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Bettschen D, Tsichlaki D, Chatzimichail E, Klukowska-Rötzler J, Müller M, Sauter TC, Exadaktylos AK, Ziaka M, Doulberis M, Burkhard JP. Epidemiology of maxillofacial trauma in elderly patients receiving oral anticoagulant or antithrombotic medication; a Swiss retrospective study. BMC Emerg Med 2024; 24:121. [PMID: 39020294 PMCID: PMC11256473 DOI: 10.1186/s12873-024-01039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/05/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND The percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED). METHODS Data were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT. RESULTS The study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases). CONCLUSIONS This study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.
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Affiliation(s)
- David Bettschen
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
| | - Dimitra Tsichlaki
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
| | - Eleftherios Chatzimichail
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
- Department of Ophthalmology, University Hospital of Basel, Basel, Switzerland
| | - Jolanta Klukowska-Rötzler
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland.
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
| | - Mairi Ziaka
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland
| | - Michael Doulberis
- Gastroklinik, Private Gastroenterolgy Practice, 8810, Horgen, Switzerland
- Division of Gastroenterology and Hepatology, Medical University Department, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - John-Patrik Burkhard
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, 3010, Bern, Switzerland.
- Limat Cleft and Craniofacial Centere, 8005, Zurich, Switzerland.
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Vieira B, Taranu V, Vieira A, Soares D, Soares A, Silva A, Galvão D, Bagnari I, Melo D, Pimentel F, Sousa J, Martins L, Pinheiro L, Vargas M, Reis Ó, Valente S, Bettencourt R, Oliveira T, Mora A. [Trauma Injuries Associated with Rope Bullfights in the Azores: A Cross-Sectional Study]. ACTA MEDICA PORT 2024; 37:267-273. [PMID: 38452740 DOI: 10.20344/amp.19440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/26/2023] [Indexed: 03/09/2024]
Abstract
INTRODUCTION The aim of the study was to describe trauma injuries associated with rope bullfights in the Azores, Portugal, regarding the cause of the incident, trauma mechanism, most affected anatomical areas, and injury severity. METHODS Two-year cross-sectional study in the local hospital with prospective data collection. Patients who were consecutively admitted to the local hospital's emergency department with trauma injuries from the bull's direct impact or from falls either during the bull's escape or when handling the rope, were included. Data on general demographics, lesion characteristics, treatments, need for hospitalization and mortality were collected. RESULTS Fifty-six incidents and 80 trauma injuries were identified. The main cause of trauma was the bull's direct impact (37; 66.07%) and the mechanism of injury was blunt trauma in all patients (100%; 56). Head and neck injuries (27; 33.75%) were the most common. The median Injury Severity Score at the emergency department admission was 4. Major trauma was noted in five patients (8.92%). Ten patients (17.85%) needed hospitalization with a median hospital stay of seven days. Three of the 10 hospitalized patients (30%) were previously admitted to the intensive care unit. Surgery was performed in six patients (10.71%). CONCLUSION The main cause of trauma was the bull's direct impact, and the mechanism of injury was blunt trauma. The most affected anatomical areas were the head and neck. These findings are a wake-up call to the impact of these events regarding the economic costs they entail, the costs for the health of the local population, the safety measures currently implemented and the availability of the necessary means to treat these patients.
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Affiliation(s)
- Bárbara Vieira
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Viorel Taranu
- Serviço de Cirurgia Geral. Hospital Lusíadas Amadora. Lisboa. Portugal
| | - Ana Vieira
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Duarte Soares
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Ana Soares
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Anaísa Silva
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Diogo Galvão
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Inês Bagnari
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Débora Melo
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Fernando Pimentel
- Serviço de Ortopedia e Traumatologia. Hospital de Santo Espírito da Ilha Terceira. Angra do Heroísmo. Portugal
| | - José Sousa
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Lisandra Martins
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Luís Pinheiro
- Serviço de Ortopedia e Traumatologia. Hospital de Santo Espírito da Ilha Terceira. Angra do Heroísmo. Portugal
| | - Marília Vargas
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Óscar Reis
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Sofia Valente
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Rui Bettencourt
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
| | - Teresa Oliveira
- Serviço de Ortopedia e Traumatologia. Hospital de Santo Espírito da Ilha Terceira. Angra do Heroísmo. Portugal
| | - António Mora
- Serviço de Cirurgia Geral. Hospital de Santo Espírito da ilha Terceira. Angra do Heroísmo. Portugal
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Migliorini F, Cocconi F, Schipper I, Ten Duis K, Marzi I, Komadina R, Hildebrand F, Wendt K. Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02389-4. [PMID: 37962595 DOI: 10.1007/s00068-023-02389-4] [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: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital. METHODS All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint. RESULTS Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups. CONCLUSION Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted. LEVEL OF EVIDENCE Level IV, meta-analysis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Federico Cocconi
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Inger Schipper
- Department of Orthopaedic and Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Kaj Ten Duis
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Ingo Marzi
- Department of Orthopaedic and Trauma Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Radko Komadina
- Department of Orthopaedic and Trauma Surgery, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Klaus Wendt
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Sarıhan A, Güllüpinar B, Sağlam C, Karagöz A, Tandon S, Turhan A, Koran S, Ünlüer EE. Comparison of tricuspid and mitral annular plane systolic excursion in determination of acute blood loss in healthy volunteers. Intern Emerg Med 2023; 18:1543-1550. [PMID: 36929348 DOI: 10.1007/s11739-023-03246-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/22/2023] [Indexed: 03/18/2023]
Abstract
Ultrasound is used more and more in determining acute blood loss. This study is to compare tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) measurement to determine volume loss pre and post blood donation in healthy volunteers. The systolic, diastolic and mean arterial blood pressures and pulses of the donors were measured in the standing and supine position by the attending physician, then, inferior vena cava (IVC), TAPSE and MAPSE measurements were made pre and post blood donation. Statistically significant differences were found in systolic blood pressure and pulse rate values that obtained in the standing position, and in the systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse values that obtained in the supine position (p < 0.05). The difference between IVC expiration (IVCexp) pre and post blood donation was 4.76 ± 2.94 mm, and the difference in IVC inspiration (IVCins) was 2.73 ± 2.91 mm. In addition, the MAPSE and TAPSE differences were 2.16 ± 1.4 mm and 2.98 ± 2.13 mm, respectively. Statistically significant differences were found between IVCins-exp, TAPSE and MAPSE values. TAPSE and MAPSE can be helpful in the early diagnosis of acute blood loss.
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Affiliation(s)
- Aydın Sarıhan
- Department of Emergency Medicine, Merkezefendi State Hospital, 45110, Manisa, Turkey.
| | - Birdal Güllüpinar
- Department of Emergency Izmir, Bozyaka Training and Research Hospital, 35122, İzmir, Turkey
| | - Caner Sağlam
- Department of Emergency Izmir, Bozyaka Training and Research Hospital, 35122, İzmir, Turkey
| | - Arif Karagöz
- Department of Emergency, Izmir Çiğli Training Hospital, 35550, İzmir, Turkey
| | - Shikha Tandon
- Parexel International Ltd., Chandigarh, 133301, India
| | - Ajda Turhan
- Ege University Blood Bank, 34014, İzmir, Turkey
| | - Serhat Koran
- Department of Family Medicine, Medipol University Hospital, 34815, Istanbul, Turkey
| | - Erden Erol Ünlüer
- Department of Emergency Izmir, Bozyaka Training and Research Hospital, 35122, İzmir, Turkey
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Djaja YP, Silitonga J, Dilogo IH, Mauffrey OJ. The management of pelvic ring fractures in low-resource environments: review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:515-523. [PMID: 36333484 DOI: 10.1007/s00590-022-03420-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.
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Affiliation(s)
- Yoshi Pratama Djaja
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Jamot Silitonga
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| | - Ismail Hadisoebroto Dilogo
- Department of Orthopaedic and Traumatology, Rumah Sakit Umum Pusat Nasional Dr Cipto Mangunkusumo, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Océane J Mauffrey
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Smedley WA, Mabry CD, Collins T, Tabor J, Bowman S, Porter A, Young S, Klutts G, Deloach J, Bhavaraju A, Maxson T, Robertson RD, Holcomb JB, Kalkwarf KJ. Access to Immediately Available Balanced Blood Products in a Rural State's Trauma System. Am Surg 2023:31348231160836. [PMID: 36877979 DOI: 10.1177/00031348231160836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION The Arkansas Trauma System was established by law more than a dozen years ago, and all participating trauma centers are required to maintain red blood cells. Since then, there has been a paradigm shift in resuscitating exsanguinating trauma patients. Damage Control Resuscitation with balanced blood products (or whole blood) and minimal crystalloid is now the standard of care. This project aimed to determine access to balanced blood products in our state's Trauma System (TS). METHODS A survey of all trauma centers in the Arkansas TS was conducted, and geospatial analysis was performed. Immediately Available Balanced Blood (IABB) was defined as at least 2 units (U) of thawed plasma (TP) or never frozen plasma (NFP), 4 units of red blood cells (RBCs), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets or 2 units of whole blood (WB). RESULTS All 64 trauma centers in the state TS completed the survey. All level I, II, and III Trauma Centers (TCs) maintain RBC, plasma, and platelets, but only half of the level II and 16% of the level III TCs have thawed or never frozen plasma. A third of level IV TCs maintain only RBCs, while only 1 had platelets, and none had thawed plasma. 85% of people in our state are within 30 min of RBCs, almost two-thirds are within 30 min of plasma (TP, NFP, or FFP) and platelets, while only a third are within 30 min of IABB. More than 90% are within an hour of plasma and platelets, while only 60% are within that time from an IABB. The median drive times for Arkansas from RBC, plasma (TP, NFP, or FFP), platelets, and an immediately available and balanced blood bank are 19, 21, 32, and 59 minutes, respectively. A lack of thawed or non-frozen plasma and platelets are the most common limitations of IABB. One level III TC in the state maintains WB, which would alleviate the limited access to IABB. CONCLUSION Only 16% of the trauma centers in Arkansas can provide IABB, and only 61% of the population can reach IABB within 60 minutes. Opportunities exist to reduce the time to balanced blood products by selectively distributing WB, TP, or NFP to hospitals in our state trauma system.
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Affiliation(s)
- W Andrew Smedley
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Terry Collins
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeff Tabor
- Arkansas Trauma Communications Center, Little Rock, AR, USA
| | - Stephen Bowman
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Austin Porter
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sean Young
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Garret Klutts
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joseph Deloach
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Avi Bhavaraju
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Todd Maxson
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald D Robertson
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John B Holcomb
- Center for Injury Sciences, Division of Acute Care Surgery, 9967University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyle J Kalkwarf
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Modifications of Glasgow Coma Scale—a Systematic Review. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03678-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Wang Y, Wang L, Chen C, Que Y, Li Y, Luo J, Yin M, Lv M, Xu G. Safety and Risk Factors of Needle Thoracentesis Decompression in Tension Pneumothorax in Patients over 75 Years Old. Can Respir J 2023; 2023:2602988. [PMID: 37181158 PMCID: PMC10174999 DOI: 10.1155/2023/2602988] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/03/2023] [Accepted: 04/15/2023] [Indexed: 05/16/2023] Open
Abstract
Background There are very few professional recommendations or guidelines on the needle thoracentesis decompression (NTD) for the tension pneumothorax in the elderly. This study aimed to investigate the safety and risk factors of tension pneumothorax NTD in patients over 75 years old based on CT evaluation of the chest wall thickness (CWT). Methods The retrospective study was conducted among 136 in-patients over 75 years old. The CWT and closest depth to vital structure of the second intercostal space at the midclavicular line (second ICS-MCL) and the fifth intercostal space at the midaxillary line (fifth ICS-MAL) were compared as well as the expected failure rates and the incidence of severe complications of different needles. We also analyzed the influence of age, sex, presence or absence of chronic obstructive pulmonary disease (COPD), and body mass index (BMI) on CWT. Results The CWT of the second ICS-MCL was smaller than the fifth ICS-MAL both on the left and the right side (P < 0.05). The success rate associated with a 7 cm needle was significantly higher than a 5 cm needle (P < 0.05), and the incidence of severe complications with a 7 cm needle was significantly less than an 8 cm needle (P < 0.05). The CWT of the second ICS-MCL was significantly correlated with age, sex, presence or absence of COPD, and BMI (P < 0.05), whereas the CWT of the fifth ICS-MAL was significantly correlated with sex and BMI (P < 0.05). Conclusion The second ICS-MCL was recommended as the primary thoracentesis site and a 7 cm needle was advised as preferred needle length for the older patients. Factors such as age, sex, presence or absence of COPD, and BMI should be considered when choosing the appropriate needle length.
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Affiliation(s)
- Yanhu Wang
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Lei Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Cheng Chen
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Yifan Que
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Yinyi Li
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Jiang Luo
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Ming Yin
- Department of Emergency, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Miao Lv
- The Third Medical Center, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Guogang Xu
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
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Rubinos C, Waters B, Hirsch LJ. Predicting and Treating Post-traumatic Epilepsy. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hof S, Truse R, Weber L, Herminghaus A, Schulz J, Weber APM, Maleckova E, Bauer I, Picker O, Vollmer C. Local Mucosal CO 2 but Not O 2 Insufflation Improves Gastric and Oral Microcirculatory Oxygenation in a Canine Model of Mild Hemorrhagic Shock. Front Med (Lausanne) 2022; 9:867298. [PMID: 35573010 PMCID: PMC9096873 DOI: 10.3389/fmed.2022.867298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Acute hemorrhage results in perfusion deficit and regional hypoxia. Since failure of intestinal integrity seem to be the linking element between hemorrhage, delayed multi organ failure, and mortality, it is crucial to maintain intestinal microcirculation in acute hemorrhage. During critical bleeding physicians increase FiO2 to raise total blood oxygen content. Likewise, a systemic hypercapnia was reported to maintain microvascular oxygenation (μHbO2). Both, O2 and CO2, may have adverse effects when applied systemically that might be prevented by local application. Therefore, we investigated the effects of local hyperoxia and hypercapnia on the gastric and oral microcirculation. Methods Six female foxhounds were anaesthetized, randomized into eight groups and tested in a cross-over design. The dogs received a local CO2-, O2-, or N2-administration to their oral and gastric mucosa. Hemorrhagic shock was induced through a withdrawal of 20% of estimated blood volume followed by retransfusion 60 min later. In control groups no shock was induced. Reflectance spectrophotometry and laser Doppler were performed at the gastric and oral surface. Oral microcirculation was visualized by incident dark field imaging. Systemic hemodynamic parameters were recorded continuously. Statistics were performed using a two-way-ANOVA for repeated measurements and post hoc analysis was conducted by Bonferroni testing (p < 0.05). Results The gastric μHbO2 decreased from 76 ± 3% to 38 ± 4% during hemorrhage in normocapnic animals. Local hypercapnia ameliorated the decrease of μHbO2 from 78 ± 4% to 51 ± 8%. Similarly, the oral μHbO2 decreased from 81 ± 1% to 36 ± 4% under hemorrhagic conditions and was diminished by local hypercapnia (54 ± 4%). The oral microvascular flow quality but not the total microvascular blood flow was significantly improved by local hypercapnia. Local O2-application failed to change microvascular oxygenation, perfusion or flow quality. Neither CO2 nor O2 changed microcirculatory parameters and macrocirculatory hemodynamics under physiological conditions. Discussion Local hypercapnia improved microvascular oxygenation and was associated with a continuous blood flow in hypercapnic individuals undergoing hemorrhagic shock. Local O2 application did not change microvascular oxygenation, perfusion and blood flow profiles in hemorrhage. Local gas application and change of microcirculation has no side effects on macrocirculatory parameters.
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Affiliation(s)
- Stefan Hof
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Richard Truse
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Lea Weber
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Jan Schulz
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Andreas P M Weber
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Eva Maleckova
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
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Bahouth H, Abramov R, Bodas M, Halberthal M, Lin S. The Feedback Form and Its Role in Improving the Quality of Trauma Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031866. [PMID: 35162888 PMCID: PMC8835460 DOI: 10.3390/ijerph19031866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 12/04/2022]
Abstract
Background: One of the tasks of a level I trauma center is quality improvement of level II and level III regional hospitals and emergency medical services by means of continuous education and learning processes. One of the tools for this, which provides constant monitoring of the quality of treatment, is feedback. The purpose of the study was to evaluate the effect of feedback on the quality of trauma care. Methods: Retrospective cohort study comprising two periods of time, 2012-2013 and 2017-2018. The study group included physicians and pre-hospital staff who treated patients prior to referral to the level I center. Upon arrival when the trauma teams identified issues requiring improvement, they were asked to fill in feedback forms. Data on patients treated in the trauma shock room for whom feedback forms were filled out were also extracted. Results: A total of 662 feedback forms were completed, showing a significant improvement (p ˂ 0.0001). The majority of the medical personnel who received the most negative feedback were the pre-hospital staff. A significant increase was revealed in the number of feedbacks with reference to mismanagement of backboard spinal fixation, of the pre-hospital staff, in 2012-2013 compared to 2017-2018 (p < 0.001). Improvement in reducing the time of treatment in the field was also revealed, from 15.2 ± 8.3 min in 2012-2013 to 13.4 ± 7.9 min in 2017-2018. Conclusion: The findings show that feedback improves the treatment of injured patients. Furthermore, constantly monitoring the quality of treatment provided by the trauma team is vital for improvement.
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Affiliation(s)
- Hany Bahouth
- Trauma and Acute Care Surgery, Division of Surgery, Rambam Health Care Campus, Haifa 3109601, Israel;
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Institute of Technology, Haifa 3109601, Israel;
| | - Roi Abramov
- Department of General Surgery, Rambam Health Care Campus, Haifa 3109601, Israel;
| | - Moran Bodas
- The Israeli National Center for Trauma & Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Ramat Gan 5262100, Israel;
- Department of Emergency Management and Disaster Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo 6997801, Israel
| | - Michael Halberthal
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Institute of Technology, Haifa 3109601, Israel;
- Rambam Management, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Shaul Lin
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Institute of Technology, Haifa 3109601, Israel;
- The Israeli National Center for Trauma & Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Ramat Gan 5262100, Israel;
- Department of Endodontics and Dental Trauma, Rambam Health Care Campus, Haifa 3109601, Israel
- Correspondence:
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van der Kolk B(BY, van den Wittenboer G(GJ, Warringa N, Nijholt IM, van Hasselt BA, Buijteweg LN, Schep NW, Maas M, Boomsma MF. Assessment of cervical spine CT scans by emergency physicians: A comparative diagnostic accuracy study in a non-clinical setting. J Am Coll Emerg Physicians Open 2022; 3:e12609. [PMID: 35079729 PMCID: PMC8776040 DOI: 10.1002/emp2.12609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/04/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To determine and compare the diagnostic accuracy of assessing injuries on cervical spine computed tomography (CT) scans by trained emergency physicians and radiologists, both in a non-clinical setting. METHODS In this comparative diagnostic accuracy study, 411 cervical spine CT scans, of which 120 contained injuries (fractures and/or dislocations), were divided into 8 subsets. Eight emergency physicians received focused training and assessed 1 subset each before and after training. Four radiologists assessed 2 subsets each. Diagnostic accuracy between both groups was compared. The reference standard used was a multiverified data set, assessed by radiologists, neurosurgeons, and emergency physicians. The neurosurgeons also classified whether an "injury in need of stabilizing therapy" (IST) was present. RESULTS Posttraining, the emergency physicians demonstrated increased sensitivity and specificity for identifying cervical spine injuries compared to pretraining: sensitivity 88% (95% confidence interval [CI] 80% to 93%) versus 80% (95% CI 72% to 87%) and specificity 89% (95% CI 85% to 93%) versus 86% (95% CI 81% to 89%). When comparing the trained emergency physicians to the group of radiologists, no difference in sensitivity was found, 88% (95% CI 80% to 83%); however, the radiologists showed a significantly higher specificity (P < 0.01): 99% (95% CI 96% to 100%). In the 12% (15 scans) with missed injuries, emergency physicians missed more ISTs than radiologists, 6 versus 4 scans; however, this difference was not significant (P = 0.45). CONCLUSION After focused training and in a non-clinical setting, no significant difference was found between emergency physicians and radiologists in ruling out cervical spine injuries; however, the radiologists achieved a significantly higher specificity.
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Affiliation(s)
- Brigitta (Britt) Y.M. van der Kolk
- Department of Emergency MedicineIsalaZwolleThe Netherlands
- Department of Radiology and Nuclear MedicineIsalaZwolleThe Netherlands
- Department of Radiology and Nuclear MedicineAmsterdam University Medical Centers, location Academic Medical CenterAmsterdamThe Netherlands
| | | | - Niek Warringa
- Department of Radiology and Nuclear MedicineIsalaZwolleThe Netherlands
| | - Ingrid M. Nijholt
- Department of Radiology and Nuclear MedicineIsalaZwolleThe Netherlands
| | | | | | - Niels W.L. Schep
- Department of Trauma SurgeryMaasstad HospitalRotterdamThe Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear MedicineAmsterdam University Medical Centers, location Academic Medical CenterAmsterdamThe Netherlands
- Amsterdam Movement SciencesAmsterdamThe Netherlands
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Zhang Y, Marsic I, Burd RS. Real-time medical phase recognition using long-term video understanding and progress gate method. Med Image Anal 2021; 74:102224. [PMID: 34543914 PMCID: PMC8560574 DOI: 10.1016/j.media.2021.102224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 01/10/2023]
Abstract
We introduce a real-time system for recognizing five phases of the trauma resuscitation process, the initial management of injured patients in the emergency department. We used depth videos as input to preserve the privacy of the patients and providers. The depth videos were recorded using a Kinect-v2 mounted on the sidewall of the room. Our dataset consisted of 183 depth videos of trauma resuscitations. The model was trained on 150 cases with more than 30 minutes each and tested on the remaining 33 cases. We introduced a reduced long-term operation (RLO) method for extracting features from long segments of video and combined it with the regular model having short-term information only. The model with RLO outperformed the regular short-term model by 5% using the accuracy score. We also introduced a progress gate (PG) method to distinguish visually similar phases using video progress. The final system achieved 91% accuracy and significantly outperformed previous systems for phase recognition in this setting.
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Affiliation(s)
- Yanyi Zhang
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ 08854, USA.
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ 08854, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, USA
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Pinnell RAM, Ramsay T, Wang H, Joo P. Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns. Can Geriatr J 2021; 24:341-350. [PMID: 34912489 PMCID: PMC8629500 DOI: 10.5770/cgj.24.518] [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] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The rate of urinary tract infection (UTI) investigation and treatment in confused older emergency department (ED) patients has not been described in the literature. We aim to describe the pattern of practice in an academic tertiary care ED for this common presentation. METHODS A health record review was conducted on 499 adults aged ≥65 presenting to academic EDs with confusion. Exclusion criteria: Glasgow Coma Scale < 13, current treatment for UTI, indwelling catheters, nephrostomy tubes, transfer from another hospital. Outcomes were the prevalence of UTI investigation, diagnosis and antibiotic treatment. RESULTS 64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics. In the subgroup with no urinary symptoms, fever, or other obvious indication for antibiotics, these numbers were 58.2%, 7.6%, and 18.1%, respectively. Patients who had urine tests or received antibiotics were older than those who did not (p values < .01). Patients receiving antibiotics had higher admission rates and 30-day and six-month mortality (OR of 2.9 [2.0-4.3], 4.0 [1.6-11], and 2.8 [1.4-5.8], respectively). CONCLUSION Older patients presenting to ED with confusion were frequently investigated and treated for UTI, even in the absence of urinary symptoms. Antibiotic treatment was associated with higher hospitalization and mortality.
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Affiliation(s)
| | - Tim Ramsay
- Ottawa Hospital Research, Institute, Ottawa, ON
| | - Han Wang
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Pil Joo
- Ottawa Hospital Research, Institute, Ottawa, ON
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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15
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Quencer KB. Endovascular interventions in trauma, an introduction. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1191. [PMID: 34430632 PMCID: PMC8350691 DOI: 10.21037/atm-20-4418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/13/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Keith Bertram Quencer
- Division of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, UT, USA
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Mors Gaudet Succurrere Vitae. The Role of Clinical Autopsy in Preventing Litigation Related to the Management of Liver and Digestive Disorders. Diagnostics (Basel) 2021; 11:diagnostics11081436. [PMID: 34441370 PMCID: PMC8392361 DOI: 10.3390/diagnostics11081436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 12/12/2022] Open
Abstract
Over the last 50 years, the number of clinical autopsies has decreased, but their role in assessing cause of death and clinical performance is still acknowledged. Few publications have studied their role in malpractice claim prevention. The paper aims to highlight the role of clinical autopsy in preventing errors and improve healthcare quality. A retrospective study was conducted on 28 clinical autopsies performed between 2015 and 2021 on patients dead unexpectedly after procedures for the diagnosis and treatment of digestive and hepatic diseases. After an accurate analysis of medical records and consultation with healthcare professionals, all cases were subjected to autopsy and histopathology. The data obtained were analyzed and shared with the risk-management team to identify pitfalls and preventive strategies. Post-mortem evaluations confirmed the clinical diagnosis only in six cases (21.4%). Discordances were observed in 10 cases (35.7%). In the remaining 12 cases (42.9%) the clinical diagnosis was labeled as "unknown" and post-mortem examinations made it possible to document the cause of death. Post-mortem examinations can concretely enrich hospital prevention systems and improve patient safety. The methodological approach outlined certainly demonstrates that, even in the risk-management field, "mors gaudet succurrere vitae" ("death delights in helping life").
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Abu Arab W, Abdulhaleem M, Eltahan S, Elhamami M. Comparative study between bedside chest ultrasound and chest CT scan in the diagnosis of traumatic pneumothorax. THE CARDIOTHORACIC SURGEON 2021. [DOI: 10.1186/s43057-021-00051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Traumatic pneumothorax (PTx) is common in chest trauma. Its incidence ranges between 10 and 28%. Chest X-ray (CXR) is the traditional imaging for the potential traumatic PTx, while CT chest is considered the gold standard diagnostic tool. However, it requires that the patient to be transferred from the Emergency Department (ED) with its resuscitative facilities. Chest US (E-FAST) has emerged as a sensitive tool that can be used on bedside basis with much higher sensitivity than CXR. The objective of this study was to compare between accuracy and usefulness of the bedside US chest and CT chest in the diagnosis of traumatic PTx, as well as its ability to quantify its size. This was a prospective clinical study that included two hundred patients who have been admitted to the ED. The inclusion criteria included any patient with chest trauma. Exclusion criteria included patients with clinical surgical emphysema, patients with life threatening PTx, and patients who did not undergo CT chest.
Results
Forty-seven hemithoraces were proved positive for PTx by CT chest, while forty-five hemithoraces out of those 47 were confirmed by bedside chest US. The sensitivity for chest US is 95.74% in detection of traumatic PTx. No false-positive cases were diagnosed. All of the forty-five hemithoraces diagnosed by chest US have been confirmed by CT scan making a specificity of 100%.
Conclusions
Chest US is a useful rapid diagnostic tool in the diagnosis and quantification of the traumatic PTx at ED. It avoids the delay in transportation of the critically ill patients to perform CT chest.
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Vellimana AK, Lavie J, Chatterjee AR. Endovascular Considerations in Traumatic Injury of the Carotid and Vertebral Arteries. Semin Intervent Radiol 2021; 38:53-63. [PMID: 33883802 DOI: 10.1055/s-0041-1724008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jayson Lavie
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam Rano Chatterjee
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Routine haemoglobin assay after uncomplicated caesarean sections. MENOPAUSE REVIEW 2021; 20:29-33. [PMID: 33935617 PMCID: PMC8077800 DOI: 10.5114/pm.2021.104474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/17/2021] [Indexed: 11/21/2022]
Abstract
Introduction This study designed to detect whether the routine haemoglobin (Hb) assay after uncomplicated caesarean section (CS) is necessary. Material and methods One hundred and twenty-two (122) women who delivered by uncomplicated elective CS were included in this observational study. Pre-operative investigations were performed according to the hospital protocol, including complete blood count, haemoglobin, prothrombin time, activated partial thromboplastin time, and liver and kidney function tests. After the uncomplicated elective CS, blood samples taken from participants immediately, 12, 24, 48 hours, and 1-week post-operative (PO) for haemoglobin assay. Student’s t-test was used to compare the pre-operative, and PO haemoglobins to detect whether or not the Hb assay after uncomplicated CSs is necessary. Results There was no significant difference between the pre-operative haemoglobin (11.6 ± 6.4 gms%), and the immediate PO haemoglobin (11.1 ± 5.9; p = 0.1 [95% CI: –1.05, 0.5, 2.05]) or 12-hour PO haemoglobin (10.9 ± 7.3; p = 0.9 [95% CI: –1.03, 0.7, 2.43]) or 24-hour PO haemoglobin (10.7 ± 8.2; p = 0.9 [95% CI: –0.95, 0.9, 2.75]). In addition, there was no significant difference between the pre-operative haemoglobin (11.6 ± 6.4 gms%), and 48-hour PO haemoglobin (11.2 ± 6.9; p = 0.7 [95% CI: –1.28, 0.4, 2.08]), or 1-week PO haemoglobin (11.4 ± 7.5; p = 0.9 [95% CI: –1.55, 0.2, 1.95]). Conclusions Routine PO haemoglobin assay after uncomplicated elective CSs is not necessary, especially when the pre-operative haemoglobin before the ECS ≥ 11 gms%, CS duration < 45 min, and estimated intra-operative blood loss ≤ 500 mL.
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Karachentsev S. Blunt trauma to abdominal solid organs: an experience of non-operative management at a rural hospital in Zambia. Pan Afr Med J 2021; 38:89. [PMID: 33889255 PMCID: PMC8033190 DOI: 10.11604/pamj.2021.38.89.20061] [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: 08/14/2019] [Accepted: 11/13/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction although non-operative management of patients with blunt trauma to abdominal solid organs has become standard care, the role of peripheral hospitals remains poorly defined. This study reviews treatment and outcomes in patients with liver and spleen injuries at a regional hospital over a 10-year period. Methods a retrospective review of prospectively collected data was performed and supplemented by case notes retrieval. All patients with solid visceral injuries managed between 2009 and 2019 at a rural surgical hospital in Zambia were included. On admission, the patients were offered either urgent laparotomy or non-operative management (NOM) depending on their haemodynamic status. Continuous variables were expressed as median and mean ± standard deviation; categorical data were expressed as percentages. Statistical evaluation of data was performed by two-sample t-test. Statistical significance was assigned at p<0.05. Results fourty-three patients were included. The majority of victims sustained isolated spleen or liver injury. Twenty-three patients were urgently operated due to haemodynamic instability. Splenectomy performed in 17 patients, liver laceration sutured in 5 patients. One patient underwent concomitant splenectomy and liver repair. Conservative management was attempted in 20 (47%) patients and was successful in 18 (42%). In two patients NOM failed and splenectomy was performed urgently. Two patients died postoperatively. There were no deaths in NOM group. Conclusion NOM of patients with injury to solid abdominal organs could be safely initiated in rural hospitals provided there is uninterrupted monitoring of patients' condition, well-trained staff and unrestricted access to the operating theatre (OT).
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Update Polytrauma und Computertomographie unter Reanimationsbedingungen. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00821-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Assessment of Nonroutine Events During Intubation After Pediatric Trauma. J Surg Res 2020; 259:276-283. [PMID: 33138986 DOI: 10.1016/j.jss.2020.09.036] [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: 12/04/2019] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes. MATERIALS AND METHODS We reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation ("critical window"). RESULTS Among 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the "critical window" was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7). CONCLUSIONS Workflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.
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Dynamics of cerebrospinal fluid levels of matrix metalloproteinases in human traumatic brain injury. Sci Rep 2020; 10:18075. [PMID: 33093584 PMCID: PMC7582923 DOI: 10.1038/s41598-020-75233-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 10/07/2020] [Indexed: 12/30/2022] Open
Abstract
Matrix metalloproteinases (MMPs) are extracellular enzymes involved in the degradation of extracellular matrix (ECM) proteins. Increased expression of MMPs have been described in traumatic brain injury (TBI) and may contribute to additional tissue injury and blood-brain barrier damage. The objectives of this study were to determine longitudinal changes in cerebrospinal fluid (CSF) concentrations of MMPs after acute TBI and in relation to clinical outcomes, with patients with idiopathic normal pressure hydrocephalus (iNPH) serving as a contrast group. The study included 33 TBI patients with ventricular CSF serially sampled, and 38 iNPH patients in the contrast group. Magnetic bead-based immunoassays were utilized to measure the concentrations of eight MMPs in ventricular human CSF. CSF concentrations of MMP-1, MMP-3 and MMP-10 were increased in TBI patients (at baseline) compared with the iNPH group (p < 0.001), while MMP-2, MMP-9 and MMP-12 did not differ between the groups. MMP-1, MMP-3 and MMP-10 concentrations decreased with time after trauma (p = 0.001-0.04). Increased concentrations of MMP-2 and MMP-10 in CSF at baseline were associated with an unfavourable TBI outcome (p = 0.002-0.02). Observed variable pattern of changes in MMP concentrations indicates that specific MMPs serve different roles in the pathophysiology following TBI, and are in turn associated with clinical outcomes.
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Park CY, Kim OH, Chang SW, Choi KK, Lee KH, Kim SY, Kim M, Lee GJ. Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Truse R, Nolten I, Schulz J, Herminghaus A, Holtmanns T, Gördes L, Raupach A, Bauer I, Picker O, Vollmer C. Topical Melatonin Improves Gastric Microcirculatory Oxygenation During Hemorrhagic Shock in Dogs but Does Not Alter Barrier Integrity of Caco-2 Monolayers. Front Med (Lausanne) 2020; 7:510. [PMID: 32984383 PMCID: PMC7484810 DOI: 10.3389/fmed.2020.00510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
Systemic administration of melatonin exerts tissue protective effects in the context of hemorrhagic shock. Intravenous application of melatonin prior to hemorrhage improves gastric microcirculatory perfusion and maintains intestinal barrier function in dogs. The aim of the present study was to analyze the effects of a topical mucosal melatonin application on gastric microcirculation during hemorrhagic shock in vivo and on mucosal barrier function in vitro. In a randomized cross-over study, six anesthetized female foxhounds received 3.3 mg melatonin or the vehicle as a bolus to the gastric and oral mucosa during physiological and hemorrhagic (-20% blood volume) conditions. Microcirculation was analyzed with reflectance spectrometry and laser doppler flowmetry. Systemic hemodynamic variables were measured with transpulmonary thermodilution. For analysis of intestinal mucosal barrier function in vitro Caco-2 monolayers were used. The transepithelial electrical resistance (TEER) and the passage of Lucifer Yellow (LY) from the apical to the basolateral compartment of Transwell chambers were measured. Potential barrier protective effects of melatonin against oxidative stress were investigated in the presence of the oxidant H2O2. During physiologic conditions topical application of melatonin had no effect on gastric and oral microcirculation in vivo. During hemorrhagic shock, gastric microcirculatory oxygenation (μHbO2) was decreased from 81 ± 8% to 50 ± 15%. Topical treatment with melatonin led to a significant increase in μHbO2 to 60 ± 13%. Topical melatonin treatment had no effect on gastric microcirculatory perfusion, oral microcirculation or systemic hemodynamics. Incubation of H2O2 stressed Caco-2 monolayers with melatonin did neither influence transepithelial electrical resistance nor LY translocation. Topical treatment of the gastric mucosa with melatonin attenuates the shock induced decrease in microcirculatory oxygenation. As no effects on local microcirculatory and systemic perfusion were recorded, the improved μHbO2 is most likely caused by a modulation of local oxygen consumption. In vitro melatonin treatment did not improve intestinal barrier integrity in the context of oxidative stress. These results extend the current knowledge on melatonin's protective effects during hemorrhage in vivo. Topical application of melatonin exerts differential effects on local microcirculation compared to systemic pretreatment and might be suitable as an adjunct for resuscitation of hemorrhagic shock.
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Affiliation(s)
- Richard Truse
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Inga Nolten
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Jan Schulz
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Tobias Holtmanns
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Lukas Gördes
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Annika Raupach
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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[Update polytrauma and computed tomography in ongoing resuscitation : ABCDE and "diagnose first what kills first"]. Radiologe 2020; 60:247-257. [PMID: 31925467 DOI: 10.1007/s00117-019-00633-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
CLINICAL ISSUE The mean number of trauma room admissions and applied CT dose increase as the severity of injuries decreases. Therefore, appropriateness of established procedures should be re-evaluated. STANDARD RADIOLOGICAL METHODS Considering severely injured patients with an Injury Severity Score (ISS) ≥16, whole body CT (WB-CT) compared to selective CT decreased mortality by about 25%. Thus, the ISS is a good indicator for the severity of injuries. However, since ISS can only be determined after diagnosis, it does not help with the primary assessment. METHODOLOGICAL INNOVATION AND EVALUATION In addition to the currently used very fast WB-CT protocol with the highest diagnostic precision, a second protocol should be established applying a substantially lower dose. Under ongoing resuscitation, WB-CT often makes a substantial contribution towards targeted therapy or to justifying the discontinuation of resuscitation measures. The WB-CT findings should be performed several times and, at least in the acute emergency situation, it should follow the ABCDE scheme as close as possible. PRACTICAL RECOMMENDATIONS In the trauma room it should be initially decided whether the classification as polytrauma is to be maintained. If yes, every institution should provide a dose-reduced WB-CT protocol in addition to the maximum variant used so far. Dose-reduced WB-CT seems to be appropriate for stable and oriented patients, who receive a CT primarily because of the trauma mechanism. Even under resuscitation conditions, WB-CT is easy to perform and medically as well as ethically of high value. The reporting and communication should be structured according to "diagnose first what kills first".
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Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017. Disaster Med Public Health Prep 2020; 15:615-623. [PMID: 32489173 DOI: 10.1017/dmp.2020.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality. METHODS We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017. RESULTS Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%). CONCLUSIONS The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.
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Bitar G, Touska P. Imaging in trauma of the facial skeleton and soft tissues of the neck. Br J Hosp Med (Lond) 2020; 81:1-15. [PMID: 32589540 DOI: 10.12968/hmed.2020.0008] [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] [Indexed: 11/11/2022]
Abstract
Trauma to the face and neck is a frequent reason for emergency department attendance. Imaging is invaluable in the characterisation of such injuries, enabling delineation of fracture patterns as well as identification of vascular and other soft tissue injuries. It may also be used to prevent long-term mortality and morbidity and provide a roadmap for surgical intervention so that form and function may be restored. This article gives a pictorial review of the imaging of craniofacial trauma, stratified according to the thirds of the face, followed by a review of blunt and penetrating trauma of the neck. It discusses appropriate imaging modalities for each trauma category, describes major patterns of craniofacial trauma on cross-sectional imaging and identifies clinically relevant imaging features that should trigger subspecialist review or be of relevance to pre-surgical planning. It starts with the upper third comprising frontal sinus fractures before describing the component fractures of the middle third (including nasal, zygomaticomaxillary and orbital fractures) and then focusing on the lower third (specifically mandibular and dentoalveolar fractures). The article concludes with a review of soft tissue injuries of the neck, particularly penetrating, blunt and laryngeal trauma.
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Affiliation(s)
- George Bitar
- Department of Radiology, Royal Marsden Hospital, Royal Marsden NHS Foundation Trust, London, UK
| | - Philip Touska
- Department of Radiology, Guy's Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
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Jesani H, Jesani L, Rangaraj A, Rasheed A. Splenic trauma, the way forward in reducing splenectomy: our 15-year experience. Ann R Coll Surg Engl 2020; 102:263-270. [PMID: 31909638 PMCID: PMC7099152 DOI: 10.1308/rcsann.2019.0164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. METHOD A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. RESULTS There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. DISCUSSION AND CONCLUSION AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.
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Affiliation(s)
- H Jesani
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
| | - L Jesani
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
| | - A Rangaraj
- Department of Radiology, Royal Gwent Hospital, Newport, UK
| | - A Rasheed
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
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Chen CL, Chang MH, Lee WJ. A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke. J Emerg Med 2020; 58:e185-e188. [PMID: 32204999 DOI: 10.1016/j.jemermed.2020.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/27/2019] [Accepted: 01/12/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Spinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately. CASE REPORT We describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.
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Affiliation(s)
- Chieh-Ling Chen
- Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Hong Chang
- Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Wei-Ju Lee
- Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Dementia and Parkinson's Disease Integrated Center, Taichung Veterans General Hospital, Taichung, Taiwan; Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan
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Zingg T, Piaget-Rossel R, Steppacher J, Carron PN, Dami F, Borens O, Albrecht R, Darioli V, Taffé P, Maudet L, Pasquier M. Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study. Sci Rep 2020; 10:5106. [PMID: 32198451 PMCID: PMC7083961 DOI: 10.1038/s41598-020-62027-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/06/2020] [Indexed: 11/20/2022] Open
Abstract
Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.
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Affiliation(s)
- Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital - CHUV, Lausanne, Switzerland.
| | - Romain Piaget-Rossel
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Julie Steppacher
- School of Medicine and Biology, University of Lausanne, Lausanne, Switzerland
| | - Pierre-Nicolas Carron
- Department of Emergency Medicine, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | - Fabrice Dami
- Department of Emergency Medicine, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | - Olivier Borens
- Department of Orthopedics and Traumatology, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | | | - Vincent Darioli
- Department of Emergency Medicine, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | - Patrick Taffé
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Ludovic Maudet
- Department of Emergency Medicine, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital - CHUV, Lausanne, Switzerland
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Varghese M. Prehospital trauma care evolution, practice and controversies: need for a review. Int J Inj Contr Saf Promot 2020; 27:69-82. [DOI: 10.1080/17457300.2019.1708409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Mathew Varghese
- Department of Orthopaedic Surgery, St Stephen’s Hospital, Delhi, India
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Abstract
Damage control resuscitation (DCR) is a bundle of care first described by Holcomb et al. that is aimed at reducing death from hemorrhage for patients with severe traumatic bleeding. DCR principles include compressible hemorrhage control; hypotensive resuscitation; rapid surgical control of bleeding; avoidance of the overuse of crystalloids and colloids, prevention or correction of acidosis, hypothermia, and hypocalcaemia; and hemostatic resuscitation (blood-based resuscitation). Remote damage control resuscitation (RDCR) is defined as the prehospital application of DCR concepts. The term RDCR was first published by Gerhardt and has been disseminated by the (Trauma Hemostasis and Oxygenation Research), or THOR Network. The history of DCR and RDCR starts well before the inception of the terms. The concepts behind the principles of DCR and RDCR stretch far back into the past. This chapter provides an outline of this history, but it is limited to the fluid resuscitation aspect of DCR/RDCR.
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Affiliation(s)
- Philip C. Spinella
- School of Medicine, Washington University in St. Louis, St. Louis, MO USA
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Truse R, Smyk M, Schulz J, Herminghaus A, Weber APM, Mettler-Altmann T, Bauer I, Picker O, Vollmer C. Regional hypothermia improves gastric microcirculatory oxygenation during hemorrhage in dogs. PLoS One 2019; 14:e0226146. [PMID: 31821374 PMCID: PMC6903746 DOI: 10.1371/journal.pone.0226146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/20/2019] [Indexed: 01/03/2023] Open
Abstract
Mild systemic hypothermia increases gastric mucosal oxygenation (μHbO2) during hemorrhagic shock in dogs. In the context of critical blood loss hypothermia might be fatal due to adverse side effects. Selective regional hypothermia might overcome these limitations. The aim of our study was to analyze the effects of regional gastric and oral mucosal hypothermia on μHbO2 and perfusion (μflow). In a cross-over study six anesthetized dogs were subjected to local oral and gastric mucosal hypothermia (34°C), or maintenance of local normothermia during normovolemia and hemorrhage (-20% blood volume). Macro- and microcirculatory variables were recorded continuously. During normovolemia, local hypothermia increased gastric microcirculatory flow (μflow) without affecting oxygenation (μHbO2) or oral microcirculation. During mild hemorrhagic shock gastric μHbO2 decreased from 72±2% to 38±3% in the normothermic group. This was attenuated by local hypothermia, where μHbO2 was reduced from 74±3% to 52±4%. Local perfusion, oral microcirculation and macrocirculatory variables were not affected. Selective local hypothermia improves gastric μHbO2 during hemorrhagic shock without relevant side effects. In contrast to systemic hypothermia, regional mucosal hypothermia did not affect perfusion and oxygen supply during hemorrhage. Thus, the increased μHbO2 during local hypothermia rather indicates reduced mucosal oxygen demand.
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Affiliation(s)
- Richard Truse
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
- * E-mail:
| | - Michael Smyk
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Jan Schulz
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Andreas P. M. Weber
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Tabea Mettler-Altmann
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
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Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation. Emerg Radiol 2019; 26:655-661. [PMID: 31446523 DOI: 10.1007/s10140-019-01712-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/31/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs. METHODS High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated. RESULTS Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96). CONCLUSIONS Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.
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Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1197-1211. [PMID: 31440893 DOI: 10.1007/s00586-019-06112-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.
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Magistretti PJ, Geisler FH, Schneider JS, Li PA, Fiumelli H, Sipione S. Gangliosides: Treatment Avenues in Neurodegenerative Disease. Front Neurol 2019; 10:859. [PMID: 31447771 PMCID: PMC6691137 DOI: 10.3389/fneur.2019.00859] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/24/2019] [Indexed: 01/09/2023] Open
Abstract
Gangliosides are cell membrane components, most abundantly in the central nervous system (CNS) where they exert among others neuro-protective and -restorative functions. Clinical development of ganglioside replacement therapy for several neurodegenerative diseases was impeded by the BSE crisis in Europe during the 1990s. Nowadays, gangliosides are produced bovine-free and new pre-clinical and clinical data justify a reevaluation of their therapeutic potential in neurodegenerative diseases. Clinical experience is greatest with monosialo-tetrahexosyl-ganglioside (GM1) in the treatment of stroke. Fourteen randomized controlled trials (RCTs) in overall >2,000 patients revealed no difference in survival, but consistently superior neurological outcomes vs. placebo. GM1 was shown to attenuate ischemic neuronal injuries in diabetes patients by suppression of ERK1/2 phosphorylation and reduction of stress to the endoplasmic reticulum. There is level-I evidence from 5 RCTs of a significantly faster recovery with GM1 vs. placebo in patients with acute and chronic spinal cord injury (SCI), disturbance of consciousness after subarachnoid hemorrhage, or craniocerebral injuries due to closed head trauma. In Parkinson's disease (PD), two RCTs provided evidence of GM1 to be superior to placebo in improving motor symptoms and long-term to result in a slower than expected symptom progression, suggesting disease-modifying potential. In Alzheimer's disease (AD), the role of gangliosides has been controversial, with some studies suggesting a "seeding" role for GM1 in amyloid β polymerization into toxic forms, and others more recently suggesting a rather protective role in vivo. In Huntington's disease (HD), no clinical trials have been conducted yet. However, low GM1 levels observed in HD cells were shown to increase cell susceptibility to apoptosis. Accordingly, treatment with GM1 increased survival of HD cells in vitro and consistently ameliorated pathological phenotypes in several murine HD models, with effects seen at molecular, cellular, and behavioral level. Given that in none of the clinical trials using GM1 any clinically relevant safety issues have occurred to date, current data supports expanding GM1 clinical research, particularly to conditions with high, unmet medical need.
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Affiliation(s)
- Pierre J. Magistretti
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
- Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Fred H. Geisler
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jay S. Schneider
- Parkinson's Disease Research Unit, Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, PA, United States
| | - P. Andy Li
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute Technology Enterprise (BRITE), North Carolina Central University, Durham, NC, United States
| | - Hubert Fiumelli
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
- Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Simonetta Sipione
- Department of Pharmacology, Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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Mitra B, Bade-Boon J, Fitzgerald MC, Beck B, Cameron PA. Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study. BURNS & TRAUMA 2019; 7:22. [PMID: 31360731 PMCID: PMC6637602 DOI: 10.1186/s41038-019-0160-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/07/2019] [Indexed: 11/10/2022]
Abstract
Background Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients. Methods A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed. Results Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0). Conclusions Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.
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Affiliation(s)
- Biswadev Mitra
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Jordan Bade-Boon
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Mark C Fitzgerald
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Ben Beck
- 3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Peter A Cameron
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Truse R, Voß F, Herminghaus A, Schulz J, Weber APM, Mettler-Altmann T, Bauer I, Picker O, Vollmer C. Local gastric RAAS inhibition improves gastric microvascular perfusion in dogs. J Endocrinol 2019; 241:235-247. [PMID: 30978701 DOI: 10.1530/joe-19-0030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/12/2019] [Indexed: 11/08/2022]
Abstract
During circulatory shock, gastrointestinal microcirculation is impaired, especially via activation of the renin-angiotensin-aldosterone system. Therefore, inhibition of the renin-angiotensin-aldosterone system might be beneficial in maintaining splanchnic microcirculation. The aim of this study was to analyze whether locally applied losartan influences gastric mucosal perfusion (µflow, µvelo) and oxygenation (µHbO2) without systemic hemodynamic changes. In repetitive experiments six anesthetized dogs received 30 mg losartan topically on the oral and gastric mucosa during normovolemia and hemorrhage (-20% blood volume). Microcirculatory variables were measured with reflectance spectrometry, laser Doppler flowmetry and incident dark field imaging. Transpulmonary thermodilution and pulse contour analysis were used to measure systemic hemodynamic variables. Gastric barrier function was assessed via differential absorption of inert sugars. During normovolemia, losartan increased gastric µflow from 99 ± 6 aU to 147 ± 17 aU and µvelo from 17 ± 1 aU to 19 ± 1 aU. During hemorrhage, losartan did not improve µflow. µvelo decreased from 17 ± 1 aU to 14 ± 1 aU in the control group. Application of losartan did not significantly alter µvelo (16 ± 1 aU) compared to the control group and to baseline levels (17 ± 1 aU). No effects of topical losartan on macrohemodynamic variables or microcirculatory oxygenation were detected. Gastric microcirculatory perfusion is at least partly regulated by local angiotensin receptors. Topical application of losartan improves local perfusion via vasodilation without significant effects on systemic hemodynamics. During mild hemorrhage losartan had minor effects on regional perfusion, probably because of a pronounced upstream vasoconstriction.
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Affiliation(s)
- Richard Truse
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Fabian Voß
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Jan Schulz
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Andreas P M Weber
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Tabea Mettler-Altmann
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
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Doud AN, Gaffley M, Hostetter O, Talton JW, Petty JK. “A-OK”: Chest Radiograph during Primary Survey Facilitates Faster, More Accurate Endotracheal Tube Position in Injured Children. Am Surg 2019. [DOI: 10.1177/000313481908500524] [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
The Advanced Trauma Life Support algorithm recommends bedside confirmatory techniques to confirm correct endotracheal tube (ETT) depth, a critical component in the care of pediatric trauma patients. We hypothesized that bedside confirmatory techniques are inaccurate and that early chest X-ray (CXR) would overcome such inaccuracies, allowing for faster intervention of malpositioned ETTs. An “A-OK” algorithm of immediate CXR following intubation in injured children aged <16 years was implemented. Eligible patients the years before and after implementation were identified. The accuracy of bedside confirmatory techniques (use of length-based depths and auscultation of breath sounds) was assessed. Post-“A-OK” patients were compared with pre-“A-OK” controls regarding the speed of malpositioned ETTrepositioning. Twenty-eight post-“A-OK” cases and 23 pre-“A-OK” controls were identified. The groups did not differ in baseline characteristics. Bedside confirmatory techniques were accurate in only 61 per cent (length-based depth) and 58 per cent (auscultation of breath sounds) of patients. Time to ETT repositioning was significantly longer in pre-“A-OK” controls than in post-“A-OK” cases (35.2 ± 15.9 minutes vs 21.1 ± 11.8 minutes, P = 0.03). Bedside confirmatory techniques to determine ETT positioning are inaccurate in children. Inclusion of CXR in the primary survey is safe and allows for more rapid repositioning of malpositioned ETTs.
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Affiliation(s)
- Andrea N. Doud
- Department of General Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- Childress Institute for Pediatric Trauma, Winston-Salem, North Carolina
| | - Michaela Gaffley
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Olivia Hostetter
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Jennifer W. Talton
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John K. Petty
- Childress Institute for Pediatric Trauma, Winston-Salem, North Carolina
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
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Affiliation(s)
- Lisa Caplan
- *Department of Anesthesiology and Pediatrics, Baylor College of Medicine, Houston, Texas †Department of Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, Houston, Texas
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Kruse AJ, Nugent AS, Peterson AR. Using sideline concussion tests in the emergency department. Open Access Emerg Med 2018; 10:113-121. [PMID: 30288131 PMCID: PMC6163013 DOI: 10.2147/oaem.s165995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Traumatic brain injury (TBI) is a significant cause of death and disability in the United States. Many patients with TBI are initially treated in the emergency department (ED), but there is no evidence-based method of detecting or grading TBI in patients who have normal structural neuroimaging. This study aims to evaluate the validity of two common sideline concussion tests. The Concussion Symptom Severity Score (CSSS) and modified Balance Error Scoring System (mBESS) tests are well-validated sideline tests for concussion, but have not been validated in the setting of non-sport-related concussion, in settings other than the sideline or athletic training room or in moderate or severe TBI. Patients and methods One hundred forty-eight subjects who had sustained a TBI within the previous 72 hours and 53 healthy control subjects were enrolled. CSSS and mBESS were administered. Clinical outcomes were followed up prospectively. Results The CSSS was collected in 147 TBI subjects but only 51 TBI subjects were able to complete the mBESS. The CSSS was collected for all 53 control subjects, and the mBESS was completed for 51 control subjects. The mean CSSS for TBI and control subjects was 32.25 and 2.70, respectively (P < 0.001). The average mBESS for TBI and control subjects was 7.43 and 7.20, respectively (P = 0.82). CSSS greater than 5.17 was 93.43% sensitive and 69.84% specific for TBI. Conclusion The mBESS is poorly tolerated and, among those who can complete the test, not sensitive to TBI in the ED. The CSSS is both sensitive to TBI and well tolerated.
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Affiliation(s)
- Adam J Kruse
- Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
| | - Andrew S Nugent
- Department of Emergency Medicine, The University of Iowa, Iowa City, IA, USA
| | - Andrew R Peterson
- Department of Pediatrics, The University of Iowa, Iowa City, IA, USA,
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Givergis R, Munnangi S, Fayaz M Fomani K, Boutin A, Zapata LC, Angus LDG. Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center. Chin J Traumatol 2018; 21:261-266. [PMID: 29776837 PMCID: PMC6235793 DOI: 10.1016/j.cjtee.2018.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/08/2018] [Accepted: 03/08/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. METHODS A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. RESULTS Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). CONCLUSION Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients.
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Affiliation(s)
- Roshan Givergis
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Swapna Munnangi
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA,Corresponding author.
| | | | - Anthony Boutin
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Luis Carlos Zapata
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - LD George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA
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Nevins EJ, Bird NTE, Malik HZ, Mercer SJ, Shahzad K, Lunevicius R, Taylor JV, Misra N. A systematic review of 3251 emergency department thoracotomies: is it time for a national database? Eur J Trauma Emerg Surg 2018; 45:231-243. [PMID: 30008075 DOI: 10.1007/s00068-018-0982-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/10/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world. METHODS Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications. RESULTS Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012). CONCLUSIONS Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.
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Affiliation(s)
- Edward John Nevins
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Nicholas Thomas Edward Bird
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Hassan Zakria Malik
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,North West Hepatobiliary Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Simon Jude Mercer
- Liverpool Medical School, University of Liverpool, Liverpool, UK.,Department of Anaesthesia, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Khalid Shahzad
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Raimundas Lunevicius
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - John Vincent Taylor
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - Nikhil Misra
- Emergency General Surgery and Trauma Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.,Liverpool Medical School, University of Liverpool, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
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Azarhomayoun A, Aghasi M, Mousavi N, Shokraneh F, Vaccaro AR, Haj Mirzaian A, Derakhshan P, Rahimi-Movaghar V. Mortality Rate and Predicting Factors of Traumatic Thoracolumbar Spinal Cord Injury; A Systematic Review and Meta-Analysis. Bull Emerg Trauma 2018; 6:181-194. [PMID: 30090812 PMCID: PMC6078479 DOI: 10.29252/beat-060301] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective To estimate the summation of mortality rate and the contributing factors in patients with traumatic thoracolumbar spinal cord injuries (TLSCI). Methods A systematic search of observational studies that evaluated the mortality associated with TLSCI in MEDLINE and EMBASE was conducted. The study quality was evaluated using a modified quality assessment tool previously designed for observational studies. Results Twenty-four observational studies involving 11,205 patients were included, published between January 1, 1997, and February 6, 2016. Ten studies were of high quality, thirteen were of moderate quality, and one study was of low quality. Seventeen reports described risk factors for mortality and eleven of these studies used a multiple regression models to adjust for confounders. The reported mortality rate ranged from 0 to 37.7% overall and between 0 and 10.4% in-hospital. The sum of mortality for in-hospital, 6-month, and 12-month were 5.2%, 26.12%, 4.3%, respectively. The mortality at 7.7 years follow-up was 10.07% and for 14 years follow-up reports ranged from 13.47% to 21.46%. Associated data such as age at injury, male to female ratio, pre-existing comorbidities, concomitant injuries, duration of follow-up, and cause of death have been underreported in studies investigating the mortality rate after TLSCI. Conclusion There is no study was found that accurately assessed mortality in the thoracolumbar spine, while there is general agreement that traumatic thoracolumbar spinal cord injuries are important.
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Affiliation(s)
- Amir Azarhomayoun
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Aghasi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Najmeh Mousavi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Shokraneh
- Division of Psychiatry and Clinical Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Alexander R Vaccaro
- Departments of Orthopaedic Surgery and Neurological Surgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, PA, USA
| | - Arvin Haj Mirzaian
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pegah Derakhshan
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Student Research Committee, Faculty of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Duke M, Tatum D, Sexton K, Stuke L, Robertson R, Sutherland M, Tyroch A, Agrawal V, Duchesne J. When Minutes Fly by: What is the True “Golden Hour” for Air Care? Am Surg 2018. [DOI: 10.1177/000313481808400633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Air transport was developed to hasten patient transport based on the “golden hour” belief that delayed care leads to poorer outcome. The primary aim of our study was to identify the critical inflection point of increased nonsurvivors on total prehospital time. This was a multicenter review of adult trauma patients transported by air between November 2014 and August 2015. Primary outcome of interest was all-cause inhospital mortality. Total helicopter emergency medical services times of nonsurvivors were plotted to visualize the distribution of prehospital time. Of 636 patients included, 71 per cent were male and 86 per cent suffered blunt trauma. Among non-survivors, mortality doubled once total helicopter emergency medical services time exceeded 30 minutes (P < 0.001). Nonsurvivors presented with significantly lower median [interquartile range (IQR)] Glasgow Coma Score compared with survivors [3 (3–13) vs 15 (12–15), respectively; P < 0.001] as well as a significantly higher median (IQR) Injury Severity Score [26 (19–41) vs 12 (5–22); P < 0.001], increased incidence of penetrating mechanism of injury [21 vs 8%; P = 0.002], and higher median (IQR) shock index [0.84 (0.63–1.06) vs 0.71 (0.6–0.87); P = 0.023]. We identified an inflection point of doubling in mortality after 30 minutes. This suggests a possible threshold effect between time and mortality in severely injured patients. Revised field criteria for determining which injured patients would most benefit from helicopter transport are needed.
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Affiliation(s)
| | - Danielle Tatum
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
| | - Kevin Sexton
- University of Arkansas Medical Center, Little Rock, Arkansas
| | - Lance Stuke
- Louisiana State University Medical Center, New Orleans, Louisiana
| | | | | | - Alan Tyroch
- Texas Tech University Health Science Center, Lubbock, Texas
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Abstract
STUDY DESIGN Benchtop model with prospective surgeon video testing. OBJECTIVE To create a surface bleeding severity scale, the SPOT GRADE (SG), for quantitative assessment of target bleeding site (TBS) blood loss. This is of particular interest for spinal surgery due to epidural bleeding and an inability to use diathermy and radiofrequency cautery close to nerve roots. SUMMARY OF BACKGROUND DATA A novel apparatus perfusable at known flow rates and simulating different sized wounds was used to create movies to educate surgeons on specific degrees of bleeding. METHODS Training (36) and testing (108) videos were created using a benchtop apparatus employing different bleeding severities based on the six-level SG (none, minimal, mild, moderate, severe, and extreme) and TBS sizes (1, 10, and 50 cm). Fourteen surgeons in four specialties (cardiothoracic, abdominal, spine, and orthopedic lower extremity) were trained and tested to evaluate SG characteristics including inter-rater and intrarater reliability. RESULTS The interclass correlation coefficient was estimated to be 0.89840 (95% confidence interval [CI]: 0.85771, 1), whereas the intraclass correlation coefficient was estimated to be 0.93673 (95% CI: 0.89603, 1). In 98% of cases (95% CI: 0.9736, 0.9927), surgeons correctly identified eligible bleeds for a future clinical trial (scores = 1, 2, or 3) and in 91% of cases (95% CI: 0.8895, 0.9344), surgeons correctly identified noneligible bleeds (scores = 4 or 5). In 98.6% of cases (95% CI: 0.9777, 0.9945), physicians correctly identified true hemostasis (score = 0). Based upon these data the probability of a physician rating a bleed incorrectly as hemostasis (score = 0) is estimated to be 1.51% (95% CI: 0.0061, 0.0363). CONCLUSION This SG is reproducible and reliable providing a basis for educating surgeons on TBS blood loss. It appears to be a new standard for evaluating wound blood loss. LEVEL OF EVIDENCE 2.
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Campos-Serra A, Montmany-Vioque S, Rebasa-Cladera P, Llaquet-Bayo H, Gràcia-Roman R, Colom-Gordillo A, Navarro-Soto S. The use of the Shock Index as a predictor of active bleeding in trauma patients. Cir Esp 2018; 96:494-500. [PMID: 29778416 DOI: 10.1016/j.ciresp.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/23/2018] [Accepted: 04/02/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. METHODS SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor «active bleeding» (defined as the presence of at least one of the 4 markers above). RESULTS Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). «Active bleeding» was present in 18.7% of patients. The SI area under the ROC curve for «active bleeding» was 0.749. CONCLUSIONS An SI cut-off point≥0.8 is more sensitive than≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.
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Affiliation(s)
- Andrea Campos-Serra
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España.
| | - Sandra Montmany-Vioque
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
| | - Pere Rebasa-Cladera
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
| | - Heura Llaquet-Bayo
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
| | - Raquel Gràcia-Roman
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
| | - Anna Colom-Gordillo
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
| | - Salvador Navarro-Soto
- Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
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3D printing-based minimally invasive cannulated screw treatment of unstable pelvic fracture. J Orthop Surg Res 2018; 13:71. [PMID: 29618349 PMCID: PMC5885308 DOI: 10.1186/s13018-018-0778-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/23/2018] [Indexed: 12/12/2022] Open
Abstract
Background Open reduction and internal fixation of pelvic fractures could restore the stability of the pelvic ring, but there were several problems. Minimally invasive closed reduction cannulated screw treatment of pelvic fractures has lots advantages. However, how to insert the cannulated screw safely and effectively to achieve a reliable fixation were still hard for orthopedist. Our aim was to explore the significance of 3D printing technology as a new method for minimally invasive cannulated screw treatment of unstable pelvic fracture. Methods One hundred thirty-seven patients with unstable pelvic fractures from 2014 to 2016 were retrospectively analyzed. Based on the usage of 3D printing technology for preoperative simulation surgery, they were assigned to 3D printing group (n = 65) and control group (n = 72), respectively. These two groups were assessed in terms of operative time, intraoperative fluoroscopy, postoperative reduction effect, fracture healing time, and follow-up function. The effect of 3D printing technology was evaluated through minimally invasive cannulated screw treatment. Results There was no significant difference in these two groups with respect to general conditions, such as age, gender, fracture type, time from injury to operation, injury cause, and combined injury. Length of surgery and average number of fluoroscopies were statistically different for 3D printing group and the control group (p < 0.01), i.e., 58.6 vs. 72.3 min and 29.3 vs. 37 min, respectively. Using the Matta radiological scoring systems, the reduction was scored excellent in 21/65 cases (32.3%) and good in 30/65 cases (46.2%) for the 3D printing group, versus 22/72 cases (30.6%) scored as excellent and 36/72 cases (50%) as good for the control group. On the other hand, using the Majeed functional scoring criteria, there were 27/65 (41.5%) excellent and 26/65 (40%) good cases for the 3D printing group in comparison to 30/72 (41.7%) and 28/72 (38.9%) cases for the control group, respectively. This suggests no significant difference between these two groups about the function outcomes. Conclusion Full reduction and proper fixation of the pelvic ring and reconstruction of anatomical morphology are of great significance to patients’ early functional exercise and for the reduction of long-term complications. This retrospective study has demonstrated the 3D printing technology as a potential approach for improving the diagnosis and treatment of pelvic fractures. Trial registration The study was retrospectively registered at the Chinese Clinical Trial Registry, number: ChiCTR-TRC-17012798, trial registration date: 26 Sept. 2017.
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