Injury最新文献

Objective: The primary objective of this study is to assess common sites of injury and the associated imaging findings in penetrating injuries. We pay particular attention to gluteal, anterior abdominal wall and junctional zone injuries. The aim is to highlight areas of diagnostic uncertainty and discrepancy between imaging and surgical findings, to improve review areas in trauma reporting.

Methods: A retrospective, observational study reviewing all paediatric admissions to the emergency department of a major trauma Centre with a penetrating injury, from 2015 to 2019.

Results: Gluteal penetrating injuries are by far the most commonly sustained injury in the adolescent population, making up over 1/3 of cases. The vast majority of these cases sustained superficial injuries or shallow intramuscular haematomas, however in a small group (15%), serious vascular or rectal injuries were demonstrated on dual phase CT, requiring emergent surgical or endovascular treatment. Penetrating injuries to the anterior abdominal wall and junctional zone are less common but are associated with higher morbidity, with 43% of cases demonstrating solid organ or bowel injury. These cases also lead to an increased degree of diagnostic uncertainty.

Conclusion: Gluteal injuries are common and although the overall morbidity of these cases is low, these patients are at risk of serious and life threatening consequences such as vascular and rectal injury and it is imperative that these complications are considered and ruled out via dual phase CT or direct visualization. Anterior abdominal wall and junctional zone injuries are less common, but lead to greater morbidity and also greater diagnostic uncertainty. The use of other salient findings as described in this report can aid diagnostic accuracy and reduce discrepancies.

Introduction: Older patients are expected to comprise 40 % of trauma admissions in the next 30 years. The use of whole blood (WB) has shown promise in improving mortality while lowering the utilization of blood products. However, the use of WB in older trauma patients has not been examined. The objective of our study is to determine the safety and efficacy of a WB first transfusion strategy in injured older patients.

Methods: Older trauma patients, defined as age ≥55 years old, were reviewed from March 2016-November 2021. Patients that received a WB first resuscitation strategy were compared to those that received a ratio based component strategy. Demographics as well as complications rates, blood product transfusion volumes, and mortality were evaluated. Univariate and multivariable analysis was used to determine independent predictors of mortality.

Results: There were 388 older trauma patients that received any blood products during the study period. A majority of patients received a WB first resuscitation strategy (83 %). Compared to patients that received component therapy, patients that received WB first were more likely female, less likely to have a penetrating mechanism, and had a slightly lower injury severity score. The-30 day mortality rate was comparable (WB 36% vs component 37 %, p = 0.914). While rates of AKI were slightly higher in those that received WB, this did not result in increased rates of renal replacement therapy (3 % vs 2 %, p = 1). Further, compared to patients that received components, patients that were resuscitated with a WB first strategy significantly utilized lower median volumes of platelets (0 mL vs 197 mL, p < 0.001), median volumes of plasma (0 mL vs 1253 mL, p < 0.001, and median total volume of blood products (1000 mL vs 2859 mL, p < 0.001).

Conclusion: The use of WB in the older trauma patient appears safe, with mortality and complication rates comparable to component therapy. Blood product utilization is significantly less in those that are resuscitated with WB first.

Background: In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection.

Methods: This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia.

Results: Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors.

Conclusion: ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.

Background: Vital signs are important factors in assessing injury severity and guiding trauma resuscitation, especially among severely injured patients. Despite this, physiological data are frequently missing from trauma registries. This study aimed to evaluate the extent of missing prehospital data in a hospital-based trauma registry and to assess the associations between prehospital physiological data completeness and indicators of injury severity.

Methods: A retrospective review was conducted on all adult trauma patients brought directly to a level 1 trauma center in Toronto, Ontario by paramedics from January 1, 2015, to December 31, 2019. The proportion of missing data was evaluated for each variable and patterns of missingness were assessed. To investigate the associations between prehospital data completeness and injury severity factors, descriptive and unadjusted logistic regression analyses were performed.

Results: A total of 3,528 patients were included. We considered prehospital data missing if any of heart rate, systolic blood pressure, respiratory rate or oxygen saturation were incomplete. Each individual variable was missing from the registry in approximately 20 % of patients, with oxygen saturation missing most frequently (n = 831; 23.6 %). Over 25 % (n = 909) of patients were missing at least one prehospital vital sign, of which 69.1 % (n = 628) were missing all four of these variables. Patients with incomplete data were more severely injured, had higher mortality, and more frequently received lifesaving interventions such as blood transfusion and intubation. Patients were most likely to have missing prehospital physiological data if they died in the trauma bay (unadjusted OR: 9.79; 95 % CI: 6.35-15.10), did not survive to discharge (unadjusted OR: 3.55; 95 % CI: 2.76-4.55), or had a prehospital GCS less than 9 (OR: 3.24; 95 % CI: 2.59-4.06).

Conclusion: In this single center trauma registry, key prehospital variables were frequently missing, particularly among more severely injured patients. Patients with missing data had higher mortality, more severe injury characteristics and received more life-saving interventions in the trauma bay, suggesting an injury severity bias in prehospital vital sign missingness. To ensure the validity of research based on trauma registry data, patterns of missingness must be carefully considered to ensure missing data is appropriately addressed.

Introduction

Traumatic chest wall injuries are common however the incidence of non-union rib fractures is unknown. Previous studies have suggested that surgical management of symptomatic non-union rib fractures could be beneficial in selected patients, although many experience persisting pain despite surgery. The aim of this study is to investigate the long-term outcome after surgical management of symptomatic non-union rib fractures.

Methods

This is a cross-sectional study including adults (≥18 years) managed surgically for symptomatic non-union rib fractures with plate fixation during the period 2010–2020 at Sahlgrenska University Hospital. Patients operated for acute chest wall injury or injury due to cardiopulmonary resuscitation were excluded. Patients answered standardized questionnaires concerning remaining symptoms and satisfaction with surgery, quality of life (QoL, EQ-5D-5L) and disability (Disability Rating Index, DRI). Lung function, movement of chest wall and thoracic spine, and shoulder function (Boström index) were assessed.

Results

Sixteen patients, 12 men and four women, with mean age 61.6±11.1 were included in the study. The mechanism of injury was trauma in 10 patients and cough-induced injuries in five patients. Lung disease was significantly more prevalent in cough-induced injuries compared to traumatic injuries, 5 vs 1 (p=0.008). The mean follow-up time was 3.5 years. Ninety-four percent were satisfied with the surgery and reported that their symptoms had decreased, although 69% had remaining symptoms, especially pain, from the chest wall. Quality of Life was decreased with EQ-5D-5L index 0.819 (0.477–0.976) and EQ-VAS 69 (10–100). Disability Rating Index was 31.5 (1.3–76.7) with problems running, lifting heavy objects, and performing heavy work. Predicted lung function was decreased with Forced Vital Capacity (FVC) 86.2±14.2%, Forced Expiratory Volume in 1 second (FEV1) 79.1±10.7% and Peak Expiratory Flow (PEF) 89.7±14.5%. Patients with cough-induced injuries had full shoulder mobility.

Conclusions

Chest wall surgery for symptomatic non-union rib fractures results in decreased symptoms and patient satisfaction in most cases despite remaining symptoms, reduced lung function, chest wall movement, and QoL and persistent disability.

Background: Drains have demonstrated no clear benefits and some potentially harmful effects in hip and knee replacements. There is little evidence about the effects of its use in shoulder arthroplasty. We hypothesized that drain use would increase postoperative blood loss without reducing wound complications.

Methods: We included 103 reverse shoulder arthroplasties (RSA), 71 were operated for degenerative pathology, 32 due to a fracture. All complications were recorded. Hemoglobin (Hb) and hematocrit (Htc.) level were collected and compared to postoperative data. Length of hospitalization and volume output were also noted.

Results: 45 patients received a closed-suction drain. Patients with coagulopathy had significant higher bleeding and were excluded (p = 0.03). Patients operated for a fracture were older (80.1y.o vs 72.1 p < 0.01) and had higher blood drop (∆Hb p = 0.01; ∆Htc p = 0.03). There were neither differences between drain and control group in ∆Hb or ∆Htc in the degenerative RSA group (1.84+/-0.89 vs 1.68+/-0.84, p = 0.36; 5.78+/-2.89 vs 5.53+/-2.87 p = 0.50) nor in the fracture RSA group (2.65+/-0.94 vs 2.65+/-1.01, p = 0.90; 7.91+/-2.99 vs. 7.09+/-4.21, p = 0.56). There were neither differences in complications (degenerative p = 0.33; fracture p = 0.21). Drain use was related to a longer hospital stay in elective surgery (2.6 vs 1.8 days; p < 0.01).

Discussion: The rate of complication is similar between patients with and without drain use. Drain use after shoulder arthroplasty does not affect postoperative bleeding but increases the length of hospital stay. Drains seems to be an unnecessary intervention after RSA that may increase associated costs and can be safely abandoned.

Level of evidence: Level III retrospective comparative study.