RESUMEN
Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥ 3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At < 4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, > 6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.
Asunto(s)
Traumatismo Múltiple , Traumatismos Torácicos , Traumatismos Torácicos/cirugía , Humanos , Alemania , Traumatismo Múltiple/cirugía , Contraindicaciones de los Procedimientos , Cirugía Torácica Asistida por Video , Toracotomía/métodos , Escala Resumida de Traumatismos , Heridas no Penetrantes/cirugía , Heridas Penetrantes/cirugíaRESUMEN
PURPOSE: The posterior cruciate ligament (PCL) is a vital knee stabilizer. While PCL injuries are rare, high-energy traumas can lead to total ruptures, with accompanying injuries requiring surgery. This study aims to investigate the demographics, concomitant injuries, and postoperative complications of patients who underwent PCL reconstruction due to high-energy trauma in a large patient sample. METHODS: Patients who underwent PCL reconstruction from 2016 to 2022 were retrospectively evaluated using data from a nationwide personal health recording system. Patient demographics, injury mechanisms, associated fractures, soft tissue injuries, and postoperative complications were collected from patient notes, clinical visits, and surgical notes. Individuals with a PCL injury following high-energy trauma (car accident, falls from height, motorcycle accident) with a minimum follow-up of 1 year were included in the study. RESULTS: The study included 416 patients with a mean age of 32.4 years. Isolated PCL injuries (n = 97, 23.3%) were observed less frequently than multiple-ligament injuries (n = 319, 76.7%). Most cases were treated with single-stage surgery (86.8%), while staged surgeries were performed in a minority of cases (13.2%). There was no relationship between trauma mechanisms and multiple-ligament involvement, accompanying injuries, or postoperative complications. Surgeries following car accidents were more likely to occur as staged surgeries (p = 0.014). Additionally, the complication rates for staged surgeries and younger patients (≤ 18 years) were significantly higher (p = 0.009). CONCLUSION: High-energy trauma-induced PCL injuries are often associated with severe concurrent knee injuries with multiple ligament involvement. PCL reconstructions following car accidents are more likely to be staged. These findings highlight the importance of careful consideration in managing these cases to minimize complications, particularly in younger age groups. LEVEL OF EVIDENCE: Level III.
Asunto(s)
Ligamento Cruzado Posterior , Complicaciones Posoperatorias , Sistema de Registros , Humanos , Adulto , Masculino , Femenino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Persona de Mediana Edad , Adulto Joven , Adolescente , Ligamento Cruzado Posterior/lesiones , Ligamento Cruzado Posterior/cirugía , Accidentes de Tránsito , Traumatismos de la Rodilla/cirugía , Traumatismos de la Rodilla/epidemiología , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/epidemiología , Accidentes por Caídas/estadística & datos numéricos , AncianoRESUMEN
We present gallbladder rupture following trauma. A 9-year-old boy admitted in 1.5 hours after injury. Considering clinical and ultrasound data, we diagnosed traumatic damage to the spleen and hemoperitoneum, biliary dyskinesia, cholestasis, sludge. Hemostatic therapy was carried out. After 3 days, signs of peritonitis appeared. Follow-up ultrasound revealed gallbladder enlargement with heterogeneous content, fluid in all parts of abdominal cavity. Intraoperatively, the gallbladder was enveloped in omentum soaked in bile. After mobilization of the gallbladder, we found longitudinal linear tear up to 3 cm clogged with omentum. Cholecystectomy was performed. Thus, we present a patient with combined injury and damage to the spleen. However, gallbladder wall thickening and heterogeneous content were interpreted as concomitant pathology. Delayed manifestation of peritonitis was due to gallbladder enveloped in omentum. The last one soaked in bile partially entered the gallbladder through perforation and prevented bile leakage into abdominal cavity. Timely diagnosis of gallbladder damage presents certain difficulties, especially in case of combined injury. Ultrasound signs of traumatic gallbladder rupture in this case were wall thickening, heterogeneous content and gradual gallbladder enlargement. It is necessary to analyze all organs at the damage site including computed tomography in patients with combined trauma.
Asunto(s)
Colecistectomía , Vesícula Biliar , Ultrasonografía , Humanos , Masculino , Niño , Vesícula Biliar/lesiones , Vesícula Biliar/cirugía , Colecistectomía/métodos , Rotura , Ultrasonografía/métodos , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/cirugía , Resultado del Tratamiento , Traumatismo Múltiple/diagnóstico , Traumatismo Múltiple/cirugía , Bazo/lesiones , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico , Peritonitis/etiología , Peritonitis/diagnóstico , Peritonitis/cirugíaRESUMEN
Traumatic anorectal injuries are rare in pediatric surgical practice. Only several similar cases are described in the world literature. This causes no generally accepted algorithms and tactics for these patients. We demonstrate successful surgical treatment of combined trauma of the rectum and bladder in a child. A 13-year-old boy was hospitalized after the child sat on the leg of an overturned chair. No evidence of penetrating abdominal injury was revealed. The boy underwent sigmoidoscopy under general anesthesia. We found a lacerated wound of anterior wall of the rectum measuring 1/3 of its diameter with damage to posterior wall of the bladder. Diagnostic laparoscopy revealed intact abdominal cavity. Wall defects were sutured (bladder wound was sutured during traditional cystotomy), and we formed protective separate double-barreled sigmostomy. In 3 months after discharge, the child was hospitalized for cystography and fistulography with subsequent closure of stoma. In long-term postoperative period (6 months), the quality of life is satisfactory. There is no pain and disturbances of urination.
Asunto(s)
Recto , Vejiga Urinaria , Humanos , Masculino , Adolescente , Vejiga Urinaria/cirugía , Vejiga Urinaria/lesiones , Recto/cirugía , Recto/lesiones , Resultado del Tratamiento , Laparoscopía/métodos , Sigmoidoscopía/métodos , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/diagnóstico , Índices de Gravedad del TraumaRESUMEN
Despite available armored personal protection in troops, the incidence of abdominal wounds in modern wars is 6.6-9.0%. Of these, penetrating abdominal injuries comprise 75-80%. Thoracoabdominal injuries occupy a special place with incidence up to 88%. We present the first case of the "Koblenz algorithm" in the treatment of a patient with mine explosion wound, combined injury of the head, limbs, thoracoabdominal trauma, widespread peritonitis, small intestinal obstruction and septic shock in a military hospital. This algorithm was implemented under import substitution considering the peculiarities of abdominal adhesive process in a patient with thoracoabdominal wound. This case demonstrates the advantage of this algorithm for patients with severe combined wounds of the chest and abdomen complicated by diffuse purulent peritonitis. Clinical status of these patients does not allow not only open laparostomy, but also "classical" redo laparotomies.
Asunto(s)
Traumatismos Abdominales , Algoritmos , Hospitales Militares , Laparotomía , Traumatismos Torácicos , Humanos , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/diagnóstico , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/complicaciones , Masculino , Laparotomía/métodos , Peritonitis/cirugía , Peritonitis/etiología , Peritonitis/diagnóstico , Traumatismos por Explosión/cirugía , Traumatismos por Explosión/diagnóstico , Adulto , Resultado del Tratamiento , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/diagnóstico , Choque Séptico/etiología , Choque Séptico/cirugía , Choque Séptico/diagnósticoRESUMEN
OBJECTIVES: To identify the infection rate in patients with combined pelvic ring and bladder injuries. Secondary aims included identifying treatment and injury factors associated with infection. DESIGN: Retrospective review. SETTING: Single Level I Tertiary Academic Center. PATIENTS SELECTION CRITERIA: All patients over a 12-year period with combined pelvic ring and bladder injuries were evaluated. Exclusion criteria were nonoperative management of the pelvic ring, isolated posterior fixation, and follow-up <90 days. OUTCOME MEASURE AND COMPARISONS: Primary outcome measured was deep infection of the anterior pelvis requiring surgical irrigation and debridement. RESULTS: In total, 106 patients with anterior stabilization of the pelvis in the setting of a bladder injury were included. Seven patients (6.6%) developed a deep infection and required surgical debridement within 90 days. Patients undergoing open reduction and internal fixation with plating of the anterior pelvis and acute concomitant bladder repair had an infection rate of 2.2% (1/43). Patients undergoing closed reduction and anterior fixation with either external fixation or percutaneous rami screw after bladder repair had an infection rate of 17.6% (3/17). There was a higher infection rate among patients with combined intraperitoneal (IP) and extraperitoneal (EP) bladder injuries (23%) when compared with those with isolated EP (3.8%) or IP (9.1%) bladder injuries (P = 0.029). CONCLUSIONS: Acute open reduction and internal fixation of the anterior pelvis in patients with combined pelvic ring and bladder injuries has a low infection rate. Patients with combined IP and EP bladder injuries are at increased risk of infection compared with those with isolated IP and EP injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas Óseas , Huesos Pélvicos , Vejiga Urinaria , Humanos , Masculino , Huesos Pélvicos/lesiones , Estudios Retrospectivos , Femenino , Vejiga Urinaria/lesiones , Vejiga Urinaria/cirugía , Adulto , Persona de Mediana Edad , Fracturas Óseas/cirugía , Fracturas Óseas/complicaciones , Fijación Interna de Fracturas/efectos adversos , Factores de Riesgo , Adulto Joven , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Desbridamiento , Anciano , Traumatismo Múltiple/cirugía , Resultado del TratamientoRESUMEN
The challenge in treating traumatic hemipelvectomy is the dynamics of the complex and life-threatening consequences of the injury. These include skin and soft tissue defects, osseous, neural and vascular injuries as well as the subsequent hemostatic derangement and organ dysfunction as part of the shock process. The treatment requires rapid and targeted decisions to save the patient's life. In this particular case a 34-year-old farmer was trapped between a wheeled loader and a stationary trailer. Upon arrival at the hospital the patient was in a state of hemorrhagic shock with accompanying acute traumatic coagulopathy and a grade III open pelvic trauma with complete ischemia of the left leg and a bladder injury. After performing emergency surgery and a two-stage approach for pelvic stabilization the patient's condition deteriorated up to multiorgan failure, necessitating left-sided hemipelvectomy as an immediate life-saving salvage procedure. In the further course multiple revision surgeries and plastic reconstructions due to wound infections and the presence of skin and soft tissue damage were required. Due to the rare confrontation with this type of injury in everyday practice and the absence of a universal treatment algorithm, the following case report is intended to contribute to a better understanding of the treatment and to illustrate the coherent interactions of the individual organ systems affected.
Asunto(s)
Hemipelvectomía , Humanos , Adulto , Masculino , Hemipelvectomía/métodos , Traumatismo Múltiple/cirugía , Resultado del Tratamiento , Huesos Pélvicos/lesiones , Huesos Pélvicos/cirugía , Traumatismos de la Pierna/cirugía , Cirugía de Cuidados IntensivosRESUMEN
BACKGROUND: Fiberoptic-guided intubation is considered as "gold standard" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist. CASE PRESENTATION: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient's recovery was uneventful, and he was discharged from the hospital one month after the surgery. CONCLUSIONS: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.
Asunto(s)
Tecnología de Fibra Óptica , Intubación Intratraqueal , Traumatismo Múltiple , Humanos , Masculino , Posición Prona , Intubación Intratraqueal/métodos , Traumatismo Múltiple/cirugía , Vigilia , Adulto , Choque Hemorrágico/etiología , Choque Hemorrágico/cirugía , Choque Hemorrágico/terapia , Posicionamiento del Paciente/métodosRESUMEN
PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.
Asunto(s)
Fracturas del Fémur , Tiempo de Internación , Humanos , Fracturas del Fémur/cirugía , Femenino , Masculino , Adulto , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Traumatismo Múltiple/cirugía , Estudios Retrospectivos , Tiempo de Tratamiento/estadística & datos numéricos , Fijación de Fractura/métodos , Complicaciones Posoperatorias/epidemiología , Fijación Interna de Fracturas/métodos , Resultado del Tratamiento , Mejoramiento de la Calidad , Puntaje de Propensión , Factores de TiempoRESUMEN
OBJECTIVE: Aim: Analyzing of the last-time papers in this subject in organizing, diagnostic and surgery tactic is the aim of this work. PATIENTS AND METHODS: Materials and Methods: The study analyzed the experience of treating patients with maxillofacial polytrauma before and after February 24, 2022. Research methods: bibliographic, systematic, comparative, general clinical, radiological and retrospective analysis. CONCLUSION: Conclusions: Tactic of the multidisciplinal team should based on the principles of damage control, which involves the initial performance of manipulations and surgical interventions that ensure the patient's survival. Modern strategies for infusion-transfusion therapy play a significant role in severe trauma cases. Choosing the rational management of this therapy for severe trauma remains an important issue. Reconstructive surgeries are recommended to be performer deferred, after surgical wound management, neurosurgical interventions and stabilization of the patient common status. Patients with maxillofacial polytrauma needs in specialized medical care at all the levels. Active wound management aimed at creating favorable conditions for healing, comprehensive medical treatment, prevention, early detection and timely treatment of complications.
Asunto(s)
Traumatismos Maxilofaciales , Traumatismo Múltiple , Humanos , Traumatismos Maxilofaciales/cirugía , Traumatismos Maxilofaciales/terapia , Traumatismo Múltiple/terapia , Traumatismo Múltiple/cirugía , Procedimientos de Cirugía Plástica/métodosRESUMEN
OBJECTIVE: To reduce the incidence of postoperative complications and mortality after conversion of external fixation device into various types of submerged osteosynthesis in patients with polytrauma. MATERIAL AND METHODS: A retrospective and prospective analysis of treatment outcomes in 351 patients with polytrauma was divided into 2 stages. At the first stage, we analyzed significant predictors of complications after conversion of osteosynthesis in the 1st group (retrospective analysis). At the second stage, we estimated the efficacy of the developed scale for assessing the risk of complications after conversion of osteosynthesis in a prospective group of patients. RESULTS: According to the complication risk assessment scale for conversion of osteosynthesis, analysis of time to surgical treatment depending on objective criteria in patients with polytrauma can significantly reduce the incidence of postoperative complications by 14% and mortality rate by 1.7%. CONCLUSION: The complication risk assessment scale after conversion of osteosynthesis will personalize the approach to timing and methods of conversion. This measure will eliminate the «second hit¼ in damage control orthopedics and improve the results of treatment.
Asunto(s)
Fijación Interna de Fracturas , Traumatismo Múltiple , Complicaciones Posoperatorias , Humanos , Masculino , Femenino , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/mortalidad , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/efectos adversos , Persona de Mediana Edad , Adulto , Federación de Rusia/epidemiología , Medición de Riesgo/métodos , Estudios RetrospectivosRESUMEN
Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.
Asunto(s)
Fracturas del Radio , Traumatismos de la Muñeca , Fracturas del Radio/cirugía , Humanos , Traumatismos de la Muñeca/cirugía , Curación de Fractura , Traumatismo Múltiple/cirugía , Fracturas del Cúbito/cirugía , Fracturas del Cúbito/terapia , Resultado del Tratamiento , Terapia Combinada , Fracturas de la MuñecaRESUMEN
BACKGROUND: Cases of bilateral hip fractures are rare, and even more so are cases of bilateral intertrochanteric fractures. Common causes include trauma, internal diseases, and primary or secondary bone diseases. We report a case of bilateral intertrochanteric fractures in an elderly patient following a severe car accident, a scenario not extensively reported in existing literature. CASE PRESENTATION: We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities. CONCLUSION: Managing bilateral intertrochanteric fractures, particularly in the elderly with severe trauma, is notably challenging due to their rarity. However, a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses.
Asunto(s)
Accidentes de Tránsito , Fijación Intramedular de Fracturas , Fracturas de Cadera , Humanos , Masculino , Anciano de 80 o más Años , Fracturas de Cadera/cirugía , Fracturas de Cadera/diagnóstico por imagen , Fijación Intramedular de Fracturas/métodos , Resultado del Tratamiento , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/diagnóstico por imagenRESUMEN
BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late trauma deaths, with primarily non-modifiable risk factors. Timing of surgery as a potentially modifiable risk factor is frequently proposed, but has not been quantified. We aimed to compare mortality, hospital length of stay (LOS), and ICU LOS between MOF patients who had surgery that preceded MOF with modifiable timings versus those with non-modifiable timings. METHODS: Retrospective analysis of an ongoing 17-year prospective cohort study of ICU polytrauma patients at-risk of MOF. Among MOF patients (Denver score>3), we identified patients who had surgery that preceded MOF, determined whether the timing of these operation(s) were modifiable(M) or non-modifiable (non-M), and evaluated the change in physiological parameters as a result of surgery. RESULTS: Of 716 polytrauma patients at-risk of MOF, 205/716 (29%) developed MOF, and 161/205 (79%) had surgery during their ICU admission. Of the surgical MOF patients, 147/161 (91%) had one or more operation(s) that preceded MOF, and 65/161 (40%) of them had operation(s) with modifiable timings. There were no differences in age (mean (SD) 52 (19) vs 53 (21)years), injury severity score (median (IQR) 34 (26-41)vs34 (25-44)), admission physiological and resuscitation parameters, between M and non-M-patients. M patients had longer ICU LOS (median (IQR) 18 (12-28)versus 11 (8-16)days, p < 0.0001) than non-M-patients, without difference in mortality (14%vs16%, p = 0.7347), or hospital LOS (median (IQR) 32 (18-52)vs27 (17-47)days, p = 0.3418). M-patients had less fluids and transfusions intraoperatively. Surgery did not compromise patient physiology. CONCLUSION: Operations preceding MOF are common in polytrauma and seem to be safe in maintaining physiology. The margin for improvement from optimizing surgical timing is modest, contrary to historical assumptions.
Asunto(s)
Tiempo de Internación , Insuficiencia Multiorgánica , Traumatismo Múltiple , Humanos , Insuficiencia Multiorgánica/mortalidad , Insuficiencia Multiorgánica/etiología , Femenino , Masculino , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Estudios Retrospectivos , Adulto , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/mortalidad , Traumatismo Múltiple/complicaciones , Factores de Tiempo , Unidades de Cuidados Intensivos/estadística & datos numéricos , Factores de Riesgo , Mortalidad Hospitalaria , Estudios Prospectivos , AncianoRESUMEN
The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.
Asunto(s)
Traumatismos Abdominales , Hígado , Páncreas , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/terapia , Traumatismos Abdominales/diagnóstico , Humanos , Hígado/lesiones , Hígado/diagnóstico por imagen , Hígado/cirugía , Páncreas/lesiones , Páncreas/cirugía , Páncreas/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/terapia , Heridas no Penetrantes/diagnóstico , Bazo/lesiones , Bazo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/diagnóstico por imagen , Traumatismo Múltiple/diagnóstico , Laparotomía , Riñón/lesiones , Riñón/diagnóstico por imagenAsunto(s)
Disección Aórtica , Traumatismo Múltiple , Humanos , Disección Aórtica/cirugía , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/etiología , Disección Aórtica/complicaciones , Masculino , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Accidentes de TránsitoRESUMEN
INTRODUCTION: There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide. METHODS: We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates. RESULTS: The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34). CONCLUSION: Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Asunto(s)
Anticoagulantes , Traumatismo Múltiple , Procedimientos Ortopédicos , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Tromboembolia Venosa/epidemiología , Femenino , Masculino , Traumatismo Múltiple/complicaciones , Traumatismo Múltiple/cirugía , Estudios Retrospectivos , Persona de Mediana Edad , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/métodos , Anticoagulantes/administración & dosificación , Adulto , Anciano , Estados Unidos/epidemiología , Factores de Tiempo , Centros Traumatológicos , Fracturas del Fémur/cirugía , Fracturas del Fémur/complicaciones , Tiempo de Tratamiento/estadística & datos numéricos , Huesos Pélvicos/lesiones , Factores de Riesgo , Fracturas de Cadera/cirugía , Fracturas de Cadera/complicaciones , Embolia Pulmonar/prevención & control , Embolia Pulmonar/etiologíaRESUMEN
BACKGROUND: Multiple displaced rib fractures often result in a poor prognosis. Open reduction and internal fixation has been shown to provide benefits for patients with displaced rib fractures and flail chest. Nevertheless, for patients who are unwilling or unsuitable for surgery, the therapeutic options are limited. We developed a novel plastic vacuum device for rib fractures external stabilization. This study aims to compare the therapeutic efficacy of this device against a traditional chest strap in polytrauma patients with multiple rib fractures. METHODS: A retrospective investigation was conducted on polytrauma patients with multiple rib fractures admitted to our trauma center between March 2020 and March 2023. Patients were categorized into two groups: vacuum external fixation and chest strap. Comparative analysis was conducted on baseline parameters, injury characteristics, and clinical outcomes between the two groups. RESULTS: In this study, 54 patients were included, with 28 receiving chest strap and 26 undergoing vacuum external fixation. Results showed that, at 3 days and 7 days postintervention, the vacuum external fixation group had significantly lower visual analog scale scores during deep breathing and coughing (P < .05). Vacuum external fixation also reduced pleural drainage duration and volume, as well as lowered the risk of pneumonia and other complications (P < .05). Furthermore, the vacuum external fixation group demonstrated notable improvements in vital capacity, tidal volume, blood-gas test results, and a shorter hospital length of stay. CONCLUSIONS: According to the study findings, vacuum external fixation appears to offer benefits to patients with multiple rib fractures, potentially reducing the risk of complications and improving overall clinical outcomes.
Asunto(s)
Fijación de Fractura , Traumatismo Múltiple , Fracturas de las Costillas , Humanos , Fracturas de las Costillas/cirugía , Fracturas de las Costillas/terapia , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/terapia , Fijación de Fractura/métodos , Fijación de Fractura/instrumentación , Vacio , Adulto , Fijadores Externos , Anciano , Resultado del Tratamiento , Tiempo de Internación , Fracturas Múltiples/cirugíaRESUMEN
OBJECTIVE: To analyze the application value of damage control strategies combining pre-hospital emergency treatment with in-hospital treatment for multiple injuries in treating pelvic fracture complicated by multiple injuries. METHODS: 120 patients with pelvic fracture complicated by multiple injuries admitted to our hospital from January 2020 to January 2023 were selected and divided into a damage control group (early temporary reduction after resuscitation, n = 60) and a control group (no reduction and resuscitation only, n = 60) by treatment methods. The control group was treated with conventional methods, while the damage control group was treated with the damage control strategy combining pre-hospital emergency treatment combined with in-hospital treatment in addition to conventional methods. The mortality rate, complication rate, fracture reduction quality, long-term efficacy, and patient satisfaction of the two groups were compared. RESULTS: The mortality rate of the damage control group was lower than that of the control group, and the difference has statistical significance (P<0.05); the incidence of infection, DIC, and MODS of the damage control group were lower than that of the control group, with the difference being statistically significant (P<0.05); the incidence of ARDS in the two groups is not that different (P>0.05); the fracture reduction quality and long-term therapeutic effect of patients in the two groups were statistically different, with the damage control group outperforming the control group in both aspects; the difference between the two groups in terms of patient satisfaction was statistically significant (P<0.05), with the patient satisfaction of the damage control group being higher than that of the control group. CONCLUSION: For patients with pelvic fracture, the application of the damage control strategy combining pre-hospital emergency treatment and in-hospital treatment is a boon to the standardization of the treatment process, the improvement of the treatment success rate and fracture reduction quality and the reduction of complications, and therefore is worth promoting in clinical practice. the early application of external fixation has helped with the definitive reduction at a time when the patuent was stable.