Advances In Trauma Care Research Articles

TBI related death has become the new epidemic in polytrauma: a 10-year prospective cohort analysis in severely injured patients.

Advances in trauma care have attributed to a decrease in mortality and change in cause of death. Consequently, exsanguination and traumatic brain injury (TBI) have become the most common causes of death. Exsanguination decreased by early hemorrhage control strategies, whereas TBI has become a global health problem. The aim of this study was to investigate trends in injury severity,physiology, treatment and mortality in the last decade. In 2014, a prospective cohort study was started including consecutive severely injured trauma patients > 15years admitted to a Level-1 Trauma Center ICU. Demographics,physiology,resuscitation, and outcome parameters were prospectively collected. Five hundred and seventy-eight severely injured patients with predominantly blunt injuries (94%) were included. Seventy-two percent were male with a median age of 46 (28-61) years, and ISS of 29 (22-38). Overall mortality rate was 18% (106/578) with TBI (66%, 70/106) being the largest cause of death. Less than 1% (5/578) died of exsanguination. Trend analysis of the 10-year period revealed similar mortality rates despite an ISS increase in the last 2years. No significant differences in demographics,and physiology in ED were noted. Resuscitation strategy changed to less crystalloids and more FFP. Risk factors for mortality were age,brain injury severity,base deficit,hypoxia,and crystalloid resuscitation. TBI was the single largest cause of death in severely injured patients in the last decade. With an aging population TBI will increase and become the next epidemic in trauma. Future research should focus on brain injury prevention and decreasing the inflammatory response in brain tissue causing secondary damage, as was previously done in other parts of the body.

Enhancing Trauma Care: A Machine Learning Approach with XGBoost for Predicting Urgent Hemorrhage Interventions Using NTDB Data.

Trauma is a leading cause of death worldwide, with many incidents resulting in hemorrhage before the patient reaches the hospital. Despite advances in trauma care, the majority of deaths occur within the first three hours of hospital admission, offering a very limited window for effective intervention. Unfortunately, a significant increase in mortality from hemorrhagic trauma is primarily due to delays in hemorrhage control. Therefore, we propose a machine learning model to predict the need for urgent hemorrhage intervention. This study developed and validated an XGBoost-based machine learning model using data from the National Trauma Data Bank (NTDB) from 2017 to 2019. It focuses on demographic and clinical data from the initial hours following trauma for model training and validation, aiming to predict whether trauma patients require urgent hemorrhage intervention. The XGBoost model demonstrated superior performance across multiple datasets, achieving an AUROC of 0.872 on the training set, 0.869 on the internal validation set, and 0.875 on the external validation set. The model also showed high sensitivity (77.8% on the external validation set) and specificity (82.1% on the external validation set), with an accuracy exceeding 81% across all datasets, highlighting its high reliability for clinical applications. Our study shows that the XGBoost model effectively predicts urgent hemorrhage interventions using data from the National Trauma Data Bank (NTDB). It outperforms other machine learning algorithms in accuracy and robustness across various datasets. These results highlight machine learning's potential to improve emergency responses and decision-making in trauma care.

Time from injury to operative intervention in traumatic intracranial hematoma: A systematic literature review and meta-analysis.

The outcomes in traumatic intracranial hematoma (TICH) have not improved significantly despite advances in trauma care. A modifiable factor in TICH management is time to operation room (TOR). TOR has become a key marker in Traumatic brain injury care despite a lack of contemporary evidence. This study aimed to determine the timing of TICH evacuation and its association with mortality and neurological outcomes. A systematic review of PubMed, OVID MEDLINE, CINAHL, and Web of Science. Included studies reported data on adult patients with acute TICH who underwent surgical evacuation. The primary outcome was TOR and its association with mortality or functional neurological recovery. From 1838 articles screened, 17 were included. Eight studies reported TOR as a continuous variable, ranging between 3 and 7.1h. Three studies found better outcomes with shorter TOR, five found no difference, and one found worse outcomes with shorter TOR. Five articles were included in meta-analysis of mortality in patients undergoing operative decompression less than or greater than 4h from injury which found lower mortality in the >4-h group, OR=1.53. Longitudinal regression analysis showed no difference in TOR over the 33-year span of articles included. There is limited data available on TOR in TICH, with equivocal results on the effect of timing on outcomes. TOR has not decreased over the last 4decades. The unvalidated 4-h cut-off seems to be associated with better survival. Contemporary assessment of this potentially important performance indicator is required.

TRAUMA-INDUCED COAGULOPATHY: PREVALENCE AND ASSOCIATION WITH MORTALITY PERSIST 20 YEARS LATER.

Introduction: A 2003 landmark study identified the prevalence of early trauma-induced coagulopathy (eTIC) at 28% with a strong association with mortality of 8.9%. Over the last 20 years, there have been significant advances in both the fundamental understanding of eTIC and therapeutic interventions. Methods: A retrospective cohort study was performed from 2018 to 2022 on patients ≥18 using prospectively collected data from two level 1 trauma centers and compared to data from 2003. Demographics, laboratory data, and clinical outcomes were obtained. Results: There were 20,107 patients meeting criteria: 65% male, 85% blunt, mean age 54 ± 21 years, median Injury Severity Score 10 (10, 18), 8% of patients were hypotensive on arrival, with an all-cause mortality 6.0%. The prevalence of eTIC remained high at 32% in patients with an abnormal prothrombin time and 10% with an abnormal partial thromboplastin time, for an overall combined prevalence of 33.4%. Coagulopathy had a major impact on mortality over all injury severity ranges, with the greatest impact with lower Injury Severity Score. In a hybrid logistic regression/Classification and Regression Trees analysis, coagulopathy was independently associated with a 2.1-fold increased risk of mortality (95% confidence interval 1.5-2.9); the predictive quality of the model was excellent [area under the receiver operating characteristic curve (AUROC) 0.932]. Conclusion: The presence of eTIC conferred a higher risk of death across all disease severities and was independently associated with a greater risk of death. Biomarkers of coagulopathy associated with eTIC remain strongly predictive of poor outcome despite advances in trauma care.

Level One Trauma Center Proliferation May Worsen Patient Outcomes.

From 2013 to 2020, Arizona state trauma system expanded from seven to thirteen level 1 trauma centers (L1TCs). This study utilized the state trauma registry to analyze the effect of L1TC proliferation on patient outcomes. Adult patients age≥15 in the state trauma registry from 2007-2020 were queried for demographic, injury, and outcome variables. These variables were compared across the 2 time periods: 2007-2012 as pre-proliferation (PRE) and 2013-2020 as post-proliferation (POST). Multivariate logistic regression was performed to assess independent predictors of mortality. Subgroup analyses were done for Injury Severity Score (ISS)≥15, age≥65, and trauma mechanisms. A total of 482,896 trauma patients were included in this study. 40% were female, 29% were geriatric patients, and 8.6% sustained penetrating trauma. The median ISS was 4. Inpatient mortality overall was 2.7%. POST consisted of more female, geriatric, and blunt trauma patients (P < .001). Both periods had similar median ISS. POST had more interfacility transfers (14.5% vs 10.3%, P < .001). Inpatient, unadjusted mortality decreased by .5% in POST (P < .001). After adjusting for age, gender, ISS, and trauma mechanism, being in POST was predictive of death (OR: 1.4, CI:1.3-1.5, P < .001). This was consistent across all subgroups except for geriatric subgroup, which there was no significant correlation. Despite advances in trauma care and almost doubling of L1TCs, POST had minimal reduction of unadjusted mortality and was an independent predictor of death. Results suggest increasing number of L1TCs alone may not improve mortality. Alternative approaches should be sought with future regional trauma system design and implementation.

Crimson Concussa - Initial Treatment of The Polytraumatized Patient in Hemorrhagic Shock

This comprehensive article, titled ‘Crimson Concussa’, delves into the complexities of hemorrhagic shock in the context of polytrauma. It offers an in-depth analysis of the pathophysiological processes, diagnostic challenges, and treatment modalities associated with this critical condition. Emphasizing the importance of the ‘golden hour’ and the Advanced Trauma Life Support (ATLS) protocol, the paper underscores the necessity of a swift, systematic approach and a multidisciplinary team in managing polytraumatized patients. The review explores the nuances of initial treatment strategies, including airway management, breathing and ventilation assessment, circulatory function, and hemorrhage control. Additionally, it addresses the intricate details of pathophysiology, etiology, clinical stages, and treatment options, including fluid therapy, blood transfusions, and coagulopathy management. The article aims to enhance understanding and provide insights into the latest advancements in trauma care, highlighting the importance of ongoing research for improving therapeutic approaches and patient outcomes in the realm of emergency medicine.

Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan

IntroductionLife-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in...

Tri-modal Distribution of Trauma Deaths in a Resource-Limited Setting: Perception Versus Reality.

Advances in trauma care in high-income countries have significantly reduced late deaths following trauma, challenging the classical trimodal pattern of trauma-associated mortality. While studies from low and middle-income countries have demonstrated that the trimodal pattern is still occurring in many regions, there is a lack of data from sub-Saharan Africa evaluating the temporal epidemiology of trauma deaths. We conducted a retrospective analysis of the trauma registry at Kamuzu Central Hospital in Lilongwe, Malawi, including all injured patients presenting to the emergency department (ED) from 2009 to 2021. Patients were compared based on timing of death relative to time of injury. We then used a modified Poisson regression model to identify adjusted predictors for early mortality compared to late mortality. Crude mortality of patients presenting to the ED in the study period was 2.4% (n = 4,096/165,324). Most patients experienced a pre-hospital death (n = 2,330, 56.9%), followed by death in the ED (n = 619, 15.1%). Early death (pre-hospital or ED) was associated with transportation by police (RR1.52, 95% CI 1.38, 1.68) or private vehicle (RR1.20, 95% CI 1.07, 1.31), vehicle-related trauma (RR1.10, 95% CI 1.05, 1.14), and penetrating injury (RR1.11, 95% CI 1.04, 1.19). Ambulance transportation was associated with a 40% decrease in the risk of early death. At a busy tertiary trauma center in Malawi, most trauma-associated deaths occur within 48h of injury, with most in the pre-hospital setting. To improve clinical outcomes for trauma patients in this environment, substantial investment in pre-hospital care is required through first-responder training and EMS infrastructure.

Shot through the heart: A 17-year analysis of pre-hospital and hospital deaths from penetrating cardiac injuries

BackgroundPenetrating cardiac injuries (PCI) are often fatal despite rapid transport and treatment in the prehospital setting. Although many studies have identified risk factors for mortality, few studies have included non-transported field mortalities. This study analyzes penetrating cardiac injuries including hospital and coroner reports in the current era. MethodsSeventeen years of data were reviewed, including the trauma center (TC) registry, medical records, and coroner reports from 2000-2016. PCI were graded using American Association for the Surgery of Trauma (AAST) cardiac organ injury score (COIS). Subjects were divided into three groups: field deaths, hospital deaths, and survivors to hospital discharge. The primary outcome is survival to hospital discharge overall and among those transported to the hospital. ResultsDuring the study period, 643 PCI patients were identified, with 52 excluded for inadequate data, leaving 591 for analysis. Mean age was 38.1 ± 17.5 years, and survivors (n=66) were significantly younger than field deaths (n=359) (32.6 ± 14.4 vs 41.1 ± 18.5, p<0.001). Stab wounds had higher survival than gunshot wounds (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004). The left ventricle is the most injured (n=177), and right ventricle PCI has the highest survival (p<0.001). Of field deaths, left ventricular injuries had the highest single chamber mortality (60%), equaling multi-chamber PCI (60%). ConclusionsSurvival to both TC evaluation and hospital discharge following PCI is influenced by many factors including age, mechanism, anatomic site, and grade. Despite advances in trauma care, survival has not appreciably improved.

Management of aseptic non-union of shaft femur using intramedullary nailing combined with bone grafting: a case report

&lt;p&gt;Despite the advances in trauma care, improved surgical techniques, latest implants and therefore the evolution of new adjuvants to healing, biologic agents, non-union still persists thanks to high energy trauma as initial event. Non-union of femur shaft represents a significant socioeconomic problem to the patient, related to prolonged patient morbidity, inability to return to figure, gait abnormality, re-operations and psycho-emotional impairment. Here we discuss the case of such non-union of fracture shaft femur presented to us with shortening of 3.5 cm managed with bone graft and intramedullary nailing. 22-year-old male patient had a history of trauma due to fall from bike due to dash from behind by tractor (high velocity road traffic accident) sustaining injury over right thigh leading to closed fracture mid-shaft femur of the same side treated immediately by femur nailing. After 6 months post-surgery, he noticed swelling over operated thigh which was increasing and causing difficulty in walking. X-rays revealed broken nail, re-operated at the same centre with dynamic compression plating (DCP) probably after freshening the fracture edges using 12-hole DCP, implant failure with whole plate and screw construct extrusion and re-fracture at the same site. This time patient presented to our institute. We planned of implant removal and intramedullary nailing with bone grafting. Management of aseptic femoral non-union with fracture gap of 2.5-4 cm range with intramedullary nailing combined with autologous fibular cortical and cancellous grafts showed good functional results at the end of 1 year post operative interval after prior repetitive failure of implants due to non-union. &lt;/p&gt;

Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol

IntroductionMajor haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase...

Sensory Modulation Dysfunction in Child Victims of Trauma: a Scoping Review.

Due to the high level of violence globally, providing intervention for child victims of trauma has become a priority for various government departments and health professionals including occupational therapists. Child appropriate sensory modulation intervention, which has its theoretical origins within the occupational therapy profession, has been suggested as a suitable treatment approach for children who are victims of trauma, since the initial experience of trauma occurs on a somatosensory level. Advances in trauma care indicate that children may experience the effects of trauma as an inability to appropriately regulate and organize sensory responses. This results in sensory modulation dysfunction associated with emotional and behavior difficulties. This scoping review provides an overview of the extent to which sensory modulation dysfunction has been identified and treated in child victims of trauma. Using the Arksey and O'Malley (2005) framework, five databases and three manual hand searches were conducted. This scoping review confirmed the scarcity of research available. The 13 studies which met the inclusion criteria indicated that child victims of trauma (CVT) present with a sensory modulation disorder (SMD). Sensory modulation intervention, within the theoretical framework of Ayres Sensory Integration® (ASI®), alone and in combination with psychotherapy approaches was found to be valuable for CVT, in the studies chartered. Identification and treatment of sensory modulation dysfunction in CVT has been researched and is becoming an area of increasing need. Therefore, to remain relevant to the violent contexts within communities, there is a need to expand research in this field.

From battlefront to homefront: creation of a civilian walking blood bank

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.

A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare

Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. To describe a consensus framework for surgical care designed to respond to this emerging need. An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

Pediatric firearm incidents: It is time to decrease on-scene mortality.

Previous epidemiological studies on pediatric firearm mortality have focused on overall mortality rather than on-scene mortality. Despite advances in trauma care, the number of potentially preventable deaths remains high. This study used the National Emergency Medical Services Information Systems database to characterize patterns of on-scene mortality in order to identify patients who may benefit from changes to prehospital care practices. National Emergency Medical Services Information Systems database was searched for all pediatric firearm incidents from 2010 to 2015. Data on demographics, anatomic location of injury, intent and location of incident, and on-scene mortality were analyzed using Student's t test for continuous variables and χ test for categorical variables. A linear regression model was used to calculate independent predictors of mortality. Sixteen thousand eight hundred eight patients were identified, with a mortality rate of 6.1%. Most mortalities suffered cardiac arrest on-scene; 72.6% of these were prior to Emergency Medical Services (EMS) arrival, which carried a significantly higher mortality rate than arrest after EMS arrival. No difference was seen in anatomic location of injury in those who arrested before and after EMS arrival. Compressible injuries were most common with the lowest mortality. Noncompressible injuries together accounted for 25.8% of injuries and 23.5% of mortalities. To our knowledge, this is the largest study of on-scene mortality in pediatric firearm injury. Cardiac arrest prior to EMS arrival was a considerable source of on-scene mortality; significantly more of these patients died than those who arrested after EMS arrival. The mortality of compressible injuries was very low, implying that use of compression and tourniquets have been effective in stopping life-threatening extremity bleeding. Noncompressible injury mortality could be decreased with education of bystanders and more aggressive on-scene intervention. Through the evaluation of on-scene mortality specifically, this study offers insight into potential areas of focus to improve prehospital care of pediatric gunshot victims. Therapeutic/Care management, level IV.

Survival trends after inferior vena cava and aortic injuries in the United States

ObjectiveRecent studies have demonstrated an increase in trauma mortality relative to mortality from cancer and heart diseases in the United States. Major vascular injuries such as to the inferior vena cava (IVC) and aortic injuries remain responsible for a significant proportion of early trauma deaths in modern trauma care. The purpose of this study was to explore patterns in epidemiology and mortality after IVC and aortic injuries in the United States. MethodsA 13-year analysis of the National Trauma Databank (2002-2014) was performed to extract all patients who sustained IVC, abdominal aortic, or thoracic aortic injuries. Demographics, clinical data, and outcomes were extracted. Patients were analyzed according to injury mechanism. ResultsA total of 25,428 patients were included in this analysis. Overall, the mean age was 39.8 ± 19.1 years, 70.3% were male, and 14.1% sustained a penetrating trauma. Although the incidence of all three injuries remained constant throughout the study period, for blunt trauma, mortality decreased over the study period (from 48.8% in 2002 to 28.7% in 2014; P < .001), in particular for thoracic aortic injuries (from 46.1% in 2002 to 23.7% in 2014; P < .001) and abdominal aortic injuries (from 58.3% in 2002 to 26.2% in 2014; P < .001). This decrease in mortality after blunt trauma was accompanied by an increase in endovascular procedures over the study period (from 1.0% in 2002 to 30.4% in 2014; P < .001), in particular for blunt thoracic aortic injuries (from 0.7% in 2002 to 41.4% in 2014; P < .001). When penetrating trauma patients were analyzed, overall there was an increase in mortality (from 43.8% in 2002 to 50.6% in 2014; P < .001), in particular after abdominal aortic injury (from 30.4% in 2002 to 66.0% in 2014; P < .001). Similar trends were observed for IVC injuries. No increase in endovascular use in penetrating trauma was identified (from 0.1% in 2002 to 3.4% in 2014; P < .001). ConclusionsThe present study demonstrates an overall decrease in mortality after blunt aortic injuries in the United States. This decrease was accompanied by an increase in the use of endovascular procedures. After penetrating trauma, however, despite contemporary advances in trauma care, mortality has increased over the study period, in particular after abdominal aortic injury. No increase in endovascular use in penetrating trauma was demonstrated.

A review of the landscape: Challenges and gaps in trauma response to civilian high threat mass casualty incidents.

The ultimate goal of the emergency response and trauma system is to reduce potentially preventable death from trauma. Tremendous advances in trauma care emerged from the past 15 years of United States' combat engagements around the globe. Unfortunately, combat and insurgency tactics have also metastasized to the civilian world, resulting in increasingly complex and dynamic acts of intentional mass violence. These high threat active violent incidents (AVIs) pose significant preparedness, response, and clinical care challenges to the civilian healthcare systems. Currently, there are several operational and policy gaps that limit the successful preparedness and response to AVIs and dynamic MCIs in the United States.

Timing of death at National Trauma Center, Abuja, Nigeria

Background: We aimed to analyse the burden and timing of trauma deaths over a 1-year period at a trauma centre in Nigeria. Methods: This was a retrospective review of in-hospital trauma deaths during the period of January to December 2015. Sociodemographic data, cause of injury, mode of presentation, time interval between presentation and death, injury diagnoses, treatment, and place of death were analysed. Results: There were 2230 trauma consultations during the study period; 85 were brought in dead from the scene. We analysed data from 103 of 121 in-hospital deaths. Patient ages ranged from 0 to 90 years, with a mean age of 31.1. The male-to-female ratio was 5:1. Following injury, 46.6% of the victims presented directly to our tertiary centre, while 53.4% were referred from other hospitals. Most of the injuries were from RTA. Isolated head injury was the predominant diagnosis (44.7%), followed by polytrauma (29%). Immediate deaths (exclusive of those brought in already dead) comprised 5.8% of cases; 37.9% were early deaths and 56.3% were late deaths. Conclusions: The timing of trauma deaths closely approximated the original trimodal description in North America about half a century ago even though advances in trauma care have resulted in changes from this pattern in developed countries. Regionalised integrated care including prehospital trauma services are recommended. https://dx.doi.org/10.4314/ecajs.v22i3.8 This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source (including a link to the formal publication), provide a link to the Creative Commons license, and indicate if changes were made.

Three-in-one protocol reduces mortality of patients with haemodynamically unstable pelvic fractures—a five year multi-centred review in Hong Kong

The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40-60%. Despite the new advances in trauma care which are in phase in trauma centres in Hong Kong, the management of haemodynamically unstable pelvic fracture is still heterogeneous. The aim of this study is to review the results of management of haemodynamically unstable pelvic fracture patients in Hong Kong over a fiveyear period. This is a retrospective multi-centred cohort study of patients with haemodynamic and mechanically unstable pelvic fractures from 1 January 2010 to 31 December 2014. The primary outcome investigated is mortality of patients (including overall, 30-day, 7-day and 24-hour mortalities). Implementation of three-in-one pelvic damage control protocol was identified to be a significant independent predictive factor for overall, 30-day, seven-day and 24-hour mortalities. The overall in-hospital and 30-day mortality rates for patients managed with three-in-one protocol was 12.5%, while it was 11% for sevenday mortality and 6% for 24 hour mortality. There were no significant differences in demographic characteristics, physiological measurements, types of pelvic fracture, severity and mechanism of injury between patients managed with or without three-in-one protocol. Implementation of the multidisciplinary three-in-one pelvic damage control protocol reduces mortality and therefore should be highly recommended. The results are convincing as it has eliminated the limitations of our previous single-centred trial.

An Innovative Way to Separate Gastrointestinal and Abdominal Wall Reconstruction after Complex Abdominal Trauma

Despite advances in trauma care, a subset of patients surviving damage control cannot achieve fascial closure and require split-thickness skin grafting (STSG) of their open abdomen. Controversy exists as to whether reconstruction of the gastrointestine (GI) should be staged or performed at the time of abdominal wall reconstruction (AWR). Many surgeons do not believe that operations through the STSG can be completed safely or without loss of graft. This series reviews the outcomes of operations for GI reconstruction performed through the elevated healed STSG. Concurrent series on all patients undergoing abdominal operation through the STSG. The technique involves elevating the STSG, lysing adhesions only as needed, avoid detaching underlying omentum or viscera to avoid devascularization, and then reattaching the elevated STSG to the abdominal wall with simple sutures. From 1995 to 2017, 27 patients underwent 40 distinct procedures during 36 separate abdominal reoperations (89% GI) through the elevated STSG approach at three Level I trauma centers at a mean interval of 11 months from application of the STSG. One STSG was lost (patient closed with skin flaps), one patient had 30 per cent loss of the STSG (regrafted), and one patient had 10 per cent loss of the STSG (allowed to granulate). One patient required a small bowel resection for intraoperative enterotomy during a difficult operative dissection. There were no GI complications, intraabdominal infections, or deaths, and all patients were deemed fit to undergo AWR after three months. Major intraabdominal reoperations can be readily and safely accomplished through the elevated STSG approach with a <4 per cent need for regrafting. This staged approach significantly simplifies and increases the safety of a second stage AWR.