Impact of self-inflicted injury on nontherapeutic laparotomy in patients with abdominal stab wounds

Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan

BACKGROUND

Traumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. We aimed to describe the characteristics of TDI patients, compare penetrating TDI with blunt TDI, and identify mortality risk factors in Japan.

METHODS

We retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression was performed to identify mortality risk factors.

RESULTS

Of the 338,744 patients, 1,147 (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Penetrating TDI represented 29.8% and blunt TDI 70.2%, and comparing penetrating and blunt TDI, the most common cause was self-inflicted (48.7%) vs. accident (85.6%), males were 68.7% vs. 66.0% of the patients (P = 0.50), and the mortality rate was 8.3% vs. 26.4% (P < 0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.04), Injury Severity Score (OR 1.03, 95%CI 1.006-1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45-0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32-4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24-9.17) were independent predictors of mortality, and computed tomography (CT) (OR 0.32, 95%CI 0.15-0.69) and diaphragm repair (OR 0.44, 95%CI 0.25-0.78) were protective factors.

CONCLUSIONS

In Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma.

Lethal injuries in single stabs to the trunk - A study on homicides and suicides in Sweden

INTRODUCTION

Homicides using knives or other sharp objects are the most common type of homicide in Europe, and the second most common type of homicide worldwide. In contrast, suicides using sharp objects are rarer, constituting only a few per cent of all suicides in western countries. We investigated single stab injuries to the trunk in both homicides and suicides to assess differences in extent of injuries and in medical care, which could be of value for trauma management, public health and forensic assessment.

METHODS

We identified all cases in Sweden between 2010 and 2021 that died of a single stab to the trunk, in either a homicide (n = 94) or a suicide (n = 45), and that were the subject of a forensic autopsy. We obtained data on demographics, hospital care and injured structures. To assess the severity of injuries, we applied AIS (Abbreviated Injury Score) and NISS (New Injury Severity Score). The inter-rater reliability of NISS between two raters was evaluated with intra-class correlation (ICC), with 95 % confidence intervals (CI). The data was analysed using Fisher's exact test, Mann-Whitney U test and logistic regression models.

RESULTS

The inter-rater reliability between the two NISS raters showed an ICC of 0.87 (95 % CI 0.68-0.95). We observed a larger variation of injuries in suicides, with a higher proportion of both unsurvivable (NISS 75) and minor injuries (NISS ≤ 8) (66.7 % and 8.9 % respectively) compared to in homicides (46.8 % and 0 % respectively). We observed a larger proportion of injuries to the heart in suicides (68.9% vs. 46.8 %, p = 0.018). In homicides, injuries involving vessels (52.1% vs. 13.3 %, p < 0.001) and hospital care (56.4 % vs. 8.9 %, p < 0.001) were significantly more common compared to suicides.

DISCUSSION AND CONCLUSION

Causation (self-inflicted or assaults) seems to be associated with characteristics of injury and the likelihood of receiving hospital care. These findings could potentially be valuable for trauma management and forensic assessment of manner of death, however, determining the mortality of the injuries would require a comparison group comprising injured survivors.

The Usefulness of Physician-Staffed Helicopters for Managing Severe Abdominal Trauma Patients

Introduction:

We retrospectively investigated prognostic factors for severe abdominal trauma patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) and ground ambulance using the Japan Trauma Data Bank (JTDB).

Methods:

The study period was from January 2004 to May 2019. The subjects were divided into two groups, according to the type of outcome: the Mortality group, which included patients who ultimately died, and the Survival group, which included patients who obtained a survival outcome.

Results:

There were 2457 in the Mortality group and 11,326 in the Survival group. When variables that showed statistical significance in the univariate analysis were included in a multivariate analysis, the following variables were identified as significant positive predictors of a fatal outcome: evacuation from the scene, blunt injury, injury severity score, and age; significant negative predictors of a fatal outcome were transportation by the HEMS and revised trauma score.

Conclusions:

The present study described the usefulness of the HEMS for severe abdominal trauma patients in comparison with ground ambulance transportation using the JTDB.

Characteristics of self-inflicted injury among suicidal patients: analysis of nation-wide trauma registry

Purpose

Self-inflicted injury is one of the most common causes of suicide. Extremity injury is thought to occur most frequently among penetrating injury; however, epidemiology among patients attempting suicide is unknown. This study aims to find the characteristics of penetrating self-inflicted trauma patients.

Methods

This is a retrospective cohort study of Japanese nation-wide trauma registry (the Japan National Trauma Data Bank) between January 1, 2004 and December 31, 2017. Patients who attempted suicide with penetrating injury were eligible. We evaluated the occurrence of injury based on injury site (neck/face, chest, abdomen, extremity) as a dependent variable and aging as an independent variable using a generalized linear model and compare those groups with spline models.

Results

4576 trauma patients were eligible. Excluding patients with missing age, missing survival data, and missing abbreviate injury score, 4183 patients were enrolled in this study. Common injury site is follows: abdomen 1772 patients (42.4%), extremity 1344 patients (32.0%), neck/face 1253 patients (30.0%), and chest 993 patients (23.7%). The occurrence of neck/face injury, chest injury, and abdominal injury increased with age. On contrary, the rate of extremity injury decreased with age.

Conclusions

Among self-inflicted trauma patients, abdominal injury was the most common injury, and neck/face injury, chest injury, and abdominal injury were related with aging. On the contrary, the rate of extremity injury decreased as patients' age progressed.

Level of evidence

Retrospective cohort study, Level III.

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

BACKGROUND

Self-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered.

METHODS

All patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II).

RESULTS

Group I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p<0.001), had more females (28.7% vs 4.9%, p <0.001), had longer length of hospitalization (median: 3 days vs. 2 days; p<0.001), underwent surgery more frequently (55.4% vs. 37.4%; p<0.001), and had higher mortality (2.9% vs. 0.7%; p=0.003). Possible covariates for mortality were examined and following logistic regression, self-inflicted injury remained associated with higher death rates compared to assault (OR 4.027, CI95% 1.380, 11.749; p=0.011).

CONCLUSION

In this study, patients with isolated self-inflicted abdominal injuries had higher mortality and more frequently underwent abdominal surgery.

Are Self-Inflicted Stab Wounds Less Severe Than Assaults? Analysis of Injury and Severity by Intent

BACKGROUND

Although there is evidence that self-inflicted abdominal stab wounds are less severe than those from assault, it is unclear if this is true in other anatomic regions. This study compares severity and injury pattern between self-inflicted stab wounds (SISWs) and wounds from assault (ASW).

MATERIALS AND METHODS

Stab wounds from our level I trauma registry from 2013 to 2018 were reviewed. Data included age, gender, self-inflicted versus assault, psychiatric or substance use history, anatomic location, operative intervention, injury severity, length of stay, and outcomes.

RESULTS

Over the study period, 1390 patients were identified. History of psychiatric diagnoses or previous suicide attempts was more frequent in SISWs (47% versus 6.5%, P < 0.01; 35% versus 0.4%, P < 0.01). SISWs had a higher incidence of wounds to the neck and abdomen (44% versus 11%, P < 0.01; and 34% versus 26%, P = 0.02). Overall, injuries from ASW had a higher injury severity score, but more procedures were performed on SISWs (46% versus 34%, P < 0.01). SISWs to the neck were more likely to undergo procedures (26% versus 15%, P = 0.04). Median hospital charges were higher in patients with SISWs ($58.6 K versus $39.4 K, P < 0.01).

CONCLUSIONS

SISWs have a distinct pattern of injuries, more commonly to the neck and abdomen, when compared with injuries resulting from ASW. The patients with SISWs have a higher rate of procedures, longer length of stay, and higher hospital charges despite low injury severity overall.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary control of arterial hemorrhage. However, its effectiveness and clinical outcomes are unclear.

METHODS

Using a nationwide database (2004-2016) in Japan, trauma patients with survival data were identified. Patients were divided between REBOA and non-REBOA groups, and a propensity score was developed using multivariate logistic regression. Survival to discharge was compared between the groups after propensity score matching.

RESULTS

Among 82,371 patients included in this study, 385 were treated with REBOA. After propensity score matching, 117 pairs were selected. Survival to discharge was significantly higher among patients treated with REBOA than among those treated without REBOA (53 [45.3%] vs. 38 [32.5%]; odds ratio = 1.72; 95% CI = 1.01-2.93; p = 0.04).

CONCLUSIONS

REBOA use was associated with improved survival to discharge and should therefore be considered during the management of severely injured trauma patients.

Self-Inflicted Stab Wounds: A Single-Center Experience from 2010 to 2016

Despite low mortality rates, self-inflicted stab wounds (SISWs) can result in significant morbidity and often reflect underlying substance abuse and mental health disorders. This study aimed to characterize demographics, comorbidities, and outcomes seen in self-inflicted stabbings and compare these metrics to those seen in assault stabbings. A Level I trauma center registry was queried for patients with stab injuries between January 2010 and December 2015. Classification was based on whether injuries were SISWs or the result of assault stab wounds (ASWs). Demographic, injury, and outcome measures were recorded. Differences between genders, ethnicities, individuals with and without psychiatric comorbidities, and SISW and ASW patients were assessed. Within the SIWS cohort, no differences were found when comparing age, gender, or race, including need for operative intervention. However, patients with psychiatric histories were less likely to have a positive toxicology test on arrival than those without psychiatric histories (22% vs. 0%, P = 0.04). When compared with 460 ASW patients, SISW were older (41 vs. 35, P < 0.001), more likely to be white (92% vs. 64%, P < 0.001), more likely to have a psychiatric history (15% vs. 4%, P < 0.001), require operative intervention (65% vs. 50%, P = 0.008), and be discharged to a psychiatric facility (47% vs. 0.2%, P < 0.001). SISW patients have higher rates of psychiatric illness and an increased likelihood to require operative intervention as compared with ASW patients. This population demonstrates an acute need for both inpatient and outpatient psychiatric care with early involvement of multidisciplinary teams for treatment and discharge planning.