Emergency Major Surgery in Thoracic Trauma: Timing and Decision Process

BackgroundSurgery plays a key role in HIV palliative care, specifically in the diagnosis and treatment of HIV related and non-related conditions. Yet major surgery depresses the immune system. Whereas the surgical consequences of HIV infection are well described, there is a paucity of published data, in resource-limited settings, on the effects of major surgery on the immune system. The purpose of this study was to determine the effect of major abdominal surgery on CD4 count in HIV positive and HIV negative patients after emergency major surgery.MethodsA prospective cohort study was done for patients who underwent emergency major abdominal surgery. Their peri-operative CD4 counts were done for both HIV- and HIV + patients. Median CD4s were used in analysis.Mann Whitney test of significance was used for continuous data and Fisher’ exact test used for categorical data. IRB approval was obtained.ResultsA total of 101 patients were recruited, 25 HIV positive and 76 HIV negative. The median CD4 cell reduction was higher in the HIV negative group (−68 cells) than HIV positive group (−29 cells) (p = 0.480).There was a general increase in the median CD4 change by 72 cells for the HIV positives and 95 cells for the HIV negatives (p = 0.44). CD4 change rose in both the HIV positive and negative groups by 27 cells for the HIV positives and 28 cells for the HIV negatives (p = 0.94). Relative Risk was 0.96, {CI 0.60 – 1.53}.ConclusionMajor emergency abdominal surgery had no significant effect on CD4 cell count among HIV positive patients.

There is limited evidence regarding the overall feasibility and success rates of the laparoscopic approach in major emergency surgery, despite its potential to improve outcomes. This study aims to investigate the association between patient, procedural, and surgical factors and likelihood of successful laparoscopic completion in emergency major surgery and derive a predictive model to aid clinical decision-making. All patients recorded in the NELA emergency laparotomy database 1 December 2013-31 November 2018 who underwent laparoscopically attempted surgery were included. A retrospective cohort multivariable regression analysis was conducted for the outcome of conversion to open surgery. A predictive model was developed and internally validated. Of 118,355 patients, 17,040 (7.7%) underwent attempted laparoscopic surgery, of which 7.915 (46.4%) were converted to open surgery. Procedure type was the strongest predictor of conversion (compared to washout as reference, small bowel resection OR 25.93 (95% CI 20.42-32.94), right colectomy OR 6.92 (5.5-8.71)). Diagnostic [free pus, blood, or blood OR 3.67 (3.29-4.1)] and surgeon [subspecialist surgeon OR 0.56 (0.52-0.61)] factors were also significant, whereas age, gender, and pre-operative mortality risk were not. A derived predictive model had high internal validity, C-index 0.758 (95% CI 0.748-0.768), and is available for free-use online. Surgical, patient, and diagnostic variables can be used to predict likelihood of laparoscopic success with a high degree of accuracy. This information can be used to inform peri-operative decision-making and patient selection.

Trauma care of thoracic and abdominal injuries is currently in turmoil because of both a decrease in the number of these injuries and a concomitant increase in their nonsurgical management. The goal of this study was to evaluate the incidence of thoracic and abdominal injuries in the province of Quebec and the number of associated surgical procedures. Patients with blunt thoracic or abdominal injuries taken to a tertiary trauma center in the province of Quebec from April 1, 1998 to March 31, 2002 were identified. Patients who were dead on arrival were excluded. Only patients with an Abbreviated Injury Scale score > or =2 for the thoracic or abdominal regions were included. During the study period, a total of 16,430 blunt trauma patients were admitted to one of the four trauma centers. A total of 2,660 (16.2%) patients sustained thoracic and/or abdominal injuries with an Abbreviated Injury Scale score >1. Among these, the median Injury Severity Score was 24 (range: 4-75) and the in-hospital mortality rate was 11.0%. There were 2,196 patients (82.5%) with thoracic injuries, 977 patients (36.7%) with abdominal injuries, and 520 patients (19.5%) with injuries to both regions. A surgical intervention was undertaken in 76 patients with thoracic injuries (3.5%) and in 414 patients with abdominal injuries (42.3%). On average, 4.7 thoracic and 28.8 abdominal trauma procedures were performed per center, yearly. Each trauma surgeon performed, on average, less than one thoracic and less than five abdominal trauma procedures yearly. The incidence of blunt thoracic and abdominal injuries needing surgical intervention is low in Quebec tertiary trauma centers. The competence of general surgeons in trauma-related procedures might be compromised by such low patient volume unless they frequently perform non-trauma surgical procedures. We think that in Quebec, trauma care must be provided by surgeons who practice both acute emergency and elective surgical care in addition to trauma care. These findings should have an important impact on the development of on-going education and resident training programs.

Patterns of concomitant injury in thoracic spine fractures

<p><strong>Background</strong>: The bulk of spine injuries that result in permanent injury happen as a result of vehicle accidents. Objective of the study was to estimate the incidence, outcome, and causes of spinal fractures.</p><p><strong>Methods</strong>: From January 2018 to December 2019, data were obtained from the trauma register database of all traumatic spinal injuries admitted to the section of trauma surgery, department of Meenakshi medical college hospital and research institute, Kanchipuram, Tamil Nadu. Demographic information as well as injury severity Ratings were gathered. SPSS (trial version 24) was used for analysis.</p><p><strong>Results:</strong> A total of 513 (14%) of the 3665 patients referred to the trauma surgery section had spinal injuries, with an average age of 34.2 11 years. The leading causes of cervical injuries (p0.05) were motor car collisions (38.5%) and accidents from great heights (20.3%). The injury level scale ranged from 4 to 70. In 25% of cases, lumbar injury was linked with thoracic injury (p<0.001). A mixture of thoracic and Lumber injuries is associated to a cervical injury in 35% of cases (p<0.001). A total of 4.4 percent of injuries were linked to neurological deficits. Fifty-nine cases of spine fractures were surgically treated, with 12 of them having neurological deficits. The overall mortality rate was 3%.</p><p><strong>Conclusions:</strong> In these areas, spinal fractures are rare. The most common neurological deficits are caused by cervical and thoracic spine injuries. Young males are the most vulnerable group, and accident prevention services in the workplace and enforcement of traffic laws should be prioritized for them.</p>

Objective: Chest trauma, as blunt or penetrating injury, account for significant amount of all traumatic injuries. They are associated with high mortality of about 75% of all trauma-related deaths, either from direct or indirect consequence of the injury. Nearly 80-85 % of chest trauma is managed conservatively with only about 10-15 % needing emergency surgery.Methodology: A retrospective cohort study of patients presenting with chest trauma and undergoing emergency thoracic surgery at the Komfo Anokye Teaching Hospital from January 2015 to June 2020 was carried out.Results: There were 29 patients, with 82.8% (24) being males. The mean age was 33.8 ± 15.0 years with range of 5-65 years. The leading mechanism of chest trauma was penetrating chest injury, which accounted for 51.7% (15). Eighteen (86%) patients underwent exploratory thoracotomy with 5 (10%) having exploratory sternotomy and the remaining 4% undergoing other procedures. Fourteen (82.1%) patients out of the eighteen who underwent the thoracotomy had a left thoracotomy with four (24.1%) patients having right thoracotomy. The major indication for surgery in acute thoracic trauma was traumatic diaphragmatic rupture (62.1%) followed byimpalement injury (17.2%), traumatic thoracotomy (6.9%), cardiac tamponade (6.9%), massive haemothorax (3.5%), and vascular injury (3.5%). There were no mortality over the 5-year period.Conclusion: The leading indication for emergency thoracic surgery in chest trauma was traumatic diaphragmatic rupture caused mostly by penetrating thoracic injury. Thoracotomy was the major emergency thoracic surgical approach performed.

Chest trauma in childhood is relatively uncommon in clinical practice, and has been the subject of few reports in the literature. This study was undertaken to examine our experience in dealing with chest trauma in children. This was a retrospective study of 74 children who sustained chest trauma, and were referred to King Fahad Hospital in Medina over a two-year period. The age, cause of injury, severity of injury, associated extrathoracic injuries, treatment and outcome were analyzed. The median age of the patients was nine years. Fifty-nine of them (80%) sustained blunt trauma, and 15 (20%) were victims of penetrating injuries. Road traffic accident was the cause of chest trauma in 62% of the children, gun shot wounds were seen in five, and stab wounds in 10 children. Head injury was the most common injury associated with thoracic trauma, and was seen in 14 patients (19%), and associated intraabdominal injuries were seen in nine patients. Chest x-ray of the blunt trauma patients revealed fractured ribs in 24 children, pneumothorax in six, hemothorax in four, hemopneumothorax in three, and pulmonary contusions in 22 patients. Fifty-one percent of children were managed conservatively, 37% required tube thoracostomy, 8% were mechanically ventilated, and 4% underwent thoracotomy. The prevalence of chest trauma in children due to road traffic accidents is high in Saudi Arabia. Head injury is thought to be the most common associated extrathoracic injuries, however, most of these patients can be managed conservatively.

Clinically Significant Occult Injuries are Rare on Advanced Chest Imaging

To undertake a national outcomes analysis following major head and neck cancer surgery in order to identify risk factors for complications and in-hospital mortality, as well as areas whose closer examination and formal benchmarking in the context of local and national quality assurance audits may lead to improved results for this condition. An analysis using Hospital Episode Statistics data. All units undertaking major head and neck cancer surgery in England. Cancer sites, co-morbidities, social deprivation, surgical and non-surgical treatments, complications, and in-hospital mortality were recorded. Regression analysis was used for casemix adjustment and for identifying independent predictors of complications and mortality. Funnel plots were used for data visualisation. We identified 10,589 major head and neck cancer operations performed in England between 2006 and 2011. There were 7312 males, and mean age at surgery was 63 ± 13 years. Oral cavity (42%) and the larynx (28%) were the commonest cancer sites. At least one complication occurred in 33.1% of patients, and there were 322 (3.05%) in-hospital deaths. Variables associated with in-hospital mortality were trust volume, age, co-morbidities, performing emergency major surgery and performing a tracheostomy or reconstructive surgery. Occurrence of major medical complications including pulmonary infections (7%), major acute cardiovascular events (4.7%) and acute renal failure (0.6%) also increased mortality risk. The analysis identified units that were outside of crude and risk-adjusted 99.8% limits of confidence for complications and mortality. Mortality following head and neck cancer surgery shows significant national variation and is associated with fixed risk factors like age and co-morbidities, but also with modifiable risk factors like performing major surgery during an emergency admission, tracheostomy, reconstructive surgery and medical complications. We propose that the quality of tracheostomy care, reconstructive surgery, emergency major surgery rate, and occurrence and treatment of major medical complications should be closely examined and formally benchmarked as part of loco-regional and national quality improvement audits.

Background:Motor vehicle crashes and falls account for most of the spine fractures with subsequent serious disability.Aim:To define the incidence, causes, and outcome of spinal fractures.Materials and Methods:Data were collected retrospectively from trauma registry database of all traumatic spinal injuries admitted to the section of trauma surgery in Qatar from November 2007 to December 2009.Results:Among 3712 patients who were admitted to the section of trauma surgery, 442 (12%) injured patients had spinal fractures with a mean age of 33.2 ± 12 years. The male to female ratio was 11.6:1. Motor vehicle crashes (36.5%) and falls from height (19.3%) were the leading causes of cervical injury (P = 0.001). The injury severity score ranged between 4 and 75. Nineteen percent of cases with cervical injury had thoracic injury as well (P = 0.04). Lumber injury was associated with thoracic injury in 27% of cases (P < 0.001). Combined thoracic and lumber injuries were associated with cervical injury in 33% of cases (P < 0.001). The total percent of injuries associated with neurological deficit was 5.4%. Fifty-three cases were managed surgically for spine fractures; 14 of them had associated neurological deficits. Overall mortalityrate was 5%.Conclusions:Spine fractures are not uncommon in Qatar. Cervical and thoracic spine injuries carry the highest incidence of associated neurological deficit and injuries at other spinal levels. Young males are the most exposed population that deserves more emphasis on injury prevention programs in the working sites and in enforcement of traffic laws.

Utilization of Cardiothoracic Surgeons for Operative Penetrating Thoracic Trauma and Its Impact on Clinical Outcomes

The 8th Albanian Congress of Trauma and Emergency Surgery (ACTES 2024) was a dynamic platform for exchanging cutting-edge knowledge, clinical expertise, and innovative trauma and emergency surgery research. This prestigious event will convene leading professionals from Albania and the international medical community, including surgeons, researchers, and healthcare providers. The congress aims to address contemporary challenges and advancements in trauma care, emergency surgical techniques, and interdisciplinary approaches to patient management. Key themes include the role of minimally invasive surgery in trauma, advancements in hemostatic techniques, damage control marks a pivotal event in the medical community, providing a dynamic platform for knowledge exchange, professional collaboration, and advancements in surgical science in Albania. This congress brings together experts, scholars, practitioners, and enthusiasts from trauma and emergency surgery, creating an opportunity for meaningful dialogue and innovation. Hosted in the vibrant city of Tirana, ACTES 2024 features a comprehensive program that addresses a broad spectrum of topics, including abdominal and chest injuries, vascular trauma, emergency surgical procedures, and the evolving challenges in nursing services for the modern era. The congress theme, "Trauma and emergency surgery and not only…” underscores a commitment to innovation, evidence-based practices, and groundbreaking discoveries. The event includes plenary sessions with renowned experts, scientific presentations, panel discussions, poster awards, networking opportunities, industry exhibitions, cultural activities, and Continuing Medical Education (CME) credits. Primary Content: Participants can expect an enriching professional experience complemented by opportunities for personal growth. The congress promotes collaboration, fosters international partnerships, and highlights the vital role of each attendee in advancing surgical knowledge and improving patient care. The ACTES 2024 is a dynamic platform for exchanging cutting-edge knowledge, clinical expertise, and innovative trauma and emergency surgery research. This prestigious event will convene leading professionals from Albania and the international medical community, including surgeons, researchers, and healthcare providers. The congress aims to address contemporary challenges and advancements in trauma care, emergency surgical techniques, and interdisciplinary approaches to patient management. Key themes include the role of minimally invasive surgery in trauma, advancements in hemostatic techniques, damage control resuscitation, the integration of trauma registries, and strategies for improving outcomes in mass casualty incidents. ACTES 2024 also emphasizes the importance of education and collaboration, featuring interactive workshops, live demonstrations, and case-based discussions. These sessions aim to enhance participants' practical skills and foster partnerships among institutions across the region and beyond. Through its comprehensive scientific program, ACTES 2024 underscores its commitment to elevating trauma and emergency surgical care standards, supporting evidence-based practice, and advocating for policy improvements in healthcare systems. This congress represents a unique opportunity to share insights, build networks, and shape the future of trauma and emergency surgery in Albania and the global healthcare community. Conclusion:ACTES 2024 is not just a gathering; it is a movement toward transforming the future of trauma and emergency surgery. Through active participation, the event aims to inspire innovation, encourage global collaboration, and make a lasting impact on surgical care worldwide. The 8th Albanian Congress of Trauma and Emergency Surgery is committed to continuously improving trauma and emergency care standards in Albania and beyond. By creating a space for learning, collaboration, and knowledge exchange, this congress strengthens the foundation for innovation and evidence-based practice. As healthcare professionals unite to share their expertise and insights, ACTES 2024 will undoubtedly impact trauma and emergency surgery trajectories, ultimately improving patient outcomes. Keywords: Trauma care; Emergency surgery; Damage control surgery; Minimally invasive techniquesMinimally invasive techniques; Multidisciplinary care; Acute care medicine; Hemostasis techniques; Mass casualty management; Surgical innovation; Trauma registries; Evidence-based practice; Healthcare systems improvement; Patient outcomes; Surgical education; Regional collaboration; ATLS, Trauma management; trauma education; BAT, PAT, abdominal injury, pelvic injury, acute care surgery, abdomen acute, oncologic surgery, cardiac surgery, AI, bariatric surgery, sleeve resection, chest trauma, lung cancer, vascular surgery, hernia surgery, colorectal cancer, pain, lung diseases, MVC, car accident, emergency medicine; Trauma care, emergency surgery, abdominal injuries, chest trauma, vascular injuries, nursing challenges, surgical innovation, CME credits, international collaboration, evidence-based practices.

Chest Injury - Horseback Riding Philipp J. Underwood, Bryan M. McCarty, Hillary Moss, North Shore University Hospital, Manhasset, NY HISTORY: A 56 year old female fell off of her horse, causing her to land on her right shoulder. She experience immediate severe pain in her right shoulder and chest. She denied any head, neck or spine injury or pain, and denied numbness, weakness, paresthesia or headache. She reported no shortness of breath, abdominal pain or extremity injury or pain. PHYSICAL EXAMINATION: The patient reported pain of 10/10 on arrival and had an elevated blood pressure. Other vital signs were normal. Primary survey was unremarkable. On secondary survey, head, neck and spine were normal. Ribs and abdomen were also normal. Examination of upper extremity revealed deformity of the right shoulder girdle with tenderness and swelling over the proximal right clavicle. The neuro-vascular exam of the upper extremities were normal and symmetrical. She was not able to move the right shoulder due to severe pain. The lower extremities were normal. Neurological examination was normal as was examination of the skin. DIFFERENTIAL DIAGNOSIS: 1.Clavicle fracture 2.Sterno-clavicular (SC) dislocation 3.Rib fracture 4.Pectoralis muscle tear TESTS AND RESULTS: Chest Xray, Clavicle Xray, Shoulder Xray - fracture medial right clavicle and possible dislocation of SC joint CT of Head and Cervical spine - unremarkable and without acute injury CT of Abdomen and Pelvis - unremarkable and without acute injury CT of Chest - fracture and posterior dislocation of the right SC joint with compression of the brachiocephalic artery and vein FINAL/WORKING DIAGNOSIS: Fracture and posterior dislocation of the right SC joint with compression of the brachiocephalic artery and vein TREATMENT AND OUTCOMES: 1.Evaluation by Trauma Surgery, Cardio-Thoracic Surgery with admission to Orthopedics for operative repair 2.Taken to OR and under general anesthesia and fluoroscopic visualization, reduction of SC dislocation 3.Reduction was unstable and ORIF performed with trans-osseous sutures and reconstruction of capsule 4.Discharged next day on Xarelto for 8 weeks and no weight bearing of right upper extremity 5.Physical therapy for 8 weeks begun 2 weeks post op. 6.Patient has returned to riding and experiences only minimal stiffness at right SC joint

Trauma surgery is a surgical specialty that utilizes both operative and non-operative management to treat traumatic injuries, typically in an acute setting. The trauma surgeon is responsible for initially resuscitating and stabilizing and later evaluating and managing the patient. Emergency surgery is surgery to treat trauma or acute illness after an emergency presentation. This book examines trauma and emergency surgery for abdominal, aortic, chest, brain, and burn injuries.

Patients with a thoracic trauma are commonly treated by large bore chest tube thoracostomy and appropriate analgesia. The initial treatment is determined by the assessment of the emergency doctor and/or trauma surgeon. Severe intrathoracic lesions in polytrauma patients are rare. However, such injuries may be acutely life-threating. After primary stabilisation of the patients, imaging studies should be performed to assess the extent of the injuries and determine the treatment of choice. Assessment of such injuries should always be performed in a multidisciplinary team of anaesthesiologists, general surgeons, trauma surgeons and thoracic surgeons. For this reason, patients with thoracic traumas should always be treated in specialised centers. This approach reduces overall mortality and shortens the length of hospital stay.