Timing of Re-Laparotomy in Blunt Trauma Patients With Damage-Control Laparotomy

INTRODUCTION

Damage-control laparotomy (DCL) was initially designed to treat patients with severe hemorrhage. There are various opinions on when to return to the operating room after DCL and there are no definitive data on the exact timing of re-laparotomy.

METHODS

All patients at regional referral trauma center requiring a DCL due to blunt trauma between January 2012 and September 2021 (N = 160) were retrospectively reviewed from patients' electronic medical records. The primary fascial closure rate, lengths of intensive care unit stay and mechanical ventilation, mortality, and complications were compared in patients who underwent re-laparotomy before and after 48 h.

RESULTS

One hundred one patients (70 in the ≤48 h group [early] and 31 in the >48 h group [late]) were included. Baseline patient characteristics of age, body mass index, injury severity score, and initial systolic blood pressure and laboratory finding such as hemoglobin, base excess, and lactate were similar between the two groups. Also, there were no differences in reason for DCL and operation time. The time interval from the DCL to the first re-laparotomy was 39 (29-43) h and 59 (55-66) h in the early and late groups, respectively. There were no significant differences in the rate of the primary fascial closure rate (91.4% versus 93.5%, P = 1.00), lengths of stay in the intensive care unit (10 [7-18] versus 12 [8-16], P = 0.553), ventilator days (6 [4-10] versus 7 [5-10], P = 0.173), mortality (20.0% versus 19.4%, P = 0.94), and complications between the two groups.

CONCLUSIONS

The timing of re-laparotomy after DCL due to blunt abdominal trauma should be determined in consideration of various factors such as correction of coagulopathy, primary fascial closure, and complications. This study showed there was no significant difference in patient groups who underwent re-laparotomy before and after 48 h after DCL. Considering these results, it is better to determine the timing of re-laparotomy with a focus on physiologic recovery rather than setting a specific time.

Blunt force trauma and blast injuries to head and chest caused by a potent pyrotechnic device: a case report

In times of peace and except for terrorist attacks, fatalities by explosions are rare. Fireworks have deadly potential, especially self-made or illegally acquired devices. The use of professional pyrotechnics by untrained persons poses a life-threatening hazard. We present a case of devastating blunt force and blast injuries to the head and chest of a young man. After ignition of a display shell (syn. a real shell or mortar shell) without the use of a launching pipe, the device hit the man's face, nearly simultaneously followed by the explosion of the burst charge. The autopsy revealed injuries to the face and forehead as well as extensive tissue structure damage and a massive contusion with a bloody edema of the lungs. Autopsy results are supplemented with CT imaging and 3D reconstruction of the fractured mid face, as well as histological and toxicological examinations. This case of a misused display shell demonstrates both its devastating destructive potential and the corresponding and rarely observed injury pattern.

Characterization of Ocular Injuries Caused by Orbeez Hydrated Gel Pellet Projectiles: Clinical Insights and Implications

PURPOSE

To examine the clinical characteristics of patients who have experienced blunt ocular injuries from "Orbeez" hydrated gel pellets (Spin Master Corp.), and to describe ocular morbidity, visual acuity (VA), and intraocular pressure (IOP) after Orbeez-related ocular trauma.

DESIGN

Retrospective, institutional, observational case series.

METHODS

Patients sustaining Orbeez-related ocular trauma at a single institution over a 13-month period were identified. Clinical parameters including VA, IOP, and anterior and fundus examination findings were assessed upon initial and final presentation. Basic statistical testing was performed to compare differences within this cohort.

RESULTS

A total of 17 eyes from 17 patients with Orbeez-related trauma were identified. Orbeez-related blunt ocular injuries included corneal abrasion (n = 7), hyphema (n = 9), commotio retinae (n = 5), intraretinal hemorrhage (n = 3), preretinal hemorrhage (n = 1), vitreous hemorrhage (n = 2), and retinal tear (n = 1). Adolescents (14-18 years of age) showed higher rates of posterior segment complications compared to other ages (P = .0152). The presence of elevated IOP and hyphema upon initial examination correlated with increased likelihood of requiring invasive treatment following Orbeez impact (P = .0275).

CONCLUSION

Orbeez-related ocular trauma may be associated with severe visual morbidity and varied anterior and posterior segment intraocular sequelae. Adolescents could be at increased risk for posterior segment complications following these injuries. Initial findings of elevated IOP and hyphema may indicate a need for more aggressive interventions. Prevention remains paramount in managing Orbeez-related ocular trauma; it is critical to raise awareness regarding the importance of wearing eye protection meeting high-impact standards and minimizing exposure to such projectiles.

Non-Anastomotic Axillofemoral Bypass Disruption After Blunt Trauma Treated by Endovascular Approach

Disruption in the non-anastomotic section of an axillofemoral bypass is a rare occurrence. In this report, we consider a patient who presented with a pseudoaneurysm in the non-anastomotic section of his axillofemoral bypass due to blunt trauma to the chest after a fall. Clinical presentation, management, treatment, and complications related to our case are discussed.

MRI detects increased aortic stiffening and myocardial dysfunction after TEVAR of blunt injury in young patients

Background: Thoracic endovascular aortic repair (TEVAR) is a well-established technique for the management of blunt thoracic aortic injury (BTAI). Despite improvements in vascular imaging, graft material properties, and implant techniques, stent-graft deployment artificially induces aortic stiffening. This study aimed to evaluate the midterm effect of thoracic endovascular aortic repair after blunt thoracic aortic injury on aortic stiffness and cardiac function in young patients using cardiovascular magnetic resonance (CMR) imaging. Patients and methods: From all patients who underwent TEVAR for BTAI between 2009 and 2019 in a single institution, 10 patients with no other comorbidities affecting arterial stiffness were sex-, age-, height-, and body surface area-matched to 10 healthy controls. Comprehensive CMR examination was performed in all controls and patients. The mean follow-up period was 5.4±1.8 years; the mean age at the time of TEVAR was 30.3±8.7 years. Results: Four patients who underwent TEVAR developed arterial hypertension. 4D flow CMR-based analysis demonstrated higher global pulse wave velocity (PWV) in TEVAR patients than in controls (p=0.012). Segmental analysis showed a higher PWV in the descending and abdominal aorta. The indexed diameter of the ascending aorta was larger in TEVAR patients than in controls (p=0.007). The CINE acquisitions demonstrated increased left ventricular myocardial thickness (p<0.001). The 3D global diastolic strain rate and diastolic longitudinal velocity (e') decreased, and the A-wave velocity increased. Native myocardial T1 values were significantly higher in TEVAR patients (p=0.037). Conclusions: Young patients with TEVAR after BTAI are at an increased risk of developing vascular and myocardial dysfunction due to increased aortic stiffness. CMR follow-up allows for a comprehensive and radiation-free evaluation of vascular stiffness and associated myocardial changes, especially at the early and subclinical stages.

Sex Related Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

OBJECTIVE

Current literature suggests that thoracic endovascular aortic repair (TEVAR) in older patients with aortic aneurysms results in higher peri-operative mortality and lower long term survival in females compared with males. However, sex related outcomes in younger patients with blunt thoracic aortic injury (BTAI) undergoing TEVAR remain unknown. This study examined the association between sex and outcomes after TEVAR for BTAI.

METHODS

A retrospective cohort study was performed of all patients who underwent TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2016 and 2019. The primary outcome was in hospital death. Secondary outcomes were peri-operative complications. Multivariable logistic regression was used to adjust for demographics, comorbidities, injury severity score, and aortic injury grade.

RESULTS

Two thousand and twenty-two patients were included; 26% were female. Compared with males, females were older (46 [IQR 30, 62] vs. 39 [IQR 28, 56] years; p < .001), more often obese (41% vs. 33%; p = .005), had lower rates of alcohol use disorder (4.1% vs. 8.9%; p < .001) and a higher prevalence of hypertension (29% vs. 22%; p = .001). The injury severity was comparable between females and males (Injury Severity Score ≥ 25; 84% vs. 80%; p = .11) and there was no difference in aortic injury grades when comparing females with males (grade 1, 33% vs. 33%; grade 2, 24% vs. 25%; grade 3, 43% vs. 40%; grade 4, 0.8% vs. 1.3%; p = .53). Multivariable logistic regression demonstrated no difference for in hospital mortality between females and males (OR 1.02; 95% CI 0.67 - 1.53, p = .93). Compared with males, females were at lower risk of acute kidney injury (AKI) (OR 0.33; 95% CI 0.17 - 0.64; p = .001) and ventilator associated pneumonia (VAP) (OR 0.50; 95% CI 0.28 - 0.91; p = .023).

CONCLUSION

This study did not demonstrate a sex related in hospital mortality difference following TEVAR for BTAI. However, female sex was associated with a lower risk of AKI and VAP. Future studies should evaluate sex differences and long term outcomes following TEVAR in patients with BTAI.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

Liver Transplantation Using Allografts With Recent Liver Blunt Trauma: A Nationwide Audit From the French CRISTAL Biomedicine Agency Registry

BACKGROUND

In the current setting of organ shortage, brain-dead liver donors with recent liver trauma (RLT) represent a potential pool of donors. Yet, data on feasibility and safety of liver transplantation (LT) using grafts with RLT are lacking.

METHODS

All liver grafts from brain-dead donors with RLT proposed for LT between 2010 and 2018 were identified from the nationwide CRISTAL registry of the Biomedicine Agency. The current study aimed at evaluating 1-y survival as the primary endpoint.

RESULTS

Among 11 073 LTs, 142 LTs (1.3%) using grafts with RLT were performed. These 142 LTs, including 23 split LTs, were performed from 131 donors (46.1%) of 284 donors with RLT proposed for LT. Transplanted grafts were procured from donors with lower liver enzymes levels ( P  < 0.001) and less advanced liver trauma according to the American Association for the Surgery of Trauma liver grading system ( P  < 0.001) compared with not transplanted grafts. Before allocation procedures, 20 (7%) of 284 donors underwent damage control intervention. During transplantation, specific liver trauma management was needed in 19 patients (13%), consisting of local hemostatic control (n = 15), partial hepatic resection on back-table (n = 3), or perihepatic packing (n = 1). Ninety-day mortality and severe morbidity rates were 8.5% (n = 12) and 29.5% (n = 42), respectively. One-year overall and graft survival rates were 85% and 81%, and corresponding 5-y rates were 77% and 72%, respectively.

CONCLUSIONS

Using liver grafts from donors with RLT seems safe with acceptable long-term outcomes. All brain-dead patients with multiorgan trauma, including liver injury, should be considered for organ allocation.

Ocular injury from foam dart (Nerf) blasters: a case series

To report clinical outcomes following ocular injury from foam dart (nerf) blasters - a spring-loaded toy guns that fire foam-coated darts or bullets at a relatively low velocity. These guns gained popularity in recent years among children and adolescents. Eleven patients with ocular injuries from foam dart blasters were included in this retrospective, single-center study. Visual acuity (VA), intraocular pressure (IOP), and anterior segment, glaucoma-related, and vitreoretinal complications were recorded at each visit. The average age at presentation was 13.4 years and 82% were male. Mean initial VA was 6/12 (range 6/6 - 1/18); On initial examination, nine patients (82%) had hyphema, three (27%) had corneal abrasions, three (27%) had vitreous hemorrhage, and two (18%) had traumatic mydriasis. Four patients (36%) experienced glaucoma-related complications, including three (27%) with angle recession and three (27%) with increased IOP. Three patients (27%) were diagnosed with posterior segment injuries, including three (27%) with commotio retinae and one (9%) with severe retinal photoreceptor damage. No patients required surgical intervention.

CONCLUSION

Foam dart blasters can cause severe blunt ocular trauma and permanent visual loss, illustrating the need for eye protection when handling these toys.

WHAT IS KNOWN

• Foam dart blasters, a blanket term for spring-loaded toy guns that fire foam-coated darts or bullets at a relatively low velocity, have gained popularity in recent years among pediatric populations, with an increase in associated ocular injuries. • To date, scattered case reporting provides insufficient insight into the full clinical spectrum of injury and prognosis of foam dart blasters related ocular injury.

WHAT IS NEW

• This case series characterizes the myriad foam dart blasters injuries that may afflict the eye, most of which are self-limiting, but some of which may result in poor visual outcomes and lifelong disability in pediatric patients. • We strongly recommend that all users wear eye protection while using foam dart blasters.

Clinical features and treatment of thoracic trauma in children. Eleven years of experience in a single center

AIM

This study aims to evaluate the characteristics of thoracic trauma in children.

MATERIAL AND METHOD

Thoracic trauma cases treated in our clinic between February 2011 and January 2022 were retrospectively analyzed.

RESULTS

31.5% (n=136) of 432 cases with thoracic trauma had isolated thoracic trauma. Mean age was 8.7±4 years, 74.3% were boys (n=321) and 25.7% were girls (n=111). In patients with thoracic trauma in children; blunt injuries were 84%, penetrating-stab wounds were 12%, and gunshot wounds were 4%, while the rate of penetrating trauma over the age of 15 was 24.8%. The most common causes were motor vehicle accidents (42.4%) and falls from height (23.9%). The most common pathologies; pulmonary contusion (71.7%), pneumothorax (48.7%), rib fracture (18%), and pulmonary laceration (12%). Tube thoracostomy was performed in 51 (46.4%) of 110 cases with pneumothorax. Thoracotomy was performed in 2 cases with penetrating gunshot wounds, and tube thoracostomy was performed in 2 cases with hemothorax. The mean hospital stay was 7 days, and1 case with severe cranial trauma died.

CONCLUSION

Chest wall, pulmonary, mediastinal, and diaphragmatic structures can be damaged in chest trauma. However, it should be kept in mind that every chest trauma patient may also have polytrauma, and accompanying injuries should be carefully examined.

KEY WORDS

Childhood, Thoracic trauma, Tube Thoracostomy.

Pancreatic Transection in a 6-year Child Following Bicycle Handlebar Injury

Bicycle handlebar injuries are the commonest cause of pancreatic trauma in children and adolescents, especially in males. Recognition of such injuries and initiation of correct treatment may be delayed when there is no abdominal wall bruising. We present a case of a 6-year boy with severe pancreatic trauma, who was referred from a local hospital following bicycle handlebar injury five days earlier. Contrast-enhanced computed tomography showed grade III pancreatic injury, which was repaired the following day; and he subsequently made a good recovery. The case highlights challenges faced by non-specialist clinicians working in resource-limited settings in diagnosing these injuries. Key Words: Bicycle handlebar injury, Blunt trauma, Pancreatic injury.

The spectrum of blunt abdominal trauma in Pietermaritzburg

BACKGROUND

This study reviews the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience with the management of blunt abdominal trauma (BAT).

METHODS

A retrospective review of the hybrid electronic medical registry (HEMR) between December 2012 and September 2019 was conducted. All patients admitted following BAT were included.

RESULTS

During the study period, 1 123 BAT patients were managed by the PMTS. The mean age was 29.19 years (SD 14.03). Of these admissions, 73.6% were male. The most common mechanism was road traffic crashes (RTCs) - 435 motor vehicle collisions (MVCs) and 250 pedestrian vehicle collisions (PVCs). There were 186 assaults, 118 falls, 62 community assaults, 22 accidents related to agriculture, construction or industry, 11 sporting injuries, nine animal injuries, seven patients injured by falling objects, five injured by trains, two hangings, one burn-related fall and two other causes. The mechanism of injury was unknown in 22 cases. There were 445 abdominal CT scans and 270 whole body CT scans. Surgical management was required for 395 patients. There were 259 index laparotomies and 176 repeat laparotomies. Four patients underwent selective arterial embolisation. Laparoscopy was undertaken in ten, and subsequently converted to laparotomy in five. There were 106 orthopaedic operations. Hospital stay ranged from 0-155 days (median stay three days). ICU admission was required in 24.9% of patients. The mortality rate was 7.5%.

CONCLUSION

BAT is common in South Africa. Whilst the vast majority of patients require non-operative treatment, a welldefined subset require a laparotomy. Imaging is central to the management of patients with BAT.

[Eye injuries related to padel]

Padel is a fast-growing racket sport in Sweden. There have been an increasing number of reports of eye injuries related to padel practice. We describe three cases during 2020 of blunt eye trauma inflicted by the padel ball causing intraocular lesions to the anterior and posterior segment of the eye. All cases needed surgical treatment of retinal tears and retinal detachment. In one case cataract surgery and pars plana vitrectomy were also performed. If the increasing number of eye injuries related to padel is only due to the raising popularity of the sport, or if padel also can be considered a high-risk sport for eye injuries, cannot yet be determined. However, some circumstances in padel sport may indicate an increased risk e.g., the size and velocity of the ball, the risk of unpredictable rebounds of the ball and the relatively close distance between the players. The most effective method of reducing the number of eye injuries is the use of protective eyewear.

Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database

BACKGROUND

The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma.

METHODS

We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS).

RESULTS

There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001).

CONCLUSION

Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction.

LEVEL OF EVIDENCE

Care management, Level IV.

Left diaphragmatic rupture in vehicle trauma: Report of surgical treatment and complications of two consecutive cases

BACKGROUND AND AIMS

Diaphragmatic ruptures are associated with blunt abdominal or thoracic trauma and often occur in car and motorbike accident with a high energy impact.

CASE PRESENTATION

We report two cases of patients victims of car and motorbike accidents that were referred to the Emergency Department of our Hospital in August and September 2017 for a politrauma. The patients were both diagnosed with a left diaphragmatic rupture with herniation of the stomach in the chest, and decomposed fractures of the ribs. One of the two patients reported a large abdominal wound with loss of substance in the site of the impact. Both patients underwent to open emergency surgery with primary repair of the phrenic rupture. The post-operative course was characterized by the occurrence of complications such as respiratory distress and emothorax for one of the patients.

CONCLUSION

Traumatic rupture of the diaphragm can be associated to blunt or penetrating abdominal trauma in car and motorbike accident with a prevalence of the left-sided lesions. In patients with politrauma an associate rupture of the diaphragm should be always suspected especially in motor accident where high energy impact can generate a traumatic laceration of the respiratory muscle. The treatment of associate thoracic wall fractures to prevent weaning and respiratory distress in intubated patient should be discussed.

Camel-Related Deaths-A Forensic Overview

ABSTRACT

Camels are ungulates of the genus Camelus and have been used for centuries in parts of Asia and Africa for transport and sustenance. Handling of camels is not without its dangers, and 4 cases from South Australia are reported with a review of lethal camel-related issues. Case 1 is a 56-year-old man who died of multiple blunt force injuries after he had attempted to move a 7-year-old female dromedary (Camelus dromedarius). Case 2 is a 65-year-old woman who was crushed by 1 or more camels that she had been training. Case 3 is a 1-year-old girl who died of blunt craniocerebral trauma after the car in which she was traveling rolled when the driver swerved to avoid a herd of camels that had strayed onto the road. Case 4 is a 66-year-old woman who died of ischemic and hypertensive cardiac disease exacerbated by physical activity while rounding up camels. Deaths associated with camels involve kicking, stomping, kneeling or sitting on a victim, or biting and shaking and throwing. Lethal mechanisms include hemorrhage from vascular injuries and internal organ disruption, crush asphyxia, and blunt craniospinal injuries. Death may also follow falls from camels or vehicle collisions. Camels also carry a wide range of zoonotic diseases, the most significant of which is Middle Eastern respiratory syndrome. Handling of camels may also exacerbate underlying organic illnesses such as cardiac disease. Those working with camels should be aware that the size, strength, and temperament of these animals may make them dangerous and that they also carry potentially lethal zoonotic diseases.

Pediatric blunt abdominal trauma with horizontal duodenal injury in school baseball: A case report

RATIONALE

Pediatric sports injuries, including those from baseball, most often are musculoskeletal injuries and rarely include blunt abdominal injuries. Duodenal injury is rare and often associated with other organ injuries. Because it has a relatively high mortality, early recognition and timely treatment are needed. Here, we report a case of successful treatment of a pediatric patient with duodenal injury incurred in the context of school baseball.

PATIENT CONCERNS

A 13-year-old boy suffered blunt abdominal trauma and a right-hand injury caused by beating his abdomen strongly with his own right knuckle after he performed a diving catch during a baseball game. On the following day, the abdominal pain had worsened.

DIAGNOSES

Computed tomography led to a suspicion of injury to the horizontal part of the duodenum.

INTERVENTIONS

The duodenal injuries were repaired by simple closure. On the 10th post-operative day, an abscess formed in the retroperitoneal cavity because of an occult pancreatic injury. Ultrasound-guided percutaneous drainage of the cavity was performed.

OUTCOMES

The post-operative course of the abscess drainage was uneventful. The patient was discharged from our hospital on day 72 after admission and was in good health at the 9-month follow-up.

LESSONS

Regardless of the type of injury, we must assess the life-threatening conditions that can be expected based on the mechanism of the injury. In duodenal injuries, it is critical to perform surgical procedures and post-operative management based on the assumption of injuries to other organs.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis

BACKGROUND

Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT.

METHODS

A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project.

RESULTS

In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model.

CONCLUSIONS

ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life

Purpose

Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL).

Methods

Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population.

Results

Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01).

Conclusion

This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01432-y) contains supplementary material, which is available to authorized users.

Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury

BACKGROUND

Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking.

METHODS

This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes.

RESULTS

A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes.

CONCLUSIONS

The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.

Aortic Transection after Blunt Abdominal Trauma in a Child

Abdominal aortic injury secondary to blunt abdominal aortic trauma (BAAI) is rare in children but frequently occurs in association with other injuries, including bowel injury and vertebral fracture. We present a case of a 14-year-old boy who sustained a partial transection of the infrarenal aorta with a lumbar chance fracture and small bowel injury after a motor vehicle accident. Repair was performed with bowel resection followed by Dacron graft interposition. We reviewed the literature on BAAI in children with a focus on the method of repair of these injuries.

Traumatic thoracoabdominal hernia repair using a novel chest-wall reconstruction technique: a case report

Thoracoabdominal hernia following blunt trauma is extremely rare. Abdominal viscera are more likely to herniate into the thorax if there is traumatic diaphragmatic rupture. We report the case of a patient presenting with a traumatic thoracoabdominal hernia containing part of the right lobe of the liver and the hepatic flexure of the colon. The hernia migrated cranially, to protrude through a seventh intercostal defect despite the diaphragm remaining fully intact. The need for early multispecialty (thoracic and hepatobiliary) surgical repair is highlighted, with improvements in surgical outcome for a complex trauma case by using a novel chest-wall reconstruction technique.

The use of computed tomography imaging for abdominal seatbelt sign: A single-center, prospective evaluation

INTRODUCTION

Guidelines surrounding abdominal seat belt sign (SBS) were made prior to the use of modern computed tomography (CT) imaging. We sought to prospectively determine whether a negative CT scan is associated with the absence of hollow viscus injury (HVI), and we hypothesized that trauma patients with an abdominal SBS without CT imaging findings would not have a hollow viscus injury (HVI).

METHODS

A prospective cohort of patients with SBS was compiled over one year. Subjects were divided into those with and without HVI. Covariate distributions were summarized by group. Bivariate tests and logistic regression were used to investigate associations between covariates and HVI.

RESULTS

Of 220 patients with SBS, the incidence of HVI was 7% (n = 15). Radiographic findings were strongly associated with HVI and no patients with a negative CT scan had HVI. Free fluid was seen in 80% (12) of patients with HVI, whereas it was found in only 11% (23) without injury. A composite variable for negative CT scan was found to be associated with the absence of HVI: (Fisher's exact 1-tailed p, doubled = 0.014).

CONCLUSION

In this study, the incidence of HVI with SBS is lower than previously reported, and no patients with negative CT imaging required an operation for HVI-suggesting there is a population of patients with SBS who could be discharged from the emergency room. A prospective multicenter study is needed to confirm these findings.

Forensic and Clinical Issues in a Case of Motorcycle Blunt Trauma and Bilateral Carotid Artery Dissection

Internal carotid artery dissection (ICAD) after motorcycle accidents is unusual but life threatening if not promptly diagnosed and treated. We report the case of a motorcyclist involved in a frontal collision with a car, suffering injuries due to direct blunt trauma and indirect trauma by sudden deceleration force. Bilateral ICAD was diagnosed by computed tomography angiogram 5 days after the accident. Here in, starting from a medicolegal case, we emphasized some clinical criteria to make a prompt diagnosis to prevent permanent neurological deficit in this pathology whose best management is still under the debate. An unusual case of ICAD is described with regard to both forensic and promptly diagnostic therapeutic management.

Trauma Team Activation at a Level I Trauma Center in Southern California: Time of Day Matters

The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC+USC (January 2008-July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (<1%), 54,826 patients were enrolled. The median age was 35 [IQR 23-53]. The median Injury Severity Score was 4 [1-10]. The most common mechanisms of injury were falls (n = 14,166; 31%), auto versus pedestrian collisions (n = 11,921; 26%), and motor vehicle collisions (n = 11,024; 24%). Penetrating trauma comprised 16 per cent (n = 8,686). The busiest hour for TTAs was 19:00 to 20:00, although penetrating trauma was most common between 23:00 and 01:00. Emergent surgical intervention in absolute numbers was most frequent between 20:00 and 01:00. As a proportion of the number of TTAs per hour, emergent operative intervention was most frequent between 23:00 and 06:00. In conclusion, the volume of TTAs and the triggering mechanism of injury vary significantly by time of day. The need for operative intervention is highest overnight. This information can be used to help increase hospital preparedness and allocate resources accordingly.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND

We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients.

METHODS

We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated.

RESULTS

Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis).

CONCLUSION

Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary.

SUMMARY

For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.

Lung Hernia Related with a Rope Bullfight: Case Report

Lung herniation is an uncommon entity which was fully classified in 1845 after the study of several case reports. Acquired lung hernia, especially traumatic, is the most common etiology. In the absence of clear guidelines, management of lung hernia is made in a case-by-case basis. We present an asymptomatic middle lobe hernia perceptible on physical examination, but diagnosed initially by imaging studies. Patient medical history included a blunt bull trauma fourteen years before.

Large Traumatic Retinal Dialysis Associated With Prominent Vitreous Base Avulsion

A 13-year-old female with a history of regressed retinopathy of prematurity presented with new-onset floaters after sustaining blunt force trauma to her left eye. Best-corrected visual acuity was 20/20 in both eyes (OU), with an intraocular pressure of 14 mm Hg and 15 mm Hg in the right eye (OD) and left eye (OS), respectively. Exam under anesthesia revealed an unremarkable anterior segment OU, including no hyphema or subluxated crystalline lens. Scleral depression OS demonstrated a retinal dialysis superotemporally (1-o'clock to 3-o'clock) and nasally (7-o'clock to 10-o'clock) associated with a prominent vitreous base avulsion but no subretinal fluid (Figure). Scleral depression OD was unremarkable. Both areas of retinal dialysis OS were treated with three rows of indirect green laser photocoagulation posterior to the edge of the dialysis. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:731.].

Endovascular Treatment of Blunt Thoracic Aortic Injury by Fractured Rib

We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.

"Mixed" trauma to the carotid artery in a mixed martial arts injury - A case report and review of the literature

We present the case of a mixed martial arts (MMA) cage fighter who presented to the emergency department with a right sided common carotid artery pseudoaneurysm as a result of a neck trauma at an MMA event. We discuss the management of blunt force neck trauma, differential diagnosis, imaging findings and review the literature on blunt cerebrovascular injury following blunt force injury to the neck.

[Firework injuries in the south-western region of the Netherlands around the turn of the year 2017-2018]

OBJECTIVE

To report the number of patients with firework-related injuries treated in December 2017 and January 2018 in a hospital in the south-west Netherlands trauma region, and to provide details about the types of firework used and the specific injuries.

DESIGN

A prospective multicentre cohort study (NTR6793).

METHODS

Patients of all ages with firework-related injuries were eligible for inclusion. The injury had to have been sustained between 1 December 2017 and 31 January 2018, and treated at a hospital in the south-west Netherlands trauma region (approximately 2.5 million inhabitants). Data were extracted from patients' medical files and additional information was obtained from patient interviews.

RESULTS

Fifty-four patients were included. The majority were male (93%) and the median age was 15 years. Twenty-five (46%) patients were bystanders and 12 (22%) were injured by illegal fireworks. Fifty patients were injured by bangers (n=22) or decorative fireworks (n=28). The patients had a total of 79 injuries, of which 29 (37%) were localised to the upper extremity and 19 (24%) to the eyes. Most upper extremity injuries were burns (69%), primarily partial thickness. Of the eye injuries, 14 were caused by blunt trauma, seven by chemical trauma, and one by penetrating trauma. Three patients sustained indirect firework-related injuries.

CONCLUSION

Between 1 December 2017 and 31 January 2018 in the south-west Netherlands trauma region mainly teenage males and bystanders sustained firework-related injuries. Most injuries were upper extremity burns and eye injuries, mainly due to legal fireworks and bangers or decorative fireworks. The extent of the sample indicates that the study findings can be extrapolated to the rest of the Netherlands.

Blunt Trauma-Induced Pericardial Tamponade After Video-Assisted Thoracoscopic Surgery

This report describes a case of blunt cardiac injury and pericardial tamponade after video-assisted thoracoscopic surgery in a patient with lung cancer, hypertension, and cardiac hypertrophy. Anatomic findings included massive hemorrhage in the pericardium, cardiac hypertrophy, and a superficial contusion with a ruptured blood vessel on the epicardium at the lateral wall of the left ventricle. The patient died of pericardial tamponade secondary to blunt trauma from the tip of the thoracoscopic instrument. This case suggests that detailed assessment of the cardiovascular system, especially cardiac hypertrophy, careful preoperative preparation, and careful monitoring of postoperative conditions are important.

Pediatric renal injury: which injury grades warrant close follow-up

PURPOSE

Most children who suffer renal trauma recover fully; however, some have long-term consequences. We sought to determine what grades of injury carry concern for complication and warrant close follow-up.

METHODS

Data on children with grade II or higher renal injuries from a single center over 20 years were reviewed. Demographics, presenting symptoms, lab values, clinical course, management, and follow-up data were analyzed.

RESULTS

One hundred seventy-one children suffered renal injuries: 75% boys, aged 11.6 ± 3.5 years. Falls-54 and sports-43 were leading injury mechanisms. Presentations included pain only-61, pain and hematuria-28 and hematuria alone-11. Eight had pre-existing abnormalities. Injury grades were: grade II-88 (52%), grade III-49 (29%), grade IV-28 (16%), and grade V-6 (3%). No grades II or III patient underwent intervention or suffered sequelae. Grade IV patients underwent: stenting-5, surgery-2, embolization-1, and drainage-1. Grade V patients underwent: surgery-2, embolization-1, and drain-1. Two grade IV patients underwent late interventions: nephrectomy-1 and stenting-1. Six patients, all grades IV-V, were newly hypertensive at follow-up.

CONCLUSION

Grades II and III renal injuries carry a low risk of complication and repeat imaging and close follow-up are likely not necessary. However, grades IV and V injuries carry a meaningful risk of adverse outcome and close follow-up is warranted.

Diagnosing and managing common genital emergencies in pediatric girls

The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery. This issue reviews the most common traumatic genital injuries in girls presenting to the emergency department, including straddle injuries, hematomas, and impalement injuries. Nontraumatic emergencies, including hematocolpos and urethral prolapse, are also discussed. Evidence-based recommendations are presented for identifying and managing these common genital injuries and emergencies in pediatric girls.

Is a "Pan-Scan" Indicated in the Older Patient with a Ground Level Fall?

Routine full-body CT "pan-scan" use in older patients after ground level falls (GLFs) is of questionable benefit. Retrospective review of new diagnosis & changes in management in patients >55 years with Glasgow Coma Scale of 15 after a GLF who received a pan-scan (routine head, cervical spine/neck, chest abdomen, and pelvis CT). Head CT results were considered separately; results described in the following paragraph pertains to cervical spine/neck, chest, abdomen, and pelvis CT. One hundred and fifty-two patients received pan-scans; 96 (63%) had new findings. Thirty-five (23%) resulted in a minor change and three (2%) in a major change in management, defined as a procedural intervention. This included tube thoracostomy in one patient and cervical spine surgery in two. A further eight patients required the use of a cervical collar. In all patients requiring intervention, there were clinical signs present that should have led to directed CT scan of area of concern. Routine pan-scans in stable, alert older patients after a GLF result in new findings in most patients, with primarily nonprocedural interventions for these additional findings.

Postdischarge Mortality after Geriatric Low-Level Falls: A Five-Year Analysis

Geriatric trauma patients with low-level falls often have multiple comorbidities and limited physiologic reserve. Our aim was to investigate postdischarge mortality in this population. We hypothesized that five-year mortality would be higher relative to other blunt mechanisms. The registry of our Level 1 trauma center was queried for patients evaluated between July 2008 and December 2012. Adult patients identified were matched with mortality data from 2008 to 2013 from the National Death Index. Low-level falls were identified by E Codes; other types of blunt trauma were based on registry classification. Patients with multiple admissions were excluded. Univariate analysis was performed using Fisher's exact and Wilcoxon tests. Kaplan-Meier curves were plotted to compare postdischarge mortality. Seven thousand nine hundred sixteen patients were evaluated, 35.1 per cent were females. Patients aged less than 65 years and penetrating trauma were excluded, yielding 1997 patients-63.7 per cent with low-level falls versus 36.3 per cent with other blunt traumas. Geriatric patients sustaining low-level falls were older, more likely female, had a higher inpatient mortality, and were less likely to return home at discharge. Injury severity score, hospital length of stay, and intensive care unit length of stay were similar. Survival analysis demonstrated increased postdischarge mortality in the low-level fall group with 25 per cent mortality at 120 days. Geriatric patients with other blunt trauma had a significantly lower postdischarge mortality. Geriatric patients injured in low-level falls have a higher inhospital mortality, are more likely to be functionally dependent on discharge, and have a high postdischarge mortality. Opportunities likely exist for injury prevention, consideration of palliative care, and postdischarge rehabilitation.

Acute myocardial infarction after blunt chest wall trauma with underlying coronary aneurysm: a case report

BACKGROUND

Kawasaki disease is an acute febrile disease with mucocutaneous and cardiovascular involvement affecting infants and young children. Though coronary artery abnormalities are common in Kawasaki disease, no consensus has been reached regarding the treatment of acute coronary artery diseases in this population.

CASE PRESENTATION

We described a case of myocardial infarction triggered by blunt chest wall trauma in a 20 years old girl. She presented with chest pain and breathlessness with brief syncope, lab results and electrocardiogram findings were consistent with acute myocardial infarction. Chest computer tomography (CT) demonstrated coronary artery calcifications and echocardiography revealed multiple giant left anterior descending aneurysms, suggestive of Kawasaki disease. Subsequent contrast enhanced 3 dimensional coronary computer tomography angiography (CTA) confirmed these findings. We managed this young patient with a conservative strategy. The patient remained symptom free during 2-years follow-ups.

CONCLUSIONS

Prompt medical treatment for traumatic myocardial infarction even with underlying giant coronary artery aneurysms can successfully preserve left ventricular function and prevent remodeling with good short term prognosis.

Blunt abdominal trauma following gunshot wound Case report and literature review

Blunt abdominal trauma following gunshot wound. Case report and literature review Introduction: Similarly to blast weapons, every firearm produces explosion at the moment of shooting, which can cause injuries in every region of the body. The aim of this paper is to present the mechanism of blunt abdominal injury following gunshot wounds, bringing this uncommon disease to the clinicians' attention and to review the literature available.

CASE REPORT

A patient developed a delayed bowel perforation following a gunshot injury of the abdomen without breaking of the peritoneum. It was clinically suspected eight hours later and confirmed with contrast-enhanced computed tomography scan. The patient underwent immediate laparotomy. Resection, end-to-end anastomosis, and large lavage of the peritoneal cavity was performed. The patient was discharged ten days after operation in good condition.

CONCLUSION

Failure to recognize blunt trauma mechanism following firearm wounds increases the risk of missed injuries. Distant injuries should be suspected in all cases after blast wave and firearms exposure and a follow up should be done for many days to make sure such injuries are excluded. CT scan total body is recommended in all such cases. Key words: Blunt trauma, Distant Injuries, Firearm injuries, Pressure Waves.

[Hemothorax - a conservative approach in a patient with multiple comorbidities]

The authors present the case of an elderly woman with multiple comorbidities hospitalized with the diagnosis of community- acquired pneumonia with pleural effusion. However, there was a history of fall with chest trauma 1 week before, coinciding with the onset of symptoms. The patient had a massive hemothorax that could not be drained. There was a progressive worsening of the patient clinical status with sustained fever and arising of inflammatory parameters, despite broad-spectrum antibiotic therapy and antipyretics. The case was discussed in a multidisciplinary team, and the possibility of surgical intervention was rejected. As life-saving therapy, it was decided to perform fibrinolysis with tissue plasminogen activator, through the thoracic drain, which occurred successfully and without complications. The hemothorax was drained completely allowing recovery of the patient.

Long-Term Functional Outcomes after Traumatic Thoracic and Lumbar Spine Fractures

The incidence of thoracolumbar spine fractures in blunt trauma is 4 to 5 per cent. These fractures may lead to neurologic injury, chronic back pain, and disability. Most studies from United States trauma centers focus on neurologic sequelae and/or compare treatment modalities. However, most patients with spine fractures do not have a neurologic deficit. Our primary objective was to determine the long-term outcome of traumatic thoracolumbar spine fractures, specifically addressing quality of life, chronic pain, and employment using a validated patient outcome survey. A chart review of 138 adult blunt trauma patients who sustained a thoracolumbar spine fracture and were admitted to our Level I trauma center from 2008 to 2013 was performed. A phone interview based on the Short-Form 12®, a general health survey, was then conducted. Of the 134 patients who met the inclusion criteria, 46 (34%) completed the survey. The average Short-Form 12® scores were 51.0 for the physical health component score and 52.9 for the mental health component score. These did not differ significantly from the national norm. Furthermore, 83 per cent (38) of the survey respondents returned to work full-time at the same level as before their injury. Majority of the patients (76%) said they did not have pain two to seven years after injury. Despite a commonly held belief that back injury leads to chronic pain and disability, after sustaining a thoracic or lumbar fracture, patients are generally able to return to work and have a comparable quality of life to the general population. This knowledge may be useful in counseling patients regarding expectations for recovery from trauma.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Left Internal Thoracic Artery Graft to Left Anterior Descending Coronary Artery after Blunt-Chest-Trauma Myocardial Infarction: 14-Year Outcome

In 2005, we reported an acute myocardial infarction secondary to a left anterior descending coronary artery injury sustained in a motorcycle accident. The treatment was late myocardial revascularization with in situ left internal thoracic artery-to-left anterior descending coronary artery anastomosis. There is little information available about the natural history of acute myocardial infarction after blunt chest trauma, especially when treated in this manner. This present communication reports the 14-year outcome in our patient.

Validation of the sensitivity of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomographic (CT) decision instrument for selective imaging of blunt head injury patients: An observational study

BACKGROUND

Clinicians, afraid of missing intracranial injuries, liberally obtain computed tomographic (CT) head imaging in blunt trauma patients. Prior work suggests that clinical criteria (National Emergency X-Radiography Utilization Study [NEXUS] Head CT decision instrument [DI]) can reliably identify patients with important injuries, while excluding injury, and the need for imaging in many patients. Validating this DI requires confirmation of the hypothesis that the lower 95% confidence limit for its sensitivity in detecting serious injury exceeds 99.0%. A secondary goal of the study was to complete an independent validation and comparison of the Canadian and NEXUS Head CT rules among the subgroup of patients meeting the inclusion and exclusion criteria.

METHODS AND FINDINGS

We conducted a prospective observational study of the NEXUS Head CT DI in 4 hospital emergency departments between April 2006 and December 2015. Implementation of the rule requires that patients satisfy 8 criteria to achieve "low-risk" classification. Patients are excluded from "low-risk" classification and assigned "high-risk" status if they fail to meet 1 or more criteria. We examined the instrument's performance in assigning "high-risk" status to patients requiring neurosurgical intervention among a cohort of 11,770 blunt head injury patients. The NEXUS Head CT DI assigned high-risk status to 420 of 420 patients requiring neurosurgical intervention (sensitivity, 100.0% [95% confidence interval [CI]: 99.1%-100.0%]). The instrument assigned low-risk status to 2,823 of 11,350 patients who did not require neurosurgical intervention (specificity, 24.9% [95% CI: 24.1%-25.7%]). None of the 2,823 low-risk patients required neurosurgical intervention (negative predictive value [NPV], 100.0% [95% CI: 99.9%-100.0%]). The DI assigned high-risk status to 759 of 767 patients with significant intracranial injuries (sensitivity, 99.0% [95% CI: 98.0%-99.6%]). The instrument assigned low-risk status to 2,815 of 11,003 patients who did not have significant injuries (specificity, 25.6% [95% CI: 24.8%-26.4%]). Significant injuries were absent in 2,815 of the 2,823 patients assigned low-risk status (NPV, 99.7% [95% CI: 99.4%-99.9%]). Of our patients, 7,759 (65.9%) met the inclusion and exclusion criteria of the Canadian Head CT rule, including 111 patients (1.43%) who required neurosurgical intervention and 306 (3.94%) who had significant intracranial injuries. In our study, the Canadian criteria for neurosurgical intervention identified 108 of 111 patients requiring neurosurgical intervention to yield a sensitivity of 97.3% (95% CI: 92.3%-99.4%) and exhibited a specificity of 58.8% (95% CI: 57.7%-59.9%). The NEXUS rule, when applied to this same cohort, identified all 111 patients requiring neurosurgical intervention, yielding a sensitivity of 100% (95% CI: 96.7%-100.0%) with a specificity of 32.6% (95% CI: 31.5%-33.6%). Our study found that the Canadian medium-risk factors identified 301 of 306 patients with significant injuries (sensitivity = 98.4%; 95% CI: 96.2%-99.5%), while the NEXUS rule identified 299 of these patients (sensitivity = 97.7%; 95% CI: 95.3%-99.1%). In our study, the Canadian medium-risk rule exhibited a specificity of 12.3% (95% CI: 11.6%-13.1%), while the NEXUS rule exhibited a specificity of 33.3% (95% CI: 32.3%-34.4%). Limitations of the study may arise from application of the rule by different clinicians in different environments. Clinicians may vary in their interpretation and application of the instrument's criteria and risk assignment and may also vary in deciding which patients require intervention. The instrument's specificity is also subject to spectrum bias and may change with variations in the proportion of "low-risk" patients seen in other centers.

CONCLUSIONS

The NEXUS Head CT DI reliably identifies blunt trauma patients who require head CT imaging and could significantly reduce the use of CT imaging.

Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery

Blunt thoracic aortic injury (BTAI) in a patient with an aberrant right subclavian artery (ARSA) presents unique challenges for patient management and aortic repair. Specific considerations include the need to treat coincidental ARSA, subclavian revascularization, and ARSA exclusion. Despite the rise of endovascular repair as the primary modality for aortic repair for BTAI, reports of this technique in the setting of ARSA are limited. Here we describe 3 patients with ARSA who underwent TEVAR for BTAI, and discuss critical management and technical issues in these patients.

Acute traumatic renal arteriocalyceal fistula: selective angioembolisation for haemodynamic instability

Abdominal angiography with selective arteriography and subsequent embolisation is an accepted management modality in the treatment of selected solid organ injuries following blunt abdominal trauma. This management practice is well established in the haemodynamically stable patient; however, this remains more controversial in haemodynamically compromised patients, though warrants consideration in both cases due to the associated benefits of non-operative management. This case report describes the successful non-operative management of a severe renal injury in a young polytraumatised patient following a high-speed motor vehicle crash. In addition, the rare CT diagnosis and management of an acute traumatic arteriocalcyeal fistula is discussed with a focus on the importance of renal parenchymal preservation.