injuries impose a substantial global burden, affecting millions of workers annually, which demands urgent attention to enhance workplace safety and health standards. We aimed to outline the frequency, patterns of injury, and clinical characteristics of patients injured by high-rotation cutting tools (grinders) and to pinpoint the neurovascular (nerves and blood vessels) injuries. METHODS: A retrospective study was conducted and included all adult patients hospitalized because of grinder-related injuries at the only level I Trauma Center in the country. The characteristics of patients, mechanism of injury, management and outcomes were analyzed based on the anatomical location of injuries. RESULTS: 127 patients were hospitalized with grinder-related injuries over ten years. The incidence of GRIs showed an increasing trend over the years. All patients were males with a mean (SD) age of 34.9 (9.8) years. The majority were general laborers (66.1 %), injured by portable grinders (86.6 %), and direct blade contact (64.6 %). The median Injury Severity Score (ISS) was 5.0(IQR 4.0-9.0), and the median Glasgow Coma Scale (GCS) at ED was 15 (3-15). The most frequently injured part was the upper extremity (36.2 %), followed by the lower extremity (33.9 %) and the face (27.6 %). One-third of cases had vascular injuries, and 23.6 % had nerve injuries. Suturing was done for all patients; repairs and debridements were performed in 62 % and 58 % of cases, respectively, and 21 % required vascular surgery. Amputations were required in 9.4 % of cases. Thirty patients had nerve injuries involving the median (11 %) and radial (9.4 %) nerves. Among patients who had neurovascular injuries, 30 % (12/40) experienced complications during the hospital stay, while 60 % (24/40) ended up with physical disabilities. CONCLUSION: Individuals affected by power-tool accidents were predominantly young males, mainly general laborers, with a significant proportion being expatriates. The trend of grinder-related injuries increases over time, with portable grinders being a primary source of injuries due to direct contact with the blade. The anatomical injuries mainly include fractures of the upper and lower extremities. Further studies are warranted to understand the cultural aspects and training requirements of workers handling power tools, aiming to achieve sustainable injury prevention effectively.

Utility of indocyanine green fluorescent dye in emergency general surgery: a review of the contemporary literature.

For decades, indocyanine green (ICG) has been available for medical and surgical use. The indications for ICG use in surgery have expanded where guided surgery directed by fluorescence and near-infrared fluorescent imaging offers numerous advantages. Recently, surgeons have reported using ICG operative navigation in the emergency setting, with fluorescent cholangiography being the most common procedure. The utility of ICG also involves real-time perfusion assessment, such as ischemic organs and limbs. The rising use of ICG in surgery can be explained by the ICG's rapid technological evolution, accuracy, ease of use, and great potential to guide precision surgical diagnosis and management. The review aims to summarize the current literature on the uses of ICG in emergency general surgery. It provides a comprehensive and practical summary of the use of ICG, including indication, route of administration, and dosages. To simplify the application of ICG, we subdivided its use into anatomical mapping and perfusion assessment. Anatomical mapping includes the biliary tree, ureters, and bowel. Perfusion assessment includes bowel, pancreas, skin and soft tissue, and gonads. This review provides a reference to emergency general surgeons to aid in implementing ICG in the emergency setting for more enhanced and safer patient care.

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.

Late development of giant hepatic artery pseudoaneurysm following abdominal trauma due to tire blast: case report and literature review.

Giant hepatic artery pseudoaneurysm is rare but could have a significant implication. A 35-year-old male was severely injured by a truck tire explosion and presented with hypotension and positive focused assessment with sonography in trauma scan. After resuscitation, abdomen computed tomography (CT) scan showed a Grade 4 liver injury. The patient was admitted to the intensive care unit, and the liver injury was treated conservatively. Seventeen days later, he developed abdominal pain with deep epigastric tenderness. Repeated abdomen CT scan detected a giant hepatic artery pseudoaneurysm. Embolization was achieved using gel foam with the placement of six microcoils. The patient had an uneventful recovery. Late development of giant hepatic artery pseudoaneurysm is a rare complication of hepatic trauma and could be life-threatening. Timely identification and treatment with endovascular intervention are crucial. We recommend, especially when dealing with trauma related to blast injury, follow-up images for patients who develop symptoms suggestive of hepatic injury.

The use of Indocyanine green fluorescent in patients with abdominal trauma for better intraoperative decision-making and less bowel anastomosis leak: case series.

Despite technological advances in the management of blunt abdominal trauma, the rate of bowel anastomotic leakage (AL) remains high. The etiology of AL is multifactorial, but insufficient blood perfusion is considered to play a substantial role in the pathogenesis. In recent years, angiography with Indocyanine green (ICG), a fluorescent dye, has been introduced in the clinical practice to assess organ perfusion in several conditions. Given the scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy that may facilitate intraoperative decisions and limit the extent of bowel resection, we presented the utility of intraoperative ICG fluorescent in abdominal trauma patients in a level 1 trauma center. The use of ICG fluoroscopy in patients with abdominal trauma is feasible and useful; however, large prospective studies in trauma patients are warranted.

Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury.

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.

Complications following chest tube insertion pre-and post-implementation of guidelines in patients with chest trauma: A retrospective, observational study.

BACKGROUND: The need to evacuate the chest after a penetrating wound was first recognized in the 18th century. Most thoracic injuries are treated with tube thoracostomy (TT) which refers to the insertion of a TT into the pleural cavity to drain air, blood, pus, or other fluids. However, TT has been challenged in the trauma care due to insertional, positional, or infective complications. METHODS: A retrospective study of all trauma patients who had TT insertion from 2008 to 2014 was conducted based on the trauma registry data to describe patient characteristics, injury characteristics, management, and outcomes. The complication incidences per TT before (2008) and after (2009-2014) the implementation of standard protocol were compared. RESULTS: During the study period, 804 patients were managed with 1004 TT procedures. The mean age was 34 years, and majority (91%) was males. Motor vehicle crash (43%) was the main mechanism of injury. Mean injury severity score was 22. The rib fractures (68%) were more frequent followed by pneumothorax (49%). Nearly 72% of patients received antibiotic coverage before insertion. The complications developed per TT reduced over the years from 2008 to 2014 (12.6% to 4.4%). The average complication per TT after the protocol implementation (2009-2014) reduced by 7% when compared to the duration before implementation (2008). CONCLUSIONS: The present study shows that standardized management of trauma patients who undergo TT results in a reduction in complications, helps improve patient flow, and ensures the proper management of resources in our high-volume trauma center.

Traumatic sternal injury in patients with rib fracture: A single-center experience.

PURPOSE: We aimed to assess the pattern and impact of sternal injury with rib fracture in a Level 1 trauma center. PATIENTS AND METHODS: We conducted a retrospective review of trauma registry data to identify patients who presented with sternal fracture between 2010 and 2017. Data were analyzed and compared in patients with and without rib fracture. RESULTS: We identified 212 patients with traumatic sternal injury, of them 119 (56%) had associated rib fractures. In comparison to those who had no rib fracture, patients with rib fractures were older (40.1 ± 13.6 vs. 37.8 ± 14.5), were frequently involved in traffic accidents (75% vs. 71%), had higher chest abbreviated injury scale (AIS 2.8 ± 0.6 vs. 2.2 ± 0.5) and Injury Severity Score ( ISS 17.5 ± 8.6 vs. 13.3 ± 9.6), were more likely to be intubated (33% vs. 19%), required chest tube insertion (13.4% vs. 4.3%), and received blood transfusion (29% vs. 17%). Rates of spine fracture, head injury, and solid organ injury were comparable in the two groups. Manubrium, clavicular and scapular fractures, lung contusion, hemothorax, and pneumothorax were significantly more evident in those who had rib fractures. Hospital length of stay was prolonged in patients with rib fractures (P = 0.008). The overall mortality was higher but not statistically significant in patients with rib fractures (5.0% vs. 3.2%). CONCLUSIONS: Sternal fractures are rare, and detection of associated injuries requires a high index of suspicion. Combined sternal and rib fractures are more evident in relatively older patients after chest trauma. This combination has certain clinical implications that necessitate further prospective studies.

Spontaneous Acute Mesenteroaxial Gastric Volvulus Diagnosed by Computed Tomography Scan in a Young Man.

BACKGROUND: Acute gastric volvulus is a surgical emergency that requires early recognition and treatment. Acute idiopathic mesenteroaxial gastric volvulus is a rare sub-type and there are few cases reported in children and there are even fewer reports in adults. CASE REPORT: We report a rare case of a 23-year-old man who presented with a 1-day history of vomiting, epigastric pain, distention, and constipation. The diagnosis for mesenteroaxial type gastric volvulus was confirmed by abdominal radiography and computed tomography. The patient was successfully treated by laparotomy with resection of the ischemic stomach wall and anastomosis. Acute spontaneous mesenteroaxial gastric volvulus is rare in adults and early diagnosis is challenging due to non-specific symptoms. A missed or delayed diagnosis may result in serious complications due to gastric obstruction. CONCLUSIONS: A patient presenting with severe epigastric pain and clinical evidence of gastric outlet obstruction should be considered as a surgical emergency to rule out gastric volvulus. High index of suspicion, early diagnosis and prompt surgical management are important for favorable outcome in patients with acute spontaneous gastric volvulus.

The Challenging Buried Bumper Syndrome after Percutaneous Endoscopic Gastrostomy.

Buried bumper syndrome (BBS) is a rare complication developed after percutaneous endoscopic gastrostomy (PEG). We report a case of a 38-year-old male patient who sustained severe traumatic brain injury that was complicated with early BBS after PEG tube insertion. On admission, bedside PEG was performed, and 7 days later the patient developed signs of sepsis with rapid progression to septic shock and acute kidney injury. Abdominal CT scan revealed no collection or leakage of the contrast, but showed malpositioning of the tube bumper at the edge of the stomach and not inside of it. Diagnostic endoscopy revealed that the bumper was hidden in the posterolateral part of the stomach wall forming a tract inside of it, which confirmed the diagnosis of BBS. The patient underwent laparotomy with a repair of the stomach wall perforation, and the early postoperative course was uneventful. Acute BBS is a rare complication of PEG tube insertion which could be manifested with severe complications such as pressure necrosis, peritonitis and septic shock. Early identification is the mainstay to prevent such complications. Treatment selection is primarily guided by the presenting complications, ranging from simple endoscopic replacement to surgical laparotomy.

Base deficit and serum lactate concentration in patients with post traumatic convulsion.

INTRODUCTION: Traumatic brain injury is a major cause of morbidity and mortality worldwide, and has been reported to be one of the risk factors for epileptic seizures. Abnormal blood lactate (LAC) and base deficit (BD) reflects hypoperfusion and could be used as metabolic markers to predict the outcome. The aim of this study is to assess the prognostic value of BD and LAC levels for post traumatic convulsion (PTC) in head injury patients. MATERIALS AND METHODS: All head injury patients with PTC were studied for the demographics profile, mechanism of injury, initial vital signs, and injury severity score (ISS), respiratory rates, CT scan findings, and other laboratory investigations. The data were obtained from the trauma registry and medical records. Statistical analysis was done using SPSS software. RESULTS: Amongst 3082 trauma patients, 1584 were admitted to the hospital. Of them, 401 patients had head injury. PTC was observed in 5.4% (22/401) patients. Out of the 22 head injury patients, 10 were presented with the head injury alone, whereas 12 patients had other associated injuries. The average age of the patients was 25 years, comprising predominantly of male patients (77%). Neither glasgow coma scale nor ISS had correlation with BD or LAC in the study groups. The mean level of BD and LAC was not statistically different in PTC group compared to controls. However, BD was significantly higher in patients with associated injuries than the isolated head injury group. Furthermore, there was no significant correlation amongst the two groups as far as LAC levels are concerned. CONCLUSION: Base deficit but not lactic acid concentration was significantly higher in head injury patients with associated injuries. Early resuscitation by pre-hospital personnel and in the trauma room might have impact in minimizing the effect of post traumatic convulsion on BD and LAC.

Early high ratio platelet transfusion in trauma resuscitation and its outcomes.

INTRODUCTION: The optimal ratio of platelets (PLTs) to packed red blood cell (PRBC) in trauma patients requiring massive transfusion protocol (MTP) is still controversial. This report aims to describe the effect of attaining a high PLT:PRBC ratio (≥1:1.5) within 4 h postinjury on the outcomes of trauma patients receiving MTP. METHODS: Over a 24-month period, records of all adult patients with traumatic injury who received MTP were retrospectively reviewed. Data were analyzed with respect to PLT:PRBC ratio ([high-MTP ≥1:1.5] [HMTP] vs. [low-MTP <1:1.5] [LMTP]) given within the first 4 h postinjury and also between (>4 and 24 h). Baseline demographic, clinical characteristics, complications, and outcomes were compared according to HMTP and LMTP. RESULTS: Of the total 3244 trauma patients, PLT:PRBC ratio was attainable in 58 (1.2%) patients who fulfilled the inclusion criteria. The mean age was 32.3 ± 10.7 years; the majority were males (89.6%) with high mean Injury Severity Score (ISS): 31.9 ± 11.5 and Revise Trauma Score (RTS): 5.1 ± 2.2. There was no significant association between age, gender, type of injury, presenting hemoglobin, International Normalized Ratio, ISS, and RTS. The rate of ventilator-associated pneumonia (38.9% vs. 10.8%; P = 0.02) and wound infection (50% vs. 10.8%; P = 0.002) were significantly higher in the HMTP group. However, HMTP was associated with lower rate of multiple organ failure (MOF) (42.1% vs. 87.2%, P = 0.001) and mortality (36.8% vs. 84.6%, P = 0.001) within the first 30 days postinjury. CONCLUSIONS: Our study revealed that early attainment of high PLT/PRBC ratio within 4 h postinjury is significantly associated with lower MOF and mortality in trauma patients.

Seatbelt versus seatbelt and airbag injuries in a single motor vehicle crash.

Seatbelt restraints are important for occupant safety which substantially reduces morbidity and mortality in severe motor vehicle crashes (MVC). Though, it has been established that the air bag and seatbelt use reduce injury severity and mortality but still there is limited information on the pattern of injury by restraint type. Herein, we presented two case reports which describe the injury pattern of two patients (both were restrained but only driver had airbag) involved in a single MVC. Both of them had severe traumatic injuries, however, the restrained passenger without airbag, sustained more severe injuries of intestine, kidney and spinal cord. In addition to seatbelt, airbag provides considerable protection against severe blunt abdominal trauma. Therefore, installation of airbags especially for front seat passenger is imperative for minimizing the risk of significant traumatic injuries.

Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time.

OBJECTIVE: We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP). METHODS: A retrospective analysis was conducted at the only level 1 national trauma center in Qatar for all adult patients(≥18 years old) who received MTP (≥10 units) of packed red blood cell (PRBC) during the initial 24 h post traumatic injury. Data were analyzed with respect to FFB:PRBC ratio [(high ≥ 1:1.5) (HMTP) vs. (low < 1:1.5) (LMTP)] given at the first 4 h post-injury and also between (>4 and 24 h). Mortality, multiorgan failure (MOF) and infectious complications were studied as well. RESULTS: During the study period, a total of 4864 trauma patients were admitted to the hospital, 1.6 % (n = 77) of them met the inclusion criteria. Both groups were comparable with respect to initial pH, international normalized ratio, injury severity score, revised trauma score and development of infectious complications. However, HMTP was associated with lower crude mortality (41.9 vs. 78.3 %, p = 0.001) and lower rate of MOF (48.4 vs. 87.0 %, p = 0.001). The number of deaths was 3 times higher in LMTP in comparison to HMTP within the first 30 days (36 vs. 13 cases). The majority of deaths occurred within the first 24 h (80.5 % in LMTP and 69 % in HMTP) and particularly within the first 6 h (55 vs. 46 %). CONCLUSIONS: Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.

Outcome of concurrent occult hemothorax and pneumothorax in trauma patients who required assisted ventilation.

Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy. Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded. Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group. Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise.

Mediastinal emphysema following fracture of the orbital floor.

Pneumomediastinum (PM) is mainly an atypical finding among traumatic neck or thoracic injury patients. Moreover, PM secondary to isolated orbital floor fracture remains a rare event which is infrequently associated with severe complications such as mediastinitis, airway obstruction and pneumothorax. Herein, we report an atypical case of mediastinal emphysema consequent to orbital floor fracture along with review of the literature.