Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions

Has the balloon really burst? Analysis of "the UK-REBOA randomized clinical trial"

BACKGROUND

Uncontrolled hemorrhagic shock is a leading cause of early death after injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents a paradigm shift in achieving hemodynamic stability and its implementation still remain controversial in different settings. The recently published UK-REBOA Randomized Clinical Trial aimed to determine the effectiveness of REBOA in patients with hemorrhagic shock, concluding its increased mortality compared with standard care alone.

METHODS

An adjustment of the statistical analysis was performed and a comprehensive analysis was proposed to address the study's limitations and demonstrate that these conclusions cannot be considered as benchmarks.

RESULTS

Primary and secondary outcomes were analyzed using Bayesian logistic regression and generalized linear models suitable for the outcome distribution. No statistically significant differences were observed between the two groups for the primary outcome (p-value 0.3341) nor in most of the secondary outcomes. The results of the principal stratum analyses (to account for intercurrent events) also did not show significant differences after the statistical analysis tests.

CONCLUSION

It cannot be stated that REBOA increases mortality compared with standard care alone in trauma patients with exsanguinating hemorrhage. Further studies and adequate simulation training programs in REBOA are critical to its successful implementation within a trauma system and to identify the optimum settings and patients.

A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database

BACKGROUND

Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach.

STUDY DESIGN

Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay.

RESULTS

Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001).

CONCLUSIONS

Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.

How trauma patients die in low resource settings: Identifying early targets for trauma quality improvement

BACKGROUND

Injury deaths in sub-Saharan Africa are among the world's highest, but hospital data rarely have sufficient granularity to direct quality improvement. We analyzed clinical care patterns among trauma patients who died in a prospective, multicenter sub-Saharan cohort to pinpoint trauma quality improvement intervention targets.

METHODS

In-hospital trauma deaths in four Cameroonian hospitals between 2017 and 2019 were included. Trauma registry data on patient demographics, injury characteristics, and clinical care were analyzed to identify opportunities for systems improvements.

RESULTS

Among 9,423 trauma patients, there were 236 deaths. Overall, 83% of patients who died in the emergency department were living on arrival (LOA). Among 183 LOA patients, 30% presented with normal vital signs, but 11% had no vital signs taken, often because of lack of equipment (43%). Of LOA patients presenting with a Glasgow Coma Scale score of <9 (56%), few received neurosurgery consults (15%), C-collar placement (9%), or intubation (1%). The most common reason for lack of c-collar placement was failure to recognize that it was indicated (66%). Tracheal deviation, unequal breath sounds, or paradoxical chest movement were present in 63% of LOA patients, but only two patients had chest tubes placed. Hypotension or active bleeding was present in 80% of LOA patients; while crystalloid bolus was given to 96% of these patients, few received transfusion (8%), tourniquet placement for extremity injury (6%), or an operation (4%).

CONCLUSION

Primary survey interventions are underperformed in trauma nonsurvivors in Cameroon. Protocolizing early treatment for head injury, hemorrhagic shock, and chest wall trauma could reduce trauma mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Using Right-Sided Roll to Improve Reliability of Focused Assessment with Sonography in Trauma: An Eastern Association for the Surgery of Trauma Multicenter Prospective Study

BACKGROUND

The Focused Assessment Sonography in Trauma (FAST) examination is the standard of care for detecting hemoperitoneum in hypotensive blunt trauma patients. A pilot study demonstrated earlier identification of intra-abdominal fluid via FAST after right-sided roll (FASTeR) when compared with the standard FAST. The purpose of this study was to evaluate this phenomenon prospectively in hypotensive blunt trauma patients.

STUDY DESIGN

An Eastern Association for the Surgery of Trauma-approved multicenter prospective trial was performed June 2016 to October 2020 at 8 designated trauma centers. Hypotensive adult blunt trauma patients were included. A traditional FAST examination was performed. After this, the secondary survey logroll for back examination was standardized to the patient's right side. A repeat supine right upper quadrant ultrasound view was obtained. The presence or absence of hemoperitoneum was confirmed by CT scan or intraoperative findings. FAST and FASTeR were compared using receiver operating characteristics. The area under the curve was calculated.

RESULTS

A total of 182 patients met inclusion criteria. A total of 65 patients (35.7%) had hemoperitoneum on CT scan or intraoperative findings. The sensitivity of FASTeR was 47.7%, and of FAST was 40.0% (p = 0.019). The receiver operating characteristics area under the curve of the FASTeR examination was 0.717 vs 0.687 for the FAST examination (p = 0.091).

CONCLUSIONS

Addition of a right upper quadrant view after right-sided roll does improve the sensitivity of the FAST examination while maintaining the standard positive predictive value. We demonstrate a trend that does not reach statistical significance about the overall accuracy. This multicenter prospective trial was underpowered to reveal a statistically significant difference in the overall accuracy as measured by the receiver operating characteristics area under the curve.

Intraperitoneal Rupture of the Urinary Bladder Mimics an Intra-Abdominal Hemorrhage: A Case Report

Hemorrhagic shock due to polytrauma is a life-threatening condition, requiring immediate diagnosis of the bleeding site and determination of an appropriate hemostatic procedure. Intra-abdominal injuries and pelvic fractures are major causes of massive hemorrhage, although the appropriate hemostatic procedures are different for each injury. We present a case of intraperitoneal rupture of the urinary bladder associated with pelvic fracture, in which urine extravasation into peritoneal spaces mimics intra-abdominal hemorrhage. A 33-year-old man with a known case of schizophrenia attempted suicide by jumping down from the 4th floor of his apartment (approximately 10 meters in height). He was in a state of shock on arrival. Focused assessment with sonography for trauma (FAST) showed fluid collection around his spleen only but not the perivesical space. Pelvic X-ray showed multiple pelvic fractures. We suspected the patient was in a state of hemorrhagic shock due to intra-abdominal hemorrhage and pelvic fracture. The patient's hemodynamic status did not respond to massive fluid infusion and blood transfusion, including eight units of packed RBCs transfusion. Resuscitative endovascular balloon occlusion of the aorta was performed; however, the patient's hemodynamic status did not recover. We performed an emergency laparotomy to control the suspected intra-abdominal hemorrhage. In peritoneal space, we found a large amount of non-bloody fluid. The liver, spleen, and bowels were not injured, whereas the urinary bladder was ruptured, indicating the correct diagnosis was intraperitoneal rupture of the urinary bladder associated with pelvic fracture. The ruptured urinary bladder wall was sutured, and temporary abdominal closure was performed. A contrast-enhanced CT performed after the laparotomy showed massive hemorrhage around the pelvic fracture. After arrival at the angiography room, the patient became bradycardia, and the pulsation at the carotid artery was not palpable. We performed cardiopulmonary resuscitation; however, the patient died eventually. Intraperitoneal rupture of the urinary bladder would mimic an intra-abdominal hemorrhage. Therefore, a comprehensive diagnostic-treatment approach such as a hybrid ER system would be beneficial for early and accurate diagnosis.

Frailty is Associated With Poor Outcomes Following Emergency Laparotomy: What’s Next?

Background and objective

The Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. We sought to evaluate the association between preoperative CFS scores and outcomes following emergency laparotomy in a dense, rural, and healthcare-deprived region of the UK inhabited by a multi-comorbid population.

Methods

We retrospectively reviewed regional National Emergency Laparotomy Audit (NELA) data across United Lincolnshire Hospitals NHS trust to identify all patients aged 65 years and above who underwent emergency laparotomy between December 2018 and March 2021. We also conducted a comprehensive multi-database literature search of Medline, Embase, and Cochrane to synthesise contemporaneous topical evidence.

Results

A total of 191 patients were assessed using the CFS before they underwent emergency laparotomy. Among 90 (47.1%) individuals categorised as vulnerable or frail (CFS score ≥4), there was no significant difference in age, gender, or length of stay related to the procedure compared with fit patients. However, vulnerable and frail patients were significantly more likely to die (84.8% vs. 39.2%, p<0.0001). Regression analysis identified a vulnerable or frail score to be a significant predictor of 30-day all-cause mortality (OR: 9.327; 95% CI: 3.101-28.054; p<0.0001). A total of six relevant papers were identified in the literature, all indicating a significant association between mortality as well as prolonged length and stay with clinical vulnerability and frailty.

Conclusions

The CFS is a practical and effective tool for assessing preoperative vulnerability and frailty among patients undergoing emergency laparotomy and can be used to predict mortality and morbidity after surgery.

A characterization of trauma laparotomies in a scandinavian setting: an observational study

BACKGROUND

Despite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports.

METHODS

A retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes.

RESULTS

A total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days.

CONCLUSION

The overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.

Percutaneous delivery of self-propelling hemostatic powder for managing non-compressible abdominal hemorrhage: a proof-of-concept study in swine

INTRODUCTION

Non-compressible intra-abdominal hemorrhage (NCIAH) is a major cause of preventable death on the battlefield and in civilian trauma. Currently, it can only be definitively managed with surgery, as there are limited strategies for controlling ongoing NCIAH in the prehospital environment. We hypothesized that a self-propelling thrombin-containing powder (SPTP) could increase survival in a swine model of NCIAH when delivered percutaneously into the closed abdomen using an engineered spray system.

MATERIALS AND METHODS

Nineteen swine underwent surgical laparotomy followed by a Grade V liver injury that created massive hemorrhage, before closing the abdomen with sutures. Animals either received treatment with standard of care fluid resuscitation (n=9) or the SPTP spray system (n=10), which consisted of a spray device and a 14 Fr catheter. Using the spray system, SPTP was delivered into a hemoperitoneum identified using a focused assessment with sonography in trauma (FAST) exam. Lactated Ringer's solution was administered to all animals to maintain a mean arterial pressure (MAP) of >50 mmHg. The primary outcome was percentage of animals surviving at three hours following injury.

RESULTS

In the swine model of NCIAH, a greater percentage of animals receiving SPTP survived to three hours, although differences were not significant. The SPTP spray system increased the median survival of animals from 1.6 hr in the fluid resuscitation group to 4.3 hr. The SPTP spray system delivered a total mass of 18.5 ± 1.0 g of SPTP. The mean change in intra-abdominal pressure following SPTP delivery was 5.2 ± 1.8 mmHg (mean ± SEM). The intervention time was 6.7 ± 1.7 min. No adverse effects related to the SPTP formulation or the spray system were observed. SPTP was especially beneficial in animals that had either severely elevated lactate concentrations or low mean arterial pressure of <35 mmHg shortly after injury.

CONCLUSIONS

This demonstrates proof-of-concept for use of a new minimally invasive procedure for managing NCIAH, which could extend survival time to enable patients to reach definitive surgical care.