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Seo D, Heo I, Choi D, Jung K, Jung H. Efficacy of direct-to-operating room trauma resuscitation: a systematic review. World J Emerg Surg 2024; 19:3. [PMID: 38238854 PMCID: PMC10795202 DOI: 10.1186/s13017-023-00532-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/26/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility. METHODS The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest. RESULTS We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR. CONCLUSION Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency.
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Affiliation(s)
- Dongmin Seo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Inhae Heo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Donghwan Choi
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hohyung Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea.
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Ntola VC, Hardcastle TC. Diagnostic Approaches to Vascular Injury in Polytrauma-A Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13061019. [PMID: 36980328 PMCID: PMC10046960 DOI: 10.3390/diagnostics13061019] [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: 02/13/2023] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Polytrauma is understood as significant injuries, occurring at the same time, to two or more anatomical regions (the ISS regions) or organ systems, with at least one of the injuries considered as posing a threat to life. Trauma is the main cause of unexpected demise in individuals below the age of 44 years and represents a huge burden on society. Vascular injury is highly morbid; it can lead to rapid exsanguination and death, posing a threat to both life and the limb. Independent predictors of outcome include mechanism of injury, associated injuries, and time from injury to definitive care. The mechanisms of vascular injury in the setting of polytrauma are either blunt, penetrating or a combination of the two. METHODS Comprehensive literature review of current diagnostic approaches to traumatic vascular injury in the context of polytrauma. The factors influencing the diagnostic approach are highlighted. The focus is the epidemiology of vascular injury and diagnostic approaches to it in the context of polytrauma. RESULTS Traumatic vascular injuries are associated with limb loss or even death. They are characterised by multiple injuries, the dilemma of the diagnostic approach, timing of intervention and higher risk of limb loss or death. The systematic approach in terms of clinical diagnosis and imaging is crucial in order save life and preserve the limb. The various diagnostic tools to individualise the investigation are discussed. CONCLUSION This paper highlights the significance of timely and appropriate use of diagnostic tools for traumatic vascular trauma to save life and to preserve the limb. The associated injury also plays a crucial role in deciding the imaging modalities. At times, more than one investigation may be required.
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Affiliation(s)
- Vuyolwethu C Ntola
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban 4058, South Africa
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban 4058, South Africa
- Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
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Ernstberger A, Reske SU, Brandl A, Kulla M, Huber-Wagner S, Popp D, Kerschbaum M, Dendl LM, Braunschweig R, Schreyer AG. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. ROFO-FORTSCHR RONTG 2021; 194:505-514. [PMID: 34911138 DOI: 10.1055/a-1682-7377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire. MATERIALS AND METHODS Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected. RESULTS With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %). CONCLUSION Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers. KEY POINTS · This is the first study on the diagnostic reality of radiology in severely injured patients in Germany. Despite a high level of standardization, significant differences were observed.. CITATION FORMAT · Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1682-7377.
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Affiliation(s)
- Antonio Ernstberger
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Osnabrücker Zentrum für muskuloskelettale Chirurgie (OZMC), Klinikum Osnabrück GmbH, Osnabrueck, Germany
| | - Stefan Ulrich Reske
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Heinrich-Braun-Klinikum gemeinnützige GmbH, Zwickau, Germany
| | - Alexandra Brandl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Germany
| | - Martin Kulla
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Ulm, Germany
| | - Stefan Huber-Wagner
- Klinik für Unfallchirurgie, Wirbelsäulenchirurgie, Alterstraumatologie, Diakonie-Klinikum Schwäbisch Hall gGmbH, Schwabisch Hall, Germany
| | - Daniel Popp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Germany
| | | | - Lena Marie Dendl
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a.d. Havel, Germany
| | - Rainer Braunschweig
- Direktor (em.) der Klinik für Bildgebende Diagnostik und Interventionsradiologie BG-Klinik Bergmannstrost Halle/S., Vorstandsmitglied der AG MSK der DRG, BG Klinikum Bergmannstrost Halle, 10587 Berlin, Germany
| | - Andreas G Schreyer
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a.d. Havel, Germany
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Khoo CY, Liew TYS, Mathur S. Systematic review of the efficacy of a hybrid operating theatre in the management of severe trauma. World J Emerg Surg 2021; 16:43. [PMID: 34454553 PMCID: PMC8403370 DOI: 10.1186/s13017-021-00390-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hybrid operating theatres (OT) allow for simultaneous interventional radiology and operative procedures, serving as a one-stop facility for the treatment of severely injured patients. Several countries have adopted the use of the hybrid OT however their clinical impact in improving efficiency and quality of care remains unclear. This study systematically reviews the clinical impact of the hybrid OT for treatment of the severely injured. Methods A literature review of the PubMed, Embase and Cochrane databases was performed to identify all published articles in English, from 1st January 2000 to 31st December 2020, reporting on the impact of a hybrid OT for severe trauma. Articles were also reviewed for references of interest. Results Five studies reporting the clinical impact of the hybrid OT, in a total of 951 patients, were shortlisted. All were cohort studies that compared patient outcomes in the hybrid OT versus a conventional group. Out of 3 studies that assessed timeliness to intervention, one reported shorter time associated with the hybrid OT, while the other two reported no difference. Mortality outcomes were reported in 4 studies and showed no significant difference associated with treatment in the hybrid OT. Two studies revealed shorter total procedure times associated with the hybrid OT. Two out of 3 studies that evaluated blood transfusion requirements reported decreased transfusion rates in the hybrid OT group. Only 1 study examined complication rates and demonstrated morbidity benefits associated with the hybrid OT. Conclusion Establishment of a hybrid OT requires a significant capital investment as well as a highly functioning multi-disciplinary team. The cost–benefit ratio remains unclear. Future studies, preferably in the form of clinical trials, are required to evaluate its usefulness in improving timeliness to definitive haemorrhage control and outcomes in severe trauma.
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Affiliation(s)
- Chun Yuet Khoo
- Department of General Surgery, Singapore General Hospital, 20 College Road, Academia, Singapore, 169856, Singapore.
| | - Terence Yi Song Liew
- Department of General Surgery, Singapore General Hospital, 20 College Road, Academia, Singapore, 169856, Singapore
| | - Sachin Mathur
- Department of General Surgery, Singapore General Hospital, 20 College Road, Academia, Singapore, 169856, Singapore
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Mader MMD, Rotermund R, Lefering R, Westphal M, Maegele M, Czorlich P. The faster the better? Time to first CT scan after admission in moderate-to-severe traumatic brain injury and its association with mortality. Neurosurg Rev 2020; 44:2697-2706. [PMID: 33340052 PMCID: PMC8490239 DOI: 10.1007/s10143-020-01456-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Fast acquisition of a first computed tomography (CT) scan after traumatic brain injury (TBI) is recommended. This study is aimed at investigating whether the length of the period preceding initial CT scan influences mortality in patients with leading TBI. A retrospective cohort analysis of patients registered in the TraumaRegister DGU® was conducted including adult patients with TBI, defined as Abbreviated Injury ScaleHead ≥ 3 and GCS ≤ 13 who had been treated in level 1 or 2 trauma centers from 2007-2016. Patients were grouped according to time intervals either from trauma or from admission to CT. A total of 6904 patients met the inclusion criteria. Mean time period from trauma to hospital admission was 68.8 min. From admission to first CT, a mean of 19.0 min elapsed. Trauma severity was higher in groups with a longer duration from trauma to CT as represented by a mean (± standard deviation) Injury Severity Score (ISS) of 19.8 ± 9.0, 20.7 ± 9.3, and 21.4 ± 7.5 and similar distribution of mortality of 24.9%, 29.9%, and 36.3% in the ≤ 60-min, 61-120-min, and ≥ 121-min groups, respectively. An adjusted multivariable logistic regression model showed a significant influence of the level of the trauma center (p = 0.037) but not for interval from admission to CT (p = 0.528). TBI patients with a longer time span from trauma to first CT were more severely injured and demonstrated a worse prognosis, but received a CT scan faster when duration from admission is observed. The duration until the CT scan was obtained showed no significant impact on the mortality.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany.,Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Detailed information gain and therapeutic impact of whole body computed tomography supplementary to conventional radiological diagnostics in blunt trauma emergency treatment: a consecutive trauma centre evaluation. Eur J Trauma Emerg Surg 2020; 48:921-931. [PMID: 32997166 PMCID: PMC9001527 DOI: 10.1007/s00068-020-01502-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/15/2020] [Indexed: 12/03/2022]
Abstract
Purpose The indication of whole body computed tomography (WBCT) in the emergency treatment of trauma is still under debate. We were interested in the detailed information gain obtained from WBCT following standardized conventional imaging (CI). Methods Prospective study including all emergency trauma centre patients examined by CI (focused assessment of sonography in trauma, chest and pelvic X-ray) followed by WBCT from 2011 to 2017. Radiology reports were compared per patient for defined body regions for number and severity of injuries (Abbreviated Injury Scale, AIS; Injury Severity Score, ISS), incidental findings and treatment consequences (Wilcoxon signed rank test, Spearman rho, Chi-square). Results 1271 trauma patients (ISS 11.3) were included in this study. WBCT detected more injury findings than CI in the equivalent body regions (1.8 vs. 0.6; p < 0.001). In 44.4% of cases at least one finding was missed by CI alone. Compared to WBCT, injury severity of specified body regions was underestimated by CI on average by an AIS of 1.9 (p < 0.001). In 22.0% of cases injury severity increased by an AIS ≥ 2 following WBCT. In 16.8% of patients additional injury findings resulted in a change of treatment (number needed to profit, NNP = 6 patients): NNP decreased from 25 for patients with an ISS < 7 up to nearly 2 for patients with an ISS > 25 at final evaluation, thereby demonstrating a significant improvement in the NNP with increasing ISS (rho = 0.33, p < 0.001). Moreover, WBCT in 88.4% of patients identified ≥ 1 incidental finding (mean 3.4) vs. 28.9% by CI only (p < 0.001). Overall, WBCT had treatment consequences in 31.9% of cases (NNP = 3.1). Conclusions The application of WBCT in addition to CI in the emergency treatment of trauma had therapy consequences for almost every third patient. On the other hand, WBCT appeared not to be indicated (ISS < 8) in at least 2/5 of patients. Electronic supplementary material The online version of this article (10.1007/s00068-020-01502-1) contains supplementary material, which is available to authorized users.
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Minnella EM, Awasthi R, Loiselle SE, Agnihotram RV, Ferri LE, Carli F. Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial. JAMA Surg 2019; 153:1081-1089. [PMID: 30193337 DOI: 10.1001/jamasurg.2018.1645] [Citation(s) in RCA: 259] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Preserving functional capacity is a key element in the care continuum for patients with esophagogastric cancer. Prehabilitation, a preoperative conditioning intervention aiming to optimize physical status, has not been tested in upper gastrointestinal surgery to date. Objective To investigate whether prehabilitation is effective in improving functional status in patients undergoing esophagogastric cancer resection. Design, Setting, and Participants A randomized clinical trial (available-case analysis based on completed assessments) was conducted at McGill University Health Centre (Montreal, Quebec, Canada) comparing prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. The study dates were February 13, 2013, to February 10, 2017. Main Outcomes and Measures The primary outcome was change in functional capacity, measured with absolute change in 6-minute walk distance (6MWD). Preoperative (end of the prehabilitation period) and postoperative (from 4 to 8 weeks after surgery) data were compared between groups. Results Sixty-eight patients were randomized, and 51 were included in the primary analysis. The control group were a mean (SD) age, 68.0 (11.6) years and 20 (80%) men. Patients in the prehabilitation group were a mean (SD) age, 67.3 (7.4) years and 18 (69%) men. Compared with the control group, the prehabilitation group had improved functional capacity both before surgery (mean [SD] 6MWD change, 36.9 [51.4] vs -22.8 [52.5] m; P < .001) and after surgery (mean [SD] 6MWD change, 15.4 [65.6] vs -81.8 [87.0] m; P < .001). Conclusions and Relevance Prehabilitation improves perioperative functional capacity in esophagogastric surgery. Keeping patients from physical and nutritional status decline could have a significant effect on the cancer care continuum. Trial Registration ClinicalTrials.gov Identifier: NCT01666158.
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Affiliation(s)
- Enrico M Minnella
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Rashami Awasthi
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Sarah-Eve Loiselle
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Lorenzo E Ferri
- Division of Thoracic Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
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Hietbrink F, Smeeing D, Karhof S, Jonkers HF, Houwert M, van Wessem K, Simmermacher R, Govaert G, de Jong M, de Bruin I, Leenen L. Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization. World J Emerg Surg 2019; 14:40. [PMID: 31428187 PMCID: PMC6694503 DOI: 10.1186/s13017-019-0257-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Diederik Smeeing
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Steffi Karhof
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Henk Formijne Jonkers
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Geertje Govaert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Miriam de Jong
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ivar de Bruin
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Born K, Amsler F, Gross T. Prospective evaluation of the Quality of Life after Brain Injury (QOLIBRI) score: minor differences in patients with major versus no or mild traumatic brain injury at one-year follow up. Health Qual Life Outcomes 2018; 16:136. [PMID: 29986710 PMCID: PMC6038178 DOI: 10.1186/s12955-018-0966-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023] Open
Abstract
Background The Quality of Life after Brain Injury (QOLIBRI) score was developed to assess disease-specific health-related quality of life (HRQoL) after traumatic brain injury (TBI). So far, validation studies on the QOLIBRI were only conducted in cohorts with traumatic brain injury. This study investigated the longer-term residuals in severely injured patients, focusing specifically on the possible impact of major TBI. Methods In a prospective questionnaire investigation, 199 survivors with an injury severity score (ISS) > 15 participated in one-year follow-up. Patients who had sustained major TBI (abbreviated injury scale, AIS head > 2) were compared with patients who had no or only mild TBI (AIS head ≤ 2). Univariate analysis (ANOVA, Cohen’s kappa, Pearson’s r) and stepwise linear regression analysis (B with 95% CI, R, R2) were used. Results The total QOLIBRI revealed no differences in one-year outcomes between patients with versus without major TBI (75 and 76, resp.; p = 0.68). With regard to the cognitive subscore, the group with major TBI demonstrated significantly more limitations than the one with no or mild TBI (p < 0.05). The AIS head correlated significantly with the cognitive dimension of the QOLIBRI (r = − 0.16; p < 0.05), but not with the mental components of the SF-36 or the TOP. In multivariate analysis, the influence of the severity of head injury (AIS head) on total QOLIBRI was weaker than that of injured extremities (R2 = 0.02; p < 0.05 vs. R2 = 0.04; p = 0.001) and equal to the QOLIBRI cognitive subscore (R2 = 0.03, p < 0.01 each). Conclusions Given the unexpected result of similar mean QOLIBRI total score values and only minor differences in cognitive deficits following major trauma independently of whether patients sustained major brain injury or not, further studies should investigate whether the QOLIBRI actually has the discriminative capacity to detect specific residuals of major TBI. In effect, the score appears to indicate mental deficits following different types of severe trauma, which should be evaluated in more detail. Trial registration NCT02165137; retrospectively registered 11 June 2014.
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Affiliation(s)
- Konstantin Born
- Department of Traumatology, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland
| | | | - Thomas Gross
- Department of Traumatology, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland.
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Three-in-one protocol reduces mortality of patients with haemodynamically unstable pelvic fractures—a five year multi-centred review in Hong Kong. INTERNATIONAL ORTHOPAEDICS 2018; 42:2459-2466. [DOI: 10.1007/s00264-018-3842-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/11/2018] [Indexed: 10/17/2022]
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Wulffeld S, Rasmussen LS, Højlund Bech B, Steinmetz J. The effect of CT scanners in the trauma room - an observational study. Acta Anaesthesiol Scand 2017. [PMID: 28635146 DOI: 10.1111/aas.12927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A CT scanner incorporated in the trauma resuscitation bay may benefit trauma patients by fastening work-up times; however, evidence in the area is still sparse. We assessed if time from admission to first CT scan was lower after incorporation of a CT scanner in the resuscitation bay. METHODS We included trauma patients admitted in two 1-year periods, before and after a major rebuilding of the trauma room. Beforehand, one CT scanner was located in an adjacent room. After the rebuilding, two mobile CT scanners were placed in the resuscitation bays, where a moving gantry was combined with a trauma resuscitation table. Subgroup analyses were performed on severely injured and patients with traumatic brain injury. RESULTS We included 784 patients before and 742 patients after the reconstruction. Case-mix differed between study periods as there was a higher proportion of severe injuries, traumatic brain injury and penetrating trauma in the after period. We found a minor increase in time to CT in the after period (20 vs. 21 min, P = 0.008). In a multivariate regression analysis adjusted for differences in case-mix and with time to CT as outcome, period was an insignificant explanatory variable [β (before vs. after): 0.96 min 95% CI: 0.9-1.02, P = 0.3]. In both subgroups, we found no significant difference in time to CT. CONCLUSION We found no reduction in time to CT scan, when comparing a period with mobile CT scanners incorporated in the resuscitation bay to an earlier period with a CT scanner next to the trauma room.
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Affiliation(s)
- S. Wulffeld
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - L. S. Rasmussen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - B. Højlund Bech
- Department of Diagnostic Radiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - J. Steinmetz
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Trauma Centre; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Xu J, Sisniega A, Zbijewski W, Dang H, Stayman JW, Mow M, Wang X, Foos DH, Koliatsos VE, Aygun N, Siewerdsen JH. Technical assessment of a prototype cone-beam CT system for imaging of acute intracranial hemorrhage. Med Phys 2017; 43:5745. [PMID: 27782694 DOI: 10.1118/1.4963220] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE A cone-beam CT scanner has been developed for detection and monitoring of traumatic brain injury and acute intracranial hemorrhage (ICH) at the point of care. This work presents a technical assessment of imaging performance and dose for the scanner in phantom and cadaver studies as a prerequisite to clinical translation. METHODS The scanner incorporates a compact, rotating-anode x-ray source and a flat-panel detector (43 × 43 cm2) on a mobile U-arm gantry with source-axis distance = 550 mm and source-detector distance = 1000 mm. Central and peripheral doses were measured in 16 cm diameter CTDI phantoms using a 0.6 cm3 Farmer ionization chamber for various scan techniques and as a function of longitudinal position, including out of field. Spatial resolution, contrast, noise, and image uniformity were assessed in quantitative and anthropomorphic head phantoms. Two reconstruction protocols were evaluated, including filtered backprojection (FBP) for high-resolution bone imaging and penalized weighted least squares (PWLS) reconstruction for low-contrast soft tissue (ICH) visualization. A fresh cadaver was imaged with and without simulated ICH using the scanner as well as a diagnostic multidetector CT (MDCT) scanner using a standard head protocol. Images were interpreted by a fellowship-trained neuroradiologist for imaging tasks of ICH detection, gray-white-CSF differentiation, detection of midline shift, and fracture detection. RESULTS The nominal scan protocol involved 720 projections acquired over a 360° orbit at 100 kV and 216 mAs, giving a dose (weighted CTDI) of 22.8 mGy (∼1.2 mSv effective dose). Out-of-field dose decreased to <10% within 6 cm of the field edge (approximate to the thyroid position). Image uniformity demonstrated <1% variation between the edge of the field (near the cranium) and center of the image. The high-resolution FBP reconstruction protocol showed ∼0.9 mm point spread function (PSF) full-width at half-maximum (FWHM). The smooth PWLS reconstruction protocol yielded ∼1.2 mm PSF FWHM and contrast-to-noise ratio exceeding 5.7 in ∼50 HU spherical ICH, resulting in conspicuous depiction of ICH down to ∼2 mm (the smallest diameter investigated). Cadaver images demonstrated good differentiation of brain and CSF (sufficient, but inferior to MDCT, recognizing that the CBCT dose was one-third that of MDCT), excellent visualization of cranial sutures and fracture (potentially superior to MDCT), clear detection of midline shift, and conspicuous detection of ICH. CONCLUSIONS Technical assessment of the prototype demonstrates dose characteristics and imaging performance consistent with point-of-care detection and monitoring of head injury-most notably, conspicuous detection of ICH-and supports translation of the system to clinical studies.
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Affiliation(s)
- Jennifer Xu
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205
| | - Alejandro Sisniega
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205
| | - Wojciech Zbijewski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205
| | - Hao Dang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205
| | - J Webster Stayman
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205
| | - Michael Mow
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205
| | | | | | | | - Nafi Aygun
- Russell H. Morgan Department of Radiology, Johns Hopkins University, Baltimore, Maryland 21205
| | - Jeffrey H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 21205; Russell H. Morgan Department of Radiology, Johns Hopkins University, Baltimore, Maryland 21205; Department of Computer Science, Johns Hopkins University, Baltimore, Maryland 21205; Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland 21205; and Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland 21205
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Kaczynski J, Hilton J. Trauma care services in the United Kingdom: past, present and future. J Perioper Pract 2012; 22:266-9. [PMID: 23248929 DOI: 10.1177/175045891202200804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current provision of trauma services in the United Kingdom is insufficient, resulting in a high mortality of trauma patients. Multiple studies proved that regionalisation of the trauma care can significantly reduce mortality and morbidity by avoiding unnecessary transfer and reducing delay in delivering definitive surgery. This evidence led to changes in delivering trauma care in London which showed a significant reduction in mortality from severe injuries.
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Affiliation(s)
- Jakub Kaczynski
- ABM University Health Board, General Surgery Department, Morriston Hospital, Swansea SA6 6NL.
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15
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Attenberger C, Amsler F, Gross T. Clinical evaluation of the Trauma Outcome Profile (TOP) in the longer-term follow-up of polytrauma patients. Injury 2012; 43:1566-74. [PMID: 21255778 DOI: 10.1016/j.injury.2011.01.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 01/01/2011] [Accepted: 01/04/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND No sufficiently validated disease-specific instrument is available to assess patient outcome after polytrauma. The aim of this investigation was to test the recently published Trauma Outcome Profile (TOP) in the longer-term outcome of multiply injured patients. METHODS Single centre validation study on the TOP in comparison with objective and subjective measures of patient, injury or treatment characteristics and longer-term outcome (e.g. medical outcomes study Short Form-36, SF-36; Nottingham Health Profile, NHP; working capacity), at least 2 years following trauma in 117 survivors of polytrauma (injury severity score, ISS>16), using comparative analysis and correlation testing of prospectively collected data. RESULTS Patients' mean weighted self-rating with regard to the 10 single TOP dimensions of Health Related Quality of Life (HRQoL, 0-100) ranged from lowest values for mental functioning (52.6+33.5) to highest values for daily activities (79.0+27.5). The rate of persons who indicated an abnormal level of function or pain increased significantly from pre-injury status (2% and 5%, resp.) to 46% for both values at longer-term follow-up (p<0.001). Observed associations between single dimensions or TOP component summary scores with the corresponding values from general HRQol instruments, such as the SF-36, resulted in R (Pearson) up to 0.85. Survivors of polytrauma who presented with a reduced working capacity (RWC) at longer-term follow-up in all TOP dimensions included a significantly higher rate of patients conspicuous for a relevantly reduced outcome compared with those with a non reduced working capacity (NRWC) (posttraumatic stress disease, PTSD: p<0.05; all other dimensions: p<0.001). Patients with a RWC were characterised by an almost fivefold probability of reduced outcome with regard to the TOP dimensions 'social interaction' or 'satisfaction' (odds ratio, OR 12.4 (95% CI 5.1-30.1) and 12.5 (4.0-39.0), resp.). CONCLUSIONS This first clinical and methodological evaluation in a well defined cohort of polytrauma patients found the TOP to be a reliable and well discriminating score covering both relevant general and trauma-specific aspects of longer-term outcome. Despite these promising primary results, until further validation, the TOP should be used together with already accepted HRQoL measures to allow adequate international comparison of data in the future.
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Affiliation(s)
- Corinna Attenberger
- Computer Assisted Radiology & Surgery Switzerland, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland
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Saltzherr TP, Bakker FC, Beenen LFM, Dijkgraaf MGW, Reitsma JB, Goslings JC. Randomized clinical trial comparing the effect of computed tomography in the trauma room versus the radiology department on injury outcomes. Br J Surg 2012; 99 Suppl 1:105-13. [PMID: 22441863 DOI: 10.1002/bjs.7705] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Computed tomography (CT) of injured patients in the radiology department requires potentially dangerous and time-consuming patient transports and transfers. It was hypothesized that CT in the trauma room would improve patient outcome and workflow. METHODS A randomized trial compared the effect of locating a CT scanner in the trauma room versus the radiology department in two Dutch trauma hospitals. Injured patients aged at least 16 years were assigned randomly to one of these hospitals at the time of transport. The primary outcome measure was the number of non-institutionalized days within the first year after randomization. Subgroup analyses were performed in patients with multiple trauma or severe traumatic brain injury (TBI). RESULTS Some 1124 patients were included, of whom 1045 were available for analysis. The median number of non-institutionalized days was 360 days in the intervention group versus 362 days for the control group (P = 0.068). The time from arrival to the first CT imaging was 13 min shorter in the intervention group (36 versus 49 min; P < 0.001). Patient transfers and transports were reduced by more than half in the intervention group. For both multiple trauma (265 patients) and TBI (121) subgroups, differences in mortality and out-of-hospital days favoured the intervention group, but were not statistically significant. CONCLUSION A CT scanner located in the trauma room reduces the time to acquire CT images and improves workflow, but does not lead to substantial improvements in clinical outcomes in a general trauma population. Observed beneficial effects on outcomes in patients with multiple trauma or severe TBI were not statistically significant. REGISTRATION NUMBER ISRCTN55332315 (http://www.controlled-trials.com).
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Affiliation(s)
- T P Saltzherr
- Trauma Unit, Department of Surgery, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
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Gross T, Attenberger C, Huegli RW, Amsler F. Factors associated with reduced longer-term capacity to work in patients after polytrauma: a Swiss trauma center experience. J Am Coll Surg 2010; 211:81-91. [PMID: 20610253 DOI: 10.1016/j.jamcollsurg.2010.02.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 02/10/2010] [Accepted: 02/10/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Knowledge of the factors associated with longer-term reduced capacity to work (RCW) is lacking in patients after polytrauma. STUDY DESIGN We studied a prospectively collected cohort of polytrauma survivors (n = 115; age 39.5 +/- 20.6 years [mean +/- SD]; 98% blunt trauma; Injury Severity Score [ISS] 27.5 +/- 8.2) at a university trauma center. Uni- and multivariable analyses of patient, trauma, and treatment characteristics as well as parameters of self-reported functional outcomes were studied to determine their association with a reduced capacity to work (RCW) at least 2 years after injury. RESULTS Postinjury quality of life was worse compared with preinjury status in univariate analysis (eg, Euro Quality of Life Group Visual Analogue Scale [EQ VAS] 66.2 +/- 24.4 vs 89.7 +/- 14.7; p = <0.001). In 53% of patients (n = 61), an RCW was found and functional outcomes were significantly lower than those in non-RCW patients (p < 0.001). Lower educational status (odds ratio [OR] 0.25; 95% CI 0.07 to 0.92; p = 0.036), higher ISS (OR 1.12; 95% CI 1.02 to 1.22; p = 0.017), less time in the emergency room (OR 0.92; 95% CI 0.86 to 0.97; p = 0.005), higher mean nurse labor per day and patient (OR 1.01; 95% CI 1.000 to 1.004; p = 0.033), and a reduced Nottingham Health Profile value (OR 1.10; 95% CI 1.06 to 1.15; p < 0.001) were associated with an RCW in the multiple logistic regression model (proportion of variance explained: 0.74). CONCLUSIONS In this cohort of patients surviving polytrauma, approximately 50% of patients sustained longer-term RCW. Several characteristics, such as level of education or trauma severity, showed an independent association with patients' capacity to work, which was significantly associated with patients' self-rated scorings of well-being.
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Affiliation(s)
- Thomas Gross
- Computer Assisted Radiology & Surgery Switzerland (CARCAS), University Hospital Basel, Basel, Switzerland.
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