Trauma and Emergency Surgery

Prevalence and patterns of maxillofacial trauma: a retrospective descriptive study Abstract Introduction We aimed to describe the prevalence and pattern of maxillofacial trauma in Qatar. Methods This is a retrospective study of trauma registry data at Hamad General Hospital during the period from January 2011 to December 2014. The study included all traumatic maxillofacial patients who underwent CT scan and were admitted during the study period. Results A total of 1187 patients with maxillofacial injuries were included in the study and 18.5% of all trauma admissions were related to maxillofacial injuries. Young age and males were predominantly affected. Mechanisms of injury were mainly traffic-related and fall. Orbital injuries were the commonest followed by maxillary injuries. The median and range face abbreviated injury score (AIS) was 2 [1–3] with 66% had a score of 2. Maxillofacial fractures were frequently associated with traumatic brain injuries. One out of five patients was managed with surgery and had median length of stays in ICU and hospital 5 and 7 days, respectively. Overall, in-hospital mortality was 8.3%. Mortality in isolated maxillofacial was low (0.3%) in comparison to 15% in polytrauma patients (p = 0.001). Multivariable regression analysis showed that Injury Severity Score, face AIS and Glasgow Coma Scale were predictors of mortality with age-adjusted odd ratio of 1.15, 2.48 and 0.82; respectively. Conclusions Maxillofacial trauma requiring admission is not uncommon in our trauma center and mostly it is mild to moderate in severity. Associated injuries are present in most of the maxillofacial injured patients and further diagnostic investigations should be part of the assessment in maxillofacial injuries.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy Abstract Purpose Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair. Methods We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10 mm, or significant left pleural effusion. Results Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI. Conclusion CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy. Level of evidence IV.

Long-term mortality and quality of life after trauma: an ancillary study from the prospective multicenter trial FROG-ICU Abstract Introduction The long-term outcomes of intensive care unit (ICU) patients are known to be worse than those of the general population, but they are poorly known in severe trauma patients. We conducted an ancillary examination of the FROG-ICU study to identify risk factors and biomarkers associated with the poorer long-term outcomes and mortality in trauma ICU patients. Methods Mortality, quality of life (QoL) and stress level scores were obtained 1 year after discharge from ICU. Blood samples were collected at ICU admission and discharge for measurement of inflammatory and cardiovascular biomarkers. Results ICU trauma patients had a significantly lower 1-year mortality than non-trauma patients (7% vs. 23%, p < 0.001), but had worse stress levels scores (19 vs. 13, p = 0.041). No difference was found regarding physical and mental QoL scores (33 vs. 31, p = 0.19 and 30 vs. 28, p = 0.42). Patients with better QoL scores had lower tracheotomy rates (11% vs. 30%, p = 0.01). Worse stress level scores are associated with poor QoL scores and vice versa. Some study biomarkers were significantly higher in those ICU trauma patients who had worse QoL scores at 1 year after discharge. Discussion Our study suggests that quality of life 1 year after an ICU stay is poor and is similar in both trauma and non-trauma patients, but ICU trauma patients are at greater risk of developing post-traumatic stress disorder-related symptoms. Tracheotomy and high levels of inflammatory biomarkers could be associated with impaired quality of life.

Reappraising the need for a control CT in mild head injury patients on anticoagulation Abstract Background Head injury is a frequent reason for admission to the emergency department. In parallel, there is a growing use of anticoagulants in an increasingly aging population, which renders this particular group of trauma patients more frequent. In several countries, including Portugal, a 24-h surveillance period followed by repetition of head computed tomography (CT) is the standard procedure for these patients. However, these recommendations have not been based on studies of prevalence of intracranial hemorrhages in control head CTs, namely in this group of anticoagulated patients. This study intends to evaluate the prevalence of de novo intracranial hemorrhages in control head CTs in anticoagulated patients. Method An observational study was carried out, which included patients admitted to Hospital de Braga between June 2017 and January 2018, victims of head injury and on anticoagulation therapy, whose admission head CT excluded intracranial hemorrhage. Results We collected a total of 201 patients, with a mean age of 81.6 years, and 57.5% of them were prescribed warfarin; 181 of these patients repeated the head CT 24 h later. Of these 181 patients, 3 (1.66%) exhibited intracranial hemorrhage in control CT, without surgical indication. All patients were followed up 1 month after the trauma, and there was no readmission requiring hospitalization, surgery or death. Conclusions In conclusion, de novo intracranial hemorrhage in control head CT of anticoagulated patients is rare. We propose that these patients may be discharged if the admission CT does not reveal intracranial hemorrhage, providing that they are accompanied by a caregiver and informed about red flags.

Spectral analysis of heart rate variability for trauma outcome prediction: an analysis of 210 ICU multiple trauma patients Abstract Purpose This study aimed to test and compare short-term spectral HRV indices with most used trauma scorings in outcome prediction of multiple trauma, and then to explore the efficacy of their combined application. Methods A prospective study was conducted for patients with blunt multiple trauma admitted to an emergency intensive care unit (ICU) between January 2016 and December 2017. Short-term spectral HRV indices on admission were measured, including normalized low-frequency power (nLF), normalized high-frequency power (nHF), and the nLF/nHF ratio. Injury severity score (ISS), new injury severity score (NISS), and revised trauma score (RTS) were evaluated for each patient, as well as probability of survival (Ps) by trauma and injury severity score (TRISS) model. The primary outcome was 30-day mortality and secondary outcomes were incidence of multiple organ dysfunction syndrome (MODS) and length of ICU stay. Results Two hundred and ten patients were recruited. The nLF/nHF ratio, RTS, and Ps(TRISS) were independent predictors of 30-day mortality, while nLF/nHF, NISS and RTS were independent predictors of MODS. The area under the receiver operating characteristic (ROC) curve (AUC) of nLF/nHF for 30-day mortality prediction was 0.924, comparable to RTS (0.951) and Ps(TRISS) (0.892). AUC of nLF/nHF-RTS combination was 0.979, significantly greater than that of each alone. Combination of nLF/nHF and Ps(TRISS) showed an increased AUC (0.984) compared to each of them. The nLF/nHF ratio presented a similar AUC (0.826) to NISS (0.818) or RTS (0.850) for MODS prediction. AUC of nLF/nHF-RTS combination was 0.884, significantly greater than that of nLF/nHF. Combination of nLF/nHF and NISS showed a greater AUC (0.868) than each alone. The nLF/nHF ratio, NISS, RTS, and Ps(TRISS) were correlated with length of ICU stay for survivors, with correlation coefficients 0.476, 0.617, − 0.588, and − 0.539. Conclusions These findings suggest that the short-term spectral analysis of HRV might be a potential early tool to assess injury severity and predict outcome of multiple trauma. Combination of nLF/nHF and conventional trauma scores can provide more accuracy in outcome prediction of multiple trauma.

Emergency room as primary point of access in the German healthcare system Abstract Background The importance of emergency rooms (ERs) as everyday healthcare suppliers is growing. Due to increasing patient flows, hospitals are forced to raise physicians' and caregivers' headcount continuously to meet the new demand of patients seeing the ER as primary point of contact in non-emergency situations. Patients from various cultural and educational backgrounds approach the ER for different reasons. Detailed understanding of these reasons and their roots is key to be able to offer guidance for patients as well as planning and staffing of hospitals in the future. Aim This study examines motivation for the entrance to the medical system via the ER in Germany via an anonymized patient survey. Evaluation in regard to socioeconomic and medical reasons is taken into account. Materials and methods Over the course of 210 h in the ER, a total of 235 patients were interviewed in the surgical emergency room of Klinikum rechts der Isar in the year 2016. Focus was set on standard cases to allow for facilitated comparability. Heavily injured patients were excluded from the study. Results The main reasons for patients entering the ER were immediate help (45.9%) and treatment by a specialist (35.4%). Furthermore, the location/good accessibility (47.9%) and prior positive experience with the emergency room (20.7%) were decisive reasons for choosing the hospital over the outpatient sector. Analysis of demands of patients in relation to their migration background and their religious confession showed no significant difference between groups. Conclusion Younger patients tend to more often access the ER instead of an outpatient clinic or doctor in private practice. As a survey suits the less urgent patients, our research describes this population in detail. The need for better information of patients regarding treatment options becomes apparent. The study's outcomes aim to teach physicians as well as operators how to influence resource management in the healthcare system by meaningful information of patients. Further research may evaluate long-term results of information measures.

Blunt cerebrovascular injury: incidence and long-term follow-up Abstract Purpose Blunt cerebrovascular injuries (BCVI), which can result in ischemic stroke, are identified in 1–2% of all blunt trauma patients. Computed tomography angiography (CTA) scanning has improved and is the diagnostic modality of choice in BCVI suspected patients. Data about long-term functional outcomes and the incidence of ischemic stroke after BCVI are limited. The aim of this study was to determine BCVI incidence in relation to imaging modality improvements and to determine long-term functional outcomes. Methods All consecutive trauma patients from 2007 to 2016 with BCVI were identified from the level 1 trauma center prospective trauma database. Three periods were identified where CTA diagnostic modalities for trauma patients were improved. Long-term functional outcomes using the EuroQol six-dimensional (EQ-6D™) were determined. Results Seventy-one BCVI patients were identified among the 12.122 (0.59%) blunt trauma patients. In the first period BCVI incidence among the overall study cohort, polytrauma, basilar skull fracture and cervical trauma subgroups was found to be 0.3%, 0.9%, 1.2%, 4.6%, respectively, which more than doubled towards the third period (0.8, 2.4, 1.9 and 8.5% respectively). Ischemic stroke as a result of BCVI was found in 20 patients (28%). In-hospital stroke rate was lower in patients receiving antiplatelet therapy (p < 0.01). Six in-hospital deaths were BCVI related. Long-term follow-up (follow-up rate of 83%) demonstrated lower functional outcomes compared to Dutch reference populations (p < 0.01). Ischemic stroke was identified as a major cause of functional impairment at long-term follow-up. Conclusions Improved CTA diagnostic modalities have increased BCVI incidence. Furthermore, BCVI patients reported significant functional impairment at long-term follow-up. Antiplatelet therapy showed a significant effect on in-hospital stroke rate reduction.

Reply to: Wanted: Automated objective proficiency assessment metrics for the FAST exam (and other POCUS studies)

Ankle ultrasound for detecting anterior talofibular ligament tear using operative finding as reference standard: a systematic review and meta-analysis Abstract Purpose To evaluate the diagnostic accuracy of ankle ultrasound for detection of anterior talofibular ligament (ATFL) tear with a reference standard of operative finding. Methods A computerized search of PubMed and EMBASE databases was performed to identify relevant original articles on ankle ultrasound for ATFL tear. The pooled proportions of the diagnostic accuracy estimates were assessed using random-effects modeling. We also assessed pooled proportions of the diagnostic accuracy according to injury stage (acute or chronic) and severity of injury (complete or partial). Heterogeneity among studies was determined using the inconsistency index (I2). Meta-regression analyses were performed to evaluate the potential sources of heterogeneity. Results Ten studies were included. The pooled proportion of the diagnostic accuracy of ankle ultrasound for ATFL was 0.95 (95% confidence interval [CI] 0.88–0.98). In subgroup analysis, the pooled proportion of the diagnostic accuracy of ankle ultrasound for acute ATFL tear was 0.92 (95% CI 0.85–0.95). The pooled proportion of the diagnostic accuracy of ankle ultrasound for chronic ATFL tear was 0.96 (95% CI 0.84–0.99). The pooled proportions of the diagnostic accuracy for complete and partial ATFL tear were 0.82 (95% CI 0.72–0.89) and 0.88 (95% CI 0.70–0.96), respectively. In the meta-regression analyses, the inclusion of pediatric patients was only significantly different (p = 0.007). Conclusions Ankle ultrasound may be a useful diagnostic modality in the detection of ATFL tear in adults and children, regardless of injury stage and severity. For correct diagnosis of ATFL tear, a high-frequency ultrasound probe and sufficient experience of the examiner are mandatory.

Diagnostic performance of thromboelastometry in trauma-induced coagulopathy: a comparison between two level I trauma centres using two different devices Abstract Purpose The implementation of a ROTEM®-based algorithm requires reliable thresholds to mirror a prothrombin time (PT) ratio > 1.2 and/or a fibrinogen concentration < 1.5 g l−1. Our goal was to compare the diagnostic performances of two devices (ROTEM® Sigma and Delta, IL Werfen, Munich, Germany) in two level-I trauma centres for the diagnostic of post-traumatic coagulopathy. Methods We conducted a retrospective analysis of two registries across two periods of time: from September 2014 to December 2015 in Lyon-Sud university trauma centre and from April 2016 to January 2018 in the Grenoble Alps Trauma Centre. Accuracies of EXTEM and FIBTEM assays to detect patients with coagulation disorders were tested for each device using receiver operating characteristic (ROC) analyses. Results Within the study period, 74 trauma patients in the Grenoble cohort and 75 trauma patients in the Lyon cohort had concomitant ROTEM® and standard coagulation testing on admission. No statistically significant difference was found between the two ROC curves for FIBTEM amplitude at 5 min (A5), FIBTEM maximum clot firmness, EXTEM clotting time (CT) and EXTEM A5 for ROTEM® Sigma and Delta to diagnose post-traumatic coagulation disorders. The best threshold for FIBTEM A5 to predict low fibrinogen concentration was 7 mm for each device. EXTEM CT thresholds to diagnose PT ratio > 1.2 were 78 s and 74 s for ROTEM® Sigma and Delta, respectively. Conclusions These results suggest that ROTEM®-based algorithms may be transposed from one trauma centre to another independently of the setting and the ROTEM® device in use.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com