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Trauma is a serious public health problem, and abdominal injuries are among the leading causes of hospitalization after trauma. Therefore, this study aimed to determine the outcome of abdominal trauma and its predictors in patients who underwent laparotomy at Asella Referral and Teaching Hospital (ARTH), South Central Ethiopia. We conducted a retrospective institutional based cross-sectional study of patients who underwent laparotomy for abdominal trauma at ARTH from October 1, 2015, to September 30, 2020. Bivariate and multivariate logistic regressions were used to determine associations between independent factors and mortality due to abdominal trauma, and a P value of <0.05 indicated statistical significance. Out of 139 patients, 110 (79.1%) were males and 88 (63.3%) aged <30 years old, with a mean age of 29 ± 15.73 years. The most common mechanism of injury was penetrating trauma, which accounted for 94 (67.6%) patients. The mortality rate was 21 (15.1%). Factors such as blunt mechanism of injury (95% CI: AOR: 3.36, 1.24-9.09), SBP < 90 mmHg at presentation (95% CI: AOR = 9.37, 3.28-26.80), time >6 hours from trauma to admission (95% CI: AOR: 5.44, 1.78-16.63), unstable intraoperative patient condition (95% CI: AOR = 8.82, 3.05-25.52), and patients who need blood transfusion (95% CI: AOR: 6.63, 1.92-22.91) were significantly associated with mortality. The mortality rate of abdominal trauma patients who underwent laparotomy was high. Therefore, healthcare providers should provide priority for traumatic patients as prolonged waiting time to get healthcare results in poor outcomes for the patients.

Asunto(s)

Traumatismos Abdominales , Hospitales de Enseñanza , Laparotomía , Humanos , Masculino , Femenino , Etiopía/epidemiología , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/mortalidad , Traumatismos Abdominales/epidemiología , Adulto , Estudios Transversales , Estudios Retrospectivos , Hospitales de Enseñanza/estadística & datos numéricos , Persona de Mediana Edad , Adolescente , Adulto Joven , Factores de Riesgo , Resultado del Tratamiento , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/epidemiología , Derivación y Consulta

RESUMEN

BACKGROUND: This multicenter study examines the contemporary management of penetrating carotid artery injury (PCAI) to identify trends in management, outcomes, and to determine prognostic factors for stroke and death. METHODS: Data from three large urban trauma centers in South Africa were retrospectively reviewed for patients who presented with PCAI from 2012 to 2020. RESULTS: Of 149 identified patients, 137 actively managed patients were included. Twenty-four patients (17.9%) presented in coma and 12 (9.0%) with localizing signs (LS). CT angiography was performed on admission for 120 (87.6%) patients. Thirty patients (21.9%) underwent nonoperative management, 87 (63.5%) open surgery, and 20 (14.6%) endovascular stenting. Eighteen patients (13.1%) died, and 15 (12.6%) surviving patients had strokes. Ligation was significantly related to death and reperfusion to survival. A mechanism of gunshot wound, occlusive injuries, a threatened airway, a systolic blood pressure <90 mmHg, hard signs of vascular injury, a low GCS, coma, a CT brain demonstrating infarct, a high injury severity score and shock index, a low pH or HCO3, and an elevated lactate were significant independent prognostic factors for death. Ligation was unsurvivable in all patients with severe neurological deficits, whereas reperfusion procedures resulted in survival in 63% (12/19) patients with coma and 78% (7/9) with LS although with high stroke rates (coma: 25.0%, LS: 85.7%). CONCLUSIONS: Outcomes in PCAI, including patients with severe neurological deficit and stroke, are better when reperfused. Reperfusion holds the best promise of survival and ligation should be reserved for technically inaccessible bleeding injuries.

Asunto(s)

Traumatismos de las Arterias Carótidas , Humanos , Sudáfrica/epidemiología , Masculino , Adulto , Femenino , Estudios Retrospectivos , Traumatismos de las Arterias Carótidas/cirugía , Traumatismos de las Arterias Carótidas/mortalidad , Traumatismos de las Arterias Carótidas/terapia , Traumatismos de las Arterias Carótidas/diagnóstico por imagen , Persona de Mediana Edad , Adulto Joven , Angiografía por Tomografía Computarizada , Heridas Penetrantes/mortalidad , Heridas Penetrantes/cirugía , Heridas Penetrantes/terapia , Heridas Penetrantes/diagnóstico por imagen , Pronóstico , Resultado del Tratamiento , Ligadura/métodos , Puntaje de Gravedad del Traumatismo , Centros Traumatológicos , Accidente Cerebrovascular/etiología , Procedimientos Endovasculares/métodos

RESUMEN

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.

Asunto(s)

Mortalidad Hospitalaria , Puntaje de Gravedad del Traumatismo , Transferencia de Pacientes , Centros Traumatológicos , Lesiones del Sistema Vascular , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Lesiones del Sistema Vascular/mortalidad , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/terapia , Estudios Retrospectivos , Masculino , Femenino , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/terapia , Heridas no Penetrantes/cirugía , Adulto , Heridas Penetrantes/mortalidad , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/cirugía , Heridas Penetrantes/terapia , Factores de Riesgo , Factores de Tiempo , Persona de Mediana Edad , California/epidemiología , Resultado del Tratamiento , Medición de Riesgo , Adulto Joven , Extremidades/irrigación sanguínea , Extremidades/lesiones , Anciano

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INTRODUCTION: Management of penetrating neck injuries (PNIs) has evolved over time, more frequently relying on increased utilization of diagnostic imaging studies. Directed work-up with computed tomography imaging has resulted in increased use of angiography and decreased operative interventions. We sought to evaluate management strategies after directed work-up, hypothesizing increased use of non-operative therapeutic interventions and lower mortality after directed work-up. METHODS: Patients with PNI from 2017 to 2022 were identified from a single-center trauma registry. Demographics, injuries, physical exam findings, diagnostic studies and interventions were collected. Patients were stratified by presence of hard signs and management strategy [directed work-up (DW) and immediate operative intervention (OR)] and compared. Outcomes included therapeutic non-operative intervention [endovascular stent, embolization, dual antiplatelet therapy (DAPT), or anticoagulation (AC)], non-therapeutic neck exploration, length of stay (LOS), and mortality. RESULTS: Of 436 patients with PNI, 143 (33%) patients had vascular and/or aerodigestive injuries. Of these, 115 (80%) patients underwent DW and 28 (20%) patients underwent OR. There were no differences in demographics or injury severity score between groups. Patients in the DW group were more likely to undergo vascular stent or embolization (p = 0.040) and had fewer non-therapeutic neck explorations (p = 0.0009), compared to the OR group. There were no differences in post-intervention stroke, leak, or mortality. Sixty percent of patients with vascular hard signs and 78% of patients with aerodigestive hard signs underwent DW. CONCLUSIONS: Directed work-up in select patients with PNI is associated with fewer non-therapeutic neck explorations. There was no difference in mortality. Selective use of endovascular management, AC and DAPT is safe.

Asunto(s)

Traumatismos del Cuello , Heridas Penetrantes , Humanos , Traumatismos del Cuello/terapia , Traumatismos del Cuello/cirugía , Traumatismos del Cuello/diagnóstico por imagen , Masculino , Femenino , Adulto , Heridas Penetrantes/terapia , Heridas Penetrantes/mortalidad , Heridas Penetrantes/complicaciones , Heridas Penetrantes/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Puntaje de Gravedad del Traumatismo , Embolización Terapéutica/métodos , Sistema de Registros , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Procedimientos Endovasculares/métodos , Centros Traumatológicos , Stents

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INTRODUCTION: Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients. METHODS: This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention. RESULTS: A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention. CONCLUSION: The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.

Asunto(s)

Heridas no Penetrantes , Humanos , Masculino , Femenino , Adulto , Brasil/epidemiología , Persona de Mediana Edad , Adulto Joven , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/terapia , Heridas no Penetrantes/epidemiología , Adolescente , Estudios Retrospectivos , Transfusión Sanguínea/estadística & datos numéricos , Heridas Penetrantes/mortalidad , Heridas Penetrantes/terapia , Anciano , Centros Traumatológicos

RESUMEN

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Asunto(s)

Traumatismos Abdominales , Puntaje de Gravedad del Traumatismo , Hígado , Centros Traumatológicos , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Masculino , Femenino , Estudios Retrospectivos , Hígado/lesiones , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/terapia , Heridas no Penetrantes/complicaciones , Adulto , Sudáfrica/epidemiología , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/terapia , Traumatismos Abdominales/cirugía , Laparotomía , Persona de Mediana Edad , Toma de Decisiones Clínicas

RESUMEN

INTRODUCTION: The COVID-19 pandemic created difficulties in access to care. There was also increased penetrating trauma in adults, which has been attributed to factors including increased firearm sales and social isolation. However, less is known about the relationship between the pandemic and pediatric trauma patients (PTPs). This study aimed to investigate the national incidence of penetrating trauma in PTPs, hypothesizing a higher rate with onset of the pandemic. We additionally hypothesized increased risk of complications and death in penetrating PTPs after the pandemic versus prepandemic. METHODS: We included all PTPs (aged ≤17-years-old) from the 2017-2020 Trauma Quality Improvement Program database, dividing the dataset into two eras: prepandemic (2017-2019) and pandemic (2020). We performed subset analyses of the pandemic and prepandemic penetrating PTPs. Bivariate analyses and a multivariable logistic regression analysis were performed. RESULTS: Of the 474,524 PTPs, 123,804 (26.1%) were from the pandemic year. The pandemic era had increased stab wounds (3.3% versus 2.8%, P > 0.001) and gunshot wounds (5.5% versus 4.0%, P < 0.001) compared to the prepandemic era. Among penetrating PTPs, the rates and associated risk of in-hospital complications (2.6% versus 2.8%, P = 0.23) (odds ratio 0.90, confidence interval 0.79-1.02, P = 0.11) and mortality (4.9% versus 5.0%, P = 0.58) (odds ratio 0.90, confidence interval 0.78-1.03, P = 0.12) were similar between time periods. CONCLUSIONS: This national analysis confirms increased penetrating trauma, particularly gunshot wounds in pediatric patients following onset of the COVID-19 pandemic. Despite this increase, there was no elevated risk of death or complications, suggesting that trauma systems adapted to the "dual pandemic" of COVID-19 and firearm violence in the pediatric population.

Asunto(s)

COVID-19 , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , Niño , Femenino , Masculino , Adolescente , Preescolar , Heridas por Arma de Fuego/epidemiología , Heridas por Arma de Fuego/mortalidad , Incidencia , Estudios Retrospectivos , Heridas Penetrantes/epidemiología , Heridas Penetrantes/mortalidad , Estados Unidos/epidemiología , Pandemias , Lactante , Bases de Datos Factuales

RESUMEN

INTRODUCTION: Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era. METHODS: This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed. RESULTS: One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%,P < .0001), required nephrectomy (27%vs5%,P = .0003), and were less likely to undergo pre-intervention CT (51%vs96%,P < .0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%,P = .004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975,P = .0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration. CONCLUSIONS: The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism.

Asunto(s)

Hematoma , Riñón , Nefrectomía , Tiempo de Tratamiento , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Estudios Retrospectivos , Masculino , Femenino , Adulto , Riñón/lesiones , Persona de Mediana Edad , Nefrectomía/métodos , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/terapia , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/terapia , Hematoma/cirugía , Hematoma/terapia , Hematoma/etiología , Puntaje de Gravedad del Traumatismo , Adulto Joven , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/mortalidad , Traumatismos Abdominales/diagnóstico , Embolización Terapéutica/métodos

RESUMEN

Empyema resulting as a complication of penetrating diaphragmatic injuries is a subject that requires further investigation, and the aim of this study was to determine the risk factors associated with empyema in patients with penetrating trauma. Consecutive adult trauma patients from a level 1 trauma center were searched for penetrating diaphragm injuries. Data were collected on patient demographics, pre-existing conditions, injury type and severity, hospital interventions, in-hospital complications, and outcomes. Patients were stratified by empyema formation and univariant analyses were performed. 164 patients were identified, and 17 patients (10.4%) developed empyema. Empyema was associated with visible abdominal contamination (35.3% vs 15%, P = .04), thoracotomy (35.5% vs 13.6%, P = .03), pneumonia (41.2% vs 14.3%, P = .01), sepsis (35.3% vs 8.8%, P = .006), increased hospital length of stay (25.5 vs 10.1 days, p =<.001), increased intensive care unit length of stay (9.6 vs 4.3 days, P = .01), and decreased in-hospital mortality (0% vs 20.4%, P = .04).

Asunto(s)

Diafragma , Heridas Penetrantes , Humanos , Masculino , Factores de Riesgo , Femenino , Adulto , Diafragma/lesiones , Heridas Penetrantes/complicaciones , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Estudios Retrospectivos , Tiempo de Internación/estadística & datos numéricos , Mortalidad Hospitalaria , Persona de Mediana Edad , Empiema/etiología , Toracotomía , Empiema Pleural/etiología , Empiema Pleural/cirugía , Adulto Joven

RESUMEN

Obesity in trauma patients is an established risk factor contributing to postoperative complications, but the relationship between body mass index (BMI) and trauma patient outcomes is not well-defined, especially when stratified by mechanism of injury. We surveyed the trauma laparotomy registry at an academic level 1 trauma center over a 3-year period to identify mortality, injury severity score, and hospital length of stay (hLOS) outcome measures across BMI classes, with further stratification by mechanism of injury: blunt vs penetrating trauma. A total of 442 patients were included with mean age 44.6 (SD = 18.7) and mean BMI 28.55 (SD = 7.37). These were subdivided into blunt trauma (n = 313) and penetrating trauma (n = 129). Within the blunt trauma subgroup, the hLOS among patients who survived hospitalization significantly increased 9% for each successive BMI class (P = .022, 95% CI = 1.29-17.5). We conclude that successive increase in BMI class is associated with longer hospital stay for blunt trauma patient survivors requiring laparotomy, though additional analysis is needed to establish this relationship to other outcome measures and among penetrating trauma patients.

Asunto(s)

Índice de Masa Corporal , Puntaje de Gravedad del Traumatismo , Laparotomía , Tiempo de Internación , Obesidad , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/mortalidad , Masculino , Adulto , Femenino , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/complicaciones , Tiempo de Internación/estadística & datos numéricos , Obesidad/complicaciones , Persona de Mediana Edad , Estudios Retrospectivos , Centros Traumatológicos , Sistema de Registros , Factores de Riesgo , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/mortalidad , Traumatismos Abdominales/complicaciones , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología

RESUMEN

Trauma-related esophageal injuries (TEIs) are a rare but highly lethal condition. The presentation of TEIs is very diverse depending on the location and mechanism of injury (blunt vs. penetrating), as well as the presence or absence of concurrent injuries. The aim of the present systematic review and meta-analysis is to delineate the clinical features impacting TEI management. A systematic review of the Medline, Embase, and web of science databases was undertaken for studies reporting on patients with TEIs. A random effects model was employed in the meta-analysis of aggregated data. Eleven studies, incorporating 4605 patients, were included, with a pooled mortality rate of 19% (95% confidence interval (CI) 13-25%). Penetrating injuries were 34% more likely to occur (RR 0.66, 95% CI 0.49-0.89, P = 0.01), predominantly in the neck compartment. Surgery was employed in 53% of cases (95% CI 32-73%), with 68% of patients having associated injuries (95% CI 43-94%). In terms of choice of surgical repair technique, primary suture repair was most frequently reported, irrespective of injury location. Postoperative drainage was employed in 27% of the cases and was more common following repair of thoracic esophageal injuries. The estimated dependence on mechanical ventilation was 5.91 days (95% CI 5.1-6.72 days), while the length of stay in the intensive care unit averaged 7.89 days (95% CI 7.14-8.65 days). TEIs are uncommon injuries in trauma patients, associated with considerable mortality and morbidity. Open suture repair of ensuing esophageal defects is by large the most employed approach, while stenting may be indicated in carefully selected cases.

Asunto(s)

Esófago , Heridas Penetrantes , Humanos , Esófago/lesiones , Esófago/cirugía , Heridas Penetrantes/terapia , Heridas Penetrantes/mortalidad , Heridas Penetrantes/cirugía , Femenino , Masculino , Adulto , Persona de Mediana Edad , Heridas no Penetrantes/terapia , Heridas no Penetrantes/mortalidad , Drenaje/métodos , Tiempo de Internación/estadística & datos numéricos , Adulto Joven , Técnicas de Sutura , Anciano , Adolescente

RESUMEN

BACKGROUND: Non-aortic arterial injuries are common and are associated with high morbidity and mortality. Historically, open surgical repair (OSR) was the conventional method of repair. With recent advancements in minimally invasive techniques, endovascular repair (ER) has gained popularity. We sought to compare outcomes in patients undergoing endovascular and open repairs of traumatic non-aortic penetrating arterial injuries. METHODS: A systematic review and meta-analysis was conducted using MEDLINE (OVID), Web of Science, Cochrane Library, and Scopus Database from January 1st, 1990, to March 20th, 2023. Titles and abstracts were screened, followed by full text review. Articles assessing clinically important outcomes between OSR and ER in penetrating arterial injuries were included. Exclusion criteria included blunt injuries, aortic injuries, pediatric populations, review articles, and non-English articles. Odds ratios (OR) and Cohen's d ratios were used to quantify differences in morbidity and mortality. RESULTS: A total of 3770 articles were identified, of which 8 met inclusion criteria and were included in the review. The articles comprised a total of 8369 patients of whom 90 % were male with a median age of 28 years. 85 % of patients were treated with OSR while 15 % underwent ER. With regards to injury characteristics, those who underwent ER were less likely to present with concurrent venous injuries (OR: 0.41; 95 %CI: 0.18, 0.94; p = 0.03). Regarding hospital outcomes, patients who underwent ER had a lower likelihood of in-hospital or 30-day mortality (OR: 0.72; 95 %CI: 0.55, 0.95; p = 0.02) and compartment syndrome (OR: 0.29, 95 %CI: 0.12, 0.71; p = 0.007). The overall risk of bias was moderate. CONCLUSION: Endovascular repair of non-aortic penetrating arterial injuries is increasingly common, however open repair remains the most common approach. Compared to ER, OSR was associated with higher odds of compartment syndrome and mortality. Further prospective research is warranted to determine the patient populations and injury patterns that most significantly benefit from an endovascular approach. LEVEL OF EVIDENCE: Level III, Systematic Reviews & Meta-Analyses.

Asunto(s)

Procedimientos Endovasculares , Lesiones del Sistema Vascular , Heridas Penetrantes , Humanos , Procedimientos Endovasculares/métodos , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/mortalidad , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Resultado del Tratamiento

RESUMEN

INTRODUCTION: Globally, chest trauma remain as a prominent contributor to both morbidity and mortality. Notably, patients experiencing blunt chest trauma exhibit a higher mortality rate (11.65%) compared to those with penetrating chest trauma (5.63%). AIM: This systematic review and meta-analysis aimed to assess the mortality rate and its determinants in cases of traumatic chest injuries. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the data synthesis process. Multiple advanced search methods, encompassing databases such as PubMed, Africa Index Medicus, Scopus, Embase, Science Direct, HINARI, and Google Scholar, were employed. The elimination of duplicate studies occurred using EndNote version X9. Quality assessment utilized the Newcastle-Ottawa Scale, and data extraction adhered to the Joanna Briggs Institute (JBI) format. Evaluation of publication bias was conducted via Egger's regression test and funnel plot, with additional sensitivity analysis. All studies included in this meta-analysis were observational, ultimately addressing the query, what is the pooled mortality rate of traumatic chest injury and its predictors in sub-Saharan Africa? RESULTS: Among the 845 identified original articles, 21 published original studies were included in the pooled mortality analysis for patients with chest trauma. The determined mortality rate was nine (95% CI: 6.35-11.65). Predictors contributing to mortality included age over 50 (AOR 3.5; 95% CI: 1.19-10.35), a time interval of 2-6 h between injury and admission (AOR 3.9; 95% CI: 2.04-7.51), injuries associated with the head and neck (AOR 6.28; 95% CI: 3.00-13.15), spinal injuries (AOR 7.86; 95% CI: 3.02-19.51), comorbidities (AOR 5.24; 95% CI: 2.93-9.40), any associated injuries (AOR 7.9; 95% CI: 3.12-18.45), cardiac injuries (AOR 5.02; 95% CI: 2.62-9.68), the need for ICU care (AOR 13.7; 95% CI: 9.59-19.66), and an Injury Severity Score (AOR 3.5; 95% CI: 10.6-11.60). CONCLUSION: The aggregated mortality rate for traumatic chest injuries tends to be higher in sub-Saharan Africa. Factors such as age over 50 years, delayed admission (2-6 h), injuries associated with the head, neck, or spine, comorbidities, associated injuries, cardiac injuries, ICU admission, and increased Injury Severity Score were identified as positive predictors. Targeted intervention areas encompass the health sector, infrastructure, municipality, transportation zones, and the broader community.

Asunto(s)

Traumatismos Torácicos , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Persona de Mediana Edad , África del Sur del Sahara/epidemiología , Comorbilidad , Estudios Observacionales como Asunto , Prevalencia , Traumatismos Torácicos/mortalidad , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/mortalidad

RESUMEN

OBJECTIVE: Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes. METHODS: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests. RESULTS: Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) (P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) (P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism (P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation. CONCLUSIONS: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization.

Asunto(s)

Amputación Quirúrgica , Arteria Axilar , Procedimientos Endovasculares , Arteria Subclavia , Centros Traumatológicos , Lesiones del Sistema Vascular , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Arteria Subclavia/lesiones , Arteria Subclavia/cirugía , Arteria Subclavia/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/mortalidad , Lesiones del Sistema Vascular/terapia , Lesiones del Sistema Vascular/epidemiología , Estudios Retrospectivos , Masculino , Arteria Axilar/lesiones , Arteria Axilar/cirugía , Arteria Axilar/diagnóstico por imagen , Femenino , Adulto , Persona de Mediana Edad , Resultado del Tratamiento , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/terapia , Procedimientos Endovasculares/efectos adversos , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/terapia , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/mortalidad , Adulto Joven , Factores de Riesgo , Recuperación del Miembro , Hospitales Urbanos , Factores de Tiempo , Anciano , Adolescente , Bases de Datos Factuales

RESUMEN

INTRODUCTION: Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS: This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS: A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION: Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Asunto(s)

Servicios Médicos de Urgencia , Mortalidad Hospitalaria , Humanos , Masculino , Femenino , Adulto , Servicios Médicos de Urgencia/métodos , Estudios Prospectivos , Paquetes de Atención al Paciente/métodos , Resucitación/métodos , Persona de Mediana Edad , Puntaje de Gravedad del Traumatismo , Servicios Urbanos de Salud/organización & administración , Sistema de Registros , Hemorragia/terapia , Hemorragia/mortalidad , Heridas Penetrantes/terapia , Heridas Penetrantes/mortalidad , Heridas y Lesiones/terapia , Heridas y Lesiones/mortalidad

RESUMEN

BACKGROUND: Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE. METHODS: The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS). RESULTS: 1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (ß = 43.9, P < .001). CONCLUSIONS: Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.

Asunto(s)

Anticoagulantes/uso terapéutico , Tiempo de Tratamiento , Tromboembolia Venosa/prevención & control , Heridas y Lesiones/complicaciones , Adulto , Anciano , Algoritmos , Anticoagulantes/administración & dosificación , Transfusión Sanguínea , Colorado/epidemiología , Enoxaparina/administración & dosificación , Enoxaparina/uso terapéutico , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Masculino , Persona de Mediana Edad , Sistema de Registros , Análisis de Regresión , Estudios Retrospectivos , Tromboembolia Venosa/mortalidad , Heridas y Lesiones/epidemiología , Heridas y Lesiones/mortalidad , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/epidemiología , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/complicaciones , Heridas Penetrantes/epidemiología , Heridas Penetrantes/mortalidad

RESUMEN

OBJECTIVES: To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings and radiological reports. DESIGN: Retrospective case note review. SETTING: UK level I trauma centre April 2012-November 2017. PARTICIPANTS: Three hundred ten cases of PNT were drawn from electronic patient records. Data were extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes. MAIN OUTCOME MEASURES: Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration. RESULTS: Two hundred seventy-one (87.4%) male and 39 (13.6%) female patients with a mean age of 36 years (16-87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%), and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r = 0.89, p = 0.045, between hard signs plus positive radiology findings and internal injury on neck exploration. CONCLUSIONS: Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.

Asunto(s)

Traumatismos del Cuello/diagnóstico por imagen , Traumatismos del Cuello/cirugía , Centros Traumatológicos , Heridas Penetrantes/diagnóstico por imagen , Heridas Penetrantes/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Traumatismos del Cuello/mortalidad , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Reino Unido , Heridas Penetrantes/mortalidad , Adulto Joven

RESUMEN

BACKGROUND: The inferior vena cava is the most frequently injured vascular structure in penetrating abdominal trauma. We aimed to review inferior vena cava injury cases treated at a limited resources facility and to discuss the surgical management for such injures. METHODS: This was a retrospective study of patients with inferior vena cava injuries who were treated at a single center between January 2011 and January 2020. Data pertaining to the following were assessed: demographic parameters, hypovolemic shock at admission, the distance that the patient had to be transported to reach the hospital, affected anatomical segment, treatment, concomitant injuries, complications, and mortality. Non-parametric data were analyzed using Fisher's exact, Chi-square, Mann-Whitney, or Kruskal-Wallis test, as applicable. The Student's t-test was used to assess parametric data. Moreover, multiple logistic regression analyses (including data of possible death-related variables) were performed. Statistical significance was set at P <0.05. RESULTS: Among 114 patients with inferior vena cava injuries, 90.4% were male, and the majority were aged 20-29 years. Penetrating injuries accounted for 98.2% of the injuries, and the infrarenal segment was affected in 52.7% of the patients. Suturing was perfomed in 69.5% and cava ligation in 29.5% of the patients, and 1 patient with retrohepatic vena cava injury was managed non-operatively. The overall mortality was 52.6% with no case of compartment syndrome in the limbs. A total of 7.9% of the patients died during surgery. CONCLUSION: The inferior vena cava is often injured by penetrating mechanisms, and the most frequently affected segment was the infrarenal segment. A higher probability of death was not associated with injury to a specific anatomical segment. Additionally, cava ligation was not related to an increased probability of compartment syndrome in the leg; therefore, prophylactic fasciotomy was not supported.

Asunto(s)

Traumatismos Abdominales/cirugía , Lesiones del Sistema Vascular/cirugía , Vena Cava Inferior/lesiones , Heridas Penetrantes/cirugía , Traumatismos Abdominales/mortalidad , Adolescente , Adulto , Brasil , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Lesiones del Sistema Vascular/mortalidad , Heridas Penetrantes/mortalidad

RESUMEN

OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.

Asunto(s)

Disparidades en Atención de Salud , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud , Pacientes no Asegurados/estadística & datos numéricos , Calidad de la Atención de Salud , Heridas Penetrantes/etnología , Heridas Penetrantes/mortalidad , Cuidados Críticos/economía , Femenino , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Puerto Rico/epidemiología , Estudios Retrospectivos , Heridas por Arma de Fuego/mortalidad , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/terapia

RESUMEN

Resumen Introducción: Los traumatismos están entre las diez principales causas de muerte a nivel mundial y son la primera en jóvenes. El traumatismo torácico (TT) está presente en un alto porcentaje de las muertes por traumatismos y es la segunda causa de muerte después del traumatismo encefalocraneano. Objetivos: Analizar las variables asociadas a mortalidad, las causas principales y la distribución temporal de la mortalidad en hospitalizados fallecidos con TT. Materiales y Método: Estudio observacional de hospitalizados con TT, período enero de 1981 a diciembre de 2018. Revisión de protocolos prospectivos de TT y base de datos. Se consignaron las causas de muerte sindromáticas principales y se realizó una regresión logística para variables asociadas a mortalidad. Se utilizó SPSS25® con pruebas chi-cuadrado para comparar clasificación, tipo de TT y su distribución temporal, considerando significativo p < 0,05. Resultados: Total 4.297 TT, mortalidad global de 120 (2,8%) casos. Las principales variables independientes asociadas a mortalidad fueron el deterioro fisiológico al ingreso, el hemotórax masivo y el TT por arma de fuego. La principal causa de muerte fue el shock hipovolémico, con diferencias significativas según tipo de TT en las primeras 4 y 24 horas. En la distribución temporal se observó que las muertes con TT penetrante y aislado fueron más precoces y no se evidenció un nuevo peak en la mortalidad luego de la primera semana. Conclusiones: Se observaron variables independientes asociadas a mortalidad en hospitalizados con TT, siendo el deterioro fisiológico al ingreso el factor más importante. Además, existen diferencias significativas en las causas de muerte y distribución temporal de la mortalidad entre diferentes subgrupos de hospitalizados con TT.

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Background: Trauma is one of the ten leading causes of death worldwide and the first among the youth. Thoracic trauma (TT) is present in a high percentage of deaths due to trauma and is the second leading cause of death after traumatic brain injury. Aim: To analyze the mortality associated variables, major causes and temporal distribution of mortality among dead hospitalized patients with TT. Materials and Method: Observational study in hospitalized patients with TT, period January 1981 to December 2018. Review of prospective TT protocols and data base. Major syndromic causes of death were recorded and a logistic regression for variables associated with mortality was made. SPSS25® with chi-quadrat tests was used to compare classification, type of TT and temporal distribution. A p value < 0,05 was considered significant. Results: Total 4.297 TT and global mortality was 120 (2,8%) cases. The main independent variables associated with mortality were the physiological decline upon admission, massive hemothorax and TT by firearms. The leading cause of death was hypovolemic shock, with significant differences according to the type of TT in the first 4 and 24 hours. In the temporal distribution was observed that, the deaths with penetrating and isolated TT were earlier and that there was no second peak of mortality following the first week. Conclusions: Independent variables associated with mortality were observed among hospitalized patients with TT, being physiological deterioration the most important factor. Besides, there are significant differences in the death causes and temporal distribution of mortality among the different subgroups of hospitalized patients with TT.

Asunto(s)

Humanos , Masculino , Femenino , Traumatismos Torácicos/mortalidad , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/mortalidad , Traumatismos Torácicos/epidemiología , Factores de Riesgo , Causas de Muerte