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Tatebe LC. Invited Commentary: Should "Damage Control Airway Management" Be Added to Our Toolkit? J Am Coll Surg 2024; 238:136-138. [PMID: 38014854 DOI: 10.1097/xcs.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
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Breeding T, Martinez B, Katz J, Kim J, Havron W, Hoops H, Elkbuli A. CAB versus ABC approach for resuscitation of patients following traumatic injury: Toward improving patient safety and survival. Am J Emerg Med 2023; 68:28-32. [PMID: 36905883 DOI: 10.1016/j.ajem.2023.02.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/19/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
INTRODUCTION Though a circulation-airway-breathing (CAB) resuscitation sequence is now widely accepted in administering CPR over the airway-breathing-circulation (ABC) sequence following cardiac arrest, current evidence and guidelines vary considerably for complex polytraumas, with some prioritizing management of the airway and others advocating for initial treatment of hemorrhage. This review aims to evaluate existing literature comparing ABC and CAB resuscitation sequences in adult trauma patients in-hospital to direct future research and guide evidence-based recommendations for management. METHODS A literature search was conducted on PubMed, Embase, and Google Scholar until September 29, 2022. Articles were assessed for comparison between CAB and ABC resuscitation sequences, adult trauma patients, in-hospital treatment, patient volume status, and clinical outcomes. RESULTS Four studies met the inclusion criteria. Two studies compared the CAB and ABC sequences specifically in hypotensive trauma patients, one study evaluated the sequences in trauma patients with hypovolemic shock, and one study in patients with all types of shock. Hypotensive trauma patients who underwent rapid sequence intubation before blood transfusion had a significantly higher mortality rate than those who had blood transfusion initiated first (50 vs 78% P < 0.05) and a significant drop in blood pressure. Patients who subsequently experienced post-intubation hypotension (PIH) had increased mortality over those without PIH. overall mortality was higher in patients that developed PIH (mortality, n (%): PIH = 250/753 (33.2%) vs 253/1291 (19.6%), p < 0.001). CONCLUSION This study found that hypotensive trauma patients, especially those with active hemorrhage, may benefit more from a CAB approach to resuscitation, as early intubation may increase mortality secondary to PIH. However, patients with critical hypoxia or airway injury may still benefit more from the ABC sequence and prioritization of the airway. Future prospective studies are needed to understand the benefits of CAB with trauma patients and identify which patient subgroups are most affected by prioritizing circulation before airway management.
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Affiliation(s)
- Tessa Breeding
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Brian Martinez
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Joshua Katz
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Jason Kim
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Will Havron
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Heather Hoops
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Sciences University, Portland, OR, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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Campos-Serra A, Mesquida J, Montmany-Vioque S, Rebasa-Cladera P, Barquero-Lopez M, Cidoncha-Secilla A, Llorach-Perucho N, Morales-Codina M, Puyana JC, Navarro-Soto S. Alterations in tissue oxygen saturation measured by near-infrared spectroscopy in trauma patients after initial resuscitation are associated with occult shock. Eur J Trauma Emerg Surg 2023; 49:307-315. [PMID: 36053289 PMCID: PMC9925470 DOI: 10.1007/s00068-022-02068-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/16/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Persistent occult hypoperfusion after initial resuscitation is strongly associated with increased morbidity and mortality after severe trauma. The objective of this study was to analyze regional tissue oxygenation, along with other global markers, as potential detectors of occult shock in otherwise hemodynamically stable trauma patients. METHODS Trauma patients undergoing active resuscitation were evaluated 8 h after hospital admission with the measurement of several global and local hemodynamic/metabolic parameters. Apparently hemodynamically stable (AHD) patients, defined as having SBP ≥ 90 mmHg, HR < 100 bpm and no vasopressor support, were followed for 48 h, and finally classified according to the need for further treatment for persistent bleeding (defined as requiring additional red blood cell transfusion), initiation of vasopressors and/or bleeding control with surgery and/or angioembolization. Patients were labeled as "Occult shock" (OS) if they required any intervention or "Truly hemodynamically stable" (THD) if they did not. Regional tissue oxygenation (rSO2) was measured non-invasively by near-infrared spectroscopy (NIRS) on the forearm. A vascular occlusion test was performed, allowing a 3-min deoxygenation period and a reoxygenation period following occlusion release. Minimal rSO2 (rSO2min), Delta-down (rSO2-rSO2min), maximal rSO2 following cuff-release (rSO2max), and Delta-up (rSO2max-rSO2min) were computed. The NIRS response to the occlusion test was also measured in a control group of healthy volunteers. RESULTS Sixty-six consecutive trauma patients were included. After 8 h, 17 patients were classified as AHD, of whom five were finally considered to have OS and 12 THD. No hemodynamic, metabolic or coagulopathic differences were observed between the two groups, while NIRS-derived parameters showed statistically significant differences in Delta-down, rSO2min, and Delta-up. CONCLUSIONS After 8 h of care, NIRS evaluation with an occlusion test is helpful for identifying occult shock in apparently hemodynamically stable patients. LEVEL OF EVIDENCE IV, descriptive observational study. TRIAL REGISTRATION ClinicalTrials.gov Registration Number: NCT02772653.
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Affiliation(s)
- Andrea Campos-Serra
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208, Sabadell (Barcelona), Spain.
| | - Jaume Mesquida
- Critical Care Department, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Sandra Montmany-Vioque
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | - Pere Rebasa-Cladera
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | | | - Ariadna Cidoncha-Secilla
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | - Núria Llorach-Perucho
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | | | | | - Salvador Navarro-Soto
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
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Griggs JE, Lyon RM, Sherriff M, Barrett JW, Wareham G, Ter Avest E. Predictive clinical utility of pre-hospital point of care lactate for transfusion of blood product in patients with suspected traumatic haemorrhage: derivation of a decision-support tool. Scand J Trauma Resusc Emerg Med 2022; 30:72. [PMID: 36514084 DOI: 10.1186/s13049-022-01061-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Pre-hospital emergency medical teams can transfuse blood products to patients with suspected major traumatic haemorrhage. Common transfusion triggers based on physiological parameters have several disadvantages and are largely unvalidated in guiding pre-hospital transfusion. The addition of pre-hospital lactate (P-LACT) may overcome these challenges. To date, the clinical utility of P-LACT to guide pre-hospital blood transfusion is unclear. METHODS A retrospective analysis of patients with suspected major traumatic haemorrhage attended by Air Ambulance Charity Kent Surrey Sussex (KSS) between 8 July 2017 and 31 December 2019. The primary endpoint was the accuracy of P-LACT to predict the requirement for any in-hospital (continued) transfusion of blood product. RESULTS During the study period, 306 patients with suspected major traumatic haemorrhage were attended by KSS. P-LACT was obtained in 194 patients. In the cohort 103 (34%) patients were declared Code Red. A pre-hospital transfusion was commenced in 124 patients (41%) and in-hospital transfusion was continued in 100 (81%) of these patients, in 24 (19%) patients it was ceased. Predictive probabilities of various lactate cut-off points for requirement of in-hospital transfusion are documented. The highest overall proportion correctly classified patients were found for a P-LACT cut-point of 5.4 mmol/L (76.50% correctly classified). Based on the calculated predictive probabilities, optimal cut-off points were derived for both the exclusion- and inclusion of the need for in-hospital transfusion. A P-LACT < 2.5 mmol/L had a sensitivity of 80.28% and a negative likelihood ratio [LR-] of 0.37 for the prediction of in-hospital transfusion requirement, whereas a P-LACT of 6.0 mmol/L had a specificity of 99.22%, [LR-] = 0.78. CONCLUSION Pre-hospital lactate measurements can be used to predict the need for (continued) in-hospital blood products in addition to current physiological parameters. A simple decision support tool derived in this study can help the clinician interpret pre-hospital lactate results and guide pre-hospital interventions in the major trauma patient.
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Affiliation(s)
- J E Griggs
- Air Ambulance Charity Kent Surrey Sussex, Hanger 10 Redhill Aerodrome, Redhill, RH1 5YP, UK. .,University of Surrey, School of Health Sciences, Priestley Rd, Guildford, GU2 7YH, UK.
| | - R M Lyon
- Air Ambulance Charity Kent Surrey Sussex, Hanger 10 Redhill Aerodrome, Redhill, RH1 5YP, UK.,University of Surrey, School of Health Sciences, Priestley Rd, Guildford, GU2 7YH, UK
| | - M Sherriff
- University of Bristol, Child Dental Health, Bristol Dental School, Faculty of Health Sciences, Lower Maudlin Street, Bristol, BS1 2LY, UK
| | - J W Barrett
- University of Surrey, School of Health Sciences, Priestley Rd, Guildford, GU2 7YH, UK.,South East Coast Ambulance NHS Foundation Trust, Neptune House, Gatwick, Surrey, RH10 9BG, UK
| | - G Wareham
- Air Ambulance Charity Kent Surrey Sussex, Hanger 10 Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - E Ter Avest
- Air Ambulance Charity Kent Surrey Sussex, Hanger 10 Redhill Aerodrome, Redhill, RH1 5YP, UK.,Department of Emergency Medicine, University Medical Center Groningen, Groningen, The Netherlands
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Resuscitation of the Traumatically Injured Patient. Crit Care Nurs Clin North Am 2021; 33:245-261. [PMID: 34340788 DOI: 10.1016/j.cnc.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Trauma is a leading cause of death. Optimal outcomes depend on a coordinated effort. Providers must be prepared to act in an organized and methodical manner. Recognizing and immediately treating causes of shock after trauma offer the best chance of survival to the patient. Incorporating evidence-based knowledge and resuscitation techniques learned from the military, the trauma victim experiencing acute hypovolemia has better outcomes because of advances in the clinical management of blood loss than ever before. Treatment focuses primarily on stopping the bleeding, providing damage control resuscitation, and monitoring and treating the patient for signs of shock. If the patient can be stabilized and avoid the lethal trauma triad, definitive surgical care can be achieved.
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Emerling AD, Bianchi W, Krzyzaniak M, Deaton T, Via D, Archer B, Sutherland J, Shannon K, Dye JL, Clouser M, Auten JD. Rapid Sequence Induction Strategies Among Critically Injured U.S. Military During the Afghanistan and Iraq Conflicts. Mil Med 2021; 186:316-323. [PMID: 33499492 DOI: 10.1093/milmed/usaa356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/29/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Rapid sequence intubation of patients experiencing traumatic hemorrhage represents a precarious phase of care, which can be marked by hemodynamic instability and pulseless arrest. Military combat trauma guidelines recommend reduced induction dose and early blood product resuscitation. Few studies have evaluated the role of induction dose and preintubation transfusion on hemodynamic outcomes. We compared rates of postintubation systolic blood pressure (SBP) of < 70 mm Hg, > 30% drop in SBP, pulseless arrest, and mortality at 24 hours and 30 days among patients who did and did not receive blood products before intubation and then examined if induction agent and dose influenced the same outcomes. MATERIALS AND METHODS A retrospective analysis was performed of battle-injured personnel presenting to surgical care facilities in Iraq and Afghanistan between 2004 and 2018. Those who received blood transfusions, underwent intubation, and had an Injury Severity Score of ≥15 were included. Intubation for primary head, facial, or neck injury, burns, operative room intubations, or those with cardiopulmonary resuscitation in progress were excluded. Multivariable logistic regression was performed with unadjusted and adjusted odds ratios for the five study outcomes among patients who did and did not receive preintubation blood products. The same analysis was performed for patients who received full or excessive versus partial induction agent dose. RESULTS A total of 153 patients had a mean age of 24.9 (SD 4.5), Injury Severity Score 29.7 (SD 11.2), heart rate 122.8 (SD 24), SBP 108.2 (SD 26.6). Eighty-one (53%) patients received preintubation blood products and had similar characteristics to those who did not receive transfusions. Adjusted multivariate analysis found odds ratios as follows: 30% SBP decrease 9.4 (95% CI 2.3-38.0), SBP < 70 13.0 (95% CI 3.3-51.6), pulseless arrest 18.5 (95% CI 1.2-279.3), 24-hour mortality 3.8 (95% CI 0.7-21.5), and 30-day mortality 1.3 (0.4-4.7). In analysis of induction agent choice and comparison of induction agent dose, no statistically significant benefit was seen. CONCLUSION Within the context of this historical cohort, the early use of blood products conferred a statistically significant benefit in reducing postintubation hypotension and pulseless arrest among combat trauma victims exposed to traumatic hemorrhage. Induction agent choice and dose did not significantly influence the hemodynamic or mortality outcomes.
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Affiliation(s)
- Alec D Emerling
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - William Bianchi
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Michael Krzyzaniak
- Department of General Surgery, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Travis Deaton
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Darin Via
- Director, Medical Systems Integration and Combat Survivability, N44, Chief of Naval Operations, 2000 Navy Pentagon, Room 2E274, Washington DC 20350, USA
| | - Benjamin Archer
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Jared Sutherland
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
| | - Kaeley Shannon
- Department of Operational Readiness, Naval Health Research Center, Bldg. 329, Ryne Rd, San Diego, CA, 92152, USA
| | - Judy L Dye
- Department of Operational Readiness, Naval Health Research Center, Bldg. 329, Ryne Rd, San Diego, CA, 92152, USA
| | - Mary Clouser
- Department of Operational Readiness, Naval Health Research Center, Bldg. 329, Ryne Rd, San Diego, CA, 92152, USA
| | - Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center San Diego, Naval Medical Center San Diego Combat Trauma Research Group, San Diego, CA, 92134
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Nolan B, Hillier M. Unlearning the ABCs: a call to reprioritize prehospital intubation for trauma patients. CAN J EMERG MED 2021; 23:271-273. [PMID: 33959924 DOI: 10.1007/s43678-020-00050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Brodie Nolan
- Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, USA. .,Li Ka Shing Knowledge Institute, Toronto, ON, USA. .,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, USA.
| | - Morgan Hillier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, USA.,Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, USA.,Sunnybrook Centre for Prehospital Medicine, Toronto, ON, USA
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Vishwanathan K, Chhajwani S, Gupta A, Vaishya R. Evaluation and management of haemorrhagic shock in polytrauma: Clinical practice guidelines. J Clin Orthop Trauma 2020; 13:106-115. [PMID: 33680808 PMCID: PMC7919934 DOI: 10.1016/j.jcot.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
Haemorrhagic shock is the most common preventable cause of early mortality in polytrauma patients. Road traffic injuries are the most common cause for polytrauma and most commonly include orthopaedic injuries. Hence, orthopaedic trainees and junior orthopaedic surgeons need to be well aware of evaluation and management of haemorrhagic shock in the multiple injured patient. The present narrative review discusses evaluation and current principles in management of haemorrhagic shock in a polytrauma patient. A classification system for haemorrhagic shock based on ATLS guidelines has been described along with novel use of colour coding to facilitate better and effective use of the classification. A treatment algorithm has also been presented for quick reference. The emphasis is to avoid overloading with crystalloid fluids, replacing with blood and blood products (Balanced resuscitation), permissive hypotension, prevent and acutely treat lethal conditions such as hypothermia, acidosis and coagulopathy. The management of haemorrhagic shock in polytrauma patient is quite challenging and require a detailed knowledge of its management. An arbitrary and haphazard management of these patients may lead to severe complications. We have mentioned the broad principles of management of hypovolemic shock in a polytrauma patient.
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Affiliation(s)
- Karthik Vishwanathan
- Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, India
- Corresponding author. Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Faculty of Medicine, Parul University, P.O Limda, Waghodia, Vadodara, 391760, India.
| | - Sunil Chhajwani
- Department of Anaesthesia and Critical Care, Pramukhswami Medical College, Karamsad, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, J.P.N. Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Vaishya
- Department of Orthopaedics & Joint Replacement, Indraprastha Apollo Hospitals, New Delhi, India
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Affiliation(s)
- Elizabeth Dauer
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA.
| | - Amy Goldberg
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
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Ito K, Nakazawa K, Nagao T, Chiba H, Miyake Y, Sakamoto T, Fujita T. Emergency trauma laparotomy and/or thoracotomy in the emergency department: risks and benefits. Trauma Surg Acute Care Open 2019; 4:e000269. [PMID: 30899796 PMCID: PMC6407529 DOI: 10.1136/tsaco-2018-000269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background It is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice. Methods The data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared. Results Compared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation. Discussion Emergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping. Level of evidence IV.
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Affiliation(s)
- Kaori Ito
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kahoko Nakazawa
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Nagao
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroto Chiba
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasufumi Miyake
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Tetsuya Sakamoto
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Takashi Fujita
- Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Fransvea P, Costa G, Massa G, Frezza B, Mercantini P, BaIducci G. Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience. Pan Afr Med J 2019; 32:52. [PMID: 31143357 PMCID: PMC6522183 DOI: 10.11604/pamj.2019.32.52.15022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 10/19/2018] [Indexed: 02/04/2023] Open
Abstract
Introduction The spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient. Methods The present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS). Results The analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001). Conclusion Splenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.
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Affiliation(s)
- Pietro Fransvea
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Gianluca Costa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Giulia Massa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Barbara Frezza
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Paolo Mercantini
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Genoveffa BaIducci
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
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