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Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Jensen AR, Burd RS. Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data? J Trauma Acute Care Surg 2024; 96:785-792. [PMID: 37752639 DOI: 10.1097/ta.0000000000004119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. METHODS We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. RESULTS We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. CONCLUSION Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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MESH Headings
- Humans
- Shock, Hemorrhagic/therapy
- Shock, Hemorrhagic/mortality
- Shock, Hemorrhagic/etiology
- Shock, Hemorrhagic/diagnosis
- Child
- Female
- Male
- Retrospective Studies
- Adolescent
- Blood Transfusion/statistics & numerical data
- Child, Preschool
- Infant
- Bias
- Wounds, Penetrating/mortality
- Wounds, Penetrating/therapy
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/complications
- Resuscitation/methods
- Resuscitation/statistics & numerical data
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Affiliation(s)
- Travis M Sullivan
- From the Division of Trauma and Burn Surgery (T.M.S., G.J.S., W.V.G.-T., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (A.R.J.), University of California San Francisco; and Division of Pediatric Surgery (A.R.J.), UCSF Benioff Children's Hospitals, San Francisco, CA
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2
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Jastaniah A, Grushka J. The Role of Minimally Invasive Surgeries in Trauma. Surg Clin North Am 2024; 104:437-449. [PMID: 38453312 DOI: 10.1016/j.suc.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
This article delves into the role of minimally invasive surgeries in trauma, specifically laparoscopy and video-assisted thoracic surgery (VATS). It discusses the benefits of laparoscopy over traditional laparotomy, including its accuracy in detecting peritoneal violation and intraperitoneal injuries caused by penetrating trauma. The article also explores the use of laparoscopy as an adjunct to nonoperative management of abdominal injuries and in cases of blunt trauma with unclear abdominal injuries. Furthermore, it highlights the benefits of VATS in diagnosing and treating thoracic injuries, such as traumatic diaphragmatic injuries, retained hematomas, and persistent pneumothorax.
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Affiliation(s)
- Atif Jastaniah
- Division of General Surgery, Department of Surgery, McGill University, 1650 Cedar Avenue, L9-521, Montreal, QC H3G1A4, Canada.
| | - Jeremey Grushka
- Division of General Surgery, Department of Surgery, McGill University, 1650 Cedar Avenue, L9-521, Montreal, QC H3G1A4, Canada
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Alcasid NJ, Banks KC, Susai CJ, Victorino GP. Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma. J Surg Res 2024; 295:393-398. [PMID: 38070252 DOI: 10.1016/j.jss.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. METHODS A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate. RESULTS We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. CONCLUSIONS Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.
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Affiliation(s)
- Nathan J Alcasid
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California.
| | - Kian C Banks
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Cynthia J Susai
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
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Decker H, Schwab M, Shao S, Kaki D, Melhado C, Cuschieri J, Bongiovanni T. Screening for Intimate Partner Violence in Trauma: Results of a Quality Improvement Project. J Surg Res 2024; 295:376-384. [PMID: 38064979 DOI: 10.1016/j.jss.2023.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Intimate partner violence (IPV) is common, especially among patients presenting with traumatic injury. We implemented an IPV screening program for patients admitted after trauma. We sought to determine whether specific demographic or clinical characteristics were associated with being screened or not screened for IPV and with IPV screen results. METHODS Retrospective cohort study evaluating all patients admitted after trauma from July 2020-July 2022 in an Adult Level 1 Trauma Center. RESULTS There were 4147 admissions following traumatic injury, of which 70% were men and 30% were women. The cohort was 46% White, 20% Asian, 15% Black, and 17% other races. Twenty-three percent were Hispanic or Latino/a. Seventy-seven percent were admitted for blunt injuries and 16% for penetrating injuries. Thirteen percent (n = 559) of the cohort was successfully screened for IPV. Screening rates did not differ by gender, race, or ethnicity. After adjustment for demographic and clinical factors, patients admitted to the intensive care unit were significantly less likely to be screened. Of the screened patients, 30% (165) screened positive. These patients were more commonly Hispanic or Latino/a, insured by Medicaid and presented with a penetrating injury. There were no differences in injury severity in patients who screened positive versus those who screened negative. CONCLUSIONS There are significant barriers to universal screening for IPV, including injury acuity, in patients admitted following trauma. However, the 30% rate of positive screens for IPV in patients admitted following trauma highlights the urgent need to understand and address barriers to screening in trauma settings to enable universal screening.
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Affiliation(s)
- Hannah Decker
- Department of Surgery, University of California at San Francisco, San Francisco, California.
| | - Marisa Schwab
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Shirley Shao
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Dahlia Kaki
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Caroline Melhado
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Joseph Cuschieri
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Tasce Bongiovanni
- Department of Surgery, University of California at San Francisco, San Francisco, California
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Lehtinen M, Nykänen A, Raivio P. No cupid, just an arrow: a penetrating injury into the interventricular septum. J Cardiothorac Surg 2024; 19:48. [PMID: 38310275 PMCID: PMC10838426 DOI: 10.1186/s13019-024-02512-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Penetrating cardiac injuries are rare but often fatal, with 16-55% mortality. We report a patient who suffered a non-fatal occupational cardiac injury. CASE PRESENTATION A 47-year-old man was operating an ironworker machine. A thin 3-cm metal fragment catapulted from the machine piercing the chest wall and the right ventricular outflow tract (RVOT), burrowing into the interventricular septum (IVS). The patient remained hemodynamically stable and walked to the nearest hospital. ECG-gated computed tomography revealed the exact location of the fragment within the IVS, allowing for detailed preoperative planning. The fragment was removed through a sternotomy and an incision through the RVOT. The postoperative course was uneventful. CONCLUSIONS This case underscores the value of detailed preoperative imaging and the wide spectrum of clinical scenarios of penetrating cardiac injuries.
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Affiliation(s)
- Miia Lehtinen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, 00290, Finland.
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Antti Nykänen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, 00290, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, 00290, Finland
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Abdel-Aziz H, Murray C, Roberts D, Capron G, Starr F, Bokhari F, Brigode W. The American Association for the Surgery of Trauma Organ Injury Scale for Spleen Does Not Equally Predict Interventions in Penetrating and Blunt Trauma. Am Surg 2023; 89:5782-5785. [PMID: 37159228 DOI: 10.1177/00031348231175495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the spleen (and other organs) was created in 1989. It has been validated to predict mortality, need for operation, length of stay (LOS), and intensive care unit (ICU) LOS. PURPOSE We aimed to determine if the Spleen OIS is applied equally to blunt and penetrating trauma. RESEARCH DESIGN/STUDY SAMPLE We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017-2019, including patients with spleen injuries. DATA COLLECTION Outcomes included the rates of mortality, operation, spleen-specific operation, splenectomy, and splenic embolization. RESULTS 60900 patients had a spleen injury with an OIS grade. Mortality rates increased in Grades IV and V for both blunt and penetrating trauma. In blunt trauma, the odds for any operation, spleen-specific operation, and splenectomy increased, for each increase in grade. Penetrating trauma showed similar trends in grades up to grade IV, but were statistically similar between grade IV and V. Splenectomy was higher in penetrating trauma for all grades. Splenic embolization peaked at 25% of grade IV trauma before decreasing in grade V. Rates in penetrating trauma were significantly lower in all grades, peaking at 2.5% of Grade III injuries. CONCLUSIONS The mechanism of trauma is a significant factor for all outcomes, independent of AAST-OIS. Hemostasis is predominantly surgical in penetrating trauma, achieved with angioembolization more frequently in blunt trauma. Penetrating trauma management is influenced by the potential for injury to peri-splenic organs.
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Affiliation(s)
- Hossam Abdel-Aziz
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Clark Murray
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Drew Roberts
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Gwenviere Capron
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Frederic Starr
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Faran Bokhari
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - William Brigode
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Hamilton JM, Chan TG, Moore CE. Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols. Otolaryngol Clin North Am 2023; 56:1013-1025. [PMID: 37353366 DOI: 10.1016/j.otc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.
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Affiliation(s)
- James M Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA.
| | - Tyler G Chan
- Emory University School of Medicine, Atlanta, GA, USA
| | - Charles E Moore
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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Kong V, Ko J, Thirayan V, Leow P, Lim J, Bruce J, Laing G, Clarke D. Penetrating buttock trauma is morbid but rarely fatal - A South African experience. Am Surg 2023; 89:4747-4751. [PMID: 36202188 DOI: 10.1177/00031348221129498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Penetrating injuries to the buttock are relatively rare but are associated with significant morbidity. This study aimed to review our experience in managing penetrating trauma to the buttocks to contextualize the injury, document the most common associated injuries, and generate an algorithm to assist with the management of these patients. METHODS A retrospective study was conducted at a major trauma center in South Africa over 8 years (January 2012 to January 2020). All patients presenting with a penetrating buttock injury were included. RESULTS Our study included 40 patients. Gunshot wounds accounted for 93% (37/40), stab wounds accounted for 5% (2/40), and 1 case was gored by a cow. The majority (98%) underwent further investigation in the form of imaging or endoscopy. Forty percent (16/40) required surgical intervention. Of these 16 cases, 14 required a laparotomy, and 2 required gluteal exploration. Fifty-six percent (9/16) required a stoma. Five percent (2/40) experienced one or more complications, both of whom had stomas. The median length of stay for all patients was 3 days, whereas for the patients with stomas was 7 days. There were no ICU admissions or mortality in this study. Only 3 of the 9 stomas were reversed, and the median time to reversal was 16 months. CONCLUSION Penetrating trauma to the buttock may result in injuries to surrounding vital structures, which must be actively excluded. Rectal injury was the most common injury, and most required a defunctioning colostomy as part of the management resulting in significant morbidity.
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Affiliation(s)
- Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Jonathan Ko
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Varun Thirayan
- Department of Psychiatry, Waikato Hospital, Hamilton, New Zealand
| | - Priscilla Leow
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Jia Lim
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Choi D, Kang BH, Jung K, Lim SH, Moon J. Risk Factors and Management of Blunt Inferior Vena Cava Injury: A Retrospective Study. World J Surg 2023; 47:2347-2355. [PMID: 37423908 DOI: 10.1007/s00268-023-07110-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Traumatic inferior vena cava (IVC) injuries are uncommon, but the mortality rate remains high at 38-70%. To date, most studies on traumatic IVC injuries have evaluated blunt rather than penetrating injuries. We aimed to identify the clinical features and risk factors that affect the prognosis of patients with blunt IVC injuries to improve treatment strategies for these patients. METHODS We retrospectively analyzed patients diagnosed with blunt IVC injury over 8 years at a single trauma center. Clinical and biochemical parameters; transfusion, surgical, and resuscitation methods; associated injuries; intensive care unit stay; and complications data were compared between survival and death groups to identify clinical features and risk factors of blunt IVC injury-related mortality. RESULTS Twenty-eight patients with blunt IVC injury were included during the study periods. Twenty-five (89%) patients underwent surgical treatment, and the mortality was 54%. The mortality rate according to the IVC injury location was the lowest for supra-hepatic IVC injury (25%, n = 2/8), whereas it was the highest for retrohepatic IVC injury (80%, n = 4/5). In the logistic regression analysis, Glasgow Coma Scale (GCS) (odds ratio [OR] = 0.566, 95% confidence interval [CI] [0.322-0.993], p = 0.047) and red blood cell (RBC) transfusion for 24 h (OR = 1.132, 95% CI [0.996-1.287], p = 0.058) were independent predictors for mortality. CONCLUSIONS Low GCS score and high-volume packed RBC transfusion requirements for 24 h were significant predictors of mortality in patients with blunt IVC injuries. Unlike IVC injuries caused by penetrating trauma, supra-hepatic IVC injuries caused by blunt trauma have a good prognosis.
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Affiliation(s)
- Donghwan Choi
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Sang-Hyun Lim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea.
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Zeineddin A, Tominaga GT, Crandall M, Almeida M, Schuster KM, Jawad G, Maqbool B, Sheffield AC, Dhillon NK, Radow BS, Moorman ML, Martin ND, Jacovides CL, Lowry D, Kaups K, Horwood CR, Werner NL, Proaño-Zamudio JA, Kaafarani HMA, Marshall WA, Haines LN, Schaffer KB, Staudenmayer KL, Kozar RA. Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale. J Trauma Acute Care Surg 2023; 95:213-219. [PMID: 37072893 DOI: 10.1097/ta.0000000000003969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
INTRODUCTION The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes. METHODS This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion. RESULTS We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13). CONCLUSION This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Ahmad Zeineddin
- From the Department of Surgery (A.Z.), Howard University Hospital, Washington, DC; Department of Surgery (A.Z., N.K.D., R.A.K.), Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (M.A., K.M.S.), Yale University, New Haven, Connecticut; Department of Surgery (G.J., B.M.), University of New Mexico Health Science Center, Albuquerque, New Mexico; Department of Surgery (M.C., A.C.S.), College of Medicine, University of Florida, Jacksonville, Florida; Department of Surgery (B.S.R., M.L.M.), University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (N.D.M., C.L.J.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.L., K.K.), Community Regional Medical Center, UCSF Fresno, Fresno, California; Department of Surgery (C.R.H., N.L.W.), Denver Health, Denver, Colorado; Department of Surgery (J.A.P.-Z., H.M.A.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (W.A.M., L.N.H.), University of California San Diego Health, San Diego; Department of Surgery (G.T.T., K.B.S.), Scripps Memorial Hospital, La Jolla; and Department of Surgery (K.L.S.), Stanford University, Stanford, California
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Rojnoveanu G, Gurghis R, Gagauz I, Malcova T. Thoracic Penetrating Wounds with Cardiac Injury: A Single-Center Experience. Chirurgia (Bucur) 2022; 117:660-670. [PMID: 36584058 DOI: 10.21614/chirurgia.2725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 12/31/2022]
Abstract
Background: Management protocols for patients with penetrating cardiac injury have undergone a dramatic transition during the last decades. However, even today cardiac trauma remains a major medical problem. Methods: Retrospective single-center case series study, 41 patients with precordial wounds hospitalized at the Institute of Emergency Medicine, Chisinau, period 2005-2020. Mean age - 45.8 Ã+- 8.9 years, M:F/19.5:1. Traumatic event: stabbing (82.9%,n=34) or gunshot wound (17.1%,n=7). Preoperative paraclinical examinations: electrocardiography, chest X-ray, FAST, pleurotomy, pericardial puncture, and thoracoscopy. Results: 36 (87.8%) patients were hemodynamically unstable on hospitalization, and 19 (52.8%) were immediately transferred to the operating room. Preferred surgical access: left anterolateral thoracotomy - 26 (63.4%), right anterolateral thoracotomy - 13 (31.7%), and left posterolateral thoracotomy - 2 (4.9%). Non-penetrating lesions were discovered in 5 (12.2%) while penetrating trauma in other 36 (87.8%) cases, most frequently the right ventricle being injured. Additional intrathoracic lesions discovered in 29 (70.7%) patients: pulmonary parenchyma rupture - 25 (86.2%), internal mammary artery injury - 3 (10.3%), and intercostal artery injury - 1 (3.5%). The average length of stay was 13.2 Ã+- 4 days, including stay in the Intensive Care Unit - 2.9 Ã+- 1.2. Mortality rate -17.1% (n=7). Conclusions: Successful cardiac suture determined the survival rate of 82.9%. Lethality increases proportionally to the severity of the cardiac injury, the volume of blood loss, and damage to the right vs left heart chambers.
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Pinto Soussa P, Sá Pinto P, França J. Penetrating Vascular Trauma To The Brachial Artery. Port J Card Thorac Vasc Surg 2022; 29:75-77. [PMID: 36197812 DOI: 10.48729/pjctvs.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 06/16/2023]
Abstract
Civilian penetrating injuries to the upper extremities are becoming seldom, with few case reports presented in the recent literature. Nevertheless, the brachial artery is the most frequently injured artery, accounting for approximately 30% of all vascular injuries. The authors present two clinical cases of brachial artery penetrating trauma with a stab corrected with an interposition saphenous bypass graft.
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Reyna-Sepúlveda F, Cantu-Alejo D, Martinez-Fernandez A, Rodriguez-Garcia J, Guevara-Charles A, Perez-Rodriguez E, Hernandez-Guedea M, Muñoz-Maldonado G. 5-Year management and outcomes of penetrating neck injury in a trauma center. Penetrating neck injury. Cir Esp 2022; 100:629-634. [PMID: 36109114 DOI: 10.1016/j.cireng.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/25/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Penetrating neck injuries represent 5-10% of all traumatic injuries, these bring with them a high rate of morbidity and mortality due to vital structures that could be injured in this area. The aim of this study was to determine the epidemiological and clinical characteristics of penetrating neck injuries. METHODS This was a retrospective, unicentric and descriptive study that included all patients who underwent neck exploration surgery. RESULTS A total of 70 neck exploration cases were reviewed, 34 (49%) didn't had any injury. Thirty (43%) had at least one hard sign, 42 (60%) patients showed at least one soft sign. Statistical analysis showed only surgical time (252±199.5 vs. 155±76.4; p=0.020) and transfusions (1.87±3 vs. 0.4±0.856; p=0.013) were statistically significant. We report a mortality of 2 (3%) patients. CONCLUSIONS Our prevalence of neck surgical exploration without vascular injury was slightly higher (49% vs. 40%) than literature. We highlight the importance of not performing neck explorations in all patients who present a penetrating injury. We did not obtain differences between groups for hard signs and soft signs. We were not able to identify whether or not there would be an injury based on clinical characteristics. Imaging studies should be performed to avoid unnecessary neck explorations; however, depending on the clinical scenario some surgery cannot be avoided.
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Affiliation(s)
| | - Daniel Cantu-Alejo
- General Surgery Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico
| | | | - Jaime Rodriguez-Garcia
- General Surgery Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico; Emergency Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico
| | - Asdrubal Guevara-Charles
- General Surgery Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico; Emergency Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico
| | | | - Marco Hernandez-Guedea
- General Surgery Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico; Emergency Department, University Hospital, Universidad Autónoma de Nuevo León, Mexico
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14
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Vielsmeier V, Hackenberg S, Schelzig H, Knapsis A. [Update on neck trauma]. HNO 2022; 70:724-735. [PMID: 36066623 DOI: 10.1007/s00106-022-01214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Important organs and structures are located in the cervical region. In case of blunt and penetrating trauma, emergency situations may arise. OBJECTIVE Emergency management as well as diagnostic and therapeutic steps pertaining to neck injuries are presented. CONCLUSION Shock therapy and airway management are essential, fast management of neck injuries highly relevant.
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Affiliation(s)
- V Vielsmeier
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - S Hackenberg
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - H Schelzig
- Klinik für Gefäß- und Endovaskularchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - A Knapsis
- Klinik für Gefäß- und Endovaskularchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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Elkbuli A, Fanfan D, Newsome K, Sutherland M, Liu H, McKenney M, Ang D. A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias? Surgery 2022; 172:410-420. [PMID: 34972592 DOI: 10.1016/j.surg.2021.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias. METHOD A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05. RESULTS A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001). CONCLUSION Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL.
| | - Dino Fanfan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Kevin Newsome
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Huazhi Liu
- Department of Surgery, Ocala Regional Medical Center, FL
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; Department of Surgery, University of South Florida, Tampa, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, FL; Department of Surgery, University of Central Florida, Ocala, FL
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16
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Smyth L, Bendinelli C, Lee N, Reeds MG, Loh EJ, Amico F, Balogh ZJ, Di Saverio S, Weber D, Ten Broek RP, Abu-Zidan FM, Campanelli G, Beka SG, Chiarugi M, Shelat VG, Tan E, Moore E, Bonavina L, Latifi R, Hecker A, Khan J, Coimbra R, Tebala GD, Søreide K, Wani I, Inaba K, Kirkpatrick AW, Koike K, Sganga G, Biffl WL, Chiara O, Scalea TM, Fraga GP, Peitzman AB, Catena F. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 2022; 17:13. [PMID: 35246190 PMCID: PMC8896237 DOI: 10.1186/s13017-022-00418-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023] Open
Abstract
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
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Affiliation(s)
- Luke Smyth
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Lee
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Matthew G Reeds
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Eu Jhin Loh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dieter Weber
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Fikri M Abu-Zidan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Solomon Gurmu Beka
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Massimo Chiarugi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vishal G Shelat
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Edward Tan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ernest Moore
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Luigi Bonavina
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Rifat Latifi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andreas Hecker
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jim Khan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Giovanni D Tebala
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kjetil Søreide
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Imtiaz Wani
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenji Inaba
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Kaoru Koike
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gabriele Sganga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gustavo P Fraga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew B Peitzman
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Fausto Catena
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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Castater C, Nguyen J, Perez M, Butler C, Meyer C, Todd SR, Sciarretta J, Smith R, Archer-Arroyo K, Grant A. Approaches to Repair of Penetrating Injuries of the Proximal, Mid, and Distal Esophagus. Am Surg 2022; 88:560-562. [PMID: 34693758 DOI: 10.1177/00031348211048837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Traumatic esophageal injuries represent less than 10% of traumatic injuries. Penetrating injuries represent an even smaller but more lethal percent. Esophageal injuries can be cervical, thoracic, or abdominal with decreasing frequency. Cervical and thoracic esophageal injuries represent >80% of these injuries and are more morbid. Morbidity and mortality are increased with delayed identification. Although diagnosis can be hard, management is similar despite location. CASES We present 3 cases of esophageal injuries to the cervical, thoracic, and abdominal esophageal segments with descriptions on diagnosis, repair, and management differences. DISCUSSION Despite low incidence of penetrating esophageal injuries, morbidity and mortality are extremely high, especially with associated injuries. Early identification and treatment is paramount. Anatomical knowledge is necessary for successful surgical management. Primary repair in 2 layers should be attempted whenever possible including musical closure with absorbable suture. Flaps, diversions, wide drainage, and feeding tube access should always be key surgical considerations. Flaps can include sternocleidomastoid muscle for cervical injuries, intercostal muscle, diaphragm, and pericardium for thoracic injuries and "Thal" gastric flaps for gastroesophageal junction and abdominal injuries. Successful identification and management can lead to increased survival.
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Affiliation(s)
| | | | - Matthew Perez
- 520713Emory University School of Medicine, Atlanta, GA, USA
| | | | - Courtney Meyer
- 520713Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Randi Smith
- 520713Emory University School of Medicine, Atlanta, GA, USA
| | | | - April Grant
- 520713Emory University School of Medicine, Atlanta, GA, USA
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18
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Vaidya S, Karmacharya RM, Bhatt S, Paudel B, Neupane M. Vascular Injury to the Neck by a Bamboo Stick: A Case Report. JNMA J Nepal Med Assoc 2022; 60:90-92. [PMID: 35199668 PMCID: PMC9157659 DOI: 10.31729/jnma.7180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/17/2022] [Indexed: 11/01/2022] Open
Abstract
Penetrating neck injuries causing rupture of sternocleidomastoid muscle along with transection of major vessels of the neck have significant morbidity and mortality due to the risk of severe hemorrhage and cerebral infarction. However, there are no universal guidelines for the management of penetrating neck injuries. Here, we report a case of a 67-year-old female with a lacerated wound on the left side of the neck with a complete transection of the left sternocleidomastoid muscle along with transection of internal jugular vein and two superficial branches of internal carotid artery following penetrating injury to the neck by a bamboo stick. It was managed by emergency wound exploration with ligation of the injured vessels with repair of sternocleidomastoid muscle. Post-operatively the hemorrhage was controlled and the patient was discharged on the fourth postoperative day. Thus, in a case of penetrating injury to the neck, prompt surgical wound exploration is beneficial.
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Affiliation(s)
- Satish Vaidya
- Department of Surgery, Kathmandu University School of Medical Sciences, Dhuiikhei Hospital, Dhuiikhei, Kavre, Nepal
| | - Robin Man Karmacharya
- Department of Surgery, Kathmandu University School of Medical Sciences, Dhuiikhei Hospital, Dhuiikhei, Kavre, Nepal
| | - Swechha Bhatt
- Kathmandu University Schooi of Medicai Sciences, Dhuiikhei Hospitai, Dhuiikhei, Kavre, Nepai.
- Correspondence: Ms. Swechha Bhatt, Kathmandu University Schooi of Medicai Sciences, Dhuiikhei Hospitai, Dhuiikhei, Kavre, Nepai. , Phone: +977-9840727936
| | - Bijaya Paudel
- Department of Surgery, Kathmandu University School of Medical Sciences, Dhuiikhei Hospital, Dhuiikhei, Kavre, Nepal
| | - Manish Neupane
- Department of Surgery, Kathmandu University School of Medical Sciences, Dhuiikhei Hospital, Dhuiikhei, Kavre, Nepal
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19
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Lewis RH, Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg 2022; 92:21-27. [PMID: 34670960 DOI: 10.1097/ta.0000000000003430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE Prognostic study, Level IV.
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Affiliation(s)
- Richard H Lewis
- From the Department of Surgery University of Tennessee Health Science Center, Memphis, Tennessee
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20
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Cherkasov MF, Startsev YM, Cherkasov DM, Sitnikov VN, Melikova SG, Galashokyan KM. [Diagnosis and treatment of patients with abdominal trauma]. Khirurgiia (Mosk) 2022:75-82. [PMID: 35920226 DOI: 10.17116/hirurgia202208175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To improve the results of diagnosis and treatment of patients with abdominal injuries through a wider introduction of laparoscopic methods. MATERIAL AND METHODS We analyzed 3556 patients with concomitant abdominal injuries. All patients had damage to several organs and systems. Laparoscopy was performed in 1962 patients, laparotomy without previous laparoscopy - in 1594 patients. RESULTS Laparoscopy found no abdominal injuries in 25.7% of patients, other 13.7% of patients required no surgery and follow-up was indicated. In 60.7% of patients, injuries required surgical correction. Among these lesions, 26.6% of injuries were successfully eliminated using laparoscopic approach. In some cases, more than one injury was corrected. Indications for laparotomy were overestimated in 30.2% of patients who underwent open surgery without previous laparoscopy. CONCLUSION There is a tendency to decrease in the number of open and laparoscopic procedures for concomitant abdominal trauma over time that is associated with widespread introduction of modern diagnostic methods and accumulation of experience. Laparoscopy should be preferred for diagnosis of abdominal injuries in patients with concomitant trauma and no contraindications. This approach diagnoses no injuries or their mild nature in 39.3% of cases. Moreover, laparoscopy effectively eliminates certain lesions in 26.6% of cases.
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Affiliation(s)
- M F Cherkasov
- Rostov State Medical University, Rostov-on-Don, Russia
| | - Yu M Startsev
- Rostov State Medical University, Rostov-on-Don, Russia
| | - D M Cherkasov
- Rostov State Medical University, Rostov-on-Don, Russia
| | - V N Sitnikov
- Rostov State Medical University, Rostov-on-Don, Russia
| | - S G Melikova
- Rostov State Medical University, Rostov-on-Don, Russia
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21
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Beattie G, Cohan CM, Tang A, Chen JY, Victorino GP. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg 2022; 92:177-184. [PMID: 34538828 DOI: 10.1097/ta.0000000000003415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Genna Beattie
- From the Department of Surgery (G.B., C.M.C., A.T., G.P.V.), University of California, San Francisco, East Bay, Oakland; Chemical Sciences Division (J.Y.C.), Lawrence Berkeley National Laboratory, Berkeley, California
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22
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Biffl WL, Ball CG, Moore EE, Lees J, Todd SR, Wydo S, Privette A, Weaver JL, Koenig SM, Meagher A, Dultz L, Udekwu PO, Harrell K, Chen AK, Callcut R, Kornblith L, Jurkovich GJ, Castelo M, Schaffer KB. Don't mess with the pancreas! A multicenter analysis of the management of low-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 91:820-828. [PMID: 34039927 DOI: 10.1097/ta.0000000000003293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma. LEVEL OF EVIDENCE Therapeutic Study, level IV.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital (W.L.B., M.C., K.B.S.), La Jolla, La Jolla, CA; University of Calgary, Calgary (C.G.B.), Alberta, Canada; Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M.), Denver, CO; University of Oklahoma (J.L.), Oklahoma City, OK; Grady Memorial Hospital (S.R.T.), Atlanta, GA; Cooper University Hospital (SW), Camden, NJ; Medical University of South Carolina (A.P.), Charleston, SC; University of California-San Diego (J.L.W.), San Diego, CA; Virginia Tech Carilion School of Medicine (S.M.K.), Carilion Clinic, Roanoke VA; Indiana University School of Medicine- Methodist (A.M.), Indianapolis, IN; Parkland- UT Southwestern Medical Center (L.D.), Dallas, TX; WakeMed Health (P.O.U.), Raleigh, NC; University of Tennessee College of Medicine (K.H.), Chattanooga, TN; UCSF Fresno (A.K.C.), Fresno, CA; and San Francisco General Hospital (R.C., L.K.), San Francisco, CA; University of California-Davis (G.J.J.), Sacramento, CA
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Keskey RC, Hampton DA, Biermann H, Cirone J, Zakrison TL, Cone JT, Wilson KL, Slidell MB. Novel Trauma Composite Score is a more reliable predictor of mortality than Injury Severity Score in pediatric trauma. J Trauma Acute Care Surg 2021; 91:599-604. [PMID: 33871405 DOI: 10.1097/ta.0000000000003235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The equivalent Injury Severity Score (ISS) cutoffs for severe trauma vary between adult (ISS, >16) and pediatric (ISS, >25) trauma. We hypothesized that a novel injury severity prediction model incorporating age and mechanism of injury would outperform standard ISS cutoffs. METHODS The 2010 to 2016 National Trauma Data Bank was queried for pediatric trauma patients. Cut point analysis was used to determine the optimal ISS for predicting mortality for age and mechanism of injury. Linear discriminant analysis was implemented to determine prediction accuracy, based on area under the curve (AUC), of ISS cutoff of 25 (ISS, 25), shock index pediatric adjusted (SIPA), an age-adjusted ISS/abbreviated Trauma Composite Score (aTCS), and our novel Trauma Composite Score (TCS) in blunt trauma. The TCS consisted of significant variables (Abbreviated Injury Scale, Glasgow Coma Scale, sex, and SIPA) selected a priori for each age. RESULTS There were 109,459 blunt trauma and 9,292 penetrating trauma patients studied. There was a significant difference in ISS (blunt trauma, 9.3 ± 8.0 vs. penetrating trauma, 8.0 ± 8.6; p < 0.01) and mortality (blunt trauma, 0.7% vs. penetrating trauma, 2.7%; p < 0.01). Analysis of the entire cohort revealed an optimal ISS cut point of 25 (AUC, 0.95; sensitivity, 0.86; specificity, 0.95); however, the optimal ISS ranged from 18 to 25 when evaluated by age and mechanism. Linear discriminant analysis model AUCs varied significantly for each injury metric when assessed for blunt trauma and penetrating trauma (penetrating trauma-adjusted ISS, 0.94 ± 0.02 vs. ISS 25, 0.88 ± 0.02 vs. SIPA, 0.62 ± 0.03; p < 0.001; blunt trauma-adjusted ISS, 0.96 ± 0.01 vs. ISS 25, 0.89 ± 0.02 vs. SIPA, 0.70 ± 0.02; p < 0.001). When injury metrics were assessed across age groups in blunt trauma, TCS and aTCS performed the best. CONCLUSION Current use of ISS in pediatric trauma may not accurately reflect injury severity. The TCS and aTCS incorporate both age and mechanism and outperform standard metrics in mortality prediction in blunt trauma. LEVEL OF EVIDENCE Retrospective review, level IV.
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Affiliation(s)
- Robert C Keskey
- From the Department of Surgery (R.C.K., D.A.H., T.L.Z., J.T.C., K.L.W., M.B.S.), Section of Trauma and Acute Care Surgery (D.A.H., T.L.Z., J.T.C., K.L.W.), University of Chicago Medicine, Chicago, Illinois; Emory School of Medicine (H.B.), Atlanta, Georgia; Department of Surgery (J.C.), Dartmouth-Hitchcock, Lebanon, New Hampshire; and Section of Pediatric Surgery (M.B.S.), Comer Children's Hospital, University of Chicago Medicine, Chicago, Illinois
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Keskey RC, Slidell MB, Bohr NL, Biermann H, Cirone J, Zakrison T, Cone J, Wilson K, Hampton D. Novel Trauma Composite Score is superior to Injury Severity Score in predicting mortality across all ages. J Trauma Acute Care Surg 2021; 91:621-626. [PMID: 34225345 DOI: 10.1097/ta.0000000000003340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality. METHODS Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems. RESULTS There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001). CONCLUSION Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages. LEVEL OF EVIDENCE Clinical outcomes, Level IV.
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Affiliation(s)
- Robert C Keskey
- From the Department of Surgery (R.C.K., M.B.S., T.Z., J.C., K.W., D.H.), Section of Trauma and Acute Care Surgery, (T.Z., J.C., K.W., D.H.), Section of Vascular Surgery and Endovascular Therapy (N.L.B.), The University of Chicago Medicine; Department of Nursing Research and Evidence-Based Practice (N.L.B.), UChicago Medicine, Chicago, Illinois; Emory School of Medicine (H.B.), Atlanta, Georgia; Department of Surgery, Section of General Surgery (J.C.), Dartmouth-Hitchcock, Lebanon, New Hampshire; and Section of Pediatric Surgery (M.B.S.), The University of Chicago Medicine, Comer Children's Hospital, Chicago, Illinois
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De Ayala-Hillman R, Diaz-Marty C, Ramos-Meléndez E, García-Rodríguez O, Guerrios L, Rodríguez-Ortiz P. A Retrospective Cohort Study on Health Insurance: Related Disparities in Trauma Patients After Penetrating Injuries: 2000-2014. P R Health Sci J 2021; 40:120-126. [PMID: 34792925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.
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Affiliation(s)
- Rafael De Ayala-Hillman
- Department of Surgery, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
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Saldarriaga LG, Palacios-Rodríguez HE, Pino LF, Hadad AG, Capre J, García A, Rodríguez-Holguín F, Salcedo A, Serna JJ, Herrera MA, Parra MW, Ordoñez CA, Kestenberg-Himelfarb A. Rectal damage control: when to do and not to do. Colomb Med (Cali) 2021; 52:e4124776. [PMID: 34188328 PMCID: PMC8216057 DOI: 10.25100/cm.v52i2.4776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/21/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022] Open
Abstract
Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.
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Affiliation(s)
- Luis Guillermo Saldarriaga
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Helmer Emilio Palacios-Rodríguez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Jessica Capre
- Fundación Valle del Lili, Department of Surgery, Division of Colorectal Surgery , Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | | | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Colorectal Surgery , Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Michael W. Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A. Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
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Ordoñez CA, Parra MW, Millán M, Caicedo Y, Padilla N, García A, Franco MJ, Aristizábal G, Toro LE, Pino LF, González-Hadad A, Herrera MA, Serna JJ, Rodríguez-Holguín F, Salcedo A, Orlas C, Guzmán-Rodríguez M, Hernández F, Ferrada R, Ivatury R. Damage control in penetrating duodenal trauma: less is better - the sequel. Colomb Med (Cali) 2021; 52:e4104509. [PMID: 34188326 PMCID: PMC8216054 DOI: 10.25100/cm.v52i2.4509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/16/2020] [Accepted: 04/28/2021] [Indexed: 11/11/2022] Open
Abstract
The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - María Josefa Franco
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Eduardo Toro
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Claudia Orlas
- Department of Surgery, Center for Surgery and Public Health, Brigham & Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston - USA
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery.Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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Briotti J, Jayamaha JY, Keogh A. Marine Penetrating Injury to the Shoulder of Uncertain Origin. Wilderness Environ Med 2021; 32:235-239. [PMID: 33839016 DOI: 10.1016/j.wem.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 11/17/2022]
Abstract
Penetrating injuries from marine animals are rare events; however, published case reports have detailed critical injuries including death occurring as a result of such incidents. We present a case of a marine penetrating injury to the right posterolateral shoulder of a 10-y-old boy. The patient underwent open surgical debridement and a course of oral antibiotics before returning to normal function. Clinicians should have an appreciation of various clinical patterns of marine penetrating wounds, the need for prompt imaging to exclude foreign bodies, and appropriate antibiotics to cover gram-negative bacteria and Vibrio species, which are commonly found in marine-related injuries.
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Affiliation(s)
- Joshua Briotti
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia.
| | | | - Angus Keogh
- Department of Orthopaedics, St John of God Subiaco, Nedlands, Australia
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González-Hadad A, Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Millán M, García A, Vidal-Carpio JM, Pino LF, Herrera MA, Quintero L, Hernández F, Flórez G, Rodríguez-Holguín F, Salcedo A, Serna JJ, Franco MJ, Ferrada R, Navsaria PH. Damage control in penetrating cardiac trauma. Colomb Med (Cali) 2021; 52:e4034519. [PMID: 34188321 PMCID: PMC8216058 DOI: 10.25100/cm.v52i2.4519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/20/2020] [Accepted: 03/18/2021] [Indexed: 11/15/2022] Open
Abstract
Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.
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Affiliation(s)
- Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Yaset Caicedo
- Fundacion Valle del Lili, Centro de Investigaciones Clinicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundacion Valle del Lili, Centro de Investigaciones Clinicas (CIC), Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Jenny Marcela Vidal-Carpio
- Hospital General Teofilo Davila, Servicio de Emergencias, Cuenca, Ecuador
- Universidad de Cuenca, Department of Surgery, Cuenca, Ecuador
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Guillermo Flórez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - María Josefa Franco
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Ricardo Ferrada
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Pradeep H Navsaria
- University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, Trauma Center, Anzio Road, Observatory, Cape Town, South Africa
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Abstract
INTRODUCTION As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines. METHODS Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities. RESULTS A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001). CONCLUSION This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations. LEVEL OF EVIDENCE Epidemiological study, level III; Care management, level IV.
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Affiliation(s)
- Samir M Fakhry
- From the Center for Trauma and Acute Care Surgery Research, Clinical Operations Group, HCA Healthcare, Nashville, Tennessee
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Buitendag JJP, Kong VY, Laing GL, Bruce JL, Manchev V, Clarke DL. A comparison of blunt and penetrating pancreatic trauma. S AFR J SURG 2020; 58:218. [PMID: 34096212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND This project reviews our experience with managing pancreatic trauma from 2012 to 2018. METHODS All patients over the age of 15 years with a pancreatic injury during the period December 2012-December 2018 were retrieved from the Hybrid Electronic Medical Registry at Grey's Hospital and reviewed. RESULTS During the study period 161 patients sustained a pancreatic injury. The mechanism of trauma was penetrating in 86 patients (53%) and blunt in 75 (47%). The blunt mechanisms included MVA in 27, PVA in 15, falls in four and assaults in the remaining 29. There were 52 stab wounds and 34 gunshot wounds of the pancreas. A total of 26 patients (16%) were shocked on presentation with a systolic blood pressure of 90 mm Hg or less. The median injury severity score was 16. There were 90 patients with American Association for the Surgery of Trauma (AAST) grade I injury to the pancreas, 36 AAST grade II, 27 AAST grade III, 7 AAST grade IV and a single AAST grade V. Fifty-four patients (34%) were initially treated non-operatively of which three eventually required surgery. Of the patients who required surgery, 26 (16%) underwent a distal pancreatectomy. The remainder simply underwent pancreatic drainage. The overall mortality rate was 13% (21/161). The operative mortality was 11% (18/161). Thirteen patients (8%) with penetrating injuries and eight patients (5%) with blunt injuries died. Of the 21 patients who died, 14 had multiple injuries. Five patients died due to overwhelming sepsis. One patient died due to hypovolemic shock and another due to a traumatic brain injury. CONCLUSION Our centre not infrequently deals with pancreatic trauma secondary to both blunt and penetrating trauma. We follow the general principles outlined in the literature. Despite this, pancreatic trauma is still associated with significant morbidity and mortality.
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Affiliation(s)
- J J P Buitendag
- Department of Surgery, Tygerberg Hospital, Stellenbosch University, South Africa
| | - V Y Kong
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
| | - G L Laing
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa
| | - V Manchev
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa
| | - D L Clarke
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
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Panossian VS, Nederpelt CJ, El Hechi MW, Chang DC, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility. J Surg Res 2020; 255:486-494. [PMID: 32622163 DOI: 10.1016/j.jss.2020.05.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/18/2020] [Accepted: 05/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.
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Affiliation(s)
- Vahe S Panossian
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Nyilas S, Ott D, von Tengg-Kobligk H, Poellinger A, Dorn P. Penetrating chest trauma after attempted suicide: An extraordinary behavior of a posttraumatic pulmonary artery pseudoaneurysm. J Radiol Case Rep 2020; 14:19-25. [PMID: 33088416 DOI: 10.3941/jrcr.v14i7.3842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Posttraumatic pulmonary artery pseudoaneurysm is a very rare, yet potentially lethal complication after thoracic trauma. Pulmonary artery pseudoaneurysm is associated with high mortality. Still literature highlights that untreated, lesions can enlarge, rupture, and lead to exsanguination and death. We present a case of a posttraumatic peripheral pulmonary artery pseudoaneurysm with complete disappearance after one year. This case confirms that conservative treatment can be an effective option in asymptomatic and stable patients.
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Affiliation(s)
- Sylvia Nyilas
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Daniel Ott
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hendrik von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Alexander Poellinger
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Patrick Dorn
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Nasser AAH, Nederpelt C, El Hechi M, Mendoza A, Saillant N, Fagenholz P, Velmahos G, Kaafarani HMA. Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients. Am J Surg 2020; 220:240-244. [PMID: 31761299 DOI: 10.1016/j.amjsurg.2019.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/02/2019] [Accepted: 11/11/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prompt surgical control of hemorrhage is crucial in penetrating trauma patients. We aimed to study the impact of prehospital response time (PreRespT) and scene time (SceneT) on hospital mortality. METHODS Using the Trauma Quality Improvement Program (TQIP) 2010-2016 database, we identified all adults with penetrating injury. We defined PreRespT as time from EMS dispatch to scene arrival, and SceneT as time spent on scene. Univariate then multivariable logistic regression analyses were performed to study the independent correlation between PreRespT and SceneT on hospital mortality, adjusting for several covariates. RESULTS Out of a total of 1,403,470 patients, 43,467 patients were included. Multivariable analyses suggested that: 1) every minute increase in PreRespT independently correlates with a 2% increase in mortality (OR 1.02, p < 0.0001), and 2) every minute increase in SceneT independently correlates with a 1% increase in mortality (OR 1.01, p = 0.001). CONCLUSION In the penetrating injury trauma patient, PreRespT and SceneT independently correlate with hospital mortality. This data suggests that a faster PreRespT and a "scoop and run" strategy may be more beneficial in this population.
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Affiliation(s)
- Ahmed A H Nasser
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlie Nederpelt
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Burmeister DM, Johnson TR, Lai Z, Scroggins S, DeRosa M, Jonas RB, Zhu C, Scherer E, Stewart RM, Schwacha MG, Jenkins DH, Eastridge BJ, Nicholson SE. The gut microbiome distinguishes mortality in trauma patients upon admission to the emergency department. J Trauma Acute Care Surg 2020; 88:579-587. [PMID: 32039976 PMCID: PMC7905995 DOI: 10.1097/ta.0000000000002612] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients. METHODS We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses. RESULTS Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05). CONCLUSION Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- David M. Burmeister
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | | | - Zhao Lai
- Greehey Children’s Cancer Research Institute, UT Health San Antonio, San Antonio, Texas
- Department of Molecular Medicine, UT Health San Antonio, San Antonio, Texas
| | | | - Mark DeRosa
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | - Caroline Zhu
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | | | | | | | | | - Susannah E. Nicholson
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
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Parreco J, Sussman MS, Crandall M, Ebler DJ, Lee E, Namias N, Rattan R. Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma. J Surg Res 2020; 250:59-69. [PMID: 32018144 DOI: 10.1016/j.jss.2019.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/27/2019] [Accepted: 12/27/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals. METHODS The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury. RESULTS There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05). CONCLUSIONS This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.
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Affiliation(s)
- Joshua Parreco
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Matthew S Sussman
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida.
| | - Marie Crandall
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, Florida
| | - David J Ebler
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, Florida
| | - Eugenia Lee
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
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Pillay V, Pillay M, Hardcastle TC. Renal trauma in a Trauma Intensive Care Unit population. S AFR J SURG 2019; 57:29-32. [PMID: 31773929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. This study in a dedicated Trauma Intensive Care Unit (TICU) population aimed to assess the outcomes of renal injuries and identify factors that predict the need for nephrectomy. METHODS Patients, older than 18 years, admitted to TICU from January 2007 to December 2014 who sustained renal injuries had data extracted from the prospectively collected Class Approved Trauma Registry (BCA207-09). Patients who underwent surgical intervention for the renal injury or received non-operative management were compared. The key variables analysed were: patient demographics, mechanism of injury, grade of renal injury, presenting haemoglobin, initial systolic blood pressure, Injury Severity Score and Renal Injury AAST Grade on CT scan in patients who did not necessarily require immediate surgery, or at surgery in those patients who needed emergency laparotomy. RESULTS There were 74 confirmed renal injuries. There were 42 low grade injuries (grade I-III) and 32 high grade injuries (5 grade IV and 27 grade V). Twenty-six (35%) had a nephrectomy: 24 with grade V injuries and 2 with grade IV injuries required nephrectomy. Six patients in the high injury grade arm had non-operative management. A low haemoglobin, low systolic blood pressure, higher injury severity score, and a high-grade renal injury, as well as increasing age were positive predictors for nephrectomy in trauma patients with renal injury. CONCLUSION Non-operative management is a viable option with favourable survival rates in lower grade injury; however, complications should be anticipated and managed accordingly. High grade injuries predict the need for surgery.
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Affiliation(s)
- V Pillay
- Department of General Surgery, University of KwaZulu-Natal, South Africa
| | - M Pillay
- Department of Virology, Inkosi Albert Luthuli Central Hospital, South Africa
| | - T C Hardcastle
- Department of Surgery, University of KwaZulu-Natal, South Africa
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Chaudhary MJ, Smith RN, Victorino GP. Rigid Sigmoidoscopy Is Superior to CT for Diagnosing Penetrating Rectal Injury. Am Surg 2019; 85:e541-e543. [PMID: 31775986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Rubens JH, Ahmed OZ, Yenokyan G, Stewart D, Burd RS, Ryan LM. Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients. J Surg Res 2019; 246:153-159. [PMID: 31586889 DOI: 10.1016/j.jss.2019.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/13/2019] [Accepted: 08/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.
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MESH Headings
- Child
- Child, Preschool
- Emergency Service, Hospital/organization & administration
- Emergency Service, Hospital/standards
- Emergency Service, Hospital/statistics & numerical data
- Facilities and Services Utilization/organization & administration
- Facilities and Services Utilization/standards
- Facilities and Services Utilization/statistics & numerical data
- Female
- Humans
- Injury Severity Score
- Length of Stay/statistics & numerical data
- Male
- Patient Admission/statistics & numerical data
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Registries/statistics & numerical data
- Retrospective Studies
- Transportation of Patients/statistics & numerical data
- Trauma Centers/organization & administration
- Trauma Centers/standards
- Trauma Centers/statistics & numerical data
- Triage/organization & administration
- Triage/standards
- Triage/statistics & numerical data
- United States
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/therapy
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/therapy
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Affiliation(s)
- Jessica H Rubens
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Omar Z Ahmed
- Department of Surgery, Children's National Health System, Washington, District of Columbia
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dylan Stewart
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Randall S Burd
- Department of Surgery, Children's National Health System, Washington, District of Columbia
| | - Leticia M Ryan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Hundersmarck D, Reinders Folmer E, de Borst GJ, Leenen LPH, Vriens PWHE, Hietbrink F. Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem. Eur J Vasc Endovasc Surg 2019; 58:455-462. [PMID: 31307866 DOI: 10.1016/j.ejvs.2019.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/16/2019] [Accepted: 04/20/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Penetrating neck injuries (PNIs) have a low incidence in European trauma populations. Selective non-operative management of PNI has been suggested as a safe alternative to standard surgical neck exploration, but evidence is lacking. This clinical scenario evaluates institutional PNI management, specifically the associated carotid artery injury, and compares it with current guidelines. METHODS Retrospectively, PNI patients presenting at two Dutch level 1 trauma centres from 2007 to 2015, were identified. International guidelines on PNI management were reviewed and recommendations were assessed in relation to current institutional management, and considering an illustrative case. RESULTS Two current guidelines on PNI management were reviewed. Both advocate a zone based approach; one recommends a prominent role for computed tomography angiography (CTA) scanning in stable patients, supplemented by endoscopy when indicated. A combined total of 43 PNI patients were identified over a nine year period. Haemodynamically unstable patients and patients with other hard signs (i.e. active bleeding, expanding haematoma, air/saliva leak, massive subcutaneous emphysema) received immediate exploration (n = 9). Haemodynamically stable patients and those responding to resuscitation (transient responders) had a CTA scan (n = 31). Three asymptomatic patients were treated conservatively, and had an uncomplicated clinical course regarding the PNI. In 10 of 14 patients who received surgical exploration, a significant vascular or aerodigestive injury was found and repaired (71%). All patients treated conservatively after CTA scanning had an uncomplicated clinical course regarding the PNI (n = 17). Six patients with penetrating carotid artery injury underwent primary arterial reconstruction, of whom five survived. CONCLUSIONS This clinical scenario evaluates institutional management in two trauma centres for PNI and associated carotid artery injury, and compares it to current guidelines. In comparison with guideline recommendations, CTA scanning and the so called "No zone" approach appears to have assumed a more prominent role in management of PNI.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
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Nicolau AE, Craciun M, Vasile R, Kitkani A, Beuran M. The Role of Laparoscopy in Abdominal Trauma: A 10-Year Review. Chirurgia (Bucur) 2019; 114:359-368. [PMID: 31264574 DOI: 10.21614/chirurgia.114.3.359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2019] [Indexed: 11/23/2022]
Abstract
Laparoscopy is accepted in penetrating abdominal trauma (PAT), but its role in blunt trauma (BAT) remains a controversial one. Our study assessed the utility of diagnostic laparoscopy (DL) and therapeutic laparoscopy (TL) in abdominal trauma between December 2006 and January 2016. We analysed the indication for laparoscopy, type of lesions, TL, conversion rate, complications and length of hospital stay. 49 patients had a DL: 42 males and 7 females, with a mean age of 36.1+-13.3. We had 20 PAT and 30BAT. The indications for laparoscopy were: diagnosis of penetration in PAT, suspicion of hollow organ injury or diaphragm injury, active bleeding in organ injuries in BAT. 11/48 of preoperative ultrasounds and 4/48 of CT's were false negative. In 3 of 20 PAT, DL was negative and in 4 nontherapeutic. There were 4 TL's and 7 conversions. The main injuries in BAT were: 9 hollow organ perforations, 6 mesenteric lacerations, 2 diaphragmatic and 2 splenic injuries. There were 10 TL's, 9 conversions and 14 TL. The operative time and length of hospital stay was higher in the conversion group. There were 6 complications and 3 mortalities. There were no missed injuries. An unnecessary laparotomy was avoided in 18/49 cases (36.73%). In selected cases of PAT and BAT with equivocal clinical and imaging diagnosis, laparoscopy is a useful tool with therapeutic role, that reduces unnecessary laparotomies, complication rate and hospital stay.
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Abstract
Doxey RJ. You're the flight surgeon: Ehlers-Danlos syndrome. Aerosp Med Hum Perform. 2019; 90(6):583-586.
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van Adrichem DC, Ratering MRHA, Rashid SM, Jusabani MA, Poppe VE, Mwaitele HA, Massawe HH, Howlett WP, Moshi HI, Dekker MCJ. Penetrating spinal cord injury causing paraplegia in a bird hunter in rural Tanzania. Spinal Cord Ser Cases 2019; 5:49. [PMID: 31632707 PMCID: PMC6786419 DOI: 10.1038/s41394-019-0195-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/03/2019] [Accepted: 05/05/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction Cultural and socioeconomic factors influence the risk of sustaining a Traumatic Spinal Cord Injury (TSCI). The standard of management and rehabilitation available to TSCI patients differs greatly between high-income and low-income countries. Case presentation We report a 17-year-old male bird hunter, with no prior medical history, presenting with paraplegia and sensory loss from the xiphoid process down after being struck by an arrow in the left lateral side of the neck. Discussion Penetrating neck injuries are potentially life threatening because of the complex arrangement of vital structures in the neck. Management of spinal cord trauma resulting from such injuries in low-resource settings is challenging.
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Affiliation(s)
| | | | - Sakina Mehboob Rashid
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Mubashir Alavi Jusabani
- Department of Orthopaedics and Traumatology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | | | - Honest Herman Massawe
- Department of Orthopaedics and Traumatology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | | | - Marieke Cornelia Johanna Dekker
- Department of Orthopaedics and Traumatology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Paediatrics and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Neurology, Radboudumc Nijmegen, Nijmegen, Netherlands
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Haines E, Fairbrother H, Pade KH. Points & Pearls: Evaluation and management of pediatric patients with penetrating trauma to the torso. Pediatr Emerg Med Pract 2019; 16:e1-e2. [PMID: 31038892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice.]
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Affiliation(s)
- Elizabeth Haines
- Associate Professor, Associate Division Chief, Pediatric Emergency Medicine, Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, New York, NY
| | - Hilary Fairbrother
- Director of Undergraduate Medical Education, Associate Professor, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Kathryn H. Pade
- Pediatric Emergency Medicine Ultrasound Fellow, Department of Emergency Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, CA
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45
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Haines E, Fairbrother H. Evaluation and management of pediatric patients with penetrating trauma to the torso. Pediatr Emerg Med Pract 2019; 16:1-24. [PMID: 31033268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/10/2019] [Indexed: 06/09/2023]
Abstract
Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso.
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Affiliation(s)
- Elizabeth Haines
- Associate Professor, Associate Division Chief, Pediatric Emergency Medicine, Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, New York, NY
| | - Hilary Fairbrother
- Director of Undergraduate Medical Education, Associate Professor, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
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Cull J, Riggs R, Riggs S, Byham M, Witherspoon M, Baugh N, Metcalf A, Kitchens D, Manning B. Development of Trauma Level Prediction Models Using Emergency Medical Service Vital Signs to Reduce Over- and Undertriage Rates in Penetrating Wounds and Falls of the Elderly. Am Surg 2019; 85:524-529. [PMID: 31126367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Determining triage activation levels in geriatric patients who fall (GF), and patients with penetrating wounds can be difficult and inaccurate, resulting in excessive overtriage (OT) and undertriage (UT) rates. We developed trauma activation prediction models using field data to predict with greater accuracy trauma activation level and triage rates consistent with the ACS recommendations. Using data from the 2014 National Trauma Data Bank, we created binary regression equations for each type of injury (GF and penetrating wounds). The 2014 data were randomized and divided into two halves. The first half for each injury type was used to generate prediction models, whereas the second half of the 2014 data were combined with 2013 and 2015 National Trauma Data Bank data for model verification. Binary regression equations were generated from vital signs collected by EMS. A Cribari grid with ISS ≥ 15 was used to determine the appropriateness of activation level. Chi-square analysis was used to determine significant differences between OT, UT, and accuracy predictions. Using our triage models, we were able to obtain UT rates of less than 4 per cent for GF with OT rates of less than 40 per cent, UT rates less than 4.1 per cent and OT of less than 50 per cent for patients with gunshot wounds, and UT rates less than 4 per cent and OT rates less than 25 per cent for patients who had stab wounds. Our developed trauma level prediction models enable health providers to predict trauma activation levels that can result in OT and UT rates in the recommended ranges by the ACS.
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Xu AA, Breeze JL, Paulus JK, Bugaev N. Epidemiology of Traumatic Esophageal Injury: An Analysis of the National Trauma Data Bank. Am Surg 2019; 85:342-349. [PMID: 31043192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010-2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.
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Wahba G, Cheung K. Pediatric hand injuries: Practical approach for primary care physicians. Can Fam Physician 2018; 64:803-810. [PMID: 30429174 PMCID: PMC6234925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To present a practical and evidence-based approach for primary care physicians to the diagnosis and initial management of common pediatric hand injuries, and to identify injuries requiring prompt referral. SOURCES OF INFORMATION Clinical evidence and expert recommendations were identified by using MEDLINE and EMBASE for each topic presented. MAIN MESSAGE Pediatric hand injuries are a common reason for physician consultation. The most common and potentially problematic pediatric hand injuries include fingertip injuries, phalangeal fractures, tendon injuries, and hand burns. Management is limited by difficulties in proper assessment of the hand and the paucity of evidence to guide treatment. Nevertheless, outcomes in children are typically excellent. CONCLUSION Appropriate assessment, initial management, and, if necessary, timely referral of pediatric patients with hand injuries are paramount given the importance of the hand in function and child development. While some principles from managing adult hand injuries might apply, children often require special considerations.
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Affiliation(s)
- George Wahba
- Medical student at the University of Ottawa in Ontario
| | - Kevin Cheung
- Pediatric plastic surgeon at the Children's Hospital of Eastern Ontario in Ottawa.
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49
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Panicker AT, Nugent K, Mink J, Glaser J, Bradley K, Siric F, Nomura JT. Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun. J Emerg Med 2018; 56:197-200. [PMID: 30389284 DOI: 10.1016/j.jemermed.2018.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 09/06/2018] [Accepted: 09/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Injuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management. CASE REPORT An elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.
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Affiliation(s)
- Ashley T Panicker
- Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware
| | - Kenneth Nugent
- Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware
| | - Jennifer Mink
- Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware
| | - Jeffrey Glaser
- Department of Trauma Surgery, Christiana Care Health System, Newark, Delaware
| | - Kevin Bradley
- Department of Trauma Surgery, Christiana Care Health System, Newark, Delaware
| | - Franjo Siric
- Department of Cardiovascular Surgery, Christiana Care Health System, Newark, Delaware
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware
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Arzubi-Hughes MK, Salts LA, Weller MA. Diagnosing and managing common genital emergencies in pediatric girls. Pediatr Emerg Med Pract 2018; 15:1-23. [PMID: 30251816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 06/08/2023]
Abstract
The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery. This issue reviews the most common traumatic genital injuries in girls presenting to the emergency department, including straddle injuries, hematomas, and impalement injuries. Nontraumatic emergencies, including hematocolpos and urethral prolapse, are also discussed. Evidence-based recommendations are presented for identifying and managing these common genital injuries and emergencies in pediatric girls.
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MESH Headings
- Adolescent
- Child
- Child, Preschool
- Congenital Abnormalities
- Critical Pathways
- Diagnosis, Differential
- Female
- Genital Diseases, Female/diagnosis
- Genital Diseases, Female/etiology
- Genital Diseases, Female/therapy
- Genitalia, Female/injuries
- Humans
- Hydrostatic Pressure/adverse effects
- Hymen/abnormalities
- Infant
- Insufflation
- Menstruation Disturbances/diagnosis
- Menstruation Disturbances/etiology
- Menstruation Disturbances/therapy
- Prolapse
- Urethral Diseases/diagnosis
- Urethral Diseases/etiology
- Urethral Diseases/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/etiology
- Wounds, Nonpenetrating/therapy
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/etiology
- Wounds, Penetrating/therapy
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Affiliation(s)
- Michelle K Arzubi-Hughes
- Division of Emergency Medicine, Children's Hospital of The King's Daughters; Assistant Professor of Pediatrics, Eastern Virginia Medical School, Norfolk, VA
| | - Laila A Salts
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Melanie A Weller
- Pediatric Emergency Medicine Fellow, Pediatric Emergency Medicine, Children's Hospital of The King's Daughters, Norfolk, VA
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