Damage control in the abdomen and beyond

Effectiveness of a thrombin-gelatin flowable for treating severe liver bleeding: an experimental study

BACKGROUND

Current scientific evidence has pointed out the relevance of hemostatic products for improving clinical outcomes in liver trauma, including increased survival rates and reductions in bleeding-related complications. The purpose of this study was to compare the use of the gelatin-thrombin flowable (Flowable) versus the standard technique of Packing in a new experimental liver injury model.

METHODS

Twenty-four swine were prospectively randomized to receive either Flowable or standard packing technique. We used a novel severe liver injury model, in which the middle and left suprahepatic veins were selectively injured, causing an exsanguinating hemorrhage. The main outcome measure was the percentage of lost blood volume.

RESULTS

The median total percentage of total blood volume per animal lost, from injury to minute 120, was significantly lower in the Flowable group (15.2%; interquartile range: 10.7-46.7%) than in the Packing group (64.9%; Interquartile range: 53.4-73.0%) (Hodges-Lehmann median difference: 41.1%; 95% CI: 18.9-58.0%, p = 0.0034). The 24-hour survival rate was significantly higher in the Flowable group (87.0%) than in the Packing group (0.0%) (Hazard ratio (HR) 0.08; 95% confidence interval 0.102 to 0.27; p < 0.0001). Mean-arterial pressure was significantly lower at minute 60 and 120 in the Flowable group than in the packing group (p = 0.0258 and p = 0.0272, respectively). At minute 120, hematocrit was higher in the Flowable than in the packing group (Hodges-Lehmann median difference: 5.5%; 95%CI: 1.0 to11.0, p = 0.0267). Finally, the overall-surgical-procedure was significantly shorter with Flowable than with Packing (Hodges-Lehmann median difference: 39.5 s, 95% CI: 25.0 to 54.0 s, p = 0.0004).

CONCLUSIONS

The use of the Flowable was more effective in achieving hemostasis, reducing blood loss, and improving survival rates than standard packing in a severe porcine-liver bleeding model.

OUP accepted manuscript

Despite well-established clinical guidelines and use of radiologic imaging for diagnosis, challenges are faced when accurate decisions must be made within seconds. Patients with life-threatening injuries represent 10–15% of all hospitalized trauma patients. In fact, 20% of abdominal injuries will require surgical intervention. In abdominal trauma, it is important to distinguish the difference between surgical intervention, which includes damage control procedures and definitive treatment. The main objective of damage control surgery is to control the bleeding, reduce the contamination and delay additional surgical stress at a time of physiological vulnerability of the patient, along with abdominal containment, visceral protection and avoiding aponeurotic retraction in situations where primary abdominal closure is not possible. However, this technique has high morbidity and comes with a myriad of complications, including development of catastrophic abdomen and formation of enterocutaneous fistulas.

Depacked patients who underwent a shortened perihepatic packing for severe blunt liver trauma have a high survival rate: 20 years of experience in a level I trauma center

INTRODUCTION

Non-operative management is currently the preferred approach in blunt liver trauma, including high grade liver lesions. However, hemodynamic instability imposes the need for an emergency laparotomy, with a perihepatic packing (PHP) to control liver bleeding in most cases. Our retrospective study aimed to assess the outcomes of liver trauma patients who underwent a shortened PHP.

METHODS

All consecutive patients who underwent PHP for blunt liver trauma from 1998 to 2019 in our Level I trauma center were included in the study. Unstable patients with severe liver trauma were transferred to the operating room without any delay, and a collective decision was made to perform abbreviated laparotomy to pack the liver. Demographics, perioperative data, postoperative outcomes, and mortality were retrospectively collected, and survivors and deceased patients were compared with a paired t-test.

RESULTS

Fifty-nine patients of 206 patients admitted with severe liver injuries were treated with shortened PHP. Thirty-four (57.6%) patients died, including 26 (76.5%) within the first 24 h. Twelve (20.3%) patients had a selective hepatic embolization and eight (13.6%) had an extrahepatic embolization. Forty-eight patients had an extra abdominal associated injury. This was not a predictive factor of mortality. The removal of packing was performed in 24 patients within 72 h after laparotomy, with an 80% survival rate in these patients.

CONCLUSION

Shortened PHP is an effective strategy for controlling liver bleeding in severe hepatic trauma. The mortality rate of these patients is high, but after the removal of packing, the survival is good.

An Overview of Gastroduodenal Perforation

Gastroduodenal perforation may be spontaneous or traumatic and the majority of spontaneous perforation is due to peptic ulcer disease. Improved medical management of peptic ulceration has reduced the incidence of perforation, but still remains a common cause of peritonitis. The classic sub-diaphragmatic air on chest x-ray may be absent and computed tomography scan is a more sensitive investigation in the stable patient. The management of perforated peptic ulcer disease is still a subject of debate. The majority of perforated peptic ulcers are caused by Helicobacter pylori, so definitive surgery is not usually required. Perforated peptic ulcer is an indication for operation in nearly all cases except when the patient is asymptomatic or unfit for surgery. However, non-operative management has a significant incidence of intra-abdominal abscesses and sepsis. Primary closure is achievable in traumatic perforation, but the management follows the Advanced Trauma Life Support (ATLS) principles.

[Vascular injuries during urologic surgery]

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

Successful management of catastrophic peripheral vascular hemorrhage using massive autotransfusion and damage control surgery in a dog

OBJECTIVE

To describe a case of massive transfusion using unwashed, non-anticoagulated, nonsterile autologous blood in a dog with catastrophic hemorrhage from a peripheral vessel during orthopedic surgery. A damage control surgical strategy was also employed.

CASE SUMMARY

A 6-year-old, 48 kg neutered male Labrador Retriever experienced massive hemorrhage after transection of a large blood vessel while undergoing femoral head and neck osteotomy. Blood was collected from clean, but not sterile, suction canisters and clots were skimmed off. The blood was then transfused back to the dog using a standard in-line blood filter. Approximately 58% of the dog's blood volume was autotransfused in less than 2 hours, thereby meeting the criteria for massive transfusion. Surgery was aborted after hemostasis was achieved by ligation of the vessel and packing of the surgical site. Two units of fresh frozen plasma were administered postoperatively due to the development of a coagulopathy. Hemoglobinuria developed but resolved within 18 hours. Three days later, completion of the surgical procedure was performed without incident. The dog was discharged 4 days after the initial surgery. Marked swelling of the affected limb developed, but resolved after the sixth day. No other significant complications developed.

NEW OR UNIQUE INFORMATION PROVIDED

In this case report, the authors describe the successful management of catastrophic hemorrhage with autotransfusion performed in the absence of sterile collection, cell washing, or anticoagulation. Although not ideal, autotransfusion under these conditions can be lifesaving in situations of massive hemorrhage. This case also highlighted the employment of a damage control surgical strategy.

Vascular Injury During Urologic Surgery: Somebody Call My Mother

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Damage control surgery: current state and future directions

PURPOSE OF REVIEW

Damage control surgery (DCS) represents a staged surgical approach to the treatment of critically injured trauma patients. Originally described in the context of hepatic trauma and postinjury-induced coagulopathy, the indications for DCS have expanded to the management of extra abdominal trauma and to the management of nontraumatic acute abdominal emergencies. Despite being an accepted treatment algorithm, DCS is based on a limited evidence with current concerns of the variability in practice indications, rates and adverse outcomes in poorly selected patient cohorts.

RECENT FINDINGS

Recent efforts have attempted to synthesize evidence-based indication to guide clinical practice. Significant progress in trauma-based resuscitation techniques has led to improved outcomes in injured patients and a reduction in the requirement of DCS techniques.

SUMMARY

DCS remains an important treatment strategy in the management of specific patient cohorts. Continued developments in early trauma care will likely result in a further decline in the required use of DCS in severely injured patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

Diverse coagulopathies in a rabbit model with different abdominal injuries

BACKGROUND

Although coagulopathy can be very common in severe traumatic shock patients, the exact incidence and mechanism remain unclear. In this study, a traumatic shock rabbit model with special abdomen injuries was developed and evaluated by examining indicators of clotting and fibrinolysis.

METHODS

Forty New Zealand white rabbits were randomly divided into four groups: group 1 (sham), group 2 (hemorrhage), group 3 (hemorrhage-liver injury), and group 4 (hemorrhage-liver injury/intestinal injury-peritonitis). Coagulation was detected by thromboelastography before trauma (T₀), at 1 hour (T₁) and 4 hours (T₂) after trauma.

RESULTS

Rabbits that suffered from hemorrhage alone did not differ in coagulation capacity compared with the sham group. The clot initiations (R times) of group 3 at T₁ and T₂ were both shorter than those of groups 1, 2, and 4 (P<0.05). In group 4, clot strength was decreased at T₁ and T₂ compared with those in groups 1, 2, and 3 (P<0.05), whereas the R time and clot polymerization were increased at T₂ (P<0.05). The clotting angle significantly decreased in group 4 compared with groups 2 and 3 at T₂ (P<0.05).

CONCLUSION

This study suggests that different abdominal traumatic shock show diverse coagulopathy in the early phase. Isolated hemorrhagic shock shows no obvious effect on coagulation. In contrast, blunt hepatic injury with hemorrhage shows hypercoagulability, whereas blunt hepatic injury with hemorrhage coupled with peritonitis caused by a ruptured intestine shows a tendency toward hypocoagulability.

Trauma and critical care III: chest trauma

Patients requiring intensive care for chest trauma are often severely injured and may have suffered trauma elsewhere. The single largest cause of significant blunt chest trauma is road traffic accidents (RTAs). RTAs account for 70-80% of such injuries. Falls and acts of violence are other causative mechanisms. Blast injuries can also result in significant blunt thoracic trauma. Penetrating chest trauma comprises a broad spectrum of injuries and severity. Particular challenges occur in patients with associated polytrauma, as well as those with a combination of blunt and penetrating chest trauma. Chest injury is the most important injury in polytrauma patients with reported incidences of 45-65% and an associated mortality of up to 60%. The treatment of these patients can be prolonged and the initial injury may become of secondary importance to the effects of systemic inflammatory response syndrome, acute lung injury (ALI), nosocomial infection and intercurrent multiorgan dysfunction syndrome (MODS). Multiply-injured patients with thoracic injuries require significantly longer periods of mechanical ventilation and longer intensive care unit lengths of stay compared with nonthoracic injury trauma patients. The use of a variety of therapeutic interventions may have to be considered during management of the disease process.

Indications for Use of Damage Control Surgery in Civilian Trauma Patients: A Content Analysis and Expert Appropriateness Rating Study

OBJECTIVES

To characterize and evaluate indications for use of damage control (DC) surgery in civilian trauma patients.

BACKGROUND

Although DC surgery may improve survival in select, severely injured patients, the procedure is associated with significant morbidity, suggesting that it should be used only when appropriately indicated.

METHODS

Two investigators used an abbreviated grounded theory method to synthesize indications for DC surgery reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. An international panel of trauma surgery experts (n = 9) then rated the appropriateness (expected benefit-to-harm ratio) of the coded indications for use in surgical practice.

RESULTS

The 1107 indications identified in the literature were synthesized into 123 unique pre- (n = 36) and intraoperative (n = 87) indications. The panel assessed 101 (82.1%) of these indications to be appropriate. The indications most commonly reported and assessed to be appropriate included pre- and intraoperative hypothermia (median temperature <34°C), acidosis (median pH <7.2), and/or coagulopathy. Others included 5 different injury patterns, inability to control bleeding by conventional methods, administration of a large volume of packed red blood cells (median >10 units), inability to close the abdominal wall without tension, development of abdominal compartment syndrome during attempted abdominal wall closure, and need to reassess extent of bowel viability.

CONCLUSIONS

This study identified a comprehensive list of candidate indications for use of DC surgery. These indications provide a practical foundation to guide surgical practice while studies are conducted to evaluate their impact on patient care and outcomes.

Damage control: The modern paradigm

It is more than 20 years since the term ‘Damage control’ was introduced to describe an emerging surgical strategy of abbreviated laparotomy for exsanguinating trauma patients. This strategy of temporisation and prioritisation of physiological recovery over completeness of anatomical repair was associated with improved survival in a subset of patients with combined major vascular and multiple visceral injuries. The ensuing years saw the rapid adoption of these principles as standard of care for massively injured and physiologically exhausted patients. Resuscitation of severely injured patients has changed significantly in the last decade with the emergence of a new resuscitation paradigm termed ‘damage control resuscitation’. Originating in combat support hospitals, damage control resuscitation emphasises the primacy of haemorrhage control while directly targeting the ‘lethal triad’ of coagulopathy, acidosis, and hypothermia. Integral to damage control resuscitation is the appropriate application of damage control surgery and together they constitute the modern damage control paradigm. This review aims to discuss the modern application of damage control resuscitation and damage control surgery and to review the evidence supporting its constituent components, as well as considering deficiencies in current knowledge and areas for future research.

A report of three cases and review of the literature on rectal disruption following abdominal seatbelt trauma

Seatbelt associated blunt trauma to the rectum is a rare but well recognised injury. The exact mechanism of hollow visceral injury in blunt trauma is unclear. Stress and shear waves generated by abdominal compression may in part account for injury to gas containing structures. A 'seatbelt sign' (linear ecchymosis across the abdomen in the distribution of the lap belt) should raise the suspicion of hollow visceral injuries and can be more severe with disruption of the abdominal wall musculature. Three consecutive cases of rectal injury following blunt abdominal trauma, requiring emergency laparotomy and resection, are described. Lumbar spine injury occurred in one case and in the other two cases, there was injury to the iliac wing of the pelvis; all three cases sustained significant abdominal wall contusion or muscle disruption. Abdominal wall reconstruction and closure posed a particular challenge, requiring a multidisciplinary approach. The literature on this topic is reviewed and potential mechanisms of injury are discussed.

Damage control surgery and combat-related maxillofacial and cervical injuries: a systematic review

Damage control surgery involves rapid assessment, life-saving resuscitation, and abbreviated surgery for a patient with severe injuries. Traditionally the concept of damage control surgery has been restricted to penetrating abdominal injuries, but more recently it has been expanded to areas outside of the abdomen including the maxillofacial and neck regions. However, we know of little evidence that, when applied to injuries to the face and neck, it changes outcomes. We systematically reviewed published papers to identify those that discussed damage control in the context of combat-related trauma of the face and neck. We identified three papers that discussed the principles of managing combat-related maxillofacial injuries, all three of which were review articles that advocated the use of damage control principles in facial injuries either in isolation or as part of a multisystem approach. Anecdotal experience and opinion indicates that the concept of damage control is applicable when managing combat-related injuries of the face and neck, but no outcomes were confirmed. Further studies are required to validate the concept.

Indications for use of damage control surgery and damage control interventions in civilian trauma patients: A scoping review

BACKGROUND

Variation in the use of damage control (DC) surgery across trauma centers may partially be driven by uncertainty as to when the procedure is indicated. We sought to scope the literature on DC surgery and DC interventions, identify their reported indications, and examine the content and evidence upon which they are based.

METHODS

We searched MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and the Cochrane Library (1950-February 14, 2014) and the grey literature for original and nonoriginal citations reporting indications for DC surgery or DC interventions in civilian trauma patients.

RESULTS

Among 27,732 citations identified, we included 270 peer-reviewed articles in the scoping review. Of these, 156 (57.8%) represented original research, primarily (75.0%) cohort studies. The articles reported 1,099 indications for DC surgery and 418 indications for 15 different DC interventions. The majority of indications for DC interventions were for abdominal (56.5%) procedures, including therapeutic perihepatic packing (56.5%), temporary abdominal closure/open abdominal management (40.7%), and staged pancreaticoduodenectomy (2.8%). Most DC surgery indications were based on intraoperative findings (71.7%) and represented characteristics of the injured patient (94.5%), including their physiology (57.6%), injuries (38.9%), and/or the amount or type of resuscitation provided (14.3%). Others were dependent on characteristics of the treating surgeon (12.1%), the patient's physiologic response to trauma care (9.6%), and/or the trauma care environment (1.5%). Approximately half (49.5%) included a decision threshold (e.g., pH < X) and, while most (74.7%) were based on a single clinical finding/injury, 25.3% required the presence of multiple findings concurrently. Only 87 indications were evaluated in original research studies and only 9 by more than one study.

CONCLUSION

The vast number, varying underlying content, and lack of original research relating to indications for DC suggests that substantial uncertainty exists around when the procedure is indicated and highlights the need to establish evidence-informed consensus indications.

Damage-control techniques in the management of severe lung trauma

BACKGROUND

Damage control (DC) has improved survival from severe abdominal and extremity injuries. The data on the surgical strategies and outcomes in patients managed with DC for severe thoracic injuries are scarce.

METHODS

This is a retrospective review of patients treated with DC for thoracic/pulmonary complex trauma at two Level I trauma centers from 2006 to 2010. Subjects 14 years and older were included. Demographics, trauma characteristics, surgical techniques, and resuscitation strategies were reviewed.

RESULTS

A total of 840 trauma thoracotomies were performed. DC thoracotomy (DCT) was performed in 31 patients (3.7%). Pulmonary trauma was found in 25 of them. The median age was 28 years (interquartile range [IQR], 20-34 years), Revised Trauma Score (RTS) was 7.11 (IQR, 5.44-7.55), and Injury Severity Score (ISS) was 26 (IQR, 25-41). Nineteen patients had gunshot wounds, four had stab wounds, and two had blunt trauma.Pulmonary trauma was managed by pneumorrhaphy in 3, tractotomy in 12, wedge resection in 1, and packing as primary treatment in 8 patients. Clamping of the pulmonary hilum was used as a last resource in seven patients. Five patients returned to the intensive care unit with the pulmonary hilum occluded by a vascular clamp or an en masse ligature. These patients underwent a deferred resection within 16 hours to 90 hours after the initial DCT. Four of them survived.Bleeding from other intrathoracic sources was found in 20 patients: major vessels in nine, heart in three, and thoracic wall in nine.DCT mortality in pulmonary trauma was 6 (24%) of 25 because of coagulopathy, or persistent bleeding in 5 patients and multiorgan failure in 1 patient.

CONCLUSION

This series describes our experience with DCT in severe lung trauma. We describe pulmonary hilum clamping and deferred lung resection as a viable surgical alternative for major pulmonary injuries and the use of packing as a definitive method for hemorrhage control.

LEVEL OF EVIDENCE

Epidemiologic study, level V.

The management of retroperitoneal haematoma discovered at laparotomy for trauma

AIM

To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome.

METHODS

Patients with retroperitoneal haematomas (RPHs) were identified from a prospective database. Data collected included demographics, clinical presentation, zones and organs involved, management and outcome.

RESULTS

Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of whom were male (M:F=15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was 7h. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty-four patients (17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median injury severity score (ISS) was 9. Fifty-two patients (36%) developed complications and 26 (18%) patients died. Sixty-four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were explored; Zones II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%, 29% and 35%, respectively. Mortality was highest for blunt trauma and lowest for stabs (p=0.146). Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p<0.0001). Eighteen of 64 patients with <6-h delay before surgery died (28%) compared to 8 of 81 (10%) with >6-h delay (p<0.017). Mortality increased with increasing ISS. Median hospital stay was 8 days.

CONCLUSION

RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay before surgery and ISS showed a significant association with mortality.

Surgical management and outcome of blunt major liver injuries: experience of damage control laparotomy with perihepatic packing in one trauma centre

INTRODUCTION

This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries.

MATERIALS AND METHODS

From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05.

RESULTS

Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005).

CONCLUSIONS

The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.

Damage control in the injured patient

The damage control concept is an essential component in the management of severely injured patients. The principles in sequence are as follows: (1) abbreviated surgical procedures limited to haemorrhage and contamination control; (2) correction of physiological derangements; (3) definitive surgical procedures. Although originally described in the management of major abdominal injuries, the concept has been extended to include thoracic, vascular, orthopedic, and neurosurgical procedures, as well as anesthesia and resuscitative strategies.

Intra-operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock

We assessed acidosis, coagulopathy and hypothermia, before and after surgery in 51 combat troops operated on for severe blast injury. Patients were transfused a median (IQR [range]) of 27 (17-38 [5-84]) units of red cell concentrate, 27 (16-38 [4-83]) units of plasma, 2.0 (0.5-3.5 [0-13.0]) units of cryoprecipitate and 4 (2-6 [0-17]) pools of platelets. The pH, base excess, prothrombin time and temperature increased: from 7.19 (7.10-7.29 [6.50-7.49]) to 7.45 (7.40-7.51 [7.15-7.62]); from -9.0 (-13.5 to -4.5 [-28 to -2]) mmol.l⁻¹ to 4.5 (1.0-8.0 [-7 to +11]) mmol.l⁻¹; from 18 (15-21 [9-24]) s to 14 (11-18 [9-21]) s; and from 36.1 (35.1-37.1 [33.0-38.1]) °C to 37.4 (37.0-37.9 [36.0-38.0]) °C, respectively. Contemporary intra-operative resuscitation strategies can normalise the physiological derangements caused by haemorrhagic shock.

Evaluation of military trauma system practices related to damage-control resuscitation

BACKGROUND

The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with the acceptance of evidence-based practices and decreases in trauma practice variability.

METHODS

The current evaluation was designed as a single time-series quasi-experimental study as a preanalysis and postanalysis relative to the implementation of clinical practice guidelines and process improvement interventions. Data captured from patients admitted to hospital-level (Level III) military treatment facilities in Iraq and Afghanistan from 2003 to 2010 were retrospectively analyzed from the Joint Theater Trauma Registry (JTTR) to determine the potential impact of process improvement initiatives on clinical practice.

RESULTS

The JTTS clinical practice guidelines for massive transfusion led to increased compliance with balanced component transfusion and decreased practice variability. During the course of the evaluation period, hypothermia on presentation decreased dramatically after the publication of the hypothermia prevention and management clinical practice guideline.

CONCLUSION

Developed metrics demonstrate that evidence-based quality improvement initiatives disseminated through the JTTS were associated with improved clinical practice of resuscitation following battlefield injury.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies

Trauma resulting in hemorrhage from vascular disruption within the torso is a challenging scenario, with a propensity to be lethal in the first hour following trauma. The term noncompressible torso hemorrhage (NCTH) was only recently coined as part of contemporary studies describing the epidemiology of wounding during the wars in Afghanistan and Iraq. This article provides a contemporary review of NCTH, including a unifying definition to promote future study as well as a description of resuscitative and operative management strategies to be used in this setting, and sets a course for research to improve mortality following this vexing injury pattern.

Management of cirrhotic patients with blunt abdominal trauma: analysis of risk factor of postoperative death with the Model for End-Stage Liver Disease score

INTRODUCTION

The aim of this retrospective study is to analyse the risk factors of mortality in cirrhotic patients with blunt abdominal trauma (BAT) underwent laparotomy and the value of the Model for End-Stage Liver Disease (MELD) score to predict postoperative death is determined.

MATERIALS AND METHODS

From July 1993 to June 2005, 34 cirrhotic patients with BAT were reviewed. Data are presented as mean ± standard deviation (SD), frequency (percentage), or Pearson correlation coefficient. Predictors were compared by uni- and multiple logistic regression analysis and results were considered statistically significant if P<0.05. The prognostic value of the MELD score in predicting postoperative death was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 34 patients (27 men, 7 women; mean age, 49 years), the Injury Severity Score (ISS) ranged from 4 to 43 (mean: 14). Of the 34 patients, 12 were treated with nonoperative management (NOM) initially and 4 succeeded and 30 patients (88.2%) eventually required laparotomy. Of the 30 operative patients, 7 died of haemorrhagic shock and the other 6 died of multiple organ failure with a 43.3% mortality rate. Of the 17 survivors after laparotomy, 4 developed intra-abdominal complication, and 3 developed extra-abdominal complication with a 41.2% morbidity rate. On univariate analysis, the significant predictors of surgical mortality were shock at emergency department, damage control laparotomy, ISS and MELD score. On multiple logistic regression analysis, the significant predictors of operative mortality were shock at ED (P=0.021) and MELD score (P=0.012). Analysis by ROC curve identified cirrhotic patients with a MELD score equal to or above 17 as the best cut-off value for predicting postoperative death.

CONCLUSIONS

Liver cirrhosis with BAT has a high operative rate, low salvage rate of NOM, high surgical mortality and morbidity rate. The MELD score can accurately predict postoperative death and a MELD score equal to or above 17 of our data is at high risk of postoperative death.

Targeted resuscitation improves coagulation and outcome

BACKGROUND

Acute trauma coagulopathy in seriously injured casualties may be initiated by tissue hypoperfusion. A targeted (or novel hybrid [NH]) resuscitation strategy was developed to overcome poor tissue oxygen delivery associated with prolonged hypotension.

METHODS

Under the Animals (Scientific Procedures) Act 1986, terminally anesthetized large white pigs were divided into four groups (n = 6). Groups 1 and 2 received blast injury and 3 and 4 no blast (sham). All were given a controlled hemorrhage (35% blood volume) and an uncompressed grade IV liver injury. Five minutes later, all were resuscitated with 0.9% saline to a systolic arterial pressure (SAP) of 80 mm Hg. After 60 minutes, the NH groups (1 and 3) were resuscitated to a SAP (110 mm Hg), whereas hypotensive groups (2 and 4) continued with SAP 80 mm Hg for up to 8 hours from onset of resuscitation.

RESULTS

Mean survival time was shorter in group 2 (258 minutes) compared with groups 1, 3, and 4 (452 minutes, 448 minutes, and 369 minutes). By the end of the study, hypotension was associated with a significantly greater prothrombin time (1.73 ± 0.10 and 1.87 ± 0.15 times presurgery, groups 2 and 4) compared with NH (1.44 ± 0.09 and 1.36 ± 0.06, groups 1 and 3, p = 0.001). Blast versus sham had no significant effect on prothrombin time (p = 0.56). Peak levels of interleukin 6 were significantly lower in NH groups. Arterial base excess was significantly lower with hypotension (-18.4 mmol/L ± 2.7 mmol/L and -12.1 mmol/L ± 3.2 mmol/L) versus NH (-3.7 mmol/L ± 2.8 mmol/L and -1.8 mmol/L ± 1.8 mmol/L, p = 0.0001). Hematocrit was not significantly different between groups (p = 0.16).

CONCLUSION

Targeted resuscitation (NH) attenuates the development of acute trauma coagulopathy and systemic inflammation with improved tissue perfusion and reduced metabolic acidosis in a model of complex injury. This emphasizes the challenge of choosing a resuscitation strategy for trauma patients where the needs of tissue perfusion must be balanced against the risk of rebleeding during resuscitation.

A quarter century experience in liver trauma: a plea for early computed tomography and conservative management for all hemodynamically stable patients

BACKGROUND

Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome.

METHODS

A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010).

RESULTS

395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P = 0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis.

CONCLUSIONS

Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver trauma.

Resuscitation and coagulation in the severely injured trauma patient

Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.

Operational critical care. Intensive care and trauma

Trauma management involves good prehospital, emergency, surgical, anaesthetic and intensive care decision-making. Optimal outcome depends on keeping abreast of the latest thinking in an ever-changing and increasingly technology-rich environment. The intensive care unit needs to represented as early as possible in the damage-control resuscitation phase. Improved trauma system care has resulted in an increasing number of multiply injured military patients surviving their initial trauma. These patients require intensive care and are at risk from sepsis and multiple organ failure. Attention to detail is important, preservation of organ function, infection control and nutrition to maintain muscle strength allowing normal metabolic function to return. Multiply injured patients often require lengthy periods of mechanical ventilation and a variety of therapeutic interventions may have to be considered during management of the disease process. As we are now seeing more survivors in the military trauma system the focus now needs to be morbidity reduction in order for these survivors to be best prepared for their rehabilitation phase of care.

Current management of hepatic trauma

With the shift toward nonoperative management, most hepatic injuries are managed nonoperatively. On the other hand, up to two-thirds of high-grade hepatic injuries require laparotomy; these cases are technically difficult and challenging. Damage-control approaches, understanding of liver anatomy, and advances in technology have dramatically changed the approach to hepatic trauma, with improved outcomes. Anatomic or nonanatomic liver resection is required in 2% to 5% of liver injuries. Mortality with liver injury following resection is 9% with current advances.

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

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

Management of ongoing arterial haemorrhage after damage control laparotomy: optimal timing and efficacy of transarterial embolisation

INTRODUCTION

Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome.

MATERIALS AND METHODS

From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage=7, extra-hepatic haemorrhage=9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries.

RESULTS

There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery (n=6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury=1, lumbar artery injury=1). Of 16 patients overall, profound haemorrhagic shock (n=4) and multiple organ failure (n=4) resulted in eight deaths (hepatic injury=4, extra-hepatic injury=4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min).

CONCLUSIONS

TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.

Emergency and urgent surgery

Patients presenting with general surgical emergencies are hypovolemic, and require early aggressive resuscitative efforts. Although these efforts may safely be accomplished preoperatively in a select subset of patients, it is often the combined task of surgeons, anesthesiologists, and internists to optimize these critically ill patients in the intraoperative and postoperative period. Early surgical consultation and intervention can be lifesaving. This article presents the current state of emergency surgical care in the United States and the approach to the patient with an emergency surgical illness. The aggressiveness of the surgical intervention is patient- and disease-specific and requires frequent and open communication between all health care providers, the patient, and his or her family. In addition to aggressive resuscitation, life-threatening general surgical conditions often require specific diagnostic and therapeutic interventions.

Current trends in resuscitation strategy for the multiply injured patient

The ideal resuscitation strategy for multiply injured patients remains a topic of ongoing debate. At present, no consensus has been reached on the ideal fluid for early resuscitation and on the threshold for blood product transfusions. The concept of "permissive hypotension" for bleeding trauma patients furthermore contributes to the controversy in the field, particularly as it relates to blunt trauma and to patients with associated head injuries. Finally, postinjury coagulopathy is a poorly defined entity, and current resuscitation strategies lack strong evidence-based scientific support. This review article provides a brief overview of the existing resuscitation protocols for multiply injured patients, including ATLS and "damage control", and will address developing controversies in the field.

Emergency and urgent surgery

Patients presenting with general surgical emergencies are hypovolemic, and require early aggressive resuscitative efforts. Although these efforts may safely be accomplished preoperatively in a select subset of patients, it is often the combined task of surgeons, anesthesiologists, and internists to optimize these critically ill patients in the intraoperative and postoperative period. Early surgical consultation and intervention can be lifesaving. This article presents the current state of emergency surgical care in the United States and the approach to the patient with an emergency surgical illness. The aggressiveness of the surgical intervention is patient- and disease-specific and requires frequent and open communication between all health care providers, the patient, and his or her family. In addition to aggressive resuscitation, life-threatening general surgical conditions often require specific diagnostic and therapeutic interventions.

Injuries to the Pancreaticoduodenal Complex

Injuries to the pancreaticoduodenal complex present a significant challenge both in diagnosis and management. The retroperitoneal location of the pancreas means that it is not a common site of injury, but this also contributes to the difficulty in diagnosis, as the organ is concealed, and investigation often results in delay with its attendant increase in morbidity. The increase in violence in society, particularly of penetrating injuries and the increase in energy of wounding from gunshots, has made pancreatic injury more common. In many cases the surgical management is relatively simple, but occasionally complex and technical surgical solutions are necessary and the position of the pancreas makes its access and all procedures on it challenging. To compound this, pancreatic trauma is associated with a high incidence of injury to adjoining organs and major vascular structures, which adds to the high morbidity and mortality, and complications occur in 30-60% of patients [1, 2].

[Current treatment of hepatic trauma]

The therapeutic and diagnostic approach of liver trauma injuries (by extension, of abdominal trauma) has evolved remarkably in the last decades. The current non-surgical treatment in the vast majority of liver injuries is supported by the accumulated experience and optimal results in the current series. It is considered that the non-surgical treatment of liver injuries has a current rate of success of 83-100%, with an associated morbidity of 5-42%. The haemodynamic stability of the patient will determine the applicability of the non-surgical treatment. Arteriography with angioembolisation constitutes a key technical tool in the context of liver trauma. Patients with haemodynamic instability will need an urgent operation and can benefit from abdominal packing techniques, damage control and post-operative arteriography. The present review attempts to contribute to the current, global and practical management in the care of liver trauma.

Continuous retention suture for the management of open abdomen: a high rate of delayed fascial closure

BACKGROUND AND AIMS

Open abdomen is most often a consequence of damage control surgery, abdominal decompression or intra-abdominal infections. Ventral hernia after unsuccessful closure of open abdomen causes marked disability to the patient. Several methods for delayed fascial closure have been developed. Patients treated with continuous retention suture were evaluated to find out how often fascial closure was achieved, and what complications were related to the technique.

METHOD

A retrospective analysis of 16 open abdomen patients treated with continuous retention suture.

RESULTS

The most common cause of open abdomen was abdominal infection. Complete fascial closure was achieved in nine of the eleven surviving patients. Closure failed in one patient. Partial closure was also achieved in one patient. The median time between leaving the abdomen open and starting the process of closure was twelve days. The longest period of open abdomen before successful fascial closure was 29 days. Five patients died before the process of closure was complete.

CONCLUSION

Delayed fascial closure can be accomplished by using the retention suture method described here.