Interventional Radiology service provision and practice for the management of traumatic splenic injury across the Regional Trauma Networks of England

A case of multiple organ injury resuscitated by collaboration of damage control surgery and interventional radiology in hybrid emergency room

Background

Hybrid emergency room systems, namely hybrid ER (HER), enable us to perform computed tomography (CT), surgery, and interventional radiology (IVR) without patient transfer. HER significantly shortened the time to CT after arrival and allowed us to achieve early intervention, resulting in reduced mortality from exsanguination in patients with severe blunt trauma.

Case Presentation

We encountered a patient diagnosed with left common iliac artery occlusion and dissection caused by blunt traumatic compressive abdominal injury with transection of the small intestine, kidney, and adrenal and pelvic ring fractures. Although the patient experienced cardiopulmonary arrest (CPA) immediately after CT, we performed damage control surgery (DCS) and IVR after temporary aortic occlusion in the HER and resuscitated the patient.

Conclusion

The present case, in which rapid diagnosis and intervention were performed and the patient was successfully resuscitated, supports the efficacy of the HER system for managing severe blunt trauma.

A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury

BACKGROUND

Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality.

METHODS

The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument.

RESULTS

Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275.

CONCLUSIONS

This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.

Retrospective Evaluation of Splenic Artery Embolization Outcomes in the Management of Blunt Splenic Trauma: A Single Centre Experience at a Large Level 1 Trauma Centre

PURPOSE

Retrospective review of splenic artery embolization (SAE) outcomes performed for blunt abdominal trauma.

MATERIALS AND METHODS

11-year retrospective review at a large level-1 Canadian trauma centre. All patients who underwent SAE after blunt trauma were included. Technical success was defined as angiographic occlusion of the target vessel and clinical success was defined as successful non-operative management and splenic salvage on follow-up.

RESULTS

138 patients were included of which 68.1% were male. The median age was 47 years (interquartile range (IQR) = 32.5 years). The most common mechanisms of injury were motor vehicle accidents (37.0%), mechanical falls (25.4%), and pedestrians hit by motor vehicles (10.9%). 70.3% of patients had American Association for the Surgery of Trauma (AAST) grade 4 injuries. Patients were treated with proximal SAE (n = 97), distal SAE (n = 23) or combined SAE (n = 18), and 68% were embolized with an Amplatzer plug. No significant differences were observed across all measures of hospitalization (Length of hospital stay: x2(2) = .358, P = .836; intensive care unit (ICU) stay: x2(2) = .390, P = .823; ICU stay post-procedure: x2(2) = 1.048, P = .592). Technical success and splenic salvage were achieved in 100% and 97.8% of patients, respectively. 7 patients (5%) had post-embolization complications and 7 patients (5%) died during hospital admission, but death was secondary to other injuries sustained in the trauma rather than complications related to splenic injury or its management.

CONCLUSION

We report that SAE as an adjunct to non-operative management of blunt splenic trauma can be performed safely and effectively with a high rate of clinical success.

Factors associated with survival in adult trauma patients undergoing angiography with and without embolization across trauma centers in the United States

INTRODUCTION

Interventional angiography is increasingly utilized in trauma management for various injuries. Despite published guidelines by the Eastern Association for the Surgery of Trauma on the use of angiography, limited data exist on factors associated with outcomes in angiography procedures. This study examines factors associated with survival to hospital discharge in trauma patients undergoing angiography with or without embolization across US trauma centers.

MATERIALS AND METHODS

This retrospective observational study used the National Trauma Data Bank 2017 dataset and included adult trauma patients who underwent conventional angiography with or without embolization. A bivariate analysis was done to compare patients' characteristics by outcome (survived/died), followed by a multivariable logistic regression analysis to determine factors associated with survival to hospital discharge after adjusting for important confounders.

RESULTS

In the included sample of 4242 patients, median age was 41 years and male gender was predominant (72.6%). Overall mean time to angiography was 263.77 ± 750.19 min. Factors positively associated with survival included treatment at large facilities with over 401 beds (OR = 2.170; 95% CI, [1.277-3.685]), helicopter ambulance/fixed-wing transport (OR = 1.736; 95% CI, [1.325-2.275]), mild Glasgow Coma Scale (OR = 7.621; 95% CI, [5.868-9.898]) and moderate Glasgow Coma Scale (OR = 3.127; 95% CI, [2.080-4.701]), SBP ≥ 90 (OR = 1.516; 95% CI [1.199-1.916]), and spleen as embolization site (OR = 1.647; 95% CI [1.119-2.423]).

CONCLUSION

This nationwide study identified variables associated with survival in trauma patients who underwent angiography. These variables can serve in creating standardized risk stratification tools that could be incorporated into evidence-based guidelines for angiography candidates.

Variation in the utilization of angioembolization for splenic injury in hospitals: a nationwide cross-sectional study in Japan

Aim

Substantial variations in the utilization of angioembolization have been reported internationally. However, the existence of variations in the utilization of angioembolization in Japan is currently unknown.

Methods

This was a cross-sectional study using data from a nationwide trauma registry in Japan. Of the 4,896 registered adult patients with splenic injury, we investigated 3,319 patients in the top 25% of the hospitals that registered the highest number of splenic injury patients in the Japan Trauma Data Bank. The primary outcome of this study was initial angioembolization. We calculated the expected initial angioembolization rates using multiple regression analysis adjusted for patient factors. In addition, we evaluated the range of observed-to-expected initial splenic angioembolization ratio for each hospital. Moreover, we assessed whether this ratio was increased with time.

Results

The frequency of initial splenic angioembolization ranged from 0% to 52%. The median expected initial angioembolization rate, calculated through multiple logistic regression analysis, was 19.7%. The observed-to-expected initial splenic angioembolization ratio for each hospital ranged from 0 to 2.36. The observed initial angioembolization rate tended to increase with time (P < 0.001).

Conclusions

Despite adjustment for patient factors, substantial variations were observed in the utilization of splenic angioembolization among hospitals in Japan.

Helicopter Emergency Medical Services Performed Extended Focused Assessment With Sonography: Training, Workflow, and Sustainable Quality

The extended focused assessment of trauma (EFAST) examination is an invaluable tool for the initial evaluation of the trauma patient. Miniaturization of ultrasound has enabled helicopter emergency medical services (HEMS) to use point-of-care ultrasound to care for trauma patients on scene. Our study demonstrated that HEMS crews accurately performed EFAST examinations after the implementation of a novel HEMS EFAST workflow, multifaceted training, and ongoing quality assurance. The HEMS crews' overall sensitivity was 53%, and specificity was 98%. The obtained image quality was highest for the lung, cardiac, and right upper quadrant components of the EFAST. Our results suggest that with a structured multifaceted training program, user-friendly workflow, and ongoing quality assurance, HEMS crews can perform EFAST examinations safely and reliably in the field. This would allow HEMS crews to detect life-threatening, time-sensitive conditions such as a pneumothorax, pericardial effusion, and intraperitoneal hemorrhage. HEMS EFAST has the potential to triage certain trauma patients directly to the operating room or newly emerging hybrid suites, bypassing the emergency room and saving crucial time.

Embolization versus Surgery for Stabilized Patients with Solid Organ Injury

PURPOSE

To compare embolization with laparotomy for the management of hemodynamically unstable patients with solid organ injury who responded to initial resuscitation.

MATERIALS AND METHODS

Data from a Japanese nationwide trauma registry were analyzed. Included were hemodynamically unstable patients (systolic blood pressure <90 mm Hg and blood transfusion within the first 24 hours) whose initial computed tomography assessment confirmed the presence of solid organ injuries (liver and/or spleen). A total of 224 patients were included (median age: 53 years, interquartile range: 32-69; 73.3% male; liver injury = 131 [58%] and spleen injury = 98 [44%]; median organ injury scale: 3, interquartile range: 3-4; median injury severity score: 19, interquartile range: 16-25). Patients who underwent embolization were compared with those who underwent laparotomy. The primary outcome was in-hospital survival. The data were evaluated using a propensity score matching analysis.

RESULTS

Laparotomy and embolization were performed in 133 (59.1%) and 91 (40.4%) patients, respectively. Of those, 111 (84%) and 84 (92%) patients achieved in-hospital survival after laparotomy and embolization, respectively. No significant difference in in-hospital survival (P = .053) was noted. The propensity score matching model did not reveal a significant difference in in-hospital survival (P = .276).

CONCLUSIONS

No significant difference was observed between embolization and laparotomy in terms of in-hospital survival among unstable patients who responded to initial resuscitation with solid organ injury.

SPLEnic salvage and complications after splenic artery EmbolizatioN for blunt abdomINal trauma: the SPLEEN-IN study

BACKGROUND

As an adjunct to non-operative management, splenic artery embolization (SAE) has been increasingly utilized throughout the world and is now the standard of care for hemodynamically stable patients. This study aimed to retrospectively assess the rate of splenic salvage and complications after SAE for blunt trauma at a level 1 trauma center using the 2018 update to the AAST criteria, and further sub-stratify the role of angiography in AAST grade III injuries with significant hemoperitoneum. All patients between 1 January 2009 and 1 January 2019 who underwent blunt trauma and proceeded to embolization were included. Data was collected concerning initial injury grade, location of embolization, type of embolic material used, complications, and need for subsequent splenectomy. Technical success was defined as successful angiographic occlusion of the target artery at the conclusion of embolization. Clinical success was defined as splenic salvage at discharge. Vascular lesions were characterized including those with active bleeding, pseudoaneurysm, and arterio-venous fistula.

RESULTS

Two hundred thirty-two patients were included in the study. Treatments were performed at a median of 0 days (range 0-28 days) and the median AAST grade was IV (range III-V). Technical success was achieved in all patients. There were 13 complications (5.6%) consisting of re-bleed (9, 3.9%), infarction (3, 1.3%), and access site haematoma (1, 0.43%). Clinical success was achieved in 97% of patients with 7 patients requiring splenectomy after SAE (3.0%) at a median time of 4 days (range 0-17 days). Angiography in patients with grade III injuries identified 18 occult vascular injuries not identified at initial CT (p < 0.0001).

CONCLUSIONS

The SPLEEN-IN study shows that treatment of intermediate-high grade blunt force traumatic splenic injuries using SAE resulted in a low rate of complication and splenic salvage in 97% of patients, providing a safe and effective treatment in stable patients. In addition, angiography of grade III injuries identified occult vascular lesions and may warrant treatment of select patients in this cohort.

LEVEL OF EVIDENCE

Level 3.

The Survival Benefit of a Novel Trauma Workflow that Includes Immediate Whole-body Computed Tomography, Surgery, and Interventional Radiology, All in One Trauma Resuscitation Room: A Retrospective Historical Control Study

Supplemental Digital Content is available in the text

Objective:

The aim of this study was to evaluate the impact of a novel trauma workflow, using an interventional radiology (IVR)–computed tomography (CT) system in severe trauma.

Background:

In August 2011, we installed an IVR-CT system in our trauma resuscitation room. We named it the Hybrid emergency room (ER), as it enabled us to perform all examinations and treatments required for trauma in a single place.

Methods:

This retrospective historical control study conducted in Japan included consecutive severe (injury severity score ≥16) blunt trauma patients. Patients were divided into 2 groups: Conventional (from August 2007 to July 2011) or Hybrid ER (from August 2011 to July 2015). We set the primary endpoint as 28-day mortality. The secondary endpoints included cause of death and time course from arrival to start of CT and surgery. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes.

Results:

We included 696 patients: 360 in the Conventional group and 336 in the Hybrid ER group. The Hybrid ER group was significantly associated with decreased mortality [adjusted odds ratio (OR), 0.50 (95% confidence interval, 95% CI, 0.29–0.85); P = 0.011] and reduced deaths from exsanguination [0.17 (0.06–0.47); P = 0.001]. The time to CT initiation [Conventional 26 (21 to 32) minutes vs Hybrid ER 11 (8 to 16) minutes; P < 0.0001] and emergency procedure [68 (51 to 85) minutes vs 47 (37 to 57) minutes; P < 0.0001] were both shorter in the Hybrid ER group.

Conclusion:

This novel trauma workflow, comprising immediate CT diagnosis and rapid bleeding control without patient transfer, as realized in the Hybrid ER, may improve mortality in severe trauma.

The hybrid emergency room system: a novel trauma evaluation and care system created in Japan

The ultimate trauma management system should allow the completion of all time-consuming life-saving procedures in one trauma resuscitation room. In 2011, the Hybrid Emergency Room System (HERS) was developed in Japan as a novel trauma care system that allows clinicians to perform all life-saving procedures for severely injured patients, including whole-body computed tomography examination, damage control surgery, and transcatheter arterial embolization by interventional radiology, on the same table in the same room without transferring the patient. Since then, the number of HERS installations has rapidly increased around Japan. To promote further innovation and dissemination of this new and creative concept of trauma management, the Japanese Association for Hybrid Emergency Room System was launched on June 21, 2018. In this article, the concept, history, and current evidence behind this new trauma workflow system are summarized. This is the first review to show the next direction of trauma care using HERS.

Impact of emergency physicians competent in severe trauma management, surgical techniques, and interventional radiology on trauma management

Aim

Despite recent advancements in trauma management following introduction of interventional radiology (IVR) and damage-control strategies, challenges remain regarding optimal use of resources for severe trauma.

Methods

In October 2014, we implemented a trauma management system comprising emergency physicians competent in severe trauma management, surgical techniques, and IVR. To evaluate this system, of 5,899 trauma patients admitted to our hospital from January 2011 to January 2018, we selected 107 patients with severe trauma (injury severity score ≥ 16) who presented with persistent hypotension (two or more systolic blood pressure measurements <90 mmHg), regardless of primary resuscitation. Patients were divided according to the date of admission: Conventional (January 2011-September 2014) or Current (October 2014-January 2018). The primary end-point was in-hospital mortality. Secondary end-points included time from arrival to start of surgery/IVR.

Results

There were 59 patients in the Conventional group and 48 in the Current group. Although patients in the Current group were more severely ill compared with those in the Conventional group, mortality in the Current group was significantly lower (Conventional 64.4% versus Current 41.7%, P = 0.019), especially among patients whose first intervention was IVR (Conventional 75.0% versus Current 28.6%, P = 0.001). Time from arrival to initiation of surgery/IVR was shorter in the Current group (Conventional 71.5 [53.8-130.8] min versus Current 41.0 [26.0-58.5] min, P < 0.0001).

Conclusions

This trauma management system based on emergency physicians competent not only in severe trauma management, but also surgical techniques and IVR, could improve outcomes in patients with severe multiple lethal trauma.