Trauma Surgery & Acute Care Open最新文献

Background: Small bowel injuries are rare in trauma. Diagnosing these injuries is difficult owing to the lack of clear signs, and delays in diagnosis might increase complications and mortality. Trauma can damage the vascular endothelial glycocalyx, with syndecan-1 emerging as a marker of injury. Here, we describe two cases of small bowel injury due to traffic motor vehicle crash trauma.

Case presentation: The patients, one in their 40s and one teenaged, were transported to our hospital after a traffic motor vehicle crash. Both patients were wearing seat belts at the time of the motor vehicle crash, and the car's airbags deployed properly. Their vital signs were stable at admission, and non-operative treatment was selected. However, their abdominal pain did not improve, and based on posthospitalization CT reconstructive imaging, intra-abdominal hemorrhage was suspected. Surgery was performed, revealing small intestinal injuries. In both patients, a high serum syndecan-1 level in the blood test at admission was a common characteristic.

Conclusion: Increased serum syndecan-1 level was observed in blood tests during the initial treatment of small intestinal injuries in these patients, suggesting its potential utility in early diagnosis. However, further accumulation of cases and detailed studies are required to substantiate these results.

Background: Non-compressible torso hemorrhage (NCTH) represents a leading cause of preventable mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) stabilizes NCTH but may predispose patients to thrombus generation. REBOA must therefore be prospectively evaluated for coagulation risks with concomitant usage of anti-fibrinolytic tranexamic acid (TXA). Using a porcine model of hemorrhage, it was hypothesized that TXA with REBOA would worsen coagulation outcomes and organ damage.

Materials and methods: Thirty-two male Yorkshire swine underwent 30% blood volume hemorrhage with randomization to vehicle control (VC; normal saline), VC+REBOA, TXA, or TXA+REBOA. At T0, animals received 10 mL/minute of group-specific infusion (GSI) followed at T10 by 500 mL of whole blood (WB), second GSI at 13 mL/hour, and Zone 1 REBOA inflation in REBOA groups. At T40, REBOA was deflated, with additional 500 mL WB, and continuation of GSI for 3 hours. Physiological, coagulation, and inflammatory parameters were measured throughout the protocol, with postmortem histopathology.

Results: After REBOA deflation at T40, lactate was significantly higher for the REBOA groups versus the non-REBOA groups, and pH, bicarbonate, and base excess were all significantly lower than the non-REBOA groups. There were no significant differences observed between groups in coagulation, inflammatory, metabolic, or histopathologic parameters.

Conclusions: Administration of TXA with REBOA did not cause more deleterious coagulation outcomes. All significant changes were expected results of REBOA ischemia, and not attributable to TXA treatment. This suggests NCTH can safely be treated with both hemorrhage control methods without exacerbating clotting outcomes.

Level of evidence: Not applicable-basic animal research.

Background: Management of traumatic liver injury includes observation, hemorrhage control laparotomy (HCL), and/or liver angioembolization (LAE). Although the literature supports LAE as an effective option, procedure-related complications are well described and not uncommon. The purpose of this study is to evaluate whether LAE is associated with worse outcomes in both patients undergoing HCL and patients managed expectantly.

Methods: This is a retrospective analysis of patients with grades III to V traumatic liver injury enrolled in the 2018 to 2020 Trauma Quality Improvement Program database. Two comparisons were performed: (1) HCL within 24 hours of admission with and without LAE, and (2) no HCL within 24 hours of admission with and without LAE. Propensity score matching was used to account for differences in patient acuity, and univariate analysis was performed to compare groups.

Results: Both groups were well balanced after matching. Among patients with initial HCL, concomitant LAE did not affect mortality, length of stay, or complications. Patients with LAE underwent more percutaneous liver drainage procedures (7.8% vs. 3.3%, p=0.016). In the second comparison, LAE was associated with a statistically significant increase in hospital length of stay (17.6 days vs. 14.2 days, p<0.001) and more percutaneous liver drainage procedures (4.3% vs. 0.8%, p=0.002) but less open liver repairs (3.5% vs. 8.3%, p=0.004). For both cohorts, patients undergoing LAE had significantly higher 4-hour transfusion volumes.

Conclusion: LAE following traumatic liver injury is associated with more percutaneous liver drainage procedures. It is associated with increased hospital length of stay when compared with patients who are managed expectantly, but does not significantly affect mortality or hospital complications. Although the literature reports a high rate of liver-related complications, we found a relatively lower rate of liver-related interventions, particularly in the non-operative group.

Level of evidence: III.

Abstract:

Background: Financial toxicity refers to financial hardship experienced because of illness or injury. Poverty is a known driver of community violence, but financial toxicity has not been studied in firearm violence survivors. The objective of our study was to explore the financial needs of firearm violence survivors enrolled in a hospital-based violence intervention program (HVIP). We hypothesized that survivors would report numerous financial needs.

Methods: This was a mixed-methods, retrospective study of firearm violence survivors enrolled in the Miami-Dade County HVIP from 2022 to 2023. Patients were eligible for enrollment if they were injured in shooting incidents that occurred in Miami-Dade police districts with high rates of group violence or gang-related violence. Social worker intake and longitudinal case records were reviewed. A qualitative thematic analysis of social worker notes was performed. Quantitative data were analyzed with descriptive statistics and χ² tests for association.

Results: 103 patients were enrolled in the program. The median age was 27 years. The majority of patients were black (82.5%) and male (83.5%). More patients were insured (59.2%) than uninsured (40.8%). Thematic analysis revealed 10 distinct financial needs, including assistance with victim crime compensation (75.7% of patients), medical bills (35.0%), wage loss (22.3%), insurance applications (14.6%), burial (13.6%), and emergency relocation (12.6%). Overall, financial needs were identified for 94 (91.3%) patients: 91 (88.3%) at initial program intake and 3 additional patients (2.9%) during longitudinal case management.

Conclusions: Survivors of firearm violence experience financial challenges after injury. Thus, financial support and assessment for financial toxicity should be included in firearm violence survivorship programs. Future investigations should use validated measures to study the financial toxicity of firearm violence survivors longitudinally.

Objectives: The goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.

Methods: Injury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.

Results: A total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).

Conclusions: The intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.

Level of evidence: Level II, randomized clinical trial.

Trial registration number: NCT03569878.