Endovascular techniques in the damage control setting

Hepatic trauma

Management of trauma-related liver injury has undergone a paradigm shift over the past four decades. In hemodynamically stable patients, the standard of care in the majority of level-one trauma centers has shifted to nonoperative management with high success rates, especially with low-grade liver injuries (i.e., grade I and II liver injuries). Advances in critical care medicine, cross-sectional imaging, and transarterial embolization techniques have led to the improvement of patient outcomes and decreased mortality rates in patients with arterial injuries. Currently, no consensus guidelines on appropriate patient selection criteria have been published by the Society of Interventional Radiology (SIR) or the American Association for the surgery of Trauma (AAST). Based off the current literature, nonoperative management with hepatic angiography and transarterial embolization (TAE) should be the treatment of choice in hemodynamically stable patients with clinical suspicion of arterial injury. TAE has been shown to improve success rates of nonoperative management and is well tolerated by most patients with low complication rates. Hepatic necrosis is the most common and concerning reported complication but can be reduced with selective approach and choice of embolic agent. The majority of literature supporting the use of TAE for trauma-related liver injury consists of retrospective case series and additional larger scale studies are needed to determine the efficacy of TAE in this setting. However, it is clear from the current literature that hepatic TAE is an effective and safer option to operative management in treating arterial hemorrhage in the setting of traumatic hepatic injury.

Traumatic blunt cardiac injuries: An updated narrative review

Blunt cardiac injury (BCI) is defined as injuries sustained due to blunt trauma to the heart, and it remains unchanged for long time. The spectrum of BCI ranges from a minor "bruise" to specific postcontusion cardiac conditions such as free-wall rupture. This is a narrative review provides a continued and updates details regarding BCIs from 2008 to 2017. For this purpose, a narrative review of literature was conducted using appropriate database for retrieval of articles through systematic search methodology. Autopsy-based studies are very limited. It can be concluded that regardless of the variability in the spectrum of modalities and medical/surgical resources, BCIs diagnosis and management remain a puzzle and needs further prospective studies.

Multidetector Computed Tomography Imaging of Damage Control Surgery Patients

Damage control surgery is a staged surgical procedure in a patient who has suffered penetrating or blunt abdominal traumatic injury with severe metabolic derangements. Multidetector computed tomography scanning is a vital tool for patient management in the damage control patient, providing many uses, including assessing the extent of traumatic injury, evaluating areas that were not surgically explored, evaluating for injuries that were missed during the initial surgery, and assessing the stability of surgical repair. Understanding the postsurgical multidetector computed tomography appearance of these patients can aid the radiologist in protocol optimization and provide immediate accurate diagnoses.

Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries

INTRODUCTION

Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR.

MATERIALS AND METHODS

Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR.

RESULTS

This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival.

CONCLUSIONS

In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.

Importance of the capability for complete resuscitative treatment combining surgery and interventional radiology for potentially lethal multiple injuries: A case report

Background

Recently, trauma management has been complicated owing to the introduction of damage-control strategies and interventional radiology. Here, we discuss important aspects regarding survival of patients with severe trauma.

Case presentation

A 74-year-old Japanese woman experienced a traffic accident on a highway. On arrival, paramedics were unable to measure her blood pressure, and her condition deteriorated. The patient was immediately transferred to our hospital in a physician-staffed emergency helicopter, during which she was administered emergency blood transfusions. On admission, her systolic blood pressure was 44 mmHg, and focused assessment with sonography for trauma yielded positive findings at the anterior mediastinum, right thoracic cavity, and intra-abdominal cavity. Plain radiography revealed a partial unstable-type pelvic fracture. Immediately, cardiac tamponade caused by the massive anterior mediastinal hematoma with internal thoracic vessel injuries was diagnosed through a median sternotomy, while a diaphragmatic rupture and hemorrhage from the intra-abdominal cavity were diagnosed through right anterior-lateral thoracotomy. Furthermore, massive bowel and mesenteric vessel injuries were diagnosed through laparotomy; all of these injuries were treated sequentially as a simplified process. The patient then underwent transcatheter arterial embolization for the retroperitoneal hematoma and the pelvic fracture. Reestablishing intestinal continuity was performed after intensive care. All procedures were seamlessly performed by trained emergency physicians, and the postoperative course was uneventful, with the patient recovering completely after rehabilitation.

Conclusions

The capability to perform complete resuscitative treatments that seamlessly combine surgery and interventional radiology in the appropriate order is important for the survival of patients with multiple traumatic injuries.

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

OBJECT

To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma.

PATIENTS AND METHODS

The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group).

RESULTS

Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group.

CONCLUSION

Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Damage control surgery and open abdominal management: recent advances and our approach

The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and nontraumatic surgical conditions. The practice of damage control surgery includes 3 components: 1) abbreviated resuscitative surgery for rapid control of hemorrhage and abdominal contamination by gastrointestinal contents, followed by temporary abdominal wall closure for planned reoperation and prevention of ACS; 2) restoration of physiologic function, including rewarming and correction of coagulopathy and hemodynamic stabilization in the intensive care unit; and 3) re-exploration for the definitive management of injuries and abdominal wall closure. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. For patients who require damage control surgery, interventional radiology should be integrated into the strategy for achieving hemostasis. Angiographic evaluation and embolization should be considered immediately after initial operation, especially for patients with combined intraperitoneal and retroperitoneal hemorrhage, severe hepatic injury, or ongoing hemorrhage after damage control surgery. In many patients who require conventional open abdominal management following damage control surgery or decompressive laparotomy for ACS, the granulating abdominal contents are covered with only a skin graft, which is associated with a risk of enterocutaneous fistula. These patients will ultimately require complex abdominal wall reconstruction at a later stage. We have performed early fascial closure using an anterior rectus abdominis sheath turnover flap method. This technique may reduce the need for skin grafting and subsequent reconstruction and can be considered as an alternative method for the early management of patients with open abdomen.

Pelvic packing or angiography: competitive or complementary?

Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres.

Visceral trauma: principles of management and role of embolotherapy

Interventional radiology for the treatment of traumatic visceral hemorrhage has emerged as an important adjunct to modern trauma care. This article outlines the general surgical concepts of the acute care of trauma patients as a guideline for catheter-based therapy. Specific considerations are presented for embolizing visceral injuries in the liver, spleen, and kidney. Expected outcomes and follow-up are reviewed.

Prise en charge radiologique des lésions vasculaires secondaires aux traumatismes du bassin

Pelvic injuries are serious, with mortality higher than 40% if the patient is in shock upon arrival at the hospital. These injuries are generally secondary to traffic accidents with violent kinetics, which explains the frequency of the associated extrapelvic lesions. With the vital prognosis at stake, management of these patients is a true challenge from both the radiographic and emergency care points of view. The objectives of this review are to present the epidemiological and physiological issues involved in pelvic injuries and the place of imaging today, necessarily integrated within a multidisciplinary team associating emergency physicians, surgeons, radiologists, and biologists.

Management of bleeding following major trauma: a European guideline

INTRODUCTION

Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature.

RESULTS

Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient.

CONCLUSION

A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.

Damage Control Surgery for Abdominal Trauma

Damage control is not a modern concept, but the application of this approach represents a new paradigm in surgery, borne out of a need to save patients with severe exsanguinating injuries. Definitive control and repair may be accomplished in the immediate post injury setting but the physiological derangement due to massive shock state resulting from the severe injury and the resuscitation that follows, often leads to a fully repaired but dead patient. The vicious triad of death in trauma, namely hypothermia, acidosis and coagulopathy should be tackled by initial abbreviated laparotomy, correction of physiological derangements and finally definitive repair of all injuries at second laparotomy. The concept needs a dedicated team effort with careful patient selection for achieving the optimal results.

The role of repeat angiography in the management of pelvic fractures

BACKGROUND

Angiographic embolization has emerged as the treatment modality of choice for bleeding pelvic fractures. The purpose of this study is to identify potential indicators for ongoing pelvic hemorrhage despite initial therapeutic or non-diagnostic angiography.

METHODS

The trauma registry of a Level I trauma center was used to identify patients with pelvic fractures between January 2000 and June 2002. Records were reviewed for demographics, severity of injury, hemodynamic status, initial and subsequent base deficit, blood and fluid requirements, length of stay, and mortality. Statistical analysis was performed using Student's t test, and univariate and multivariate analysis, significance was assigned to p < or = 0.05.

RESULTS

During the study period, 678 patients had pelvic fractures. Angiography was performed in 31 (4.6%) of these patients. Arterial hemorrhage was diagnosed initially on 16 (51.6%) patients requiring embolization. Three (18.8%) of these embolized patients required repeat angiography and embolization due to ongoing pelvic hemorrhage. Of the initial 15 patients with negative angiograms, five (33.3%) had repeat angiograms due to continued hypotension and acidosis. Four (80.0%) of these five patients were found to have arterial hemorrhage requiring embolization. Of the seven (22.6%) patients requiring repeat angiography for control of ongoing pelvic hemorrhage, three independent factors were predictive: continued or recurrent hypotension (SBP < 90), absence of intra-abdominal injury, and persistent base deficit of 10 for greater than 6 hours. The presence of all three independent predictors was associated with a 97% probability of pelvic bleeding (p = 0.001).

CONCLUSION

Angiographic embolization is highly effective in controlling arterial bleeding associated with pelvic fractures. However, repeat angiography should be performed in patients with pelvic fractures with ongoing evidence of hemorrhage demonstrated by persistent base deficit and hypotension once other potential sources of bleeding have been excluded.

Guidelines for the management of haemodynamically unstable pelvic fracture patients

BACKGROUND

Haemodynamically unstable pelvic fracture patients have a high mortality, and decision-making is crucial. The present article discusses key clinical practice guidelines and options in the early management of these challenging patients.

METHODS

A multidisciplinary consensus committee developed guidelines following standard scientific methodology, comprehensive Medline searches and level of evidence grading. Clinical practice guidelines and options addressed four key questions: (i) how to determine the source of haemorrhage?; (ii) how to control haemorrhage?; (iii) what is the optimal angiography and embolization technique?; and (iv) what is the optimal pelvic stabilization technique?

RESULTS

The consensus best evidence recommends that the source of intra-abdominal haemorrhage should be assessed using diagnostic peritoneal aspiration and/or focused abdominal sonography in trauma within 30 min of patient arrival. Immediate laparotomy and concomitant pelvic stabilization control intra-abdominal haemorrhage and venous pelvic haemorrhage, followed by angiography if pelvic arterial bleeding is also present. If intra-abdominal bleeding is absent, non-invasive pelvic stabilization and transfer to angiography within 45 min of arrival is recommended to control venous and arterial pelvic haemorrhage. Optimal embolization is performed with steel coils or Gelfoam (Pharmacia & Upjohn, Peapack, NJ, USA) suspension. The optimal pelvic stabilization technique for rotationally unstable fractures with haemodynamic instability is non-invasive.

CONCLUSION

The consensus committee successfully developed best evidence recommendations identifying the issues and providing guidelines and options for this challenging condition.

The role of interventional radiology in patients requiring damage control laparotomy

BACKGROUND

Interventional angiography has been used as a less invasive alternative to surgery to control hemorrhage resulting from trauma. This retrospective study analyzed the role of interventional radiology in patients requiring damage control laparotomy.

METHODS

Twenty patients underwent damage control laparotomy between January 1994 and May 2001. Eight of the 20 patients also underwent angiographic evaluation and treatment before or after the damage control laparotomy.

RESULTS

Three patients underwent angiography before damage control laparotomy, because a large, pelvic retroperitoneal hematoma was seen on computed tomographic scan, and the amount of intraperitoneal blood seemed insufficient to account for the magnitude of the patient's hemodynamic instability. Five patients underwent angiography after damage control laparotomy. The indication was a nonexpanding retroperitoneal hematoma in three patients, a nonexpanding hepatic hilar hematoma in one patient, and a hepatic injury associated with cirrhosis in one patient. Lumbar artery injuries were identified and treated by embolization in three patients. Four of the eight patients who underwent both damage control laparotomy and angiography survived.

CONCLUSION

Angiography before damage control laparotomy may be indicated to control retroperitoneal pelvic hemorrhage in hemodynamically unstable patients who have insufficient intraperitoneal blood loss to account for their hemodynamic instability. Angiography after damage control laparotomy should be considered when a nonexpanding, inaccessible hematoma is found at operation in a patient with a coagulopathy.

Damage control in trauma surgery

The technique or approach of damage control surgery in trauma is not new; packing liver injuries has been an accepted treatment strategy for some time. What is new is the realization that an abbreviated laparotomy, or completion of only the essential portions of the operation, is often the best treatment for the patient as a whole. Recent developments include strategies in the operating room and the intensive care unit to manage patients undergoing trauma laparatomy, including prevention of hypothermia, methods to accurately assess resuscitation status with right ventricular catheters and measurements of end-organ perfusion, and recognition of abdominal compartment syndrome, with emphasis on prevention.