European Journal of Trauma and Emergency Surgery最新文献

Purpose: Our aim was to update the evidence-based and consensus-based recommendations on criteria for trauma team activation (TTA) and staffing requirements for the management of patients with (suspected) multiple and/or severe injuries in the resuscitation room on the basis of available evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

Methods: MEDLINE and Embase were systematically searched to August 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared criteria for identifying severely injured patients requiring trauma team activation or different staffing components (e.g. team composition, training) for the management of patients with (suspected) multiple and/or severe injuries in the resuscitation room. We considered patient relevant outcomes such as mortality as well as prognostic accuracy outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

Results: Twenty-one new studies were identified. Potential trauma team activation criteria included vital signs (e.g. systolic blood pressure), type and extent of injury (e.g. central gunshot wound), mechanism of injury (e.g. traffic accident), interventions (e.g. chest tube), specific criteria for geriatric patients, and combined criteria (N = 20). Staffing requirements for the resuscitation room included specific training for orthopaedic trainees (N = 1). Two recommendations were modified, and six additional recommendations were developed. All but two recommendations achieved strong consensus.

Conclusion: The key recommendations address the following topics: inter-professional trauma teams in the resuscitation room; trauma team activation for geriatric patients; and trauma team activation criteria based on physiological, anatomical, interventional, and mechanism of injury parameters.

Background: Necrotizing Fasciitis (NF) is a life-threatening infection characterized by rapid tissue destruction and high mortality. The role of timely diagnosis and surgical intervention in improving patient outcomes remains debated. This study investigates the impact of "time to diagnosis" (TTD) and "time to surgical treatment" (TTS) on the outcomes of NF patients, with a specific focus on the first six hours of critical diagnosis.

Methods: A retrospective analysis was conducted for patients hospitalized with NF between June 2016 and June 2023. Demographic data, comorbidities, clinical features, treatment, and outcomes were analyzed. The study stratified patients based on TTD (early (≤ 6 h) vs. delayed (> 6 h) and TTS (≤ 6 vs. > 6 h). Outcomes included severity scores, intensive care unit admission, length of stay (LOS), and mortality.

Results: One hundred and twenty-one patients were diagnosed with NF with a mortality rate of 10%. Early diagnosis (≤ 6 h) was associated with lower mortality (5.7% vs. 13.2%) and shorter LOS (17 vs. 27 days) compared to delayed diagnosis. Early diagnosis was associated with a lower Sequential Organ Failure Assessment (SOFA) score compared to delayed diagnosis (p = 0.02). A combined analysis of TTD and TTS revealed that the group with early diagnosis and early treatment (TTD and TTS were ≤ 6 h) had a 3% mortality rate, and 7% of them had a SOFA score > 9. In contrast, delayed diagnosis (TTD > 6 h) was significantly associated with increased mortality, regardless of the TTS.

Conclusion: Timely diagnosis within 6 h is crucial for improving outcomes in NF. While early surgical intervention is vital, our findings suggest that the time to diagnosis and subsequent resuscitation efforts may significantly impact survival. This study highlights the importance of optimizing early recognition and diagnosis in the emergency room to reduce delays and improve patient prognosis in NF. Further multicenter studies are needed to validate these findings and refine clinical protocols.

Purpose: Incisional hernias (IH) occur after 20-30% of laparotomies. Modern closure techniques including small bite closure and prophylactic mesh augmentation (PMA) demonstrate significant reduction in IH rates. European and American Hernia Society guidelines suggest use of small bite closure and consideration of PMA at elective laparotomy closure but do not make a recommendation for emergency surgery. International surveys demonstrate poor uptake of small bite closure and PMA. This survey aims to assess the uptake of these techniques specifically in emergency abdominal surgery.

Methods: An online, cross-sectional survey was circulated through emergency general surgery (EGS) and abdominal closure networks between June and August 2024. This interrogated surgeons' technical approach to all elements of emergency laparotomy closure including use of wound bundles, small bite, suture-to-wound ratio, suture choice, and PMA.

Results: The survey was completed by 234 general surgeons from 32 countries. Wound bundle components varied between surgeons. Small bite closure was used by 85.8% during midline laparotomy closure but only 42.2% of surgeons used 5 mm wide tissue bites placed every 5 mm. Suture-to-wound ratio was rarely measured (7.7%). A looped PDS (size 0 or 1) was used preferentially (42.7%). Self-locking (15.8%) and antiseptic coated sutures (20.2%) were used infrequently. One in ten surgeons used PMA and most often placed the mesh in the retrorectus space (39.6%).

Conclusion: Uptake of new techniques in emergency laparotomy has been variable and with limited penetrance amongst emergency general surgeons. Many surgeons are using adapted versions of the original descriptions of these approaches.

This section outlines the essential requirements for managing trauma patients in ICUs across Europe. It emphasizes the need for ICU accreditation at the highest national level and highlights criteria, including staffing, equipment, training programmes, protocols, and documentation for quality control. Key requirements encompass 24/7 admission capability, trained staff, multidisciplinary rounds, specialised observation beds, organ donation programmes, and participation in trauma resuscitations and hospital disaster planning. Desirable criteria, such as education, research activities, trauma protocol development, cross-rotation training, outreach services, and combined team training are also discussed, focused on fostering collaboration between trauma and intensive care services to ensure comprehensive trauma management.

Purpose: Conventional Coagulation Tests (CCTs) and Viscoelastic Haemostatic Assays (VHAs) are currently used in guiding trauma resuscitation. However, the role of these tests in predicting mortality is less known. This study aims to analyze both CCTs and VHAs in predicting mortality.

Methods: A prospective observational study was conducted on adult trauma patients who presented in shock. They underwent VHA using rotational thromboelastometry (ROTEM ^® delta viscoelastic system by Werfen) and CCTs. Univariable and multivariable regression analysis was done to compare the predictive power of mortality between CCTs and VHAs.

Results: Out of 8,765 trauma patients screened, 106 were included. Descriptive statistics showed a majority of blunt injuries with road traffic incidents as the predominant mechanism. The median Injury Severity Score (ISS) was 24 (IQR 14-34). Mortality rate at 24 h was 9.4% and overall 30-day mortality was 26% (n = 28). Univariable analysis showed that reduced clotting time had better survival (p = 0.005) while prolonged INR, reduced fibrinogen and elevated d-dimer levels were associated with mortality. In multivariable analysis, prolonged INR > 1.66 (AUC 0.74, OR 9.4, 95% CI 2.6-34.1) and prolonged clotting time > 384 s (AUC 0.67, OR 7.4, 95% CI 1.1-51.9) had best prediction of mortality. Overall, CCTs were better at predicting mortality than VHA.

Conclusion: CCTs, especially INR proved to be a more reliable predictor of mortality compared to VHAs in trauma patients. These findings suggest that CCTs offer better prognostic value, although integrating both testing modalities could potentially enhance overall assessment and management strategies in trauma care.

Introduction: The management of abdominal trauma in older patients is challenging due to preexisting comorbidities, impaired physiology, frailty and atypical clinical presentations. Few studies focus on the characteristics of abdominal trauma in older populations.

Methods: A retrospective service evaluation was conducted during the period January 2017 - December 2022 at University Hospital Southampton, the designated Major Trauma Centre (MTC) of Wessex Trauma Network in the United Kingdom. Data was collected from the local Trauma Registry. Patients aged ≥ 65 years old and with Abbreviated Injury Scale (AIS) over one for the Abdomen were included. Patients aged less than 65 years old and those who died on arrival to the MTC were excluded.

Results: Out of 4977 geriatric trauma patients, only 150 cases (3%) were eligible, with a mean age of 77 years and a median Injury Severity Score of 22. The trauma team activation code was triggered in just under half of all cases (49%). All-level falls were the leading mechanism (52%) and low-energy falls were significantly higher in patients aged ≥ 85 years (P <0.001). The spleen was the most frequently affected organ (27%). About 47% of abdominal injuries were severe (AIS Abdomen ≥3) and about 22% of patients required surgical or radiological intervention. Three patients sustained occult abdominal injuries and one of them had a negative CT scan initially. The overall 30-day mortality rate was 20%. Of all casualties, most were polytrauma cases (87%).

Conclusion: Despite the low incidence of abdominal injuries in the elderly, when these occurred, almost half were serious with AIS Abdomen ≥ 3 and almost one in four required surgical or radiological intervention. The use of single-time imaging may not be sufficient to ensure the absence of injury, as delayed manifestations of occult abdominopelvic trauma may occur. Close monitoring and regular reassessments are recommended, even with a negative CT scan on arrival. The high all-cause mortality rate may correlate with the high incidence of polytrauma in this cohort and the failure to trigger a trauma call in the Emergency Department. Future studies should focus on the development of triage tools and include the use of validated and designated frailty tools for larger population analysis.

Purpose: The aim of this study was to compare one-year mortality and the incidence of complications, particularly fracture-related infections, between patients with proximal femur fractures treated with novel noble metal-coated implants and those treated with uncoated implants, to detect possible effects of the coating on these endpoints.

Methods: Design: Retrospective cohort observational study.

Setting: Level 1 trauma centre. Patient Selection Criteria: All patients ≥ 18 years old with proximal femur fracture, who were treated with an intramedullary femur nail between 01.09.2020 and 01.10.2022 were included. The coated group (COATED) included patients who were treated with a coated implant. The control group (CONTROL) was treated with uncoated implants. Pathological fractures were excluded.

Results: 188 patients who matched the criteria were included (COATED: 93, CONTROL: 95). There was no significant difference in the one-year mortality or complication rate between the two groups. The fracture-related infection rate did not differ (p = 0.31) between both groups. Complications were observed in 59% of all cases and the overall one-year mortality rate was 42%. There was a significant correlation between complication occurrence and hospital stay (p < 0.01).

Conclusion: The coated intramedullary nail was similar to the uncoated nail in terms of perioperative complications and 1-year mortality rate. This suggests that the novel coated implant is safe for common clinical use. Further prospective multicentre studies with larger sample sizes are needed to detect a potential impact of coated implants on the incidence of fracture-related infections.

Purpose: Major trauma is a leading cause of acute morbidity and mortality. While injury severity drives much of the associated burden, pre-existing comorbidities may influence both acute management and long-term outcomes. This scoping review examines the impact of comorbidities on trauma outcomes.

Methods: Embase, Medline, CINAHL, Cochrane Library, and PubMed were systematically searched from inception to 22/04/2021 (update 22/03/2024). Studies investigating comorbidities as risk factors for adverse outcomes in adults (≥ 18 years) with major trauma were included.

Results: Of 5448 studies identified, 33 met inclusion criteria. No studies examined whether comorbidities increases the risk of major trauma, and only two studies investigated the development of comorbidities post-trauma. Among trauma patients with pre-existing comorbidities particularly cardiovascular disease, diabetes, liver disease, and kidney disease were associated with higher case fatality. Comorbidities were also associated with increased morbidity, longer hospital stays and higher complication rates.

Conclusions: Trauma patients with comorbidities suffer experience worse outcomes, yet limited research explores whether comorbidities contribute to trauma risk or emerge as a consequence. Further research is needed to clarify these relationships and guide targeted interventions.

Background: Percutaneous minimally invasive retrograde screw fixation is a widely accepted treatment strategy for patients with superior ramus fractures and has shown good biomechanical stability compared to plating. Recently, elastic stable intramedullary nailing (ESIN) devices have been proposed as an alternative in the treatment of superior ramus fractures. However, biomechanical studies on this new treatment are lacking. Thus, the aim of this study was to compare the biomechanical stability of ESIN in pubic ramus fractures versus retrograde screw fixation.

Methods: Standardized pubic ramus fractures (Nakatani type II) were created in fresh-frozen paired hemipelves. Fractures were either stabilized with a 6.5 mm cannulated screw (n = 4) or a 3.5 mm Stainless Steel Elastic Nail System (n = 4). In a validated setup, a cyclic loading protocol was applied with increasing axial force (1500 cycles, 250-750 N). Outcome parameters were fracture mobility over time, fracture displacement and construct survival. Descriptive and opto-metric methods were used to describe the mode of failure.

Results: Amongst all tested hemipelves (n = 8), no construct failure was observed. There was no significant difference in mean vertical fracture displacement between the groups (ESIN 0.07 mm, SD 0.12 versus screw 0.04 mm, SD 0.05; p = 0.773). After 500 cycles at 250 N, mean vertical fracture displacement was 0.09 mm (SD 0.16) in the ESIN group and 0.03 mm (SD 0.04) in the screw group (p = 0.773). After subsequent 500 cycles at 500 N in the vertical plane, mean fracture displacement increased to 0.35 mm (SD 0.31) in the ESIN group and to 0.14 mm (SD 0.17) in the screw group (p = 0.281). With a maximum load of 750 N, after 500 cycles, mean fracture displacement was 0.58 mm (SD 0.51) in the ESIN group and 0.31 mm (SD 0.26) in the screw group (p = 0.376). There was no difference between the implants regarding the accumulated fracture movement over time (ESIN 494 mm*cycles, SD 385 versus screw 220 mm*cycles, SD 210; p = 0.259).

Conclusions: In this in-vitro biomechanical study, fixation of superior ramus fracture using ESIN was not different in construct survival, relative motion to fracture, and fracture displacement when compared to retrograde screw fixation.

Purpose: To analyze the anatomic distribution and influencing factors on deep vein thrombosis (DVT) in patients with spinal fractures caused by high-energy injuries.

Methods: A retrospective analysis was performed on 302 patients of lower extremity DVT who were admitted to our hospital from January 2018 to December 2023. All patients underwent ultrasonography of DVT before and after surgery. The thrombus location and clinical data of thrombus were recorded in detail. Logistic regression was used to analyze the influencing factors on thrombus distribution.

Results: There were 27 cases of central DVT and 261 cases of peripheral DVT before surgery, 90 cases of central DVT and 212 cases of peripheral DVT after surgery. There were statistically significant differences in the types of thrombus during perioperative period among patients with cervical, thoracic, and lumbar fractures. After surgery, there were 120 cases of thrombus progression, 33 cases of thrombus regression, and 149 cases of thrombus without change. The intermuscular veins account for 75.57%. The time from injury to surgery and D-dimer at admission were influencing factors for preoperative DVT distribution while blood loss, time from injury to surgery and post 3-D-dimer were influencing factors for postoperative DVT distribution.

Conclusions: The proportion of postoperative thrombus progression was relatively high, with only a small portion experiencing thrombolysis. Patients with cervical fractures were more prone to central DVT. The intermuscular vein was the most common vein for thrombosis. The time from injury to surgery, D-dimer at admission, blood loss and post 3-D-dimer were influencing factors for DVT distribution.