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Frassini S, Gupta S, Granieri S, Cimbanassi S, Sammartano F, Scalea TM, Chiara O. Extraperitoneal packing in unstable blunt pelvic trauma: A single-center study. J Trauma Acute Care Surg 2020; 88:597-606. [PMID: 32317576 DOI: 10.1097/ta.0000000000002618] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization even at the most advanced trauma centers may take hours. Extraperitoneal packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hours and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma. METHODS All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients 14 years or older who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (Abbreviated Injury Scale >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a no-EPP group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient. RESULTS Two hundred forty-four patients presented hemodynamically unstable, with a pelvic fracture (180 no-EPP, 64 EPP). With propensity score matching, 37 patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p = 0.042) and we registered similar results in overall survival rate (78.4% EPP group vs. 56.8% no-EPP group, p = 0.047). Those patients who underwent early EPP (n = 64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure of 49.9 mm Hg and post-EPP mean arterial pressure of 70.1 mm Hg (p < 0.01). CONCLUSION Extraperitoneal pelvic packing is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Simone Frassini
- From the General Surgery and Trauma Team (S.F., S.G., O.C., S.C., F.S.), University of Milan, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; R Adams Cowley Shock Trauma Center (S.G., T.M.S.), University of Maryland, Baltimore, Maryland
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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Use in Temporizing Intra-Abdominal and Pelvic Hemorrhage: Physiologic Sequelae and Considerations. Shock 2020; 54:615-622. [DOI: 10.1097/shk.0000000000001542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dreizin D, Zhou Y, Chen T, Li G, Yuille AL, McLenithan A, Morrison JJ. Deep learning-based quantitative visualization and measurement of extraperitoneal hematoma volumes in patients with pelvic fractures: Potential role in personalized forecasting and decision support. J Trauma Acute Care Surg 2020; 88:425-433. [PMID: 32107356 PMCID: PMC7830753 DOI: 10.1097/ta.0000000000002566] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Admission computed tomography (CT) is a widely used diagnostic tool for patients with pelvic fractures. In this pilot study, we hypothesized that pelvic hematoma volumes derived using a rapid automated deep learning-based quantitative visualization and measurement algorithm predict interventions and outcomes including (a) need for angioembolization (AE), pelvic packing (PP), or massive transfusion (MT), and (b) in-hospital mortality. METHODS We performed a single-institution retrospective analysis of 253 patients with bleeding pelvic fractures who underwent admission abdominopelvic trauma CT between 2008 and 2017. Included patients had hematoma volumes of 30 mL or greater, were 18 years and older, and underwent contrast-enhanced CT before surgical or angiographic intervention. Automated pelvic hematoma volume measurements were previously derived using a deep-learning quantitative visualization and measurement algorithm through cross-validation. A composite dependent variable of need for MT, AE, or PP was used as the primary endpoint. The added utility of hematoma volume was assessed by comparing the performance of multivariable models with and without hematoma volume as a predictor. Areas under the receiver operating characteristic curve (AUCs) and sensitivities, specificities, and predictive values were determined at clinically relevant thresholds. Adjusted odds ratios of automated pelvic hematoma volumes at 200 mL increments were derived. RESULTS Median age was 47 years (interquartile range, 29-61), and 70% of patients were male. Median Injury Severity Score was 22 (14-36). Ninety-four percent of patients had injuries in other body regions, and 73% had polytrauma (Injury Severity Score, ≥16). Thirty-three percent had Tile/Orthopedic Trauma Association type B, and 24% had type C pelvic fractures. A total of 109 patients underwent AE, 22 underwent PP, and 53 received MT. A total of 123 patients received all 3 interventions. Sixteen patients died during hospitalization from causes other than untreatable (abbreviated injury scale, 6) head injury. Variables incorporated into multivariable models included age, sex, Tile/Orthopedic Trauma Association grade, admission lactate, heart rate (HR), and systolic blood pressure (SBP). Addition of hematoma volume resulted in a significant improvement in model performance, with AUC for the composite outcome (AE, PP, or MT) increasing from 0.74 to 0.83 (p < 0.001). Adjusted unit odds more than doubled for every additional 200 mL of hematoma volume. Increase in model AUC for mortality with incorporation of hematoma volume was not statistically significant (0.85 vs. 0.90, p = 0.12). CONCLUSION Hematoma volumes measured using a rapid automated deep learning algorithm improved prediction of need for AE, PP, or MT. Simultaneous automated measurement of multiple sources of bleeding at CT could augment outcome prediction in trauma patients. LEVEL OF EVIDENCE Diagnostic, level IV.
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Affiliation(s)
- David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Yuyin Zhou
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University
| | - Tina Chen
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Guang Li
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Alan L. Yuille
- Department of Computer Science, Head, Center for Cognition Vision and Learning, Johns Hopkins University
| | - Ashley McLenithan
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan J. Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Preperitoneal balloon tamponade and resuscitative endovascular balloon occlusion of the aorta: Alternatives to open packing for pelvic fracture-associated hemorrhage. J Trauma Acute Care Surg 2020; 87:18-26. [PMID: 31260423 DOI: 10.1097/ta.0000000000002266] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective of this study was to compare the efficacy of preperitoneal balloon tamponade (PPB), resuscitative endovascular balloon occlusion of the orta (REBOA), and open preperitoneal packing (OP) in a realistic animal model of pelvic fracture-associated hemorrhage. METHODS Thirty-nine swine underwent creation of open-book pelvic fracture and iliac vascular injury. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), zone 1 REBOA (n = 7), and zone 3 REBOA (n = 6) at a mean arterial pressure less than 40 mm Hg from uncontrolled hemorrhage. Primary outcome was survival at 1 hour. Secondary outcomes included survival in the immediate 10 m following intervention reversal, peak preperitoneal pressure (PP), blood loss, bleed rate, and peak lactate. RESULTS Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p = NS). The injury was uniformly lethal without intervention, with survival time (mean) of 5 m, peak PP of 14 mm Hg, blood loss of 960 g, bleed rate of 450 g/m, and peak lactate of 2.6 mmol/L. Survival time (m) was extended to 44 with OP, 60 with PPB, and 60 with REBOA (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, 10 with zone 1 REBOA, and 6 with zone 3 REBOA (p < 0.05). Blood loss (g) was 850 with OP, 930 with PPB, 610 with zone 1 REBOA, and 370 with zone 3 REBOA (p < 0.01). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, 13.4 with zone 1 REBOA, and 5.3 with zone 3 REBOA (p < 0.01). Only 33% of zone 1 REBOA animals survived the initial 10 m after balloon deflation, compared to 60% for OP, 67% for PPB, and 100% for zone 3 REBOA (p < 0.01). CONCLUSION Preperitoneal balloon tamponade and zone 3 REBOA are effective alternatives to OP in this animal model of lethal pelvic fracture-associated hemorrhage. Zone 1 REBOA extends survival time but with high mortality upon reversal.
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Chen HT, Wang YC, Hsieh CC, Su LT, Wu SC, Lo YS, Chang CC, Tsai CH. Trends and predictors of mortality in unstable pelvic ring fracture: a 10-year experience with a multidisciplinary institutional protocol. World J Emerg Surg 2019; 14:61. [PMID: 31889991 PMCID: PMC6935111 DOI: 10.1186/s13017-019-0282-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background Pelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture. Material and methods This retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications. Results During the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure < 90 mmHg (odds ratio [OR] 2.53; confidence interval [CI] 1.11–5.73), Glasgow Coma Scale < 9 (OR 3.87; CI 1.57–9.58), 24 > ISS > 15 (OR 4.84; CI 0.85–27.65), pulse rate < 50 (OR 11.54; CI 1.21–109.6), and diabetes mellitus (OR 3.18; CI 1.10–9.21) were associated with higher mortality. No other specific system in the high Abbreviated Injury Scale increased the rates of mortality or complications. Conclusion Poor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.
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Affiliation(s)
- Hsien-Te Chen
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yu-Chun Wang
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,5Department of Surgery, School of Medicine, China Medical University, Taichung, Taiwan.,6Division of Emergency Disease Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chen-Chou Hsieh
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Li-Ting Su
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,6Division of Emergency Disease Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Chi Wu
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,5Department of Surgery, School of Medicine, China Medical University, Taichung, Taiwan.,6Division of Emergency Disease Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yuan-Shun Lo
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Chien-Chun Chang
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Chun-Hao Tsai
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan.,7Department of Orthopedic Surgery, School of Medicine, China Medical University, #91 Hsueh-Shih Road, Taichung, 404 Taiwan
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Utilization of endovascular and open surgical repair in the United States: A 10-year analysis of the National Trauma Databank (NTDB). Am J Surg 2019; 218:1128-1133. [DOI: 10.1016/j.amjsurg.2019.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 11/17/2022]
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Odedra D, Mellnick V, Patlas M. A 2019 international survey to assess trends in follow-up imaging of blunt splenic trauma. Emerg Radiol 2019; 27:51-56. [PMID: 31691876 DOI: 10.1007/s10140-019-01734-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE There are no published guidelines on the follow-up imaging of non-operatively managed blunt splenic trauma (BST). We conducted an international survey of emergency radiologists to determine the ideal patient population, time period, and technique for follow-up imaging of BST. METHODS An anonymous 10-question online survey was distributed via email to 34 emergency radiologists around the world. The survey was open for a 2-week period in 2019. A commercially available website (SurveyMonkey®) was used for survey generation and data acquisition. RESULTS We received 29 responses (85% response rate) primarily from USA, Canada, and Europe. Majority of the institutions handled > 1000 trauma cases (69%). The initial protocol consisted of arterial and portal venous phases (PVP) in 72% of responses. Sixty-two percent of the institutions did not have a routine protocol for follow-up imaging of BST. There was no consensus on which patients received follow-up imaging. The most frequent responses had been case-per-case basis or injuries above a set AAST grade (42% and 37%, respectively). There was no set time period for follow-up imaging, but MDCT was most often performed at 24-48 h. Dual-phase protocol was utilized most commonly (69%). Majority of the institutions (88%) utilized angioembolization for hemodynamically stable patients with contained vascular injury or active extravasation. CONCLUSION There is no consensus on the optimal patient population or time period for follow-up imaging of BST. A dual-phase follow-up MDCT protocol is utilized for follow-up by majority of institutions.
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Affiliation(s)
- Devang Odedra
- Department of Radiology, McMaster Universitiy, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.
| | - Vincent Mellnick
- Abdominal Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Michael Patlas
- Division of Emergency/Trauma Radiology, McMaster University, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.,Department of Radiology, Hamilton General Hospital, 237 Barton St. E, Hamilton, ON, L8L 2X2, Canada
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Schmal H, Larsen MS, Stuby F, Strohm PC, Reising K, Goodwin Burri K. Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures. Injury 2019; 50:1959-1965. [PMID: 31477239 DOI: 10.1016/j.injury.2019.08.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/21/2019] [Accepted: 08/25/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Unstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate. PATIENTS AND METHODS The analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n = 957 with vs n = 4,542 without). Furthermore, the subgroups with secondary surgery (n = 713 vs n = 1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n = 24 vs n = 219). Calculated odds ratios were adjusted for potential confounders. RESULTS Patients treated by CC/EF were younger (45 ± 20 vs 62 ± 24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3 mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p < 0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02-1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06-20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation. INTERPRETATION Primary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use.
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Affiliation(s)
- Hagen Schmal
- Department of Orthopaedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Denmark.
| | - Morten Schultz Larsen
- Department of Orthopaedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Denmark.
| | | | - Peter C Strohm
- Clinic for Orthopaedics and Trauma Surgery, Sozialstiftung Bamberg, Buger Straße 80, 96049 Bamberg, Germany.
| | - Kilian Reising
- Department for Orthopaedic Surgery, University Teaching Hospital Harburg, Hamburg, Germany.
| | - Kelly Goodwin Burri
- Swiss medical Registries and Data Linkage (SwissRDL), Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
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Dreizin D. Commentary on "Multidetector CT in Vascular Injuries Resulting from Pelvic Fractures". Radiographics 2019; 39:2130-2133. [PMID: 31721653 PMCID: PMC6884065 DOI: 10.1148/rg.2019190192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine Baltimore, Maryland
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Ciriano Hernández P, Moreno Hidalgo A, Grao Torrente I, Ruiz Moreno C, Seisdedos Rodrigez L, Kayser Mata S, Echenagusia Boyra MJ, González Leyte M, Pérez Díaz MD, Turégano Fuentes F. Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados. Cir Esp 2019; 97:261-267. [DOI: 10.1016/j.ciresp.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/22/2019] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
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Pelvic Fractures and Indications for Pelvic Packing: An Update. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aoki M, Ogura T, Hagiwara S, Nakamura M, Oshima K. Prediction of arterial extravasation in pelvic fracture patients with stable hemodynamics using coagulation biomarkers. World J Emerg Surg 2019; 14:14. [PMID: 30930958 PMCID: PMC6425576 DOI: 10.1186/s13017-019-0234-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/08/2019] [Indexed: 11/28/2022] Open
Abstract
Background Determining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics. Methods We studied patients with a pelvic fracture who had a systolic blood pressure above 90 mmHg and lactate level less than 5.0 mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [−] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR). Results Sixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time–international normalized ratio (PT–INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (−) group (FDP, 242 μg/mL [145–355] vs. 96 μg/mL [58–153]; D-dimer, 81 μg/mL [41–140] vs. 39 μg/mL [21–75]; PT–INR, 1.09 [1.05–1.24] vs. 1.02 [0.98–1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85–2.01] vs. 0.46 [0.25–0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656–0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90). Conclusion Coagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics. Electronic supplementary material The online version of this article (10.1186/s13017-019-0234-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Makoto Aoki
- 1Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takayuki Ogura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Gunma, Japan
| | - Shuichi Hagiwara
- 1Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mitsunobu Nakamura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Gunma, Japan
| | - Kiyohiro Oshima
- 1Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
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Use of open and endovascular surgical techniques to manage vascular injuries in the trauma setting: A review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial registry. J Trauma Acute Care Surg 2019; 84:411-417. [PMID: 29462113 DOI: 10.1097/ta.0000000000001776] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Vascular trauma data have been submitted to the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial (PROOVIT) database since 2013. We present data to describe current use of endovascular surgery in vascular trauma. METHODS Registry data from March 2013 to December 2016 were reviewed. All trauma patients who had an injury to a named artery, except the forearm and lower leg, were included. Arteries were grouped into anatomic regions and by compressible and noncompressible region for analysis. This review focused on patients with noncompressible transection, partial transection, or flow-limiting defect injuries. Bivariate and multivariate analyses were used to assess the relationships between study variables. RESULTS One thousand one hundred forty-three patients from 22 institutions were included. Median age was 32 years (interquartile range, 23-48) and 76% (n = 871) were male. Mechanisms of injury were 49% (n = 561) blunt, 41% (n = 464) penetrating, and 1.8% (n = 21) of mixed aetiology. Gunshot wounds accounted for 73% (n = 341) of all penetrating injuries. Endovascular techniques were used least often in limb trauma and most commonly in patients with blunt injuries to more than one region. Penetrating wounds to any region were preferentially treated with open surgery (74%, n = 341/459). The most common indication for endovascular treatment was blunt noncompressible torso injuries. These patients had higher Injury Severity Scores and longer associated hospital stays, but required less packed red blood cells, and had lower in hospital mortality than those treated with open surgery. On multivariate analysis, admission low hemoglobin concentration and abdominal injury were independent predictors of mortality. CONCLUSION Our review of PROOVIT registry data demonstrates a high utilization of endovascular therapy among severely injured blunt trauma patients primarily with noncompressible torso hemorrhage. This is associated with a decreased need for blood transfusion and improved survival despite longer length of stay. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Johnson MC, Miller CP, Stolarski AE, Ata A, Bartscherer A, Geary SP, Rosati C, DuBose J, Tafen M, Stain SC. Perceptions in rib injuries: A multidisciplinary single center survey of clinician differences in risk stratification and management of patients with rib fractures. Am J Surg 2019; 218:32-36. [PMID: 30709551 DOI: 10.1016/j.amjsurg.2019.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/28/2018] [Accepted: 01/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although associated with significant morbidity, there is no universally accepted management of rib fractures. We hypothesized that variations in risk stratification may influence this. METHODS A questionnaire was developed to assess providers' perceived risk factors and injury stratification of rib fracture patients at a Level 1 trauma center. RESULTS There were 143 responses (36% physician response rate). Hypoxia, age, number of ribs fractured, pre-existing pulmonary disease, and flail chest were identified as the most important risk factors determining morbidity and mortality in blunt chest trauma. While clinicians agreed on predicted mortality for <2 fractured ribs, significant variation for 5-6 and >8 rib fractures was seen. EM and surgery providers significantly differed in assessment of injury severity. CONCLUSION Providers identified common risk factors for increased morbidity and mortality. However, the difference in perceived severity between providers indicates a need for clinical tools to assist in better standardizing rib fracture management.
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Affiliation(s)
- Matthew C Johnson
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Claire P Miller
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Allan E Stolarski
- Department of Surgery, Boston University Medical Center, Boston, MA, USA.
| | - Ashar Ata
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Ashley Bartscherer
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Sean P Geary
- Department of Emergency Medicine & Department of Surgery, Division of Surgical Critical Care, Albany Medical Center, Albany, NY, USA.
| | - Carl Rosati
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Marcel Tafen
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Steven C Stain
- Section of Trauma and Acute Care Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA.
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65
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The compatibility of computed tomography scanning and partial REBOA: A large animal pilot study. J Trauma Acute Care Surg 2019; 83:557-561. [PMID: 28538633 DOI: 10.1097/ta.0000000000001574] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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66
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Awwad A, Dhillon PS, Ramjas G, Habib SB, Al-Obaydi W. Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre. CVIR Endovasc 2018; 1:32. [PMID: 30652163 PMCID: PMC6319536 DOI: 10.1186/s42155-018-0031-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm. MAIN BODY Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE. CONCLUSION Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.
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Affiliation(s)
- Amir Awwad
- NIHR Nottingham Biomedical Research Centre, Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, NG72UH UK
- Radiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, CB23 3RE UK
| | - Permesh Singh Dhillon
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
- NIHR Nottingham Biomedical Research Centre, Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, NG72UH UK
| | - Greg Ramjas
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Said B. Habib
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Waleed Al-Obaydi
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
- Interventional Radiology, Royal Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE UK
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67
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Kim SK, Park YC, Jo YG, Kang WS, Kim JC. Internal Iliac Artery Ligation with Pad Packing for Hemodynamic Unstable Open Comminuted Sacral Fracture. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.4.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Kyu Kim
- Department of Orthopaedics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Current use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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69
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Current use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201712002-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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70
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Ordoñez CA, Manzano-Nunez R, del Valle AM, Rodriguez F, Burbano P, Naranjo MP, Parra MW, Ferrada P, Solís-Velasco MA, García AF. Uso actual del balón de resucitación aórtico endovascular (REBOA) en trauma. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rca.2017.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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71
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Dehli T, Skattum J, Christensen B, Vinjevoll OP, Rolandsen BÅ, Gaarder C, Næss PA, Wisborg T. Treatment of splenic trauma in Norway: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2017; 25:112. [PMID: 29169401 PMCID: PMC5701344 DOI: 10.1186/s13049-017-0457-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/17/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Non-operative management of splenic injuries has become the treatment of choice in hemodynamically stable patients over the last decades. The aim of the study is to describe the incidence, initial treatment and early outcome of patients with splenic injuries on a national level. METHODS All hospitals in Norway admitting trauma patients were invited to participate in the study. The study period was January through December 2013. The hospitals delivered anonymous data on primarily admitted patients with splenic injury. RESULTS Three of the four regional trauma centers and 26 of the remaining 33 acute care hospitals delivered data on a total of 151 patients with splenic injury indicating an incidence of 4 splenic injuries per 100,000 inhabitants/year, and a median of 4 splenic injuries per hospital per year. A total of 128 (85%) patients were successfully treated non-operatively including 20 patients who underwent an angiographic procedure. The remaining 23 (15%) patients underwent open splenectomy or spleen-preserving surgery. CONCLUSION Most patients with splenic injuries are managed non-operatively. Despite the low number of splenic injuries per hospital, the results indicate satisfactory outcome on a national level.
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Affiliation(s)
- Trond Dehli
- Department of Gastrointestinal Surgery, University Hospital North Norway Tromsø, Tromsø, Norway
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Jorunn Skattum
- Department of Traumatology, Division of Emergencies and Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
| | - Bjørn Christensen
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | | | - Bent-Åge Rolandsen
- Department of Surgery, St. Olav’s University Hospital, Trondheim, Norway
| | - Christine Gaarder
- Department of Traumatology, Division of Emergencies and Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
| | - Pål Aksel Næss
- Department of Traumatology, Division of Emergencies and Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
- Fauculty of Medicine, University of Oslo, Oslo, Norway
| | - Torben Wisborg
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
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Evans C, Quinlan DO, Engels PT, Sherbino J. Reanimating Patients After Traumatic Cardiac Arrest: A Practical Approach Informed by Best Evidence. Emerg Med Clin North Am 2017; 36:19-40. [PMID: 29132577 DOI: 10.1016/j.emc.2017.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Resuscitation of traumatic cardiac arrest is typically considered futile. Recent evidence suggests that traumatic cardiac arrest is survivable. In this article key principles in managing traumatic cardiac arrest are discussed, including the importance of rapidly seeking prognostic information, such as signs of life and point-of-care ultrasonography evidence of cardiac contractility, to inform the decision to proceed with resuscitative efforts. In addition, a rationale for deprioritizing chest compressions, steps to quickly reverse dysfunctional ventilation, techniques for temporary control of hemorrhage, and the importance of blood resuscitation are discussed. The best available evidence and the authors' collective experience inform this article.
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Affiliation(s)
- Chris Evans
- Trauma Services, Department of Emergency Medicine, Queen's University, Kingston General Hospital, Victory 3, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - David O Quinlan
- Division of Emergency Medicine, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, 2nd Floor McMaster Clinic, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - Paul T Engels
- Trauma, General Surgery and Critical Care, Department of Surgery, McMaster University, Hamilton General Hospital, 6 North Wing - Room 616, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada; Department of Critical Care, McMaster University, Hamilton General Hospital, 6 North Wing - Room 616, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, 2nd Floor McMaster Clinic, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
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Multicenter retrospective study of noncompressible torso hemorrhage: Anatomic locations of bleeding and comparison of endovascular versus open approach. J Trauma Acute Care Surg 2017. [PMID: 28632581 DOI: 10.1097/ta.0000000000001530] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management. METHODS This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess, <-4) or truncal operation in 90 minutes or less, or pelvic fracture with ring disruption. Exclusion criteria include isolated hip fractures, falls from standing, or prehospital cardiopulmonary resuscitation. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, Injury Severity Score, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. RESULTS Five hundred forty-three patients with NCTH underwent ENDO (n = 166, 31%), OPEN (n = 309, 57%), or RT (n = 68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, whereas OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs. 34% vs. 32%); severe injuries (median Injury Severity Score, 34 vs. 27 vs. 21), and increased time to intervention (median, 298 vs. 92 vs. 51 minutes) compared with OPEN and RT. Mortality was 15% versus 20% versus 79%. ENDO was associated with decreased mortality compared to OPEN (relative risk, 0.58; 95% confidence interval, 0.46-0.73). CONCLUSION Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. LEVEL OF EVIDENCE Therapeutic, level V.
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Impact of early operative pelvic fixation on long-term self-reported outcome following severe pelvic fracture. J Trauma Acute Care Surg 2017; 82:444-450. [DOI: 10.1097/ta.0000000000001346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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