Reliable variables in the exsanguinated patient which indicate damage control and predict outcome

CT imaging of clinically significant abdominopelvic injuries in the damage control surgery patient

PURPOSE

Damage Control Surgery (DCS) refers to a staged laparotomy performed in patients who have suffered severe blunt or penetrating abdominopelvic trauma with the goal of managing critical injuries while avoiding life threatening metabolic derangements. Within 24 h of the initial laparotomy, computed tomography (CT) is used to assess the full extent of injuries. The purpose of this study was to assess the incidence of clinically significant unknown abdominopelvic injuries which required further dedicated surgical or interventional radiology management and failed surgical repairs identified on CT following initial laparotomy.

METHODS

CT findings were correlated with surgical findings from the initial and subsequent staged laparotomy to determine known and unknown injuries. Frequency and percentage analyses was performed.

RESULTS

Out of 63 patients who underwent DCS with an open abdomen following initial laparotomy and subsequent CT within 24 h, a total of 13 clinically significant abdominopelvic injuries were identified in 12 patients. Seven clinically significant injuries were identified in seven patients (11.1% of patients) in surgically explored areas. Six clinically significant injuries were identified in six patients (9.5%) in surgically unexplored areas. Four instances of failed initial surgical repair were identified in four patients (6.3%) involving the liver and gastrointestinal tract. Overall, 23.8% of the DCS patient population had an actionable finding on the post laparotomy CT.

CONCLUSION

CT demonstrated value for identifying the extent of clinically significant abdominopelvic injuries and evidence of failed initial surgical repair, which informed surgical planning for subsequent laparotomy. The authors advocate for performing CT in post-DCS patients with an open abdomen as soon as possible following correction of metabolic and hemodynamic derangements.

Impact of ABO blood group on mortality in trauma patients: A systematic review

BACKGROUND

Haemorrhage is a significant cause of death in trauma patients. There is evidence that individuals with blood group O have higher rates of non-traumatic haemorrhage. It has been suggested that blood group O may be associated with higher mortality in trauma, however existing evidence is limited and conflicting.

OBJECTIVE

A systematic review was conducted to evaluate the impact of ABO blood group on mortality in trauma patients.

METHODS

MEDLINE via OVID, the Cochrane library and grey literature were searched to identify studies investigating the effect of ABO blood group on mortality of trauma patients admitted to hospital. PRISMA guidelines were followed throughout, study quality was assessed using CASP checklists and certainty of evidence was evaluated using GRADE. Meta-analysis was precluded by significant study heterogeneity.

RESULTS

180 relevant records were screened and seven studies met inclusion criteria, representing 12,240 patients. Two studies found that there was a higher mortality in blood group O compared to other ABO groups. Included studies had substantial variability in methods and population. Study quality was variable with certainty of evidence rated as very low.

CONCLUSIONS

There is insufficient evidence to definitively establish an association between mortality and ABO group in trauma patients. In an age of increasingly individualised care, there is a need to determine the existence and cause for any association through further studies across multiple settings, trauma mechanisms and populations.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

Emergency Medicine with Advanced Surgery Protocols: A Review

One of the most burning issues in health system is the concern of handling patients that requires emergency surgery. Emergency general surgery is done on both traumatic and nontraumatic acute disorders. Severe traumatic injury and bleeding is one of the causing agents for high mortality rate globally. Another group of patients that are in need of emergency surgery are those with heart failure, and in this particular paper, we analyzed emergency medicine with advanced surgery protocols focusing on gastric cancer, cardiac surgery, and bleeding as well as coagulopathy following traumatic injury.

Novel tool (BIS) heralds the need for blood transfusion and/or failure of non-operative management in pediatric blunt liver and spleen injuries

BACKGROUND

Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI.

METHODS

Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM.

RESULTS

Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%.

CONCLUSION

The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective comparative study.

Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report

BACKGROUND

Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae.

CASE PRESENTATION

An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury.

CONCLUSION

The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.

Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series

BACKGROUND

Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization.

METHODS

A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically.

RESULTS

Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)).

CONCLUSION

Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®

INTRODUCTION

Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma.

METHODS

Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene.

RESULTS

The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004).

CONCLUSION

DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

The association of ABO blood groups and trauma outcomes: A retrospective analysis of 3779 patients

Background:

There is currently a lack of understanding regarding the link between ABO blood types with outcomes of traumatically injured patients. The purpose of this study was to determine the association of ABO blood types with outcomes in traumatically injured patients separated by injury type.

Methods:

This retrospective study evaluated trauma patients at an urban, Level 1 trauma center from January 1, 2017, through December 31, 2017. Patients were excluded if they were pregnant or <16 years old. Recorded outcomes included: ABO blood group, mortality, Injury Severity Score (ISS), race, injury type, mechanism of injury, and complications. Data analysis was performed using descriptive statistics including Chi-squared, Kruskal–Wallis, and F-test calculations.

Results:

A total of 3779 patients were included in this study. No significant differences were present in mean age or ISS between blood types. In patients with penetrating injuries, blood type O was associated with a significant increase in mortality (P = 0.017), red blood cell transfusion (P = 0.027), and massive transfusion protocol (MTP) (P = 0.026) compared to non-O blood types. In patients with blunt injuries, blood type AB was associated with a significant increase in mortality rate compared to non-AB blood types (P = 0.03).

Conclusion:

ABO blood type is connected with an underlying process which affects trauma outcomes, including mortality. Blood type O is associated with increased blood transfusion, MTP, and mortality during the initial hospitalization following a traumatic penetrating injury, while blood type AB is associated with increased mortality during the initial hospitalization following a blunt traumatic injury.

Early Maladaptive Cardiovascular Responses are Associated with Mortality in a Porcine Model of Hemorrhagic Shock

BACKGROUND

Hemorrhage is a leading cause of death on the battlefield. Current methods for predicting hemodynamic deterioration during hemorrhage are of limited accuracy and practicality. During a study of the effects of remote ischemic preconditioning in pigs that underwent hemorrhage, we noticed arrhythmias among all pigs that died before the end of the experiment but not among surviving pigs. The present study was designed to identify and characterize the early maladaptive hemodynamic responses (tachycardia in the presence of hypotension without a corresponding increase in cardiac index or mean arterial blood pressure) and their predictive power for early mortality in this experimental model.

METHODS

Controlled hemorrhagic shock was induced in 16 pigs. Hemodynamic parameters were monitored continuously for 7 h following bleeding. Changes in cardiovascular and laboratory parameters were analyzed and compared between those that had arrhythmia and those that did not.

RESULTS

All animals had similar changes in parameters until the end of the bleeding phase. Six animals developed arrhythmias and died early, while 10 had no arrhythmias and survived longer than 6 h or until euthanasia. Unlike survivors, those that died did not compensate for cardiac output (CO), diastolic blood pressure (DBP), and stroke volume (SV). Oxygen delivery (DO2) and mixed venous saturation (SvO2) remained low in animals that had arrhythmia, while achieving certain measures of recuperation in animals that did not. Serum lactate increased earlier and continued to rise in all animals that developed arrhythmias. No significant differences in hemoglobin concentrations were observed between groups.

CONCLUSIONS

Despite similar initial changes in variables, we found that low CO, DBP, SV, DO2, SvO2, and high lactate are predictive of death in this animal model. The results of this experimental study suggest that maladaptive responses across a range of cardiovascular parameters that begin early after hemorrhage may be predictive of impending death, particularly in situations where early resuscitative treatment may be delayed.

Shock, Not Blood Pressure or Shock Index, Determines the Need for Thoracic Damage Control Following Penetrating Trauma

BACKGROUND

Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control.

STUDY DESIGN

Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6 h of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population.

RESULTS

Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure.

CONCLUSIONS

Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.

Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

BACKGROUND

Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).

METHODS

We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.

RESULTS

Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.

CONCLUSIONS

Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

Dilemma of crystalloid resuscitation in non-exsanguinating polytrauma: what is too much?

Background

Aggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes.

Methods

A 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0–5, 5–10, 10–15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value <0.05 was considered significant.

Results

367 patients (70% men) were included with median age of 46 (28–61) years, median Injury Severity Score was 29 (22–35) and 95% sustained blunt injuries. 17% developed multiple organ dysfunction syndrome (MODS), 4% ARDS and 14% died. Increasing injury severity, acidosis and coagulopathy were associated with more crystalloid administration. Increasing crystalloid volumes were associated with more blood products, increased ventilator days, ICU length of stay, hospital length of stay, MODS, infectious complications and mortality rates. Urgent laparotomy was found to be the most important independent predictor for crystalloid resuscitation in multinominal regression analysis. Further, fresh frozen plasma (FFP) <8 hours was less likely to be administered in patients >5 L compared with the group 0–5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3–4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03).

Discussion

Polytrauma patients received large amounts of crystalloids with few FFPs <24 hours. In patients with <10 L crystalloids, <24-hour mortality and MODS rates were not influenced by crystalloid resuscitation. Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs.

Level of evidence

Level 3.

Study type

Population-based cohort study.

The Need for a Physiological Classification of Hemorrhagic Shock

Classifications mean to conceptualize in a cluster and rapidly summarize the assessment and management of a clinical scenario. In the specific case of a hemorrhagic shock (HS), a classification should serve the purpose of allowing a rapid clinical assessment of the shock level and the earliest or right timing of source control, possibly also on whether to apply damage control surgery (DCS) strategy or not. ATLS® classification of HS is not sensitive and specific enough to help decision-making in reference to the timing of management, based only on the amount of blood loss that may be or may not rightly estimated, for example, blood loss on the floor in penetrating injuries before theatre. Moreover, it focuses also on other parameters, which are taken singularly, instead of the individual generalized physiological response to hemorrhage, which is the core by definition of the derangement we call "shock." It is unhelpful, difficult, and impractical to apply as well. A new classification, which may well be called as the "physiological HS classification" or "therapeutic HS classification," was proposed since 2010, following the new developments on microcirculation and an already going-on sensible praxis among some trauma surgeons. It bases on some physiological considerations such as the significance of fluid-blood resistant hypotension, body natural hemostatic mechanisms, the right definition of shock, and the relevance that hemorrhage-triggered ischemia-reperfusion toxemia and systemic inflammatory response have in critical illness scenarios as secondary insults from ischemia, which is what we mean to prevented with DCS. The key factor remains the persistence of hypotension, following fluid challenge.

Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as damage control surgery (DCS). This surgery is part of a series of resuscitation steps, with the goal of stabilizing the patient's condition, with rapid surgical control of hemorrhage followed by supportive measures in the intensive care unit before definitive repair of injuries. These patients often are imaged with multidetector CT within 24-48 hours of the initial surgery. Knowledge of this treatment plan is critical to CT interpretation, because there are anatomic derangements and foreign bodies that would not be present in patients undergoing surgery for other reasons. Patients may have injuries beyond the surgical field that are only identified at imaging, which can alter the care plan. Abnormalities related to the resuscitation period such as the CT hypoperfusion complex and ongoing hemorrhage can be recognized at CT. Familiarity with these imaging and clinical findings is important, because they can be seen not only in trauma patients after DCS but also in other patients in the critical care setting. The interpretation of imaging studies can be helped by an understanding of the diagnostic challenges of grading organ injuries with surgical materials in place and the awareness of potential artifacts on images in these patients. Online supplemental material is available for this article. ^©RSNA, 2019 See discussion on this article by LeBedis .

[Vascular injuries during urologic surgery]

This review article summarizes the epidemiology of vascular injuries during urologic surgery and discusses intraoperative strategies to control bleedings. Techniques of vascular approaches (arteries and veins) are discussed and tricks for vascular repair are explained. Generally, vascular injuries during urologic surgery are rare. However, hemorrhage due to vascular injury is a common cause of critical morbidity and mortality in the perioperative period. Susceptibility to vascular complications such as oncological debulking and revision surgery increase risk for damage. As vascular injuries range from arrosion to avulsion, treatment is also broad, ranging from vascular suture to open or endovascular repair. Prevention of exsanguination requires visual control to stop the bleeding. The surgeon must act quickly to initiate appropriate repair, aiming for damage control and stabilization of the patient. Planning the surgery and consulting an experienced surgeon are decisive for successful management. Catastrophic bleeding has to be controlled and in the case of arterial injury it is often necessary to reconstitute perfusion. Reconstructions such as vascular anastomoses, patch angioplasty or interposition grafts are the preferred surgical techniques which are influenced by the nature of the injury. Vessels have to be thoroughly prepared before cross clamping to prevent injury by vascular clamps. Veins can often be ligated. Endovascular repair is also a possibility to control the bleeding, but nowadays it is often a definitive therapy method. For example, resuscitative endovascular balloon occlusion is useful to stabilize the patient and then to initiate vascular repair. Depending on the type of surgery performed, different vessels are concerned. Severe bleeding is usually located retroperitoneal affecting the aorta, renovisceral and iliac vessels. Predisposing urologic operations are lymphadenectomy, nephrectomy and (cysto)prostatectomy and also the laparoscopic approach can cause bleeding complications.

Outcomes following resuscitative thoracotomy for abdominal exsanguination, a systematic review

Background

Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain.

Objective

The primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy.

Methods

A systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival.

Results

Seventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0–9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn.

Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity.

Conclusions

Pre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.

Early management of severe abdominal trauma

OBJECTIVE

To develop French guidelines on the management of patients with severe abdominal trauma.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded.

METHODS

The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology.

RESULTS

The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question.

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.

Decision-making criteria for damage control surgery in Japan

Controversy still remains regarding the optimal criteria for selecting damage control surgery (DCS). Our objective was to propose an indication for implementing DCS for abdominal trauma requiring emergency laparotomy. This was a multicenter, retrospective, observational study that used data from the Japan Trauma Data Bank. Patients who underwent emergency laparotomy were included. We compared the patients regarding the performance of DCS. Of the 4447 patients included in the study, 532 patients were in the DCS group and 3915 patients were in the non-DCS group. Logistic regression analysis revealed that body temperature, level of consciousness (Glasgow Coma Scale), and type of injury (blunt or penetrating) were independent predictors of DCS. Using these predictors, we created the Damage Control Indication Detecting score. The score showed a positive correlation with mortality. The score was obtained as 5 of 9 points in total, revealing mortality of 30.8%, sensitivity of 64.8%, and specificity of 70.0%. The area under the curve for the receiver operating characteristic curve was 0.715. This score can help surgeons determine when to perform DCS. However, more than 95% of trauma cases in Japan involve blunt injuries, suggesting that the results of our study may not be applicable internationally.

Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries: A CARE-compliant case report

RATIONALE

Damage control is a staged surgical approach to manage polytraumatized patients. The damage control approach comprises three steps. First, bleeding is controlled and fractures are stabilized temporarily; second, vital parameters are stabilized and the child is rewarmed in the intensive care unit; and third, the child is reoperated for definitive repair of injuries. We aimed to describe the feasibility of the damage control orthopedic approach in a child.

PATIENT CONCERNS

An 8-year-old girl fell from the balcony of the 5th floor onto concrete pavement and was admitted to our accident and emergency ward in a stable cardiorespiratory state, but with gross deformity of the lower limbs, left thigh, and forearm.

DIAGNOSES

The child had sustained multiple injuries with severe bilateral lung contusion, pneumothorax, fracture of first rib, liver laceration, stable spine fractures, transforaminal fracture of sacrum, pelvic ring fracture, displaced baso-cervical femoral neck fracture, displaced bilateral multifragmental growth plate fractures of both tibiae, fractures of both fibulae, displaced fracture of left forearm, and displaced supracondylar fracture of the humerus.

INTERVENTION

In the initial operation, we performed closed reduction and K-wire fixation of the right tibia, closed reduction and external fixation of the left tibia, open reduction and screw osteosynthesis of the femoral neck fracture, closed reduction and K-wire fixation of the radius, and closed reduction of the supracondylar fracture. Subsequently, we transferred the girl to the pediatric intensive care unit for hemodynamic stabilization, respiratory therapy, rewarming, and treatment of crush syndrome. In a third step, 10 days after the injury, we managed the supracondylar fracture of the humerus by closed reduction and K-wire fixation.

OUTCOMES

Growth arrest of the left distal tibial growth plate and osteonecrosis of the femoral head and neck, slipped capital femoris epiphysis (SCFE), and coxa vara of the right femur led to balanced leg length inequality 2 years after the injury. The lesion of the left sciatic nerve improved over time and the girl walked without walking aids and took part in school sports but avoided jumping exercises.

LESSONS

We emphasize the importance of damage control principles when managing polytraumatized children.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Vascular Injury During Urologic Surgery: Somebody Call My Mother

PURPOSE OF REVIEW

To provide the critical elements to effectively manage hemorrhage from vascular injuries sustained during planned urological interventions.

RECENT FINDINGS

The frequency of intraoperative vascular injuries is increasing. However, literature concerning the management of iatrogenic operative vascular injuries is scarce. Although rare, intraoperative vascular injuries may be associated with potential catastrophic complications and death. The decision-making process following a potential life-threatening intraoperative vascular injury occurs in a very short time frame. Appropriate knowledge of the critical elements to identify the source of bleeding, initiate first-line hemostatic measures, select the candidate for damage control strategies, and perform the indicated operative repairing maneuvers and techniques have been proved crucial to ensure hemodynamic stability and bleeding cessation. The key surgical principles to counteract the impact of exsanguinating bleeding, and the aim to obtain the best achievable outcomes after definitive repair, are described in detail in this review.

The First Aid and Hospital Treatment of Gunshot and Blast Injuries

BACKGROUND

When gunshot and blast injuries affect only a single person, first aid can always be delivered in conformity with the relevant guidelines. In contrast, when there is a dynamic casualty situation affecting many persons, such as after a terrorist attack, treatment may need to be focused on immediately life-threatening complications.

METHODS

This review is based on pertinent publications retrieved by a selective search in Medline and on the authors' clinical experience.

RESULTS

In a mass-casualty event, all initial measures are directed toward the survival of the greatest possible number of patients, in accordance with the concept of "tactical abbreviated surgical care." Typical complications such as airway obstruction, tension pneumothorax, and hemorrhage must be treated within the first 10 minutes. Patients with bleeding into body cavities or from the trunk must be given priority in transport; hemorrhage from the limbs can be adequately stabilized with a tourniquet. In-hospital care must often be oriented to the principles of "damage control surgery," with the highest priority assigned to the treatment of life-threatening conditions such as hemodynamic instability, penetrating wounds, or overt coagulopathy. The main considerations in initial surgical stabilization are control of bleeding, control of contamination and lavage, avoidance of further consequences of injury, and prevention of ischemia. Depending on the resources available, a transition can be made afterward to individualized treatment.

CONCLUSION

In mass-casualty events and special casualty situations, mortality can be lowered by treating immediately life-threatening complications as rapidly as possible. This includes the early identification of patients with lifethreatening hemorrhage. Advance preparation for the management of a masscasualty event is advisable so that the outcome can be as favorable as possible for all of the injured in special or tactical casualty situations.

Implementation of Trauma Center and Massive Transfusion Protocol Improves Outcomes for Major Trauma Patients: A Study at a Single Institution in Korea

BACKGROUND

This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system.

METHODS

We included patients (1) aged >15 years, (2) with an Injury Severity Score >15, (3) who received ≥10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for ≥24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups.

RESULTS

Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the fresh-frozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre- to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p < 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors.

CONCLUSIONS

Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.

Analysis for Patient Survival after Open Abdomen for Torso Trauma and the Impact of Achieving Primary Fascial Closure: A Single-Center Experience

Open abdomen indicates the abdominal fascia is unclosed to abbreviate surgery and to reduce physiological stress. However, complications and difficulties in patient care are often encountered after operation. During May 2008 to March 2013, we performed a prospective protocol-directed observation study regarding open abdomen use in trauma patients. Bogota bag is the temporary abdomen closure initially but negative pressure dressing is used later. A goal-directed ICU care is applied and primary fascial closure is the primary endpoint. There were 242 patients received laparotomy after torso trauma and 84 (34.7%) had open abdomen. Twenty patients soon died within one day and were excluded. Among the included 64 patients, there were 49 (76.6%) males and the mean Injury Severity Score was 31.7. Uncontrolled bleeding was the major indication for open abdomen (64.1%) and the average duration of open abdomen was about 4.2 ± 2.2 days. After treatment, 53(82.8%) had primary fascia closure, which is significant for patient survival (odds ratio 21.6; 95% confidence interval: 3.27–142, p = 0.0014). Factors related to failed primary fascia closure are profound shock during operation, high Sequential Organ Failure Assessment Score in ICU and inadequate urine amount at first 48 hours admission.

Open abdomen in liver transplantation

INTRODUCTION

Damage control laparotomy with vacuum assisted closure (VAC) is used for selective cases in trauma. In liver transplantation, VAC has also been applied for management of intra-operative hemorrhage. The primary objective was to evaluate peri-operative blood loss and blood product utilization in VAC compared to primary abdominal closure (PAC) at the index transplant operation.

METHODS

Retrospective review of all adults undergoing deceased donor liver transplantation (2007-2011) at a single center tertiary care institution.

RESULTS

201 deceased donor liver transplantations were performed, with 167 PAC and 34 VAC cases. Intra-operative blood loss (4.4L vs 10.7L), cell saver return (1399 ml vs 3998 ml), FFP (7.6U vs 15.9U) and PLT requirements (8.5U vs 18.3U), were all significantly elevated in VAC compared to PAC. VAC patients had significantly increased RBC, FFP, PLT, and total volume requirements during initial ICU admission. 30 PAC cases required on demand laparotomy and most commonly for post-operative bleeding.

CONCLUSION

In liver transplantation, application of VAC secondary to massive intra-operative exsanguination was safely utilized. Further evaluation is required to identify long-term morbidity and mortality.

The Evolution of Damage Control in Concept and Practice

Damage control surgery (DCS) began as an adjunct approach to hemorrhage control, seeking to facilitate the body's innate clotting ability when direct repair or ligation was impossible, but it has since become a valuable instrument for a broader collection of critically ill surgical patients in whom metabolic dysfunction is the more immediate threat to life than imminent exsanguination. Modern damage control is a strategy that combines the principles of DCS with those of damage control resuscitation. When used correctly, damage control may improve survival in previously unsalvageable patients; when used incorrectly, it can subject patients to imprudent risk and contribute to morbidity. This review discusses the evolution of damage control in both concept and practice, summarizing available literature and experience to guide patient selection, medical decision-making, and strategy implementation throughout the preoperative, intraoperative, and early postoperative periods.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies

BACKGROUND

Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children.

METHODS

An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications.

RESULTS

Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury.

CONCLUSION

DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries

BACKGROUND

Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management.

STUDY DESIGN

This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression.

RESULTS

101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97 ± 47, mean HR 92 ± 47, and mean admission pH 7.22 ± 0.17. Mean RTS 6.25 ± 2.7, mean ISS 36 ± 22. The mean estimated blood loss (EBL) was 5277 ± 4955 mls. Predictors of outcome are: admission pH (p = 0.0014), admission base deficit (p < 0.0001), packed red blood cells (PRBCs) transfused (p = 0.023), whole blood transfused (p < 0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p = 0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p < 0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p = 0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p = 0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p = 0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome.

CONCLUSIONS

Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.

Development of Novel Criteria of the "Lethal Triad" as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

OBJECTIVES

To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy.

DESIGN

Retrospective observational study.

SETTINGS

Fifteen acute critical care medical centers in Japan.

PATIENTS

In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and -3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%.

CONCLUSIONS

Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.

Prognostic predictors of early mortality from exsanguination in adult trauma: a Malaysian trauma center experience

Background

Trauma mortality due to exsanguination is the second most common cause of death. The objective of this study is to investigate the predictors for early death from exsanguination.

Methods

A prognostic study was done to identify predictors of early mortality due to exsanguination. Data were extracted from our Trauma Surgery Registry database of Sultanah Aminah Hospital, Johor Bahru, Malaysia. All patients who were treated from May 1, 2011 to April 31, 2014 by the trauma team were included. Adult trauma patients included from the Trauma Surgery Registry were divided into two groups for analysis: early death from exsanguination and death from non-exsanguination/survivors. Univariate and multivariate analysis was performed to look for significant predictors of death from exsanguination. Variables analyzed were demography, mechanism of injury, organ injury scale, physiological parameters (systolic blood pressure (SBP), respiratory rate, heart rate, temperature), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS) and cause of death.

Results

A total of 2208 patients with an average age of 36 (±16) years were included. Blunt trauma was the majority with 90.5%, followed by penetrating injuries (9.2%). The overall mortality is 239 out of 2208 (10.8%). Seventy-eight patients (32.6%) died due to central nervous system injury, 69 due to sepsis (28.9%) and 58 due to exsanguination (24.3%). After multivariate analysis, age (OR 1.026 (1.009 to 1.044), p=0.002), SBP (OR 0.985 (0.975 to 0.995), p=0.003) and temperature (OR 0.203 (0.076 to 0.543), p=0.001) were found to be the significant physiological parameters. Intra-abdominal injury and NISS were significant anatomic mortality predictors from exsanguination (p<0.001). Patients with intra-abdominal injury had four times higher risk of mortality from exsanguination (OR 3.948 (2.331 to 6.686), p<0.001).

Discussion

In a Malaysian trauma center, age, SBP, core body temperature, intra-abdominal injury and NISS were significant predictors of early death from exsanguination.

Level of evidence

II.

Contemporary damage control surgery outcomes: 80 patients with severe abdominal injuries in the right upper quadrant analyzed

Background

Damage control laparotomy (DCL) is a well-established surgical strategy in the management of the severely injured abdominal trauma patients. The selection of patients by intra-abdominal organs involvement for DCL remains controversial. The aim of this study was to assess the injury to the abdominal organs that causing severe metabolic failure, needing DCL.

Methods

Severely injured abdominal trauma patients with a complex pattern of injuries were reviewed over a 52-month period. They were divided into DCL and definitive repair (DR) group according to the operative strategy. Factors identifying patients who underwent a DCL were analyzed and evaluated.

Results

Twenty-five patients underwent a DCL, and 55 patients had DR. Two patients died before or during surgery. The number and severity of overall injuries were equally distributed in the two groups of patients. Patients who underwent a DCL presented more frequently hemodynamically unstable (p = 0.02), required more units of blood (p < 0.0001) and intubation to secure the airway (p < 0.0001). The onset of metabolic failure was more profound in these group of patients than DR group. The mean Basedeficit was − 7.0 and − 3.8, respectively, (p = 0.003). Abdominal vascular (p = 0.001) and major liver injuries (p = 0.006) were more frequently diagnosed in the DCL group. The mortality, complications (p < 0.0001), hospital (p < 0.0001), and ICU stay (p < 0.009) were also higher in patients with DCL.

Conclusion

In severely injured with an intricate pattern of injuries, 31% of the patients required a DCL with 92% survival rate. Severe metabolic failure following significant liver and abdominal vascular injuries dictates the need for a DCL and improves outcome in the current era.

Feeding the Open Abdomen

BACKGROUND

The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA).

METHODS

Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation.

RESULTS

Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than $50,000.

CONCLUSIONS

EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

The art and science of pediatric damage control

Damage control is a surgical strategy that has evolved and expanded considerably over the past 25 years. The approach was initially developed as a "bail out" procedure to control bleeding with severe abdominal injuries in the setting of unmitigated hemorrhagic shock. Damage control is now more broadly applied as a comprehensive management plan for the resuscitation and surgical treatment of injured patients with exhausted physiologic and metabolic reserve. This article reviews the most current concepts in damage control that are important and relevant to the practicing pediatric surgeon. It also provides evidence-based recommendations about how damage control principles can be pragmatically applied to severely injured children. This review focuses specifically on the fundamentals of damage control with respect to resuscitation and the operative treatment of children with severe abdominal, thoracic, and extremity injuries.

Opinions of Practicing Surgeons on the Appropriateness of Published Indications for Use of Damage Control Surgery in Trauma Patients: An International Cross-Sectional Survey

BACKGROUND

Variation in use of damage control (DC) surgery across trauma centers may be partially driven by surgeon uncertainty as to when it is appropriately indicated. We sought to determine opinions of practicing surgeons on the appropriateness of published indications for trauma DC surgery.

STUDY DESIGN

We asked 384 trauma centers in the United States, Canada, and Australasia to nominate 1 to 3 surgeons at their center to participate in a survey about DC surgery. We then asked nominated surgeons their opinions on the appropriateness (benefit-to-harm ratio) of 43 literature-derived indications for use of DC surgery in adult civilian trauma patients.

RESULTS

In total, 232 (64.8%) trauma centers nominated 366 surgeons, of whom 201 (56.0%) responded. Respondents rated 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate. Indications respondents agreed had the greatest expected benefit included a temperature <34°C, arterial pH <7.2, and laboratory-confirmed (international normalized ratio/prothrombin time and/or partial thromboplastin time >1.5 times normal) or clinically observed coagulopathy in the pre- or intraoperative setting; administration of >10 units of packed red blood cells; requirement for a resuscitative thoracotomy in the emergency department; and identification of a juxtahepatic venous injury or devascularized or destroyed pancreas, duodenum, or pancreaticoduodenal complex during operation. Ratings were consistent across subgroups of surgeons with different training, experience, and practice settings.

CONCLUSIONS

We identified 38 indications that practicing surgeons agreed appropriately justified the use of DC surgery. Until further studies become available, these indications constitute a consensus opinion that can be used to guide practice in the current era of changing trauma resuscitation practices.

Anatomical, physiological, and logistical indications for the open abdomen: a proposal for a new classification system

Background

A systematic approach to the appropriate use of the open abdomen strategy has not been described. We propose three fundamental reasons for the use of this strategy, anatomical, physiological and logistical. Anatomical reasons pertain to the inability to bring the fascial edges together including soft tissue defects. Physiological reasons relate to features of systemic dysfunction. Logistical reasons involve any anticipated abdominal re-intervention while preserving fascia. These categories occur either as a single reason or in any combination.

Methods

A single-center prospective observational study of patients with open abdomens in trauma and acute abdomen. Surgeons were asked to select from the three reasons (single or any combination of) their motivation for using the open abdomen upon completion of the initial operation. Patients were compared using the non-parametric Wilcoxon two-sample test or Kruskal-Wallis test. Chi-square or Fisher’s exact test was used for categorical variables; Statistical significance set at P-value ≤ 0.05.

Results

Forty-five consecutive patients with open abdomens were evaluated (Jan. 1- Dec. 31, 2012). Mean age was 38.8 years, 32 were male, 39 (86.7 %) sustained trauma. The most common single reason for the open abdomen was physiological (24.4 %), 33 patients had multiple reasons, the most common combination being anatomical and physiological (22.2 %). A physiological reason was linked to: lower pH, higher lactate, and lower systolic blood pressure on admission (p < 0.05). A logistical reason was associated with earlier primary fascial closure, intra-operative packing, and bowel left in discontinuity. Logistic regression and adjusted odds ratio of primary fascial closure was: physiological (0.08, 95 % CI, 0.01–0.92, p = 0.043); logistical (6.03, 95 % CI, 1.13–32.29, p = 0.036); and anatomical (0.83, 95 % CI, 0.16–4.18, p = 0.816).

Conclusion

We defined three basic indications for the use of the open abdomen, anatomical physiological and logistical. These indications establish a practical and comprehensive terminology that could help to promote appropriate use of the open abdomen.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery

Background

The staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients.

Methods

All EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined.

Results

215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died.

Conclusions

The acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.

Open abdomen with negative pressure device vs primary abdominal closure for the management of surgical abdominal sepsis: a retrospective review

BACKGROUND

Open abdomen with temporary abdominal closure remains a controversial management strategy for surgical abdominal sepsis compared with primary abdominal closure (PAC) and on-demand laparotomy. The primary objective was to compare mortality between PAC and open abdomen with vacuum assisted closure (VAC).

METHODS

Retrospective review of a tertiary center intensive care unit database (2006 to 2010) including suspected/diagnosed severe abdominal sepsis/septic shock requiring source control laparotomy. Groups were categorized according to closure method at index source control laparotomy. APACHE-IV was used as a measure of disease severity.

RESULTS

Of 211 patients, 75 PAC and 136 VAC cases were included. Controlling for disease severity, adjusted odds ratio of mortality for VAC was .41 95% confidence interval (.21, .81; P = .01) compared with PAC. PAC and VAC APACHE-1V predicted mortality rate were both 45%. VAC mortality was lower than PAC (22.8% vs 38.6%; P = .012).

CONCLUSIONS

Open abdomen with VAC is associated with significantly improved survival compared with PAC in abdominal sepsis requiring laparotomy.

Fluid management in patients with trauma: Restrictive versus liberal approach

Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.