Trauma Surgery & Acute Care Open最新文献

Background: The "surgical soul" indicates a small spherical area at the head of pancreas with adjacent major vessels. Traumatic injuries to this area are known for the extreme complexity to manage. The aim of this study was to describe the characteristics and outcomes of patients with wounded surgical soul using a nationwide dataset.

Methods: We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database (2013-2018). We included patients (age ≥16 years) with Abbreviated Injury Scale (AIS) ≥4 pancreatic and/or duodenal injuries with associated injuries to any of the following vessels: inferior vena cava (IVC), superior mesenteric artery/vein injury (SMA/SMV), portal vein (PV), renal vein (RV), and splenic vein (SV). Multivariate logistic regression was performed to identify factors associated with in-hospital mortality.

Results: A total of 219 patients were identified. Of those, 178 (81.3%) sustained penetrating trauma. Pancreatic injury accounted for 73.5% of all patients, 39.8% with duodenal injury, 45.2% with IVC injury, 11.0% with SMA injury, and 56.6% with PV/SMV/RV/SV injury. Liver (56.2%), colon (47.0%), and stomach (37.9%) were common associated injuries. The overall in-hospital mortality rate was 58% with most deaths occurring <48 hours. In the multivariate analysis, older age, systolic blood pressure <90 mm Hg, chest AIS>3, abdominal aortic injury, and packed red blood cell transfusion >10 units within 24 hours were factors associated with mortality.

Conclusions: Injuries to the surgical soul are rare but associated with a significant mortality risk. The surgical strategy should focus on early hemorrhage control to improve the likelihood of patient survival.

Level of evidence: Prognostic/epidemiological, level IV.

Background: Aortic diameter (AoD) changes with age and can decrease in shock states. Accurate AoD assessment is crucial for managing hypovolemic shock and guiding interventions such as resuscitative endovascular balloon occlusion of the aorta. This study hypothesized that clinical factors (eg, initial hemodynamic parameters, trauma severity, and laboratory results) would have a greater impact on the AoD than would age- or anthropometric-related factors in traumatic massive hemorrhage patients. We aimed to identify significant predictors of the descending AoD across two age groups (18-60 years and 61-91 years).

Methods: A retrospective analysis was conducted on 243 massive hemorrhage patients at a level I trauma center. The aorta was automatically segmented in CT images via a deep learning architecture based on a Shallow Attention Network to obtain diaphragm-level AoD values. 152 patients were assigned to the younger group and 91 to the senior group. A random forest model was used to incorporate various clinical factors.

Results: In the younger group, age and body surface area were the most important features (root mean square error (RMSE): train, 1.03; test, 2.70). In the senior group, hemoglobin, arterial pH, and heart rate were the most significant indicators (RMSE: train, 1.19; test, 3.95). The importance of age diminished in the senior group, whereas vital signs and laboratory values gained prominence.

Conclusion: Our findings reveal age-specific differences in factors influencing the AoD during traumatic hemorrhage. The results highlight the limitations of traditional methods for AoD estimation, especially in senior patients in whom dynamic physiological factors may play a major role. These insights can improve the accuracy of AoD assessment and management in hemorrhage patients across different age groups. The findings may contribute to developing an artificial intelligence-derived score that estimates the AoD, incorporating static and dynamic physiological factors.

Level of evidence: IV, retrospective study having more than one negative criterion.

Background: Prior research explored the effect of elevation on deep vein thrombosis (DVT) but primarily examined injuries at elevations <1000 or >4000 feet, excluding elevations in between, and focused on specific subsets of trauma patients. This study aimed to conduct a more detailed analysis of the relationship between elevation and DVT in all trauma admissions.

Methods: This retrospective cohort study at four level I trauma centers included adult trauma patients (October 1, 2022 to October 1, 2023). Injury zip codes were used to define elevation. High-elevation (H-ELV) injuries (≥5000 feet) were compared with low-elevation (L-ELV) injuries (<5000 feet). Elevation was further categorized into 1000-foot increments. An alpha of <0.0001 defined statistical significance.

Results: Of 8620 patients, 49% (4231) had L-ELV injuries and 51% (4389) had H-ELV injuries. Compared to patients with L-ELV injuries, those with H-ELV injuries were significantly older, had lower oxygen saturation and higher heart rate, suffered falls and sports injuries more often, and motor vehicle collisions less often, and had a higher rate of comorbidities, including alcohol use disorder and anticoagulant use. DVTs occurred significantly more often after H-ELV injuries than L-ELV injuries (1.9% vs. 0.5%, p<0.0001). For each 1000-foot increase in elevation, there was a corresponding 0.4% average increase in the rate of DVT (moderate R²=0.6). After adjustment for alcohol use disorder and oxygen saturation, H-ELV injuries were associated with a 3.8-fold increase (95% CI 2.3 to 6.4) in the risk of DVT when compared with L-ELV injuries.

Conclusions: Even after adjustment, H-ELV injuries were associated with 3.8 increased odds of developing a DVT compared with L-ELV injuries. There was a significant positive linear association between DVT and injury elevation, with the rate of DVT increasing with increasing elevation. This finding may suggest the need for enhanced screening or tailored DVT prophylaxis methods at higher elevation trauma centers to improve outcomes.

Level of evidence: Level IV.

Background: Costosternal cartilages and the costal margin, collectively termed costal cartilage, are hyaline cartilage connecting ribs to the sternum and to adjacent ribs, respectively. Presence of intact costal cartilage is essential for elasticity of the chest wall. Anecdotally, costal cartilage injuries are underdiagnosed on trauma CT scan in patients with rib fractures. Our aim was to determine a baseline frequency of acute costal cartilage injury among patients presenting with rib fractures.

Methods: We performed a retrospective cohort study of injured adult patients admitted to Level I/II trauma centers with rib fractures from January 2020 to July 2024. CT images obtained at admission were manually reviewed by chest wall surgeons for presence of costal cartilage injury. Concordance with the original radiology report was obtained. Multivariable regression was used to analyze factors associated with costal cartilage injury and missed cartilage fractures.

Results: 1441 patients were identified; 197 (14%) had a costal cartilage fracture. A plurality of injuries included falls (n=667, 46%). Median ISS (Injury Severity Score) was 13 (IQR: 9 to 21), median Abbreviated Injury Scale thorax score was 3 (IQR: 3 to 3), and median number of fractured ribs was 3 (IQR: 3 to 7). 294 (21%) patients had radiographic flail segments, and 136 (9%) had sternal fractures. 172 (87%) patients had a costal cartilage fracture missed on initial trauma chest CT. On multivariable analysis, ISS (adjusted OR (aOR) 1.02 (95% CI 1.01 to 1.04), radiographic flail segment (aOR 1.6 (95% CI 1.10 to 2.31)) and presence of sternal fracture (aOR 1.85 (95% CI 1.19 to 2.89)) were associated with costal cartilage fractures. Only the total number of rib fractures was associated with a missed costal cartilage fracture on univariate analysis (OR 1.17 (95% CI 1.01 to 1.36)).

Conclusions: Costal cartilage injuries are common and frequently are not identified during interpretation of the initial trauma CT. A higher index of suspicion is warranted for costal cartilage fractures among patients with greater injury burden, radiographic flail segment, and sternal fractures.

Level of evidence: Level III.

Trauma and acute care surgeons are constantly balancing the need for rapid, decisive intervention with the ongoing evolution of surgical technique and cutting-edge technology. This article presents a collection of practical, experience-driven insights across four topics that reflect the modern breadth of trauma and acute care surgery presented during a lunch session at the American Association for the Surgery for Trauma Annual Meeting 2024: preperitoneal pelvic packing, trauma video review, video-assisted thoracic surgery for retained hemothorax, and laparoscopic common bile duct exploration. Although seemingly disparate, these topics are united by a common goal: enhancing technical precision, team performance, and patient outcomes through deliberate, refined practice.

Background: The healthcare burden and fatality rate associated with pediatric firearm injuries is increasing substantially. Most published studies evaluating outcomes and disparities of pediatric firearm-related injuries have focused primarily on hospital-level data. This study aimed to investigate mortality indicators among pediatric decedents referred to the Tennessee Chief Medical Examiner (CME) having a confirmed firearm-related cause of death.

Methods: In this retrospective cross-sectional study, the Tennessee CME database was queried to reveal 643 death certificates of children ages 17 years and younger who died from a firearm-related injury between 2012 and 2022. Death certificates were surveyed for demographics and residential data. Autopsy reports were reviewed for anatomic injury patterns. The neighborhood of residence for each decedent was geocoded for analysis using the Child Opportunity Index (COI). Pearson, Kruskal-Wallis, Wilcoxon, and linear regression modeling were completed.

Results: Significant increases in both homicide (n=369; p<0.0001) and suicide (n=202; p=0.001) were documented over time. Firearm deaths increased with age (median age, 16.0 years; IQR (13-17)), with ≥70% of homicide and suicide cases occurring between ages 15 years and 17 years. 272 homicide decedents (76%) were black, and 165 (82%) suicides were white (p<0.001). Over half of decedents sustained a head wound (p<0.001). Geocoded density maps indicated a correlation between pediatric population race density and predominating manners of firearm death. Residences with a lower COI level were associated with a higher risk of homicide.

Conclusion: In this query of the Tennessee CME registry, homicide rates increased and remained higher than all other firearm manners of death impacting children. This study revealed opportunities to affect meaningful change regarding different ages and manners of lethal firearm injuries among children.

Level of evidence: III.