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He R, Kong V, Ko J, Narayanan A, Wain H, Bruce J, Laing G, Manchev V, Bekker W, Clarke D. A decade long overview of damage control laparotomy for abdominal gunshot wounds. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02563-2. [PMID: 38888788 DOI: 10.1007/s00068-024-02563-2] [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: 03/16/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. METHODS Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. RESULTS There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). CONCLUSION One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.
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Affiliation(s)
- Reuben He
- Department of Surgery, The University of Auckland, Auckland, New Zealand.
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Jonathan Ko
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | - Howard Wain
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Vassil Manchev
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Wanda Bekker
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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2
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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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3
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García A, Millán M, Burbano D, Ordoñez CA, Parra MW, González Hadad A, Herrera MA, Pino LF, Rodríguez-Holguín F, Salcedo A, Franco MJ, Ferrada R, Puyana JC. Damage control in abdominal vascular trauma. Colomb Med (Cali) 2022; 52:e4064808. [PMID: 35027780 PMCID: PMC8754163 DOI: 10.25100/cm.v52i2.4808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/30/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.
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Affiliation(s)
- Alberto García
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Fundación Valle del Lili Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Universidad Icesi, Cali, Colombia. Universidad Icesi Universidad Icesi Cali Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia. Universidad Icesi Universidad Icesi Cali Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia Fundación Valle del Lili Department of Surgery Division of Transplant Surgery Cali Colombia
| | - Daniela Burbano
- Universidad de Caldas, Departamento de Cirugía. Manizales, Colombia. Universidad de Caldas Universidad de Caldas Departamento de Cirugía Manizales Colombia
| | - Carlos A Ordoñez
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Fundación Valle del Lili Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Universidad Icesi, Cali, Colombia. Universidad Icesi Universidad Icesi Cali Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA Broward General Level I Trauma Center Department of Trauma Critical Care Fort LauderdaleFL USA
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Hospital Universitario del Valle Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia.,Centro Médico Imbanaco, Cali, Colombia. Centro Médico Imbanaco Cali Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Hospital Universitario del Valle Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Hospital Universitario del Valle Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Fundación Valle del Lili Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Fundación Valle del Lili Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Universidad Icesi, Cali, Colombia. Universidad Icesi Universidad Icesi Cali Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Hospital Universitario del Valle Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia
| | - María Josefa Franco
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Fundación Valle del Lili Department of Surgery Division of Trauma and Acute Care Surgery Cali Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia. Universidad del Valle Universidad del Valle Facultad de Salud Escuela de Medicina Cali Colombia.,Centro Médico Imbanaco, Cali, Colombia. Centro Médico Imbanaco Cali Colombia
| | - Juan Carlos Puyana
- University of Pittsburgh. Critical Care Medicine. Pittsburgh, PA, USA. University of Pittsburgh University of Pittsburgh Critical Care Medicine PittsburghPA USA
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Awad S, Dawoud I, Negm A, Althobaiti W, Alfaran S, Alghamdi S, Alharthi S, Alsubaie K, Ghedan S, Alharthi R, Asiri M, Alzahrani A, Alotaibi N, Abou Sheishaa MS. Impact of laparoscopy on the perioperative outcome of penetrating abdominal trauma management during the post revolution period. Asian J Surg 2021; 45:461-467. [PMID: 34400049 DOI: 10.1016/j.asjsur.2021.07.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 07/14/2021] [Accepted: 07/22/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. Laparotomy is still the most popular procedure for managing PAT but has high morbidity and mortality rates. Presently, laparoscopy aims to provide equal or superior visualization compared to open approaches but with less morbidity, postoperative discomfort, and recovery time. The aim of this research is to assess the impact of laparoscopy on the management of PAT. METHODS This was a retrospective observational study carried out at the Emergency Hospital of Mansoura University/Egypt and at King Faisal Medical Complex, Taif/KSA from September 2014 to September 2018. All hemodynamically stable patients with PAT who were managed by laparoscopy were included in this study. Data extracted for analysis included demographic information, criteria of abdominal stabs, type of management, and perioperative outcome. RESULTS Forty patients were recruited in this research and the male-to-female ratio was 5.6:1. The mean age of the patients was 31.4 ± 12.318 years. During the laparoscopic procedure, no peritoneal penetration was observed in 4 patients (negative laparoscopy), while peritoneal penetration was observed in the remaining 36 patients. No visceral injuries were noted in 2 patients of the 36 patients with peritoneal penetration, while the remaining 34 patients had intra-abdominal injuries. CONCLUSION Laparoscopy performed on hemodynamically stable trauma patients was found to be safe and technically feasible. It also reduced negative and non-therapeutic laparotomies and offered paramount therapeutic and diagnostic advantages for traumatic diaphragmatic injuries.
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Affiliation(s)
- Selmy Awad
- Department of General Surgery, Faculty of medicine Mansoura University, Egypt.
| | - Ibrahim Dawoud
- Department of General Surgery, Faculty of medicine Mansoura University, Egypt
| | - Ahmed Negm
- Department of General Surgery, Faculty of medicine Mansoura University, Egypt
| | - Waleed Althobaiti
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Shaker Alfaran
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Saleh Alghamdi
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Saleh Alharthi
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Khaled Alsubaie
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Soliman Ghedan
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Rayan Alharthi
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Majed Asiri
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Azzah Alzahrani
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
| | - Nawal Alotaibi
- General Surgery Department, King Faisal Medical Complex, TAIF, Saudi Arabia
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5
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Stopenski S, Grigorian A, Inaba K, Lekawa M, Matsushima K, Schellenberg M, Kim D, de Virgilio C, Nahmias J. Prehospital Variables Alone Can Predict Mortality After Blunt Trauma: A Novel Scoring Tool. Am Surg 2021; 87:1638-1643. [PMID: 34128401 DOI: 10.1177/00031348211024192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We sought to develop a novel Prehospital Injury Mortality Score (PIMS) to predict blunt trauma mortality using only prehospital variables. STUDY DESIGN The 2017 Trauma Quality Improvement Program database was queried and divided into two equal sized sets at random (derivation and validation sets). Multiple logistic regression models were created to determine the risk of mortality using age, sex, mechanism, and trauma activation criterion. The PIMS was derived using the weighted average of each independent predictor. The discriminative power of the scoring tool was assessed by calculating the area under the receiver operating characteristics (AUROC) curve. The PIMS ability to predict mortality was then assessed by using the validation cohort. The score was compared to the Revised Trauma Score (RTS) using the AUROC curve, including a subgroup of patients with normal vital signs. RESULTS The derivation and validation groups each consisted of 163 694 patients. Seven independent predictors of mortality were identified, and the PIMS was derived with scores ranging from 0 to 20. The mortality rate increased from 1.4% to 43.9% and then 100% at scores of 1, 10, and 19, respectively. The model had very good discrimination with an AUROC of .79 in both the derivation and validation groups. When compared to the RTS, the AUROC were similar (.79 vs. .78). On subgroup analysis of patients with normal prehospital vital signs, the PIMS was superior to the RTS (.73 vs. .56). CONCLUSION The PIMS is a novel scoring tool to predict mortality in blunt trauma patients using prehospital variables. It had improved discriminatory power in blunt trauma patients with normal vital signs compared to the RTS.
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Affiliation(s)
- Stephen Stopenski
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, CA, USA.,Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Dennis Kim
- Department of Surgery, Harbor - UCLA Medical Center, Torrance, CA, USA
| | | | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA, USA
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6
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Yehia Elbarmelgi M, AbdAllah Salman M. Role of conservative management in low energy transfer penetrating shotgun abdominal injuries. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620916630] [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
Background and aims Penetrating abdominal trauma can be caused by a variety of weapons which require different management protocols. After a long era of mandatory laparotomy for abdominal gunshot wounds, the concept of selective laparotomy and conservative management in the form of serial observations has been introduced in some centers. This study aims to assess the feasibility and safety of conservative management and close observation of victims of low energy transfer shotgun penetrating abdominal injury. Methods A prospective cohort study of hemodynamically stable patients who had sustained low energy transfer shotgun injuries to the abdomen who presented to the surgical emergency department of Cairo University Hospitals from May 2016 to January 2019. They were subjected to a conservative management and follow-up protocol. Results A total of 250 patients (167 males and 83 females) were included. The conservative management protocol was successful in 217/250 patients (86.8%), unsuccessful in 22 patients (8.8%) where abdominal exploration was done either open or laparoscopically. Delayed diagnosis of bowel injury occurred in one patient (0.4%). There was one death (0.4%) and abdominal exploration was negative in 10 (4%) patients. Conclusion We recommend this conservative protocol for the victims of low energy transfer penetrating shotgun injuries which may save many patients from the morbidities of unnecessary laparotomy. We accept that the injury pattern may not be sufficiently common in many countries to allow comfort with this non-operative approach.
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7
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Hughes M, Perkins Z. Outcomes following resuscitative thoracotomy for abdominal exsanguination, a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:9. [PMID: 32028977 PMCID: PMC7006065 DOI: 10.1186/s13049-020-0705-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/19/2020] [Indexed: 12/11/2022] Open
Abstract
Background Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain. Objective The primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy. Methods A systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival. Results Seventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0–9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn. Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity. Conclusions Pre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.
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Affiliation(s)
- Michael Hughes
- Scarborough Hospital, York Teaching Hospital NHS Trust, Woodlands drive, Scarborough, YO12 6QL, UK.
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8
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Nahmias J, Grigorian A, Kim DY. Penetrating Abdominal Trauma. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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9
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Franke A, Bieler D, Friemert B, Schwab R, Kollig E, Güsgen C. The First Aid and Hospital Treatment of Gunshot and Blast Injuries. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:237-243. [PMID: 28446350 DOI: 10.3238/arztebl.2017.0237] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 08/10/2016] [Accepted: 01/24/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND When gunshot and blast injuries affect only a single person, first aid can always be delivered in conformity with the relevant guidelines. In contrast, when there is a dynamic casualty situation affecting many persons, such as after a terrorist attack, treatment may need to be focused on immediately life-threatening complications. METHODS This review is based on pertinent publications retrieved by a selective search in Medline and on the authors' clinical experience. RESULTS In a mass-casualty event, all initial measures are directed toward the survival of the greatest possible number of patients, in accordance with the concept of "tactical abbreviated surgical care." Typical complications such as airway obstruction, tension pneumothorax, and hemorrhage must be treated within the first 10 minutes. Patients with bleeding into body cavities or from the trunk must be given priority in transport; hemorrhage from the limbs can be adequately stabilized with a tourniquet. In-hospital care must often be oriented to the principles of "damage control surgery," with the highest priority assigned to the treatment of life-threatening conditions such as hemodynamic instability, penetrating wounds, or overt coagulopathy. The main considerations in initial surgical stabilization are control of bleeding, control of contamination and lavage, avoidance of further consequences of injury, and prevention of ischemia. Depending on the resources available, a transition can be made afterward to individualized treatment. CONCLUSION In mass-casualty events and special casualty situations, mortality can be lowered by treating immediately life-threatening complications as rapidly as possible. This includes the early identification of patients with lifethreatening hemorrhage. Advance preparation for the management of a masscasualty event is advisable so that the outcome can be as favorable as possible for all of the injured in special or tactical casualty situations.
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Affiliation(s)
- Axel Franke
- Department of Trauma, Orthopedic, Reconstructive, and Hand Surgery, Burns Medicine, Bundeswehr Central Hospital, Koblenz; Department of Trauma, Orthopedic, Septic, and Reconstructive Surgery, Sports Injuries, Bundeswehr Hospital, Ulm; Department of General, Visceral, and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz
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10
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Chowdhury S, Alenazi AM, Alharthi YA. Significant bleeding from Meckel's diverticulum after blunt abdominal trauma: a case report. J Med Case Rep 2018; 12:269. [PMID: 30227894 PMCID: PMC6145116 DOI: 10.1186/s13256-018-1799-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 08/13/2018] [Indexed: 11/24/2022] Open
Abstract
Background Meckel’s diverticulum, with an incidence of 2%, is the most common congenital anomaly in the gastrointestinal tract. Its main complications are perforation, obstruction, and bleeding. A few studies have reported that blunt abdominal trauma may result in perforation or obstruction to Meckel’s diverticulum. However, reports of significant major intestinal bleeding from Meckel’s diverticulum as a complication of blunt abdominal trauma is rare. This paper present what we believe to be the first reported case of significant intestinal bleeding from a Meckel’s diverticulum following blunt abdominal trauma. Case presentation A 12-year-old Saudi boy of Arab ethnicity presented to the King Saud Medical City emergency department with bleeding per rectum and mild abdominal pain following blunt trauma to his abdomen. On examination, his abdomen was slightly tender, bowel sounds were present, and he was hemodynamically stable. During admission, rectal bleeding was ongoing. On day 3 he deteriorated with decreasing blood pressure and hemoglobin, and increasing pulse rate with fever. After resuscitation and stabilization, he was urgently taken to the operating room for further diagnostic management and treatment. His nasogastric tube revealed bile without blood, and an intraoperative colonoscopy revealed altered blood within his whole colon and terminal ileum without a definite bleeding site. A laparotomy was performed, and an injured branch of the mesenteric artery supplying the Meckel’s diverticulum was identified as the source of the significant arterial bleeding. Suture ligation controlled the bleeding, and the Meckel’s diverticulum was resected. The patient remained stable after that until discharge without any further intestinal bleeding. Conclusion Identifying bleeding as a complicated Meckel’s diverticulum following blunt trauma to the abdomen can be challenging due to its low incidence and difficulties while making the diagnosis.
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Affiliation(s)
- Sharfuddin Chowdhury
- King Saud Medical City, 7790 Al-Imam Abdul Aziz Ibn Muhammad Ibn Saud, Ulaishah, Riyadh, 12746, Kingdom of Saudi Arabia.
| | | | - Yam Alwi Alharthi
- King Saud Medical City, 7790 Al-Imam Abdul Aziz Ibn Muhammad Ibn Saud, Ulaishah, Riyadh, 12746, Kingdom of Saudi Arabia
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11
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Occupational outcomes following combat-related gunshot injury: Cohort study. Int J Surg 2017; 48:286-290. [DOI: 10.1016/j.ijsu.2017.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/10/2017] [Accepted: 11/24/2017] [Indexed: 11/24/2022]
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12
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Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries. World J Surg 2017; 42:713-726. [DOI: 10.1007/s00268-017-4212-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Treatments and other prognostic factors in the management of the open abdomen: A systematic review. J Trauma Acute Care Surg 2017; 82:407-418. [PMID: 27918375 DOI: 10.1097/ta.0000000000001314] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications. METHODS An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality. RESULTS Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level. LIMITATIONS Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed. CONCLUSION Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model. LEVEL OF EVIDENCE Systematic review, level III.
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Harvin JA, Podbielski J, Vincent LE, Fox EE, Moore LJ, Cotton BA, Wade CE, Holcomb JB. Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial. Trauma Surg Acute Care Open 2017; 2:e000083. [PMID: 29766087 PMCID: PMC5877899 DOI: 10.1136/tsaco-2017-000083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/19/2017] [Accepted: 03/21/2017] [Indexed: 01/17/2023] Open
Abstract
Background Damage control laparotomy (DCL) is an abbreviated operation intended to prevent the development of hypothermia, acidosis, and coagulopathy in seriously injured patients. The indications for DCL have since been broadened with no high-quality data to guide treatment. For patients with an indication for DCL, we aim to determine the effect of definitive laparotomy on patient morbidity. Method This is a pragmatic, parallel-group, randomized controlled pilot trial. Emergent laparotomy is defined as admission directly to the operating room from the emergency department within 90 min of arrival. DCL indications excluded from the study include packing of the liver or retroperitoneum, abdominal compartment syndrome prophylaxis, to expedite interventional radiology for hemorrhage control, and the need for ongoing transfusions and/or continuous vasopressor support. When a surgeon determines a DCL is indicated, the patient will be screened for inclusion and exclusion criteria. Patients with any indication for DCL that is not excluded are eligible for randomization. Patients will be randomized intraoperatively to DCL (control) or definitive fascial closure of the laparotomy (intervention). The primary outcome will be major abdominal complication or death within 30 days. Major abdominal complication is a composite outcome including fascial dehiscence, organ/space surgical site infection, enteric suture line failure, and unplanned reopening of the abdomen. Outcomes will be compared using both frequentist and Bayesian statistics. Discussion In patients with an indication for DCL, this trial will determine the effect of definitive laparotomy on major abdominal complications and death and will inform clinicians on the risks and benefits of this procedure. Regardless of the study outcome, the results will improve the quality of care provided to injured patients. Trial registration number NCT02706041.
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Affiliation(s)
- John A Harvin
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jeanette Podbielski
- The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura E Vincent
- The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Erin E Fox
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura J Moore
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - John B Holcomb
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,The Center for Translational Injury Research, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Abstract
PURPOSE OF REVIEW Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. Despite this reality, indications for initiating DCS remain debated. RECENT FINDINGS Despite discussion surrounding the appropriate indications for DCS, this series of fundamental principles includes a rapidly abbreviated operative intervention aimed at arresting ongoing hemorrhage and containing gastrointestinal contamination in a patient approaching physiologic exhaustion, which includes both vascular and nonvascular damage control techniques, in addition to management of the open abdomen. Patients are then returned to the operating theater for definitive reconstruction once their physiology has been stabilized within the ICU. SUMMARY DCS is lifesaving when applied in appropriate clinical scenarios involving critically injured patients. Overuse of this technique can lead to increased patient morbidity and cost however.
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Abstract
Massive transfusions occur frequently in pediatric trauma patients, among some children undergoing surgery, or in children with critical illness. Over the last years, many authors have studied different aspects of massive transfusions, starting with an operative definition. Some information is available on transfusion strategies and adjunctive treatments. Areas that require additional investigation include: studies to assess which children benefit from transfusion protocols based on fixed ratios of blood components vs transfusion strategies based on biophysical parameters and laboratory tests; whether goal-directed therapies that are personalized to the recipient will improve outcomes; or which laboratory tests best define the risk of bleeding and what clinical indicators should prompt the start and stop of massive transfusion protocols. In addition, critical issues that require further study include transfusion support with whole blood vs reconstituted whole blood prepared from packed red blood cells, plasma, and platelets; and the generation of high quality evidence that would lead to treatments which decrease adverse consequences of transfusion and improve outcomes.
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Affiliation(s)
- Oliver Karam
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.
| | - Marisa Tucci
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada.
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Kevric J, O’Reilly GM, Gocentas RA, Hasip O, Pilgrim C, Mitra B. Management of haemodynamically stable patients with penetrating abdominal stab injuries: review of practice at an Australian major trauma centre. Eur J Trauma Emerg Surg 2015; 42:671-675. [DOI: 10.1007/s00068-015-0605-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
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Benefits of CT tractography in evaluation of anterior abdominal stab wounds. Am J Emerg Med 2015; 33:1188-90. [DOI: 10.1016/j.ajem.2015.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/27/2015] [Accepted: 05/18/2015] [Indexed: 11/23/2022] Open
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Abstract
Abdominal trauma represents the leading cause of haemorrhagic shock in the severely injured patient and is associated with high mortality and morbidity rates. The trauma surgeon has a central role in the multidisciplinary team addressing the specific diagnostic and therapeutic needs of patients with abdominal trauma. The management of blunt and penetrating abdominal trauma has undergone substantial changes in recent decades. Major innovations have been established in the field of diagnostic imaging and of nonoperative interventions such as angioembolization and endoscopic procedures. Another key development is the introduction of the damage control concept for the care of patients with abdominal trauma. The present manuscript comprises a review of the current management of abdominal trauma with an emphasis on diagnostic and therapeutic innovations.
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Maciel JD, Gifford E, Plurad D, de Virgilio C, Bricker S, Bongard F, Neville A, Smith J, Putnam B, Kim D. The impact of a massive transfusion protocol on outcomes among patients with abdominal aortic injuries. Ann Vasc Surg 2015; 29:764-9. [PMID: 25725276 DOI: 10.1016/j.avsg.2014.11.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 11/14/2014] [Accepted: 11/25/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Injuries of the abdominal aorta are uncommon and associated with a high mortality. The purpose of this study was to examine the impact of an institutional massive transfusion protocol (MTP) on outcomes in patients with injuries of the abdominal aorta. METHODS A 12.5-year retrospective analysis of a Level 1 trauma center database to identify patients with abdominal aortic injuries was conducted. Demographics, associated injuries and severity, operative procedures, resuscitation requirements, and outcomes were compared among patients before and after implementation of an MTP. RESULTS Of the 46 patients with abdominal aortic injuries, 29 (63%) were in the pre-MTP group and 17 (37%) were in the post-MTP group. The mean age of the entire cohort was 32 ± 17 years and the two most common mechanisms of injury were gunshot wounds (63%) followed by motor vehicle collisions (24%). Thirteen patients (28%) underwent an emergency department thoracotomy and 11 patients (24%) sustained concomitant inferior vena cava injuries. There was a significant reduction in the volume of pre- and intraoperative crystalloids administered between the pre- and post-MTP groups. Intraoperatively, the use of tranexamic acid was increased in the post-MTP group (P < 0.001). A statistically significant difference in achievement of a low packed red blood cells to fresh frozen plasma ratio was observed for the post- versus the pre-MTP group (88% vs. 30%, P = 0.015). Overall survival was improved among post- versus pre-MTP patients (47% vs. 14%, P = 0.03). CONCLUSIONS Abdominal aortic injuries continue to represent a challenge and remain associated with a high mortality. Modern improvements in damage control resuscitation techniques including implementation of an institutional MTP may improve outcomes in patients with these injuries.
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Affiliation(s)
- James D Maciel
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Edward Gifford
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - David Plurad
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | | | - Scott Bricker
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Fred Bongard
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Angela Neville
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Jennifer Smith
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Brant Putnam
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Dennis Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA.
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22
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Kim DY, Grigorian A. Penetrating Abdominal Trauma. Surgery 2015. [DOI: 10.1007/978-1-4939-1726-6_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Simoneau E, Chughtai T, Razek T, Deckelbaum DL. Pancreaticoatmospheric fistula following severe acute necrotising pancreatitis. BMJ Case Rep 2014; 2014:bcr-2014-206131. [PMID: 25519860 DOI: 10.1136/bcr-2014-206131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Severe acute necrotising pancreatitis is associated with numerous local and systemic complications. Abdominal compartment syndrome requiring urgent decompressive laparotomy is a potential complication of this disease process and is associated with increased morbidity and mortality. We describe the case of a pancreaticoatmospheric fistula following decompressive laparotomy in a patient with severe acute necrotising pancreatitis. While this fistula was managed successfully using the current standard of care for pancreatic fistulas, the wound care for in this patient with drainage of the fistula through an open abdomen, is a significant challenge.
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Affiliation(s)
- Eve Simoneau
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Talat Chughtai
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Tarek Razek
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Dan L Deckelbaum
- Department of Surgery, McGill University, Montreal, Quebec, Canada
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24
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Ball CG. Current management of penetrating torso trauma: nontherapeutic is not good enough anymore. Can J Surg 2014; 57:E36-43. [PMID: 24666458 DOI: 10.1503/cjs.026012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.
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Affiliation(s)
- Chad G Ball
- From the University of Calgary, Calgary, Alta
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25
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Kobayashi L, Coimbra R. Planned re-laparotomy and the need for optimization of physiology and immunology. Eur J Trauma Emerg Surg 2014; 40:135-42. [PMID: 26815893 DOI: 10.1007/s00068-014-0396-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/10/2014] [Indexed: 12/31/2022]
Abstract
Planned re-laparotomy or damage control laparotomy (DCL), first described by Dr. Harlan Stone in 1983, has become a widely utilized technique in a broad range of patients and operative situations. Studies have validated the use of DCL by demonstrating decreased mortality and morbidity in trauma, general surgery and abdominal vascular catastrophes. Indications for planned re-laparotomy include severe physiologic derangements, coagulopathy, concern for bowel ischemia, and abdominal compartment syndrome. The immunology of DCL patients is not well described in humans, but promising animal studies suggest a benefit from the open abdomen (OA) and several human trials on this subject are currently underway. Optimal critical care of patients with OA's, including sedation, paralysis, nutrition, antimicrobial and fluid management strategies have been associated with improved closure rates and recovery.
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Affiliation(s)
- L Kobayashi
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego, 200 W. Arbor Dr. #8896, San Diego, CA, 92103-8896, USA.
| | - R Coimbra
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego, 200 W. Arbor Dr. #8896, San Diego, CA, 92103-8896, USA.
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Abstract
Damage control resuscitation (DCR) represents the natural evolution of the initial concept of damage control surgery. It currently includes early blood product transfusion, immediate arrest and/or temporization of ongoing hemorrhage (i.e., temporary intravascular shunts and/or balloon tamponade) as well as restoration of blood volume and physiologic/hematologic stability. As a result, DCR addresses the early coagulopathy of trauma, avoids massive crystalloid resuscitation and leaves the peritoneal cavity open when a patient approaches physiologic exhaustion without improvement. This concept also applies to severe injuries within anatomical transition zones as well as extremities. This review will discuss each of these concepts in detail.
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Affiliation(s)
- Chad G Ball
- From the University of Calgary and Foothills Medical Centre, Calgary, Alta
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Yuan Y, Ren J, He Y. Current status of the open abdomen treatment for intra-abdominal infection. Gastroenterol Res Pract 2013; 2013:532013. [PMID: 24198827 PMCID: PMC3807717 DOI: 10.1155/2013/532013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 08/31/2013] [Accepted: 09/15/2013] [Indexed: 01/13/2023] Open
Abstract
The open abdomen has become an important approach for critically ill patients who require emergent abdominal surgical interventions. This treatment, originating from the concept of damage control surgery, was first applied in severe traumatic patients. The ultimate goal is to achieve formal abdominal fascial closure by several attempts and adjuvant therapies (fluid management, nutritional support, skin grafting, etc.). Up to the present, open abdomen therapy becomes matured and is multistage-approached in the management of patients with severe trauma. However, its application in patients with intra-abdominal infection still presents great challenges due to critical complications and poor clinical outcomes. This review focuses on the specific use of the open abdomen in such populations and detailedly introduces current concerns and advanced progress about this therapy.
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Affiliation(s)
- Yujie Yuan
- Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital of Sun Yat-Sen University, 58 2nd Zhongshan Road, Guangzhou, Guangdong 510080, China
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, Jiangsu 210002, China
| | - Yulong He
- Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital of Sun Yat-Sen University, 58 2nd Zhongshan Road, Guangzhou, Guangdong 510080, China
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Abstract
The damage control concept is an essential component in the management of severely injured patients. The principles in sequence are as follows: (1) abbreviated surgical procedures limited to haemorrhage and contamination control; (2) correction of physiological derangements; (3) definitive surgical procedures. Although originally described in the management of major abdominal injuries, the concept has been extended to include thoracic, vascular, orthopedic, and neurosurgical procedures, as well as anesthesia and resuscitative strategies.
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Affiliation(s)
- Jeremy M Hsu
- Department of Surgery, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA
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Abstract
PURPOSE Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions. This method compromises fascial integrity creating functionally and aesthetically debilitating hernias. The purpose of this study is to present our technique and outcomes with these complex abdominal wall reconstructions. METHODS A retrospective review was conducted on 56 patients with previous damage control laparotomies who underwent elective single-stage abdominal wall reconstruction between 1999 and 2006. Mean age was 42 years. Reconstruction consisted of a double-layer, subfascial Vicryl mesh buttress, combined with components separation and rectus muscle turnover flaps. Hernia recurrence and function were evaluated by clinical examinations and telephone surveys. RESULTS The major etiologies of abdominal hernias were gunshot wounds, motor vehicle accidents or blunt trauma, and sepsis or perforated bowel. The mean abdominal wall defect was 865 cm, and the average interval time to definitive repair was 17 months. The average length of follow-up was 29 months. Most patients (88%) had successful repair of their abdominal wall, with no hernia recurrence. There were 7 cases of hernia. Of these, 2 cases were from reopening of abdomen because of compartment syndrome that was not repaired, 3 were small asymptomatic hernias for which patients elected not to undergo further repair. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 12% (7 patients) and abdominal compartment syndrome 7.1% (4 patients), resulting in 2 postoperative mortalities in the initial part of the series. There were no mesh exposures, seromas, or fistulas. In all, 29% or 52% of patients were reached by telephone. Of those, 90% surveyed and who worked full-time prior to injury returned to their jobs, and 92% were functioning at premorbid activity levels. CONCLUSION Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We believe the use of a Vicryl mesh buttress is an important adjunctive tool in complex abdominal wall reconstruction. Functional results are excellent with most returning to work and preinjury activity levels.
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Swaroop M, Straus DC, Agubuzu O, Esposito TJ, Schermer CR, Crandall ML. Pre-hospital transport times and survival for Hypotensive patients with penetrating thoracic trauma. J Emerg Trauma Shock 2013; 6:16-20. [PMID: 23494152 PMCID: PMC3589853 DOI: 10.4103/0974-2700.106320] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 08/07/2012] [Indexed: 11/28/2022] Open
Abstract
Background: Achieving definitive care within the “Golden Hour” by minimizing response times is a consistent goal of regional trauma systems. This study hypothesizes that in urban Level I Trauma Centers, shorter pre-hospital times would predict outcomes in penetrating thoracic injuries. Materials and Methods: A retrospective cohort study was performed using a statewide trauma registry for the years 1999-2003. Total pre-hospital times were measured for urban victims of penetrating thoracic trauma. Crude and adjusted mortality rates were compared by pre-hospital time using STATA statistical software. Results: During the study period, 908 patients presented to the hospital after penetrating thoracic trauma, with 79% surviving. Patients with higher injury severity scores (ISS) were transported more quickly. Injury severity scores (ISS) ≥16 and emergency department (ED) hypotension (systolic blood pressure, SBP <90) strongly predicted mortality (P < 0.05 for each). In a logistic regression model including age, race, and ISS, longer transport times for hypotensive patients were associated with higher mortality rates (all P values <0.05). This was seen most significantly when comparing patient transport times 0-15 min and 46-60 min (P < 0.001). Conclusion: In victims of penetrating thoracic trauma, more severely injured patients arrive at urban trauma centers sooner. Mortality is strongly predicted by injury severity, although shorter pre-hospital times are associated with improved survival. These results suggest that careful planning to optimize transport time-encompassing hospital capacity and existing resources, traffic patterns, and trauma incident densities may be beneficial in areas with a high burden of penetrating trauma.
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Affiliation(s)
- Mamta Swaroop
- Northwestern University Feinberg School of Medicine, University of Chicago Department of Neurosurgery, Loyola University Medical Center, University of California, Davis, USA
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Makama JG, Garba ES. Abscess rate of patients with penetrating abdominal injury in Zaria. Health (London) 2013. [DOI: 10.4236/health.2013.54102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Shan CX, Ni C, Qiu M, Jiang DZ. Is laparoscopy equal to laparotomy in detecting and treating small bowel injuries in a porcine model? World J Gastroenterol 2012; 18:6850-5. [PMID: 23239924 PMCID: PMC3520175 DOI: 10.3748/wjg.v18.i46.6850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/23/2012] [Accepted: 10/16/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the safety and effectiveness of laparoscopy compared with laparotomy for diagnosing and treating small bowel injuries (SBIs) in a porcine model.
METHODS: Twenty-eight female pigs were anesthetized and laid in the left recumbent position. The SBI model was established by shooting at the right lower quadrant of the abdomen. The pigs were then randomized into either the laparotomy group or the laparoscopy group. All pigs underwent routine exploratory laparotomy or laparoscopy to evaluate the abdominal injuries, particularly the types, sites, and numbers of SBIs. Traditional open surgery or therapeutic laparoscopy was then performed. All pigs were kept alive within the observational period (postoperative 72 h). The postoperative recovery of each pig was carefully observed.
RESULTS: The vital signs of all pigs were stable within 1-2 h after shooting and none of the pigs died from gunshot wounds or SBIs immediately. The SBI model was successfully established in all pigs and definitively diagnosed with single or multiple SBIs either by exploratory laparotomy or laparoscopy. Compared with exploratory laparotomy, laparoscopy took a significantly longer time for diagnosis (41.27 ± 12.04 min vs 27.64 ± 13.32 min, P = 0.02), but the time for therapeutic laparoscopy was similar to that of open surgery. The length of incision was significantly reduced in the laparoscopy group compared with the laparotomy group (5.27 ± 1.86 cm vs 15.73 ± 1.06 cm, P < 0.01). In the final post-mortem examination 72 h after surgery, both laparotomy and laparoscopy offered a definitive diagnosis with no missed injuries. Postoperative complications occurred in four cases (three following laparotomy and one following laparoscopy, P = 0.326). The average recovery period for bowel function, vital appearance, and food re-intake after laparoscopy was 10.36 ± 4.72 h, 14.91 ± 3.14 h, and 15.00 ± 7.11 h, respectively. All of these were significantly shorter than after laparotomy (21.27 ± 10.17 h, P = 0.004; 27.82 ± 9.61 h, P < 0.001; and 24.55 ± 9.72 h, respectively, P = 0.016).
CONCLUSION: Compared with laparotomy, laparoscopy offers equivalent efficacy for diagnosing and treating SBIs, and reduces postoperative complications as well as recovery period.
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Newell MA, Skarupa DJ, Rotondo MF. The damage control sequence in the elderly: Strategy, complexities, and outcomes. TRAUMA-ENGLAND 2012. [DOI: 10.1177/1460408612463867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traditional management in cases of exsanguinating abdominal trauma led to poor outcomes in critically injured patients. Because prolonged operations were not well tolerated due to the severe physiologic derangements, an abbreviated laparotomy began to be used. Patients were then resuscitated in the intensive care unit and brought back to the operating room once their physiology had been normalised. This approach has been termed the damage control sequence. Elderly trauma patients are susceptible to significant injury that may mandate a damage control sequence. For myriad reasons, including pre-existing medical conditions, decreased physiologic reserve, and the emergent nature of their injuries, the application of this management approach in the elderly is fraught with challenges. The purpose of this review is to enumerate the damage control sequence, describe the complexities of its use in the elderly, and discuss associated outcomes in this challenging patient population.
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Affiliation(s)
- Mark A Newell
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
| | - David J Skarupa
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
| | - Michael F Rotondo
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
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Nasal cannula end-tidal CO2 correlates with serum lactate levels and odds of operative intervention in penetrating trauma patients. J Trauma Acute Care Surg 2012; 73:1202-7. [DOI: 10.1097/ta.0b013e318270198c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Frischknecht A, Lustenberger T, Bukur M, Turina M, Billeter A, Mica L, Keel M. Damage control in severely injured trauma patients - A ten-year experience. J Emerg Trauma Shock 2012; 4:450-4. [PMID: 22090736 PMCID: PMC3214499 DOI: 10.4103/0974-2700.86627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 03/05/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND This study reviews our 10-year institutional experience with damage control management and investigates risk factors for early mortality. MATERIALS AND METHODS The trauma registry of our level I trauma centre was utilized to identify all patients from 01/96 through 12/05 who underwent initial damage control procedures. Demographics, clinical and physiological parameters, and outcomes were abstracted. Patients were categorized as either early survivors (surviving the first 72 hours after admission) or early deaths. RESULTS During the study period, 319 patients underwent damage control management. Overall, 52 patients (16.3%) died (early deaths) and 267 patients (83.7%) survived the first 72 hours (early survivors). Early deaths showed significantly deranged serum lactate (5.81±0.55 vs. 3.46±0.13 mmol/L; P<0.001), base deficit (10.10±0.95 vs. 4.90±0.28 mmol/L; P<0.001) and pH (7.16±0.03 vs. 7.29±0.01; P<0.001) levels compared to early survivors on hospital admission. An International Normalized Ratio >1.2, base deficit >3 mmol/L, head Abbreviated Injury Scale ≥3, body temperature <35°C, serum lactate >6 mmol/L, and hemoglobin <7 g/dL proved to be independent risk factors for early mortality on hospital admission. CONCLUSIONS Several risk factors for early mortality such as severe head injury and the lethal triad (coagulopathy, acidosis and hypothermia) in patients undergoing damage control procedures were identified and should trigger the trauma surgeon to maintain aggressive resuscitation in the intensive care unit.
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Abstract
Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.
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Effect of damage control surgery on major abdominal vascular trauma. J Surg Res 2012; 177:320-5. [PMID: 22682716 DOI: 10.1016/j.jss.2012.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 04/23/2012] [Accepted: 05/04/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND In 1982, we reported our experience with abdominal vascular trauma, highlighting the critical role of hypothermia, acidosis, and coagulopathy. Damage control surgery was subsequently introduced to address this "lethal triad." The purpose of the present study was to evaluate the outcomes from our most recent 6-year experience compared with a cohort from 30 years ago. METHODS Patients with major abdominal vascular injuries were examined, and the most recent 6-year period was compared with archived data from a similar 6-year period three decades ago. RESULTS The number of patients with major abdominal vascular injuries decreased from 123 patients in 1975 to 1980 to 64 patients in 2004 to 2009. The mean initial pH decreased from 7.21 to 6.96 (1975 to 1980 versus 2004 to 2009) for patients with overt coagulopathy. Despite increasingly protracted acidosis, mortality attributable to refractory coagulopathy decreased from 46% to 19% (1975 to 1980 versus 2004 to 2009, chi-square = 4.36, P = 0.04). No significant difference was found in mortality from exsanguinating injuries (43% versus 62%, 1975 to 1980 versus 2004 to 2009, chi-square = 1.96, P = 0.16). The prehospital transport times were unchanged (22 versus 20 min, 1975 to 1980 versus 2004 to 2009). Despite the administration of additional clotting factors and the advent of damage control surgery, the overall mortality remained largely unchanged (37% versus 33%, 1975 to 1980 versus 2004 to 2009, chi-square = 0.385, P = 0.53). CONCLUSIONS The adoption of damage control surgery, including the implementation of a massive transfusion protocol, was associated with a reduction in mortality for abdominal vascular injuries due to coagulopathy; however, patients have continued to die of exsanguination.
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Verdam FJ, Dolmans DEJGJ, Loos MJ, Raber MH, de Wit RJ, Charbon JA, Vroemen JPAM. Delayed primary closure of the septic open abdomen with a dynamic closure system. World J Surg 2012; 35:2348-55. [PMID: 21850603 PMCID: PMC3170463 DOI: 10.1007/s00268-011-1210-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall. Methods Eighteen cases with severe peritonitis of various origin (e.g., gastrointestinal perforations, anastomotic leakage) were primarily stabilized by laparostomy, sealed with either the vacuum-assisted closure abdominal dressing or the Bogotá bag. After hemodynamic stabilization and control of the sepsis, the Abdominal Re-approximation Anchor System (ABRA; Canica Design, Almonte, Ontario, Canada) was applied. This system approximates the wound margins through dynamic traction exerted by transfascial elastomers. Before ABRA application, 5/18 patients had a grade 2B, 2/18 a grade 3, and 11/18 a grade or 4 status according to the open abdomen classification of Björck. Results In this severely ill population the mean time before ABRA system application was 12 days (range: 2–39 days). Two of 18 patients died of non-ABRA-related causes within three weeks. In 14 of the remaining 16 patients (88%) primary abdominal closure of the midline was accomplished in 15 days (range: 7–30 days). The other two patients needed a component separation technique according to Ramirez to reach closure. However, secondary wound dehiscence occurred in both these patients. Two thirds of patients (12/18) developed pressure sores to the skin and/or dermis, but all healed without further complications. During outpatient clinic follow-up, 4/14 successfully closed patients still developed a midline hernia. Conclusions Delayed primary closure of OA in septic patients could be achieved in 88% with this new approximation system. However, the risk of hernia development remained. We consider this system a useful tool in the treatment of septic patients with an open abdomen. Electronic supplementary material The online version of this article (doi:10.1007/s00268-011-1210-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Froukje J Verdam
- Department of General Surgery, Amphia Hospital, P.O. Box 90158, 4800 RK Breda, The Netherlands.
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Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM. Imaging vascular trauma. Br J Surg 2011; 99:494-505. [DOI: 10.1002/bjs.7763] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2011] [Indexed: 01/06/2023]
Abstract
Abstract
Background
Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.
Methods
A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.
Results
Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.
Conclusion
Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.
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Affiliation(s)
- B O Patterson
- St George's Vascular Institute, St George's University of London, London, UK
| | - P J Holt
- St George's Vascular Institute, St George's University of London, London, UK
| | - M Cleanthis
- Imperial College Regional Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - N Tai
- Trauma Clinical Academic Unit, Barts and the London NHS Trust, London, UK
| | - T Carrell
- National Institute for Health Research Comprehensive Biomedical Research Centre of Guy's and St Thomas' NHS Foundation Trust and Department of Vascular Surgery, King's College London, London, UK
| | - T M Loosemore
- St George's Vascular Institute, St George's University of London, London, UK
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Lustenberger T, Talving P, Schnüriger B, Eberle BM, Keel MJB. Impact of Advanced Age on Outcomes Following Damage Control Interventions for Trauma. World J Surg 2011; 36:208-15. [DOI: 10.1007/s00268-011-1321-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Dutton WD, Diaz JJ, Miller RS. Critical care issues in managing complex open abdominal wound. J Intensive Care Med 2011; 27:161-71. [PMID: 21436165 DOI: 10.1177/0885066610396162] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Over the past 30 years, surgical specialties have introduced and expanded the role of open abdominal management in complicated operative cases, necessitating an intensivist's understanding of the indications and unique intensive care unit (ICU) issues related to the open abdomen. When presented with the open abdomen, resuscitation to correct shock is of primary concern. This is accomplished by correction of hypothermia, acidosis, and coagulopathy in trauma and adequate resolution of intra-abdominal hypertension or source control in general surgery. These patients typically require deep sedation and often paralysis and benefit from low-volume ventilatory strategies to prevent and treat acute lung injury. Antibiotics must be tailored to the clinical situation, but in most cases, 24 hours of perioperative treatment is all that is required. In cases of gross contamination and peritonitis, a 5- to 7-day course of broad-spectrum antibiotics may be of benefit.Adequate source control has been demonstrated to have the greatest impact on outcome and when the patient's clinical milieu dictates, bedside washouts. Enteral nutrition should be instituted as early as possible after intestinal continuity has been reestablished. Additional protein is required to account for losses from the open abdomen. Reconstruction may require staging, but in general, should proceed following resolution of shock and control of sepsis. Elevated multiorgan dysfunction score, Acute Physiology And Chronic Health Evaluation II (APACHE II), and a rise in peak inspiratory pressure portend poor source control and could result in failure of fascial closure. If unable to proceed to fascial closure, then considerations should be made for planned ventral hernia and subsequent abdominal wall reconstruction.
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Affiliation(s)
- William D Dutton
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37221, USA
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[Interruption of the diagnostic algorithm and immediate surgical intervention after major trauma--incidence and clinical relevance. Analysis of the Trauma Register of the German Society for Trauma Surgery]. Unfallchirurg 2011; 113:832-8. [PMID: 20393832 DOI: 10.1007/s00113-010-1772-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Life-threatening situations after multiple trauma which require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. The purpose of this study was to evaluate the incidence, causes, implications and relevance of life-threatening situations for major trauma patients after admission to trauma centers. PATIENT AND METHODS Data of 12,971 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) > 16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to patients where the diagnostic algorithm in the resuscitation room was interrupted to perform emergency surgery (group Notop, n = 713, 5.5%) and patients who received early surgical care after completed diagnostics (group Frühop, n = 5,515, 42.5%). Comparative parameters were the pattern and severity of injury, physiological state and clinical outcome. RESULTS Patients receiving emergency surgery showed an average ISS score of 39 ± 15 points, whereas patients receiving early surgery showed an average ISS of 31 ± 12 points. On admission patients in the emergency surgery group (44%) suffered from hemodynamic shock considerably more often than patients in the early surgery care group (15%, p < 0.001). This was indicated by the significant differences in systolic blood pressure on admission, amount of preclinical substituted volume, base excess on admission and substituted erythrocyte concentrates in early clinical course. Mortality was 46% in the emergency surgery group and 13% in the early surgical care group (p < 0.001). Severe injuries (AIS ≥ 4) of the thorax, abdomen and extremities (including the pelvis) were encountered considerably more often in the emergency surgery group. There was no statistical difference in occurrence of severe head injuries between the groups. Emergency surgery consisted of 50.5% laparatomy, 19.8% craniotomy, 10.0% thoracotomy and 9.3% pelvic surgery. CONCLUSION Life-threatening situations after major trauma which require immediate surgical intervention in the resuscitation room rarely occur in Germany. Nevertheless, they are associated with a high mortality and prolonged and complex clinical course if primarily survived. Indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms and should be considered for the future education of orthopedic surgeons in Germany.
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Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med 2010; 18:35. [PMID: 20565804 PMCID: PMC2898680 DOI: 10.1186/1757-7241-18-35] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Accepted: 06/17/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed. RESULTS Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference. CONCLUSION The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.
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Affiliation(s)
- Philipp Lichte
- Department of Trauma Surgery, University Hospital of the RWTH Aachen, Aachen, Germany.
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Sandler G, Leishman S, Branson H, Buchan C, Holland AJA. Body wall thickness in adults and children--relevance to penetrating trauma. Injury 2010; 41:506-9. [PMID: 19729157 DOI: 10.1016/j.injury.2009.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 07/16/2009] [Accepted: 08/03/2009] [Indexed: 02/02/2023]
Abstract
AIM Although uncommon in children, penetrating trauma may be associated with considerable risk of morbidity and mortality. In part this reflects the child's thinner body wall. No data exists on the difference in body wall thickness in children as compared to adults. METHOD Computer tomography (CT) scans (23 adults and 17 children) selected at random were reviewed. Measurements of the thickness of the skin and subcutaneous tissue were taken from anatomically defined regions on the thoracic and abdominal wall. The differences between adults and children were compared and analysed statistically. RESULTS The mean ages were 51.3 years for an adult and 8.9 years for a child. Indications for the CT scans included malignancy, inflammatory conditions and blunt trauma. Statistically significant differences in the median thicknesses of adult and paediatric thoraco-abdominal wall were found in all of the regions measured. This difference ranged from 7 mm at the xiphisternum to 14 mm in the right and left axillary lines at the level of the iliac crests. CONCLUSIONS The demonstrated difference in thickness of the thoraco-abdominal wall of an adult as compared to a child means that for a penetrating injury of equal depth, the body wall will be more easily breached and more organs potentially damaged in a child, particularly if the injury is sustained in the flanks. This supports the principle that all penetrating thoraco-abdominal wounds in children should be explored in the operating theatre under general anaesthesia to reduce the risk of a missed injury.
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Affiliation(s)
- Gideon Sandler
- The University of Sydney, Department of Academic Surgery, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales, 2145, Australia.
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Abstract
This article is one of ten reviews selected from the Yearbook of Intensive Care and Emergency Medicine 2010 (Springer Verlag) and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/yearbook. Further information about the Yearbook of Intensive Care and Emergency Medicine is available from http://www.springer.com/series/2855.
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Combined Splenectomy and Nephrectomy for Trauma: Morbidity, Mortality, and Outcomes Over 30 Years. ACTA ACUST UNITED AC 2010; 68:519-21. [DOI: 10.1097/ta.0b013e3181cda28d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Sepsis is a major cause of mortality and morbidity in the trauma patient. Sepsis following traumatic injury is related to the type of injury, together with the extent of injury and the anatomical location. Burn injuries are associated with the highest risk of sepsis. The diagnosis of sepsis in the trauma patient remains difficult. Interpretation of abnormal results is key to successful diagnosis, particularly in conjunction with clinical findings. This review will consider the specific features of sepsis in the context of trauma relating to epidemiology, risk factors, diagnosis and management.
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Affiliation(s)
- Robert Thornhill
- Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Raddlebarn Road, Selly Oak, Birmingham, B29 6JD, UK, , Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
| | - Dan Strong
- Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
| | - Suresh Vasanth
- Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
| | - Iain Mackenzie
- Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK, School of Clinical and Experimental Medicine, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Leppäniemi AK. Laparostomy: Why and When? Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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