European Journal of Trauma and Emergency Surgery最新文献

Introduction: While there is evidence supporting the use of ultrasound for real-time monitoring of primary blast lung injury (PBLI), uncertainties remain regarding the timely detection of early PBLI and the limited data correlating it with commonly used clinical parameters. Our objective is to develop a functional incapacity model for PBLI that better addresses practical needs and to verify the early diagnostic effectiveness of lung ultrasound in identifying PBLI.

Methods: We selected six healthy male pigs to develop an animal model using a bio-shock tube (BST-I). The injuries were induced at a pressure of 4.8 MPa. We monitored the animals before and after the injury using various methods to detect changes in vital signs, lung function, and hemodynamics.

Results: The experimental peak overpressure was measured at 405.89 ± 4.14KPa, with the duration of the first positive peak pressure being 50.01ms. The mortality rate six hours after injury was 50%. The average Military Combat Injury Scale was higher than 3. Significant increases were observed in heart rate (HR), shock index (SI), alveolar-arterial oxygen gradient (AaDO₂), lung ultrasound scores(LUS), and pulmonary vascular permeability index (PVPI) at 0.5 h, 3 h, and 6 h after-injury (p < 0.05). Conversely, there were notable decreases in average arterial pressure(MAP), oxygenation index (OI), stroke volume per heartbeat(SV), cardiac output power index(CPI), global end-diastolic index (GEDI), and intrathoracic blood volume index (ITBI) during the same time periods (p < 0.05). Meanwhile, the extrapulmonary water index (ELWI) showed a significant increase at 0.5 h and 6 h after injury (p < 0.05). At 6 h after injury, pulmonary ultrasound scores were positively correlated with HR (R = 0.731, p < 0.001), AaDO₂ (R = 0.612, p = 0.012), SI (R = 0.661, p = 0.004), ELWI (R = 0.811, p < 0.001), PVPI (R = 0.705, p = 0.002). In contrast, these scores were negatively correlated with SpO₂ (R = -0.583, p = 0.007),OI (R = -0.772, p < 0.001), ITBI (R = -0.637, p = 0.006).

Conclusion: We have successfully developed a novel, and highly reproducible animal model for assessing serious PBLI functional incapacity. This model displays immediate symptoms of hypoxia, decreased cardiac output, decreased blood volume, and abnormal lung ultrasound findings within 0.5 h of injury, with syptoms lasting for up to 6 h. Lung ultrasound evaluation is crucial for the early assessment of injuries, and is comparable to commonly used clinical parameters.

Purpose: Guidelines for management and treatment of appendicitis recommends the removal of a normal-looking appendix, but the recommendations are deemed as weak because they are based on low quality evidence. We aimed to provide an overview of the recommendations from the European societies or associations of surgeons regarding the treatment of acute appendicitis and especially recommendations for the macroscopically normal-looking appendix.

Methods: European surgical societies were contacted and sent an electronic questionnaire. Questions concerned if the association had a national guideline or recommended an existing one, and if they recommended a specific approach for the management of the normal-looking appendix, including who decided to remove the appendix.

Results: We contacted surgical societies from 28 European countries, and 17 surgical societies (61%) responded. Two societies had a national guideline for the treatment of appendicitis and one of these addressed how to treat the normal-looking appendix. Most societies (59%) answered that the operating surgeon decided whether to remove the normal-looking appendix. Eleven societies recommended using an existing guideline (65%), four societies (24%) did not recommend a guideline, and two societies did not know.

Conclusion: Only two surgical societies had a published national recommendation or guideline on the treatment of suspected appendicitis, only one had a guideline for the management of the normal-looking appendix, and most societies answered that the operating surgeon decided.

Purpose: Evidence to guide the application of damage control laparotomy (DCL) in emergency surgery patients is limited. We assessed whether DCL use for emergent small bowel or colon surgery increased over time and its impact on outcomes. We hypothesized that DCL would be utilized more often in patients with significant comorbidities or septic shock with improved outcomes.

Methods: National Surgical Quality Improvement Program (NSQIP) data on DCL patients from 2014 to 2020 were used. Endpoints were incidence of DCL, in-hospital mortality, hospital length of stay (LOS), complications, and 30-day readmission over time. P-values < 0.05 were considered statistically significant.

Results: DCL incidence increased over time (OR = 1.07 [1.05-1.08], p < 0.001). Presence of pre-operative septic shock increased over the years (OR = 1.04 [1.01-1.07], p = 0.007). Mortality, readmission, and post-operative septic complications did not change over the study period. Average LOS significantly decreased over time (OR = 0.93 [0.92-0.95], p < 0.001).

Conclusion: The odds of a surgeon using DCL increased by 7% each year. Although pre-operative septic shock incidence increased, LOS decreased over time while mortality remained unchanged.

Purpose: To investigate the factors that prolonged the operative duration (OD) in patients who underwent single-stage locked intramedullary nailing of their multiple concurrent long-bone fractures (LBFs) using Surgical Implant Generation Network (SIGN) nails.

Methods: Forty-nine patients who fulfilled the inclusion criteria were enrolled prospectively over 8½ years. Data collected included age, sex, injury mechanism and severity, fracture characteristics, nail types and diameter, OD, fracture-to-fixation time, length of hospital stay (LOS), functional outcomes and complications. Factors associated with prolonged OD were identified using Pearson's chi-square test.

Results: The mean age was 40.6 years. There were 101 fractures of the humerus (8), femur (41) and tibia (52). The median ISS was 14. The mean OD per fracture was 55.8 min. The average LOS was 11 days. A prolonged OD was significantly associated with fracture-to-fixation time > 5 days, fractures with end-segment involvement, fixation with SIGN standard and thinner nails, open reduction, supplemental plating, and antegrade femoral nailing. Radiographic and functional outcomes were satisfactory. Ten patients developed post-operative breathing difficulty warranting oxygen administration. Four fractures were infected. No mortality within the first post-operative year.

Conclusion: The study identified fracture fixation beyond five days, end-segment involvement, open reduction, use of standard and thinner nails, supplemental plating, and antegrade femoral nailing as factors that can prolong the OD during single-stage fixation of multiple concurrent LBFs in settings without modern fracture-care equipment. While some of these factors are unmodifiable on certain occasions, bearing them in mind can improve pre-operative planning and intra-operative efficiency to reduce OD.

Purpose: D-dimer, a fibrinolysis indicator, may predict functional and life outcomes in traumatic brain injury (TBI) patients. We aimed to identify optimal D-dimer cutoff values for poor functional outcomes in severe TBI.

Methods: We used data from a multi-centre prospective observational cohort study that included patients with TBI with a Glasgow Coma Scale (GCS) score ≤ 8 within 48 h after injury or required neurosurgical procedures. We selected patients admitted ≤ 1 h after injury. Neurological function at discharge was assessed using the modified Rankin Scale (mRS). The association between D-dimer levels at admission and neurological function (mRS ≥ 4 or < 4), adjusted for age, GCS, systolic blood pressure, and head abbreviated injury scale (AIS) score, was determined by logistic regression analysis. The predictive utility of D-dimer levels was assessed using the area under the receiver operating characteristic curve (AUC), with the cutoff value being determined using Youden's index.

Results: Among the 336 patients, most were male; approximately half had experienced motor vehicle accidents. The median (interquartile range) of age, GCS scores, and head AIS scores were 65 (40.25 - 78.75) years, 7 (4 - 9), and 5 (4 - 5), respectively. Overall, 214 (63.7%) patients had poor neurological function (mRS ≥ 4). D-dimer levels > 28 µg/mL predicted poor functional prognosis (odds ratio = 3.84 [95% confidence interval 1.62 - 9.11]); the AUC and cutoff values were 0.73 and 27.2 µg/mL, respectively.

Conclusion: A cutoff value of 27.2 µg/mL for early-stage D-dimer levels could predict the functional prognosis of patients with severe isolated TBI.

Purpose: One of the key challenges trauma centres are currently facing is the management of polytraumata in an ageing population. The aim of this study is to assess the extent to which demographic changes are reflected in the trauma bay population and the impact on geriatric polytrauma patient outcomes.

Methods: This is a retrospective single-centre cohort study of a level one trauma centre in Germany. The data were collected from the DGU TraumaRegister. All patients exhibiting vital signs who were primarily admitted to the trauma bay were included in the study. Patient characteristics were compared for years 2011 and 2021. Polytrauma was defined as ISS > 15, and patients aged 65 and over were assigned to the geriatric group.

Results: The study included 214 patients. During the study period, there was a significant increase in the mean age of patients (from 47.7 to 55.9 years) and in the proportion of geriatric patients (from 30.37 to 40.51%). Injury severity, as measured by the Injury Severity Score (ISS), also increased significantly. In the entire patient population, the proportion of patients discharged to their place of residence decreased, while the hospital mortality (2011: 9.63%; 2021: 21.52%) increased.

Conclusions: The ageing trauma bay population presents new challenges for medical staff, because polypharmacy, multiple comorbidities and frailty become more significant in an ageing population. Enhanced interdisciplinary management, particularly between trauma and geriatric specialists, may mitigate rising mortality rates. Geriatric trauma centres or at least more geriatric expertise might be required to improve the treatment and outcome in this changing population.

Purpose: In patients with traumatic brain injury (TBI), adequate oxygenation is crucial to optimize survival and neurological outcome. However, supranormal oxygen partial pressure (PaO₂) only leads to minor increase in cerebral oxygen delivery but can cause numerous pathophysiological disturbances. Therefore, we aimed to study effects of hyperoxia on patient outcome and identify optimum PaO₂ ranges.

Methods: This retrospective, single-center cohort study included TBI patients receiving mechanical ventilation for ≥ 72 h. Time-weighted mean PaO₂ and integrals above thresholds of 80, 100, 120, and 150 mmHg were calculated over periods of 1, 3, 7, and 14 days. The effects on in-hospital mortality and favorable functional outcome defined as Glasgow Outcome Scale (GOS) ≥ 4 were explored at discharge and after 3-6 months.

Results: From 01/2013 until 12/2021, 290 patients fulfilled the inclusion criteria. Hyperoxia was dose-dependently associated with a worsened functional outcome 3-6 months post-injury. Regarding the first 24 h, odds ratios were 0.959 (95% confidence intervals: 0.932-0.990; p = 0.009) for time-weighted mean PaO₂ and 0.955 (0.923-0.988; p = 0.008), 0.939 (0.897-0.982; p = 0.006), 0.923 (0.871-0.978; p = 0.007) and 0.922 (0.858-0.992; p = 0.029) per mmHg above 80, 100, 120 and 150 mmHg, respectively. For exposure within 72 h, odds ratios were 0.897 (0.819-0.983; p = 0.020), 0.842 (0.738-0.961; p = 0.011) and 0.832 (0.705-0.981; p = 0.029) per mmHg per day over 100, 120 and 150 mmHg, respectively. No significant association could be established between PaO₂-exposure and in-hospital mortality, GOS at discharge or the 7- and 14-day periods.

Conclusion: In this cohort, hyperoxia within 72 h after admission was dose-dependently associated with an unfavorable neurological outcome after 3-6 months.

Purpose: The incidence of severely injured older trauma patients is increasing globally, portraying high mortality rates. Exploring the demographics and clinical outcomes of this subgroup is essential to further improve specialised care at the right place. This study was performed to identify severely injured older patients at high risk for mortality by examining their characteristics and identifying prognostic factors contributing to mortality.

Methods: A retrospective cohort study was conducted using data from the Dutch National Trauma Registry to identify all trauma patients aged 70 years and older from 2016 to 2022. Subgroup analyses for characteristics and outcomes were performed based on Injury Severity Score (ISS) 16-24 and ISS ≥ 25, as well as age groups of 70-79, 80-89 and ≥ 90 years. A logistic, backwards regression analysis was performed to identify predictors for mortality within each ISS groups.

Results: In total, 10,901 patients were included. The mean age was comparable between the ISS groups (80.48 ± 6.8 vs. 80.54 ± 6.6 years). The main trauma mechanisms in both the ISS 16-24 and ISS ≥ 25 were low energy falls and bicycle accidents. The head and thorax were the most frequently injured body regions, with a significantly higher proportion of severe head injuries in the ISS ≥ 25 group (32.6% vs. 73.4%). Mortality rates increased significantly with higher injury severity (13.9% vs. 48.9%) and advancing age (22.6% vs. 32.4% vs. 35.8%). The most significant predictors of mortality in the ISS 16-24 group were an increase in ASA score and a GCS 3-8 at arrival (OR for GCS: 7.2 (95% CI 5.7-9.1), AUC 0.76). Similarly, in the ISS ≥ 25 group, an increased ASA score and a GCS 3-8 at arrival were the most significant predictors of mortality as well (OR for GCS: 10.8 (9.1-12.9), AUC 0.79). Although increasing age was also associated with a higher risk of mortality in both ISS groups, its impact was less significant than the aforementioned variables.

Conclusion: Severe injuries in older patients are predominantly caused by low energy falls and bicycle accidents, leading to high mortality rates. A low GCS at arrival and high ASA scores are most strongly associated with an increased risk for mortality. Notably, despite the prevalence of severe injuries among the oldest patients, the proportion of intensive care unit admissions decreases markedly with age. This raises the question what feasible care for these often frail patients should comprise of and where this care should be provided, especially for those with severe pre-existent comorbidities.

Level of evidence and study type: Level III, prognostic/epidemiological.

Purpose: Our study explores the utilization of objective tools for preoperative assessment of elderly patients by Emergency General Surgeons (EGS).

Methods: A descriptive cross-sectional survey was conducted via the European Society for Trauma and Emergency Surgery (ESTES) Research Committee. EGS were invited through the ESTES members' mailing list and social media platforms. The survey included two sections: (1) clinical scenarios involving elderly patients with varying chronic conditions, and (2) participant characteristics. Data collection lasted 12 weeks, with reminders sent every 4 weeks. Statistical analyses were performed using Microsoft Excel and EasyMedStat.

Results: One hundred and seven surgeons responded to the survey. Median respondent age was 41 years, with a male prevalence (72.9%). Most participants were from Europe (85%). Key-findings included that 62.6% reported using one or more risk assessment tools (RATs), while 35.5% used one or more frailty scores. Additionally, 4.7% were unaware of any RATs, and 35.5% were unaware of any frailty scores. Decision-making strategies leveraging personal experience with minimal impact from RATs predominated.

Conclusions: Preoperative risk assessment tool and frailty score use for elderly patients requiring emergency surgery remains limited among ESTES surgeons. Our study highlights the need for focused education and tool workflow integration to improve risk stratification, decision-making and outcomes. Institutional approaches coupled with targeted educational interventions using implementation science principles are recommended to bridge this knowledge-to-action gap. Future research should focus on developing comprehensive, user-friendly tools and evaluating their impact on patient-centered outcomes.

Purpose: This study was planned to evaluate limb survival and clinical outcomes of fasciotomies done before and after 24-48 h due to compartment syndrome in the extremities caused by crush injuries after the earthquakes in Turkey on February 6-7, 2023.

Methods: We retrospectively analyzed 129 extremities of 84 patients that underwent fasciotomy after the 2023 Turkey earthquakes in this single center study. Demographical data of patients, affected limb, time to fasciotomy, limb survival, number of debridements, necrotic muscle debridement, whether graft-flap was needed, and the need for hemodialysis were analyzed. Extremities were grouped according to timing of fasciotomy (24-48 h) and subgroups were defined in terms of affected limb (upper/lower).

Result: 43 females (51.2%) and 41 males (48.8%) were included in the study. Mean age of patients was 34.5 ± 12.8 years. There were 39 upper, 90 lower extremities totaling 129. Amputations were performed in 25 (19.4%) extremities of 20 (23.8%) patients of which 5 were upper (5 transhumeral) and 20 were lower (3 hip disarticulation, 7 transfemoral, 10 transtibial). There was no need for amputation in patients fasciotomised within 24 h. Amputation was performed in 9 (11.5%) of 78 extremities fasciotomized between 24 and 48 h and in 16 (31.4%) of 51 extremities fasciotomized after 48 h (p = 0.005). Amputation rates were significantly higher in lower extremities after 48 h (p = 0.002) in contrast to upper extremities (p = 0.661). The median number of debridements in all extremities was 2 [1-4]. Muscle compartment excision was required in 27 extremities (%26). Of the remaining 34 upper extremities, 17 (50.0%) were closed with graft/flap application and of the remaining 70 lower extremities, 25 (35.7%) were closed with graft/flap application. 19 patients (22.6%) received hemodialysis, with significantly higher rate with late fasciotomies (p < 0.001 and 0.004 for 24 h and 48 h respectively).

Conclusion: Fasciotomies earlier than 24 h prevented amputation and rate of muscle compartment excision was higher in fasciotomies done after 24 h especially for lower extremities. Upper extremity fasciotomy timing early or late did not change the outcomes.