[Management of penetrating abdominal trauma: what we need to know?]

[Ballistic wound in the pre-hospital and emergency room: Damage Control Resuscitation]

Damage Control Resuscitation (DCR) is a strategy designed to prioritize hemostasis procedures, from the point of injury to surgical management, whether faced with an influx of bleeding casualties or a single casualty with severe hemodynamic instability. Widely disseminated, it provides clear objectives for prioritizing physiological restoration to the anatomy required for short-term survival. Initially applied to surgery, DCR has now been extended to the entire upstream care chain, including first aid and emergency medicine.

Effect of the implementation of a checklist in the prehospital management of a traumatised patient

BACKGROUND

In October 2021, French acute care societies jointly published cognitive aids to standardise practices and limit cognitive biases to ensure greater safety in management of severe trauma patients. The aim of the study was to evaluate the impact of a checklist on emergency physicians' adherence to the recommendations.

METHODS

This prospective before-and-after study study took place in a French mobile emergency and resuscitation service. All adults trauma patients referred to hospital were included. A checklist on trauma management inspired by the MARCHE acronym was produced. During phase I, the checklist was performed within 24 h after the end of the intervention. During phase II, the checklist was performed during the patient's transport to hospital, thus allowing potentially omitted procedures to be performed initially. The use of the checklist was systematically evaluated using an anonymous questionnaire among doctors and nurses. In phase II, doctors and nurses who did not perform checklist were systematically asked to answer a specific online questionnaire. The primary outcome was the overall omission rate of checklist items during each phase of the study.

RESULTS

One hundred and sixteen patients were included, 53 in phase I and 63 in phase II. Eleven patients did not have a checklist in phase II. The overall omission rate of checklist items was significantly lower with checklist (17%) than without (25%) (p = 0.02). This trend increased in proportion to severity with an omission rate of 30% without checklist versus 15% with checklist (p = 0.03) for patients with an ISS ≥ 25. A majority of doctors and nurses who used the checklist considered that it should be made compulsory (82% and 67% respectively). Paradoxically, only 55% of doctors who did not perform the checklist thought it was useful, while the omission rate was significantly higher (17% with checklist compared with 59% without checklist, p < 0.01).

CONCLUSION

This work shows a significant reduction in the number of omissions on the actions carried out during the management of a trauma patient in prehospital settings, allowing better adherence to the recommendations. Its benefit is increased in severely traumatised patients.

A characterization of trauma laparotomies in a scandinavian setting: an observational study

BACKGROUND

Despite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports.

METHODS

A retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes.

RESULTS

A total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days.

CONCLUSION

The overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.

Evaluation of follow-up and long-term outcomes of gunshot and stab wounds in a French civilian population

PURPOSE

The data concerning long-term follow-up and outcomes of penetrating trauma are poorly detailed in the literature. The main objective of our study was to analyze the hospital and extra-hospital follow-up of penetrating trauma victims and to evaluate the late complications and long-term consequences of these traumas.

METHODS

This work was a retrospective longitudinal monocentric observational study conducted at Laveran Military Hospital, from January 2007 to January 2017. All patients hospitalized for gunshot wound or stab wound management during this period were identified via a retrospective systematic query in the hospital information system using the ICD-10 codes. Epidemiological data, traumatism characteristics, hospital management, follow-up and traumatism consequences (i.e., persistent disability) were analyzed. To improve evaluation of traumatism long-term consequences, extra-hospital follow-up data from general physicians (GP) were collected by phone call. During this interview, 9 closed questions were asked to the GP. The survey evaluated: the date of the last consultation related to injury with the GP, the specific follow-up carried out by the GP, traumatism consequences, and recurrence of traumatism. Descriptive, univariate and multivariate with regression analysis were used for statistical analysis.

RESULTS

A total number of 165 patients were included. Median (Q1, Q3) of hospital follow-up was 28 (4, 66) days. One hundred one patients (61.2%) went to their one-month consultation at hospital. GP follow-up was achieved for 76 patients (55.2%). Median (Q1, Q3) of GP follow-up was 47 (21, 75) months. Twenty-four patients (14.5%) have been totally lost to follow up. The overall follow-up identified 54 patients (32.7%) with long-term consequences, 20 being psychiatric disorders and 30 organic injuries. Organic consequences were mainly peripheral nerve damages (n = 20; 12.1%). Most of the psychiatric consequences were diagnosed during GP follow-up (n = 14; 70%). Seventeen cases (10.3%) of recurrence were found and late mortality occurred in 4 patients (2.4%). High injury severity score, older age and gunshot wound were significantly linked to long-term consequences. Data collection and analysis were carried out in accordance with MR004 reference methodology.

CONCLUSION

This study showed a high rate of long-term consequences among patients managed for penetrating injury. If all organic lesions are diagnosed during hospital follow-up and jointly managed by hospital and extra-hospital physicians, most socio-psychiatric consequences were detected and followed by extra-hospital workers. However, for half of the patients, the extra-hospital follow-up could not be assessed. Thus, these consequences are very probably underestimated. It appears imperative to strengthen the compliance and adherence of these patients to the care network. Awareness and involvement of medical, paramedical teams and GP role seems essential to screen and manage these consequences.

Selective non-operative management for penetrating abdominal injury in a Dutch trauma centre

INTRODUCTION

Selective non-operative management (SNOM) for penetrating abdominal injury (PAI) is accepted in trauma centres in South Africa and the US. Owing to the low incidence of gunshot wounds (GSWs) in Western Europe, few are inclined to practise SNOM for such injuries although it is considered for stab wounds (SWs). This study evaluated the outcome of patients admitted to a Dutch level 1 trauma centre with PAI.

METHODS

A retrospective study was undertaken of all PAI patients treated over 15 years. In order to prevent bias, patients admitted six months prior to and six months following implementation of a treatment algorithm were excluded. Data concerning type of injury, injury severity score and treatment were compared.

RESULTS

A total of 393 patients were included in the study: 278 (71%) with SWs and 115 (29%) with GSWs. Of the 178 SW patients in the SNOM group, 111 were treated before and 59 after introduction of the protocol. The SNOM success rates were 90% and 88% respectively (p=0.794). There were 43 patients with GSWs in the SNOM cohort. Of these, 32 were treated before and 11 after implementation of the algorithm, with respective success rates of 94% and 100% (p=0.304).The protocol did not bring about any significant change in the rate of non-therapeutic laparotomies for SWs or GSWs. However, the rate of admission for observation for SWs increased from 83% to 100% (p<0.001). There was a decrease in ultrasonography for SWs (from 84% to 32%, p<0.001) as well as for GSWs (from 87% to 43%, p<0.001). X-ray was also used less for GSWs after the protocol was introduced (44% vs 11%, p=0.001).

CONCLUSIONS

SNOM for PAI resulting from either SWs or GSWs can be safely practised in Western European trauma centres. Results are comparable with those in trauma centres that treat high volumes of PAI cases.

Aspergillus terreus spondylodiscitis following an abdominal stab wound: a case report

Background

Aspergillus terreus, a saprophytic fungus, is recognized as an emerging pathogen in various infections in humans. However, bone and joint involvement is uncommon. To the best of our knowledge, only seven cases of spondylodiscitis caused by Aspergillus terreus have been reported previously in humans. We report a case of a patient with Aspergillus terreus spondylodiscitis following an abdominal stab wound.

Case presentation

A 74-year-old Japanese man with no particular medical history fell from a ladder and sustained a left abdominal stab wound from an L-shaped metal peg. Computed tomography showed the trace of the L-shaped metal peg from the left abdomen to the left rib and left kidney. The scan also showed an anterolateral bone avulsion of the left side of the T12 vertebral body, as well as fractures of the L1 left transverse process and the left 10th–12th ribs. He was hospitalized and treated with conservative therapy for 6 weeks. He was readmitted to the hospital with complaints of sudden back pain, numbness of both legs, and inability to walk 13 weeks after the fall. Magnetic resonance imaging findings were typical of spondylodiscitis. Gadolinium-enhanced T1-weighted magnetic resonance imaging indicated increased signal intensity at T11–T12 vertebral bodies and severe cord compression and epidural abscess at T11–T12 associated with infiltration of soft paravertebral tissues. On the seventh day after admission, he underwent partial laminectomy at T11 and posterior fusion at T9 to L2. The result of his blood culture was negative, but Aspergillus terreus was isolated from the material of T11–T12 intervertebral disc and vertebral bodies. His Aspergillus antigen was positive in a blood examination. Histological examination showed chronic suppurative osteomyelitis. On the 35th day after admission, he underwent anterior fusion at T11 and T12 with a rib bone graft. For 5 months, voriconazole was administered, and he wore a rigid corset. Posterior partial laminectomy at T11 and anterior fusion at T11 and T12 resulted in a good clinical course. The patient’s neurological dysfunction was completely recovered, and his back pain disappeared. Two years after the operation, computed tomography was performed and showed bone fusion at T11 and T12. Magnetic resonance imaging revealed no evidence of increased signal intensity at T11–T12 vertebral bodies and severe cord compression and epidural abscess at T11–T12.

Conclusions

To our knowledge, this is the first report of spondylodiscitis caused by Aspergillus terreus after an abdominal penetrating injury. The histological finding of chronic suppurative osteomyelitis and the radiological findings strongly suggested direct inoculation of Aspergillus terreus.

Epidemiology and outcome of penetrating injuries in a Western European urban region

PURPOSE

Severe life-threatening injuries in Western Europe are mostly caused by blunt trauma. However, penetrating trauma might be more common in urban regions, but their characteristics have not been fully elucidated.

METHODS

Retrospective analysis of data from patients admitted to our urban university level I trauma center between 2008 and 2013 with suspicion of severe multiple injuries. Collection of data was performed prospectively using a PC-supported online documentation program including epidemiological, clinical and outcome parameters.

RESULTS

Out of 2095 trauma room patients admitted over the 6-year time period 194 (9.3 %) suffered from penetrating trauma. The mean Injury Severity Score (ISS) was 12.3 ± 14.1 points. In 62.4 % (n = 121) the penetrating injuries were caused by interpersonal violence or attempted suicide, 98 of these by stabbing and 23 by firearms. We observed a widespread injury pattern where mainly head, thorax and abdomen were afflicted. Subgroup analysis for self-inflicted injuries showed higher ISS (19.8 ± 21.8 points) than for blunt trauma (15.5 ± 14.6 points). In 82.5 % of all penetrating trauma a surgical treatment was performed, 43.8 % of the patients received intensive care unit treatment with mean duration of 7.4 ± 9.3 days. Immediate emergency surgical treatment had to be performed in 8.0 vs. 2.3 % in blunt trauma (p < 0.001). Infectious complications of the penetrating wounds were observed in 7.8 %.

CONCLUSIONS

Specific characteristics of penetrating trauma in urban regions can be identified. Compared to nationwide data, penetrating trauma was more frequent in our collective (9.3 vs. 5.0 %), which may be due to higher crime rates in urban areas. Especially, self-inflicted penetrating trauma often results in most severe injuries.

[Blunt and penetrating trauma the abdomen: retrospective analysis of 175 cases and review of literature]

Les traumatismes abdominaux sont relativement fréquents mais graves dans les pays en développement. Le but de cette étude était de décrire les aspects épidémiologiques, diagnostiques, thérapeutiques et évolutifs des contusions et plaies pénétrantes de l'abdomen prises en charge dans un pays à faibles ressources. Patients et méthodes: Il s'agissait d'une étude rétrospective et descriptive de 2 ans (2011-2012) ayant colligé 175 cas de traumatisés abdominaux au CHU-JRA Tananarive Madagascar. Parmi ces blessés (144 hommes et 31 femmes), il existait 122 vivants (69,7%) et 53 décès (30,3%) avant tout geste thérapeutique hospitalier. Les étiologies étaient dominées par les accidents à responsabilité civile (52,5%) et de la voie publique (38,5%). Les contusions et plaies pénétrantes représentaient respectivement 41,8% et 58,2%. Parmi les blessés vivants, 112 ont été opérés (91,8%). L’évolution hospitalière était favorable dans 94,3%. Quatre patients avaient des suites opératoires compliquées (3,6%). Sept patients étaient décédés (5,7%). Parmi les décès préhospitaliers, nous avons observé 73,6% de polytraumatisme (n = 39) et 26,4% de traumatismes abdominaux isolés (n = 14). A l'autopsie, les lésions abdominales étaient hémorragiques dans 94,3% incluant des plaies vasculaires rétropéritonéales, des ruptures hépatospléniques et des traumatismes graves du bassin. En situation précaire, les traumatismes abdominaux ont une mortalité préhospitalière assez importante. A l'hôpital, l’évolution était généralement favorable au prix d'un acte opératoire invasif.

Candida albicans spondylodiscitis following an abdominal stab wound: forensic considerations

Candida albicans spondylodiscitis is a fungal infection of the spine which is still unusual in spite of the increasing frequency of predisposing factors. A 22-year-old man received an abdominal stab wound during a physical assault. Initial medical care included surgery, prolonged use of indwelling vascular catheters with administration of broad-spectrum antibiotics, and hospitalization in intensive care. Two months after the event, the victim experienced back pain in the right lumbar region and septic spondylodiscitis secondary to C. albicans was diagnosed three weeks later. This case is noteworthy because of its clinical forensic context. In France, the public prosecutor orders a medico-legal assessment after an assault for all living victims in order to establish a causal relationship between the assault and its complications. In our case, the patient presented numerous risk factors for candidemia and the forensic specialist reasonably accepted that the causal relationship was certain but indirect. We have only found one published case of spondylodiscitis after an abdominal penetrating injury and the pathogenic agent was not mentioned. We have found no case reported in a forensic context. This unusual observation shows that it may be genuinely difficult to prove the causal relationship between an abdominal penetrating injury and an unusual infectious complication such as fungal spondylodiscitis.