Trauma systems in Asian countries: challenges and recommendations

INTRODUCTION

Trauma burden is one of the leading causes of young human life and economic loss in low- and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries.

METHOD

This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries.

RESULT

Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting.

The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards

BACKGROUND

Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims.

METHODS

Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared.

RESULTS

TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel.

CONCLUSIONS

The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.

Revisiting the Role of Amniotic Membrane Dressing in Acute Large Traumatic Wounds: A Randomized Feasibility Study at a Level 1 Trauma Centre

Introduction

Acute large traumatic wounds require temporary dressing prior to the definitive soft tissue reconstruction, as the physiological derangement during the immediate postinjury period delays the definitive surgical intervention. Selecting an ideal dressing material from numerous available synthetic dressings and skin substitutes poses a challenge. Although amniotic membrane (AM) scaffold has a definitive role in promoting wound healing in burns and chronic wounds, however, its efficacy in acute large traumatic wound is lacking. The present trial aimed to evaluate the safety and efficacy of AM in wound bed preparation before the definitive soft-tissue reconstruction in acute large traumatic wounds.

Methods

Sixty patients with acute large traumatic wounds (>10 cm × 10 cm) were divided into two groups (conventional dressing and AM dressing) using simple mixed block randomization. Wounds were assessed using the Bates Jensen Score at various timelines for the signs of early wound healing. The primary outcome was to evaluate the time taken for the wound bed preparation for definitive soft-tissue reconstruction. The secondary outcome was the pain assessment and complications, if any.

Results

There was significant reduction in the wound exudate as well as peripheral tissue edema in the intervention group (P = 0.01). AM dressing was significantly less painful (P = 0.01). The incidence of wound infection and need for debridement was decreased in the intervention group. However, the time interval to definitive soft-tissue coverage was statistically insignificant and comparable in both the groups. No adverse reactions were seen in either group.

Conclusion

AM dressings are safe and efficacious with significant reduction in wound exudates and peripheral edema. However, these dressings do not hasten the wound maturation as compared to conventional dressings. AM dressings can be used as a less painful alternative to conventional dressing in the management of large acute posttraumatic wounds.

Comprehensive Management of the Patient With Traumatic Cardiac Injury

Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.

Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial

PURPOSE

Penetrating abdominal trauma was traditionally managed by mandatory exploration, which led to high rates of non-therapeutic surgery and prolonged hospital stay. Diagnostic laparoscopy (DL) is a less-invasive alternative; however, it requires general anaesthesia and carries a potential risk of iatrogenic injuries. Contrast-enhanced computed tomography (CECT)-guided selective non-operative management (SNOM) may avoid surgery altogether, but there is apprehension of missed injury. Randomised trials comparing these two modalities are lacking. This study is aimed at comparing outcomes of these two management approaches.

METHODS

Hemodynamically stable patients with penetrating trauma to anterior abdominal wall were randomised in 1:1 ratio to DL or CECT-based management. Primary outcome was length of hospital stay (LOS). Secondary outcomes were rate of non-therapeutic surgery, complications, and length of intensive care unit (ICU) stay.

RESULTS

There were 52 patients in DL group and 54 patients in CECT group. Mean LOS was comparable (3 vs 3.5 days; p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (65.4 vs 17.4%, p = 0.0001). Rate of complications and length of ICU stay were similar. Selective non-operative management based on CECT findings was successful in 93.8% of patients; 2 patients had delayed surgery.

CONCLUSION

In patients with penetrating trauma to anterior abdominal wall, DL and CECT-based management led to comparable hospital stay. Significant reduction in non-therapeutic surgery could be achieved using a CECT-based approach.

TRIAL REGISTRATION

Clinical trials registry-India (CTRI/2019/04/018721, REF/2019/01/023400).

Protocolized approach saves the limb in peripheral arterial injury: A decade experience

PURPOSE

Outcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The aim of this study was to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients.

METHODS

This is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas).

RESULTS

Out of 716 patients with PAI, the majority (92%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2-7 h). Brachial artery (28%) was the most common injured vessel followed by popliteal artery (18%) and femoral artery (17%). Limb salvage rate was 78%. Out of them, 158 (22%) patients needed amputation, and 53 (7%) had undergone primary amputation. The majority (86%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation.

CONCLUSION

Over all limb salvage rates was 78% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.

Successful airway management of traumatic complete tracheal transection

A man in his 20s sustained complete tracheal transection after being injured by a sandbag pile falling on his neck. An oral endotracheal tube (ETT) was inserted by rapid sequence induction in view of respiratory distress. CT revealed that the ETT did not traverse the distal tracheal segment; however, there were rebreathing bag movements, and normal capnograph and oxygen saturation, which were misleading clinical findings. We describe the successful airway management in this challenging case.

Validation of the adapted clavien dindo in trauma (ACDiT) scale to grade management related complications at a level I trauma center

Objectives

Complications during trauma management are the main factor responsible for the overall increase in treatment cost. There are very few grading systems to measure the burden of complications in trauma patients. A prospective study was conducted using the Adapted Clavien Dindo in Trauma (ACDiT) scale, with the primary aim of validating it at our center. As a secondary aim, it was also wanted to measure the mortality burden among our admitted patients.

Material and Methods

The study was conducted at a dedicated trauma center. All patients with acute injuries, who were admitted, were included. An initial treatment plan was made within 24 hours of admission. Any deviation from this was recorded and graded according to the ACDiT. The grading was correlated with hospital-free days and ICU-free days within 30 days.

Results

A total of 505 patients were included in this study, with a mean age of 31 years. The most common mechanism of injury was road traffic injury, with a median ISS and NISS of 13 and 14, respectively. Two hundred and forty-eight out of 505 patients had some grade of complication as determined by the ACDiT scale. Hospital-free days (13.5 vs. 25; p <0.001) were significantly lower in patients with complications than those without complications, and so were ICU-free days (29 vs. 30; p <0.001). Significant differences were also observed when comparing mean hospital free and ICU free days across various ACDiT grades. Overall mortality of the population was 8.3 %, the majority of whom were hypotensive on arrival and required ICU care.

Conclusion

We successfully validated the ACDiT scale at our center. We recommend using this scale to objectively measure in-hospital complications and improve trauma management quality. ACDiT scale should be one of the data points in any trauma database/registry.

"Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe"

INTRODUCTION

Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources.

METHODS

Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors.

RESULTS

The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality.

CONCLUSIONS

Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial

Background

The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma.

Methods

In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate.

Results

Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups.

Conclusion

ERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications.

Level of evidence

Level 1, randomized controlled trial, care management.

Trial registration number

Clinical Trials Registry of India (CTRI/2019/06/019533).

Massive parietal defect with multiple enteroatmospheric fistulae after thermal injury abdomen in a metal industry accident: Case report of a rare survivor

In industrial foundries, raw metal is heated almost up to its melting point and then passed through the rolling mill to mould it into a desired shape. Contact with hot machinery or the hot metal can cause severe deep burns. When such thermal injury involves the abdominal wall, complex bowel injury can occur, leading to life-threatening abdominal sepsis. We report successful management of a patient with abdominal wall defect and multiple open fistulae. Severe thermal injury of the anterior abdominal wall may be associated with latent bowel injuries and abdominal compartment syndrome. A low threshold for surgery and re-look surgery may prevent complications.

Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial

BACKGROUND

Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial.

MATERIALS AND METHODS

After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge.

RESULTS

Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits.

CONCLUSION

Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.

Missed diaphragmatic injury after blunt trauma presenting with colonic strangulation: a rare scenario

Diaphragmatic rupture occurs in 4%-5% cases of thoracoabdominal injuries. It may present acutely, in a delayed fashion or as a complicated hernia. We are describing the case of a young male presenting in respiratory distress with history of chest trauma 1.5 years back. On investigation, he was found to have left side diaphragmatic hernia containing gangrenous colon with lung collapse. The patient underwent successful operative intervention and discharged after 25 days of hospital stay. Record review suggested that the above mentioned diaphragm injury was missed in his evaluation 1.5 years back. Diaphragmatic injury must always be suspected in thoracoabdominal injuries, as missed injury may cause devastating complications like the one narrated above in due course.

Effects of preoperative carbohydrates drinks on immediate postoperative outcome after day care laparoscopic cholecystectomy

BACKGROUND

Postoperative nausea and vomiting is the most common cause for unexpected hospital admission of patients undergoing day care surgery. Overnight fasting changes patient metabolic state and influences their perioperative stress response. Preoperative carbohydrate loading may have accelerated recovery and better overall outcome after major abdominal surgery. The aim of the study was to investigate the effects of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting and pain after day care laparoscopic cholecystectomy.

METHODS

A total of 120 patients posted for day care laparoscopic cholecystectomy were included in the study and were randomized into three groups. Group A (Cases)-receiving the carbohydrate-rich drink before surgery (CHO), group B (placebo)-receiving the placebo drink before surgery and group C (controls)-fasting from midnight before surgery. Postoperative nausea and vomiting and visual analogue score for pain were noted and analyzed for 24 h.

RESULTS

Mean score of nausea in 0-4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4-12 and 12-24 h between groups was not significant (p = 0.066), (p = 0.257). Mean score of vomiting in 0-4 and 4-12 h in group A was significantly less than that of group B and group C (p = 0.004), (p = 0.001). Mean score of pain in group A was significantly less when compared to group B and group C in 0-4 h (p = 0.001) and 4-12 h (0.005).

CONCLUSION

Perioperative consumption of a carbohydrate-rich drink can minimize postoperative nausea, vomiting and pain in patients undergoing outpatient cholecystectomy. Consumption of carbohydrate drinks up to 2 h prior to surgery is not associated with additional complications.