European Journal of Trauma and Emergency Surgery最新文献

Over recent decades, advancements in trauma care have significantly reduced mortality rates among severely injured patients. These improvements are largely attributable to the establishment of trauma care systems, including prehospital management protocols and the creation of trauma centres with immediate surgical team availability. However, patient outcomes continue to vary, reflecting differences in the quality of trauma care influenced by organisational models and local practices. To address this, governments and scientific organisations have underscored the importance of evaluating care quality at local, national, and international levels. This chapter explores strategies for assessing quality of trauma care, establishing reliable quality indicators (QIs), and standardising auditing processes to guide improvements in patient outcomes and system performance.

Purpose: The study aim was to investigate the long-term outcomes after hardware removal (HR) in patients with blunt chest trauma. We hypothesized that HR might be beneficial in indicated patients to improve patient health.

Methods: We performed a retrospective single-center study between 2017 and 2023. Descriptive statistics were used for the analysis. One study-specific follow-up visit was conducted, 28 months (range 3-72) after HR. The study-specific health survey used, consisted of four functional dimensions (mobility, self-care, usual activities, mental health) and two symptom dimensions (thoracic pain, chest tightness) which were rated on a numerical scale and compared to the status before HR in four categories (much better to worse).

Results: Of the 28 patients, the average age was 59 years (range 29-83), 12 fractures (1-39) were fixed, and 4 implants (1-11) were used. The indications for HR were persistent thoracic pain (36%), discomfort (25%), chest tightness (21%), hardware dislocation (11%) and hardware infection (7%). HR was performed 18 months (5 days-104 months) after surgery for trauma. Patients with chest tightness and infection exhibited the greatest improvement in symptoms (75%), followed by those with hardware dislocation (61%). The improvement rate in the other 2 groups was 58%. All patients who experienced chest tightness, hardware dislocation and infection were completely satisfied and would undergo HR again.

Conclusion: HR is safe and feasible, resulting in significant symptom relief and improvement in health status in approximately two-thirds of patients. In indicated patients, HR might be performed earlier and more liberally if symptoms are disabling.

Clinical trial registration number: NCT06003595 registered on July 18, 2023.

Introduction: Although the transportation of passengers in the open back area of pickup trucks is associated with significant risk of injury, this practice remains ubiquitous in South Africa. This study reviews the spectrum of injury and clinical outcome of these patients in a large city in South Africa The intention of the study is to highlight the inherent dangers associated with the practice and hence provide impetus to legislators and authorities to attempt to restrict and ultimately eliminate this practice.

Materials and methods: This was a retrospective study conducted over a decade (Jan 2012-Dec 2023) at a major trauma centre in South Africa.

Results: A total of 371 patients were included (male: 53%, mean age: 25 years). The mean Injury Severity Score (ISS) was 11. The most common anatomical region injured was head, followed by face and thorax. All patients underwent radiological investigations. 15% percent required operative intervention, with laparotomy and wound debridement being the most common. 9% required intensive care unit admission. The mean length of hospital stay was four days. The overall morbidity was 8%. The overall mortality was 4% and 71% of all mortalities were related to severe traumatic brain injury.

Conclusions: Transporting passengers in the load area of a pickup truck is dangerous and results in preventable morbidity and mortality. Attention should be given in South Africa to developing legislation in order to prevent this activity and to enforce these rules once passed.

Purpose: Our aim was to update evidence-based and consensus-based recommendations for the initial surgical management of urogenital injuries in patients with polytrauma and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Polytrauma and/or Severe Injuries.

Methods: MEDLINE and Embase were systematically searched to June 2021. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared surgical and/or therapeutic interventions for urogenital injuries in the hospital setting. We considered patient-relevant clinical outcomes such as mortality and bleeding control, or coagulation parameters as surrogate 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: Two new studies were identified. The topics covered were the comparison of outcomes after surgical and nonsurgical management as well as the use of surgical repair versus catheter drainage in patients with extraperitoneal bladder injuries. Three recommendations were modified, one of which for editorial reasons. All achieved strong consensus.

Conclusion: The following key recommendations are made. 1. Renal artery injuries can be managed using an endovascular approach. 2. Depending on the type and severity of the injury and concomitant injuries, renal injuries should be managed with the intent to preserve the organ. 3. Extraperitoneal bladder ruptures without involvement of the bladder neck should be conservatively treated with catheterisation.

Background: Peri-operative cardiopulmonary collapse (CPC) poses an increased risk of in-hospital mortality, especially in frail patients. Bone Cement Implantation Syndrome (BCIS) is CPC following, cemented, arthroplasty, characterized by hypoxia and/or hypotension. The main objective of this study was to evaluate the association between cemented hemiarthroplasty and CPC, in patients with a femoral neck fracture (FNF) and increased pre-operative risk, and identify other risk factors for cardiopulmonary collapse.

Methods: This retrospective cohort study included patients with a FNF treated with a cemented or uncemented hemiarthroplasty, aged ≥ 80 years, with ASA score ≥ 3 and ≥ 1 cardiac or pulmonal comorbidity. CPC was defined as hypoxia/hypotension grade ≥ 2 according to Donaldson's criteria. Multivariable logistic regression analysis was used to adjust for confounding in the relation between cemented hemiarthroplasty and CPC, and to identify other risk factors for CPC in patients with a cemented hemiarthroplasty.

Results: The incidence of CPC was 51.1% in 221 cemented hemiarthroplasty patients compared to 23.3% in 73 uncemented hemiarthroplasty patients (p < 0.001). The use of cement increased the risk for CPC almost threefold (adjusted odds ratio [aOR] 2.87, 95% confidence interval [CI] 1.46-5.64). Preoperative reduced left ventricle ejection fraction (aOR 3.03, 95% CI 1.50-6.14) was another independent risk factor for CPC.

Conclusion: Cementation increases the risk of CPC in frail FNF patients treated with hemiarthroplasty. Emphasis on euvolemia and avoidance of excessive pressurization, and careful consideration of an indicated cemented hemiarthroplasty in frail hip fracture patients may be advised for patients with an increased preoperative risk for BCIS.

Background: The reform of emergency and acute care in Germany focuses on efficiently managing patient flows to reduce overcrowding in emergency departments, primarily caused by a rise in patients with low urgency and a lack of alternative care options. The aim of this work was to analyze the emergency care of orthopedic and trauma surgery patients in a Level I trauma center in order to improve patient care and manage resources more effectively.

Material and methods: In this retrospective study, the data of orthopaedic and trauma surgery patients from the emergency department of a university in 2022 were analyzed. Data included demographics, triage levels, transport modes, diagnoses, and treatment outcomes. Process metrics like length of stay and time to medical contact were also evaluated. Descriptive and statistical analyses were conducted to examine patient distribution and resource use.

Results: A total of 9414 patients (47.5% females; mean age 42.4 ± 24.1 years) were included, with 7500 treated for trauma and 1914 for orthopedic diagnoses. Most patients (79.6%) received outpatient care, while 21.3% were admitted as inpatients. Manchester Triage System distribution revealed 48.5% green, 31.0% yellow, 14.8% orange, and 0.8% red. The most common MTS flowcharts were limb problems (38.3%), falls (19.7%), and back pain (11.1%). Ambulance transport accounted for 33.7% of arrivals, while 65.1% presented independently. The average length of stay in the ED was 213 min, varying significantly across triage categories and working hours.

Conclusion: This study highlights key challenges in orthopedic and trauma emergency care, emphasizing the prevalence of low-urgency cases contributing to overcrowding. Enhancing outpatient care capacity and implementing reforms like integrated emergency centers and optimized triage systems are crucial to improving efficiency and aligning resources with patient needs.

Purpose: Increasing incidence of fragility pelvic ring fractures (FFP) is driven by demographic. An analysis of the patient population, along with the factors influencing total length of stay (LoS), and endpoints such as complications is essential for a better understanding and treatment of FFP injuries.

Methods: This retrospective data analysis includes all inpatients treated from January 2018 to December 2022, with an FFP. Excluded were patients < 65 years, high-energy trauma, acetabular fractures, or pathological fractures. Collected data included demographics as well as information about comorbidities, diagnostics, therapy, LoS and complications.

Results: A total of 363 patients were included, of which 14% (n = 52) were male and 86% (n = 311) female. The average age was 84.4 ± 6.6 years. While 31.1% (n = 113) were mobile without aid before onset of symptoms there was a significant (p < 0.01) decrease to 5.2% (n = 19) at discharge. Only 43.8% (n = 159) remained self-dependent at discharge, compared to 62.3% (n = 226) before injury (p < 0.01). Significantly longer LoS was found with higher FFP types (p < 0.01), higher number of complications (p < 0.01) as well as operative treatment (p < 0.01) and MRI diagnostics (p < 0.01). A significant increase on the number of complications was found with FFP IV (p = 0.02) and operative treatment (p < 0.01).

Conclusion: Higher FFP types, higher number of complications, as well as operative treatment and MRI diagnostics prolonged the total LoS. FFP IV and operative treatment were associated with higher number of complications. By identifying specific factors influencing the inpatient stay, further prospective studies may show improved complication/ mortality rates by optimizing those factors.

Purpose: Sepsis is a life-threatening condition with cardiac complications being an independent predictor of poor outcome. Although their mechanisms have been widely investigated, therapeutic options remain limited. One promising therapeutic tool are mesenchymal stromal cells (MSCs). The aim of this study is to investigate the immunomodulatory effects of human MSCs from two different sources (bone marrow/BMMSC and adipose tissue/ASC) and to evaluate their cardioprotective potential.

Methods: 60 adult male C57BL/6 mice were divided into sham, sepsis (cecal ligation puncture (CLP)) and two i.v. treatment groups CLP + human BMMSC and CLP + human ASC with 5 animals in each group. The observation periods were 8, 24 and 72 h. Left ventricular tissue was analyzed histologically, by qPCR (C3ar, C5ar1, Il-1b, Il-6, Il-10, Tlr2, Tlr4, Tnfa, and Nlrp3) and western blot. Cardiac damage markers troponin I and heart fatty acid binding protein (HFABP) were detected in serum by ELISA.

Results: Troponin I and HFABP were significantly increased in CLP group after 8 h compared to sham. In cardiac tissue the expression of C3ar, C5ar1, Il-1b, Il-6, Il-10, Tlr2, Tlr4, Tnfa and Nlrp3 inflammasome was upregulated up to 24h after CLP compared to sham. After BMMSC treatment, C3ar as well as C5ar, Tlr2 and Il-10 mRNA expression in left ventricle was downregulated compared to CLP, whereas ASC treatment was associated with the downregulation of Il-6 and Nlrp3.

Conclusions: CLP-induced polymicrobial sepsis in mice was associated with cardiac damage and increased inflammation in left ventricular tissue. Therapeutic systemic application of human BMMSC and ASC ameliorated damage and inflammation in the heart.

Purpose: Our aim was to update evidence-based and consensus-based recommendations for the surgical management of abdominal injuries in patients with multiple and/or severe injuries based on current 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 May 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 interventions for the surgical management of abdominal injuries in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. 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: Three studies were identified. The topics of these studies were nonoperative management in haemodynamically stable patients with isolated blunt hepatic (n = 1) or splenic injuries (n = 1) and selective angioembolisation (n = 1). None of the recommendations were modified, one new recommendation was developed, and one was deleted based on the updated evidence and expert consensus. All recommendations achieved strong consensus.

Conclusion: The following recommendations are made. All but one of the previous guideline recommendations were confirmed. The recommendation to perform diagnostic peritoneal lavage in exceptional cases was completely deleted. An additional recommendation was made and states that the performance of a diagnostic laparoscopy can be considered in haemodynamically stable patients with penetrating trauma when there is therapeutic uncertainty.