Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS: This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS: Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS: SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe.

INTRODUCTION: Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. METHODS: Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. RESULTS: The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. CONCLUSIONS: Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Protocolized approach saves the limb in peripheral arterial injury: A decade experience.

PURPOSE: Outcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The aim of this study was to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients. METHODS: This is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas). RESULTS: Out of 716 patients with PAI, the majority (92%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2-7 h). Brachial artery (28%) was the most common injured vessel followed by popliteal artery (18%) and femoral artery (17%). Limb salvage rate was 78%. Out of them, 158 (22%) patients needed amputation, and 53 (7%) had undergone primary amputation. The majority (86%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation. CONCLUSION: Over all limb salvage rates was 78% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.

Yoga-An Alternative Form of Therapy in Patients with Blunt Chest Trauma: A Randomized Controlled Trial.

BACKGROUND: Yoga as alternative form of therapy has shown positive impact on pulmonary functions, exercise capacity, behavioral changes, and inflammation in non-trauma patients. However, the efficacy of Yoga has not been studied in chest trauma patients. METHODS: This randomized controlled trial was conducted at level-1 Trauma Centre. Isolated chest injury patients were randomized into either standard physiotherapy or Yogatherapy groups. Patients in physiotherapy group received conventional chest physiotherapy and Yogatherapy group received a set of Yogic exercises in addition to conventional chest physiotherapy. Primary outcome measure was changes in pulmonary function tests (PFT) at 4 weeks of discharge. Secondary outcomes were changes in quality of life (QoL), respiratory muscle strength and endurance, chest wall mobility, and levels of cytokines at 4 weeks. Data were analyzed using STATA v14.0. RESULTS: A total of 89 eligible patients were randomized to physiotherapy (n = 46) and Yoga therapy (n = 43) groups. Demographic characteristics were comparable in both the groups. There were statistically significant improvements in PFT in the Yogatherapy group compared with physiotherapy with an increase in Forced vital capacity (p = 0.02) and Forced expiratory volume (p = 0.01) at 4 weeks. In addition, there were significant improvement in physical component of QoL, respiratory muscle endurance (p = 0.003) and axillary cirtometry (p = 0.009) in the Yogatherapy group. However, no statistically significant difference in the trends of cytokine markers seen between the groups. CONCLUSION: Yoga was found to be effective in improving pulmonary functions and QoL in patients with chest trauma. (Trial registered at ctri.nic.in/clinicaltrials/login.php, numberREF/2016/05/011,287).

Train-Associated Injuries Pose a Significant Burden on Trauma Care Systems of Emerging Economies.

BACKGROUND: The Indian railway system is the fourth largest in the world and causes about 15 deaths every day, due to intentional or unintentional reasons. This study presents a 5-year retrospective analysis of patients injured due to train-associated events, managed at a level-1 trauma center in India. MATERIALS AND METHODS: Hospital-based trauma registry data of train-associated injuries presenting between 2012 and 2016 were analyzed. Data from 726 patients were analyzed for demographics, injury events, injury regions, their management and outcomes. ISS and NISS were used to quantify the injury severity. RESULTS: Mean age was 33 years, with male-to-female ratio 86 to 14%. The majority of patients (62%) were between 20-40 years. The median ISS was 9 (IQR 4-16), median hospital stays 11 days (IQR6-23), with in-hospital mortality of 17.4%. Presence of head injury; ISS > 9 and CPR in ED were independent risk factors of mortality. Trespassers on the rail track had significantly more severe injuries compared to passengers (Median ISS 13 vs. 9, p = 0.012; Median NISS 22 vs.17, p = 0.015); however, mortality and hospital length of stay were not significantly different. Location of injury event (on platform or tracks) showed no difference between the severity of injuries, mortality and hospital length of stay. CONCLUSIONS: Current study reports comprehensive injury patterns and outcomes of train-associated injuries from a low- and middle-income country (LMIC). Apart from the mortality, there is a high incidence of permanent disabilities from extremity amputations. No significant difference was noted in the severity and outcomes among patients injured on or off train platforms, emphasizing the need for comprehensive safety measures including enforcement and promoting safe behavior not only on locations like train tracks but equally at platforms.

Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study.

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty-six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer-generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In-hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train-associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.

Challenges in Management of Pediatric Life-threatening Neck and Chest Trauma.

INTRODUCTION: Neck and thoracic trauma in children pose unforeseen challenges requiring variable management strategies. Here, we describe some unusual cases. PATIENTS AND METHODS: Pediatric cases of unusual neck and thoracic trauma prospectively managed from April 2012 to March 2014 at a Level 1 trauma center were studied for management strategies, outcome, and follow-up. RESULTS: Six children with a median age of 5.5 (range 2-10) years were managed. Mechanism of injury was road traffic accident, fall from height and other accidental injury in 2, 3 and 1 patient respectively. The presentation was respiratory distress and quadriplegia, exposed heart, penetrating injury in neck, dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases respectively. Injuries included lung laceration, open chest wall, vascular injury of the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis. One patient had a flare of miliary tuberculosis. Immediate management included chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal stapling, and feeding jejunostomy (followed by gastric pull-up 8 months later). Chest tube insertion and total parenteral nutrition was required in one each. 2 and 4 patients required tracheostomy and mechanical ventilation. The patient with gastric pull-up developed a stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. At follow-up of 40-61 months, five patients are well. One patient with penetrating neck injury suffered from blindness due to massive hemorrhage from the vascular injury in the neck and brain ischemia with only peripheral vision recovery. CONCLUSION: Successful management of neck and chest wall trauma requires timely appropriate decisions with a team effort.

Retroperitoneal and mediastinal follicular dendritic cell sarcoma: report of 3 cases with review of literature.

Follicular dendritic cell sarcoma (FDCS) is a rare malignant histiocytic proliferation of antigen presenting follicular dendritic cell. It is an uncommon primary malignancy first described by Monda et al. in 1986. Most commonly reported cases are lymph nodal. Occasional cases occur in extra nodal sites. Here, we describe the clinicopathological features, histomorphology and outcome of three patients with extranodal FDCS along with a concise review of literature on the topic. All three patients were adult females. Two patients were in third decade, and one had age of 50 years. Among the three cases, two cases are presented as retroperitoneal mass and one as mediastinal mass. CT scans revealed heterogeneously enhancing masses. All the cases showed ovoid to spindle neoplastic cells arranged predominantly in whorling, fascicular and storiform patterns with inflammatory infiltrate. Immunohistochemically, the tumor cells are positive for CD21, CD23, CD35 and Clustrin. In view of rarity and variable clinical presentation in FDCS, accurate diagnosis is necessary. Copyright © 2015 John Wiley & Sons, Ltd.

Innocuous cardiac gunshot that proved fatal: A bitter lesson learned.

The management of hemodynamically normal patients with retained intra-pericardial foreign body remains a matter of conjecture. The available literature supports non-operative management of such innocuous foreign bodies. We report our experience of a hemodynamically normal patient with a retained intra-pericardial pellet from a firearm injury. He initially received successful non-operative management but developed fatal hemopericardium 21 days after injury. In this paper, we discussed the pitfalls in the management of such injuries in light of the available literature and summarized the clinical experience.

Traumatic cardiac injury: Experience from a level-1 trauma centre.

PURPOSE: Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI. METHODS: Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15. RESULTS: Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio be- tween blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p =0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%. CONCLUSION: High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Are falls more common than road traffic accidents in pediatric trauma? Experience from a Level 1 trauma centre in New Delhi, India.

PURPOSE: The epidemiology of pediatric trauma is different in different parts of the world. Some re- searchers suggest falls as the most common mechanism, whereas others report road traffic accidents (RTAs) as the most common cause. The aim of this study is to find out the leading cause of pediatric admissions in Trauma Surgery in New Delhi, India. METHODS: Inpatient data from January 2012 to September 2014 was searched retrospectively in Jai Prakash Narayan Apex Trauma Centre Trauma Registry. All patients aged 18 years or less on index presentation admitted to surgical ward/ICU or later taken transfer by the Department of Trauma Surgery were included. Data were retrieved in predesigned proformas. Information thus compiled was coded in unique alphanumeric codes for each variable and subjected to statistical analysis using SPSS version 21. RESULTS: We had 300 patients over a 33 month period. Among them, 236 (78.6%) were males and 64 (21.3%) females. Overall the predominant cause was RTAs in 132 (43%) patients. On subgroup analysis of up to 12 years age group (n = 147), the most common cause was found to be RTAs again. However, falls showed an incremental upward trend (36.05% in up to 12 age group versus 27% overall), catching up with RTAs (44.89%). Pediatric Trauma Score (PTS) ranged from 0 to 12 with a mean of 8.12 ± 2.022. 223 (74.33%) patients experienced trauma limited to one anatomic region only, whereas 77 (25.66%) patients suffered polytrauma. 288 patients were discharged to home care. Overall, 12 patients expired in the cohort. Median hospital stay was 6 days (range 1-182). CONCLUSION: Pediatric trauma is becoming a cause of increasing concern, especially in the developing countries. The leading cause of admissions in Trauma Surgery is RTAs (43%) as compared to falls from height (27%); however, falls from height are showing an increasing trend as we move to younger age groups. Enhancing road safety alone may not be a lasting solution for prevention of pediatric trauma and local injury patterns must be taken into account when formulating policies to address this unique challenge.

Feasibility of fast track discharge in breast cancer patients undergoing definitive surgery and impact on quality of life: a prospective study from tertiary care center in India.

OBJECTIVE: To evaluate the feasibility and impact of fast track discharge in patients undergoing definitive breast cancer surgery. METHODS: One hundred six breast cancer patients older than 20 years of age were assigned to undergo definitive breast cancer surgery. It was ensured that enrolled patients had a ready access to hospital, reasonable home circumstances. They were assessed by using post-anesthesia discharge scoring system (PADSS) for fast track discharge. Quality of life both in preoperative and postoperative period was assessed by Functional Assessment of Cancer Therapy-Breast cancer version 4 (FACT-B4) questionnaires. RESULT: Overall 90 patients (84.9%) were fit for fast track discharge. Eighty-nine patients (83.96%) were successfully discharged within 48 hr. One patient (0.94%) could not be discharged despite being fit as she was of concern that it would put too much responsibility on the family. Mean duration of postoperative hospital stay in patients fit for fast track surgery was 42.27 ± 5.73 hr with a median of 44 hr. All patients undergoing breast conservation could be discharged on fast track basis with a mean postoperative hospital stay of 32.12 hr. CONCLUSION: Fast track discharges in breast cancer patients after definitive surgery are feasible in Indian setting.

Evaluation of diagnostic utility of multidetector computed tomography and magnetic resonance imaging in blunt pancreatic trauma: a prospective study.

BACKGROUND: Blunt pancreatic trauma is an uncommon injury with high morbidity and mortality. Retrospective analyses of computed tomography (CT) performance report CT to have variable sensitivity in diagnosing pancreatic injury. Both a prospective analysis of multidetector CT (MDCT) performance and diagnostic utility of magnetic resonance imaging (MRI) in acute blunt pancreatic injury remain unexplored. PURPOSE: To prospectively evaluate the utility of MDCT with MRI correlation in patients with blunt pancreatic trauma using intraoperative findings as the gold standard for analysis. MATERIAL AND METHODS: The contrast-enhanced CT (CECT) scans of patients admitted with blunt abdominal trauma were prospectively evaluated for CT signs of pancreatic injury. Patients detected to have pancreatic injury on CT were assigned a CT grade of injury according to American Association for Surgery of Trauma classification. MRI was performed in patients not undergoing immediate laparotomy and MRI grade independent of CT grade was assigned. Surgical grade was taken as gold standard and accuracy of CT and MRI for grading pancreatic injury and pancreatic ductal injury (PDI) was calculated. A quantitative and qualitative comparison of MRI was also done with CT to determine the performance of MRI in acute pancreatic injury. RESULTS: Thirty out of 1198 patients with blunt trauma abdomen were detected to have pancreatic injury on CT, which was surgically confirmed in 24 patients. Seventeen underwent MRI and surgical correlation was available in 14 patients. CT and MRI correctly identified the grade of pancreatic injury in 91.7% (22/24) and 92.86% (13/14) patients, respectively. Both CT and MRI correctly identified PDI in 18/19 and 11/12 patients, respectively, with good inter-modality agreement of 88.9% (kappa value of 0.78). MRI also qualitatively added to the information provided by CT and increased diagnostic confidence in 58.8% of patients. CONCLUSION: MDCT performs well in grading pancreatic injury and evaluating pancreatic ductal injury. MRI is useful in evaluation of acute pancreatic trauma as it can increase diagnostic confidence and provide more qualitative information regarding the extent of injury.

Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial.

BACKGROUND: Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD. METHODS: This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma. RESULTS: Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay. CONCLUSION: The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema. LEVEL OF EVIDENCE: Therapeutic Study, Level II TRIAL REGISTRATION: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403.

Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center.

Introduction: Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous. Methods: Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate. Results: The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality. Conclusion: VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

No role of antibiotics in patients with chest trauma requiring inter-costal drain: a pilot randomized controlled trial.

PURPOSE: To study the role of prolonged prophylactic antibiotic therapy (PAT) in the prevention of Inter-costal drain (ICD) related infectious complications in patients with Blunt Trauma Chest (BTC). METHODS: Patients of age 15 years and above with BTC requiring ICD were included. Patients with penetrating chest injuries, associated injuries/illnesses requiring antibiotic administration, need for mechanical ventilation, known pulmonary disease or immuno-compromised status and need for open thoracotomy were excluded. 120 patients were randomized equally to two groups; no prolonged PAT group (Group A) and prolonged PAT group (group B). Both group patients received one shot of injectable antibiotic prior to ICD insertion. Primary outcome measure was comparison of ICD related infectious complications (pneumonia, empyema and SSI) and secondary outcome measures included the duration of ICD, Length of Hospital stay (LOS) and in-hospital mortality in both the groups. RESULTS: Infectious complications (pneumonia, empyema and SSI) were seen in only one patient in antibiotic group, and none in no antibiotic group (p value = 0.500). Other complications such as post ICD pain scores, respiratory failure requiring ventilatory support, retained hemothorax or recurrent pneumothorax, did not show any statistical difference between both groups. Also, no significant difference was seen in both the groups in terms of mean duration of ICD (p value = 0.600) and LOS (p value = 0.259).m CONCLUSION: Overall prevalence of ICD related infectious complications are low in BTC patients. Definitive role of prolonged prophylactic antibiotics in reducing infectious complications and other associated co morbidities in BTC patients with ICDs could not be established. TRIAL REGISTRY DETAILS: Clinical Trial Registry, India (Trial registered at ctri.nic.in/clinical trials/login.php, number REF/2019/021704 dated 18/10/2019).

Validation of the adapted clavien dindo in trauma (ACDiT) scale to grade management related complications at a level I trauma center.

Objectives: Complications during trauma management are the main factor responsible for the overall increase in treatment cost. There are very few grading systems to measure the burden of complications in trauma patients. A prospective study was conducted using the Adapted Clavien Dindo in Trauma (ACDiT) scale, with the primary aim of validating it at our center. As a secondary aim, it was also wanted to measure the mortality burden among our admitted patients. Material and Methods: The study was conducted at a dedicated trauma center. All patients with acute injuries, who were admitted, were included. An initial treatment plan was made within 24 hours of admission. Any deviation from this was recorded and graded according to the ACDiT. The grading was correlated with hospital-free days and ICU-free days within 30 days. Results: A total of 505 patients were included in this study, with a mean age of 31 years. The most common mechanism of injury was road traffic injury, with a median ISS and NISS of 13 and 14, respectively. Two hundred and forty-eight out of 505 patients had some grade of complication as determined by the ACDiT scale. Hospital-free days (13.5 vs. 25; p <0.001) were significantly lower in patients with complications than those without complications, and so were ICU-free days (29 vs. 30; p <0.001). Significant differences were also observed when comparing mean hospital free and ICU free days across various ACDiT grades. Overall mortality of the population was 8.3 %, the majority of whom were hypotensive on arrival and required ICU care. Conclusion: We successfully validated the ACDiT scale at our center. We recommend using this scale to objectively measure in-hospital complications and improve trauma management quality. ACDiT scale should be one of the data points in any trauma database/registry.

Splenic trauma - our experience at a level I Trauma Center.

BACKGROUND: A retrospective study was performed to identify the effect of non -operative management on splenic trauma patients and its implications at our Level I Trauma Centre between January 2007 and June 2008. METHODS: Data regarding patient demography, mode of splenic injury, computerized tomography (CT) grading, blood transfusion requirement, operative findings, hospital stay, and followup were collected. The results of abdominal sonography and CT scan were utilized as proof of splenic injury and to determine the grade of injury. Subjects were divided into splenectomy and non-operative groups. Results were analyzed using non-parametric Mann-Whitney U tests. RESULTS: Sixty-seven patients were enrolled in this study. All patients with grade I injury and 12 of 13 patients with grade II injury were managed non-operatively, whereas 9 of 16 patients with grade III injuries, 12 of 14 patients with grade IV injuries and all patients with grade V injuries were managed operatively. Thus, the higher the grade of injury, the greater the likelihood of operative management. The mean Injury Severity Score of the operative group was 20.12, significantly higher (p=0.001) than in the non-operative group, at 11.9. Mean hospital stays in the operative and non-operative groups were 12.8 and 8.3 days, respectively. CONCLUSION: Non-operative management of splenic trauma can be performed with an acceptable outcome.

Profile of Injuries in Children: Report From a Level I Trauma Center.

OBJECTIVE: We present our experience of pediatric injuries over 5 years from a level I trauma centre. METHODS: De-identified data from a prospectively maintained database of pediatric patients was analyzed for demography and injury-related parameters, and management provided. RESULTS: There were 906 patients (698 male, median age 12 years). Predominant cause was road traffic injuries. The median injury severity score was 9. Abdomen and thorax were the commonest regions affected. There were 44 deaths. Sepsis and hemorrhage were the commonest causes of mortality. CONCLUSIONS: The magnitude of pediatric injuries is significant, and maintenance of dedicated trauma registries is the need of the hour.

Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial.

BACKGROUND: The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma. METHODS: In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate. RESULTS: Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups. CONCLUSION: ERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications. LEVEL OF EVIDENCE: Level 1, randomized controlled trial, care management. TRIAL REGISTRATION NUMBER: Clinical Trials Registry of India (CTRI/2019/06/019533).