American Association For Surgery Of Trauma Research Articles

Interrater Agreement of CT Grading of Blunt Splenic Injuries: Does the AAST Grading Need to Be Reimagined?

Introduction: The Revised Organ Injury Scale (OIS) of the American Association for Surgery of Trauma (AAST) is the most widely accepted classification of splenic trauma. The objective of this study was to evaluate inter-rater agreement for CT grading of blunt splenic injuries. Methods: CT scans in adult patients with splenic injuries at a level 1 trauma centre were independently graded by 5 fellowship trained abdominal radiologists using the AAST OIS for splenic injuries - 2018 revision. The inter-rater agreement for AAST CT injury score, as well as low-grade (IIII) versus high-grade (IV-V) splenic injury was assessed. Disagreement in two key clinical scenarios (no injury versus injury, and high versus low grade) were qualitatively reviewed to identify possible sources of disagreement. Results: A total of 610 examinations were included. The inter-rater absolute agreement was low (Fleiss kappa statistic 0.38, P < 0.001), but improved when comparing agreement between low and high grade injuries (Fleiss kappa statistic of 0.77, P < .001). There were 34 cases (5.6%) of minimum two-rater disagreement about no injury vs injury (AAST grade ≥ I). There were 46 cases (7.5%) of minimum two-rater disagreement of low grade (AAST grade I-III) versus high grade (AAST grade IV-V) injuries. Likely sources of disagreement were interpretation of clefts versus lacerations, peri-splenic fluid versus subcapsular hematoma, application of adding multiple low grade injuries to higher grade injuries, and identification of subtle vascular injuries. Conclusion: There is low absolute agreement in grading of splenic injuries using the existing AAST OIS for splenic injuries.

PD12-02 URINARY EXTRAVASATION AFTER RENAL TRAUMA: SHOULD IT BE A CRITERION FOR THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GRADE IV INJURY?

You have accessJournal of UrologyCME1 Apr 2023PD12-02 URINARY EXTRAVASATION AFTER RENAL TRAUMA: SHOULD IT BE A CRITERION FOR THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GRADE IV INJURY? Sorena Keihani, Douglas Rogers, Sherry Wang, Joel Gross, Ryan Joyce, Judith Hagedorn, J. Patrick Selph, Rachel Moses, Rachel Sensenig, Joshua Broghammer, Shubham Gupta, Nima Baradaran, and Jeremy Myers Sorena KeihaniSorena Keihani More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Sherry WangSherry Wang More articles by this author , Joel GrossJoel Gross More articles by this author , Ryan JoyceRyan Joyce More articles by this author , Judith HagedornJudith Hagedorn More articles by this author , J. Patrick SelphJ. Patrick Selph More articles by this author , Rachel MosesRachel Moses More articles by this author , Rachel SensenigRachel Sensenig More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Shubham GuptaShubham Gupta More articles by this author , Nima BaradaranNima Baradaran More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary extravasation (UE) is a main criterion for grade IV renal trauma. An appropriately-timed excretory phase CT is needed for accurate diagnosis. We aimed to assess the compliance with excretory phase imaging in a multi-center study and evaluate the management of UE after high-grade renal trauma (HGRT). METHODS: We used HGRT data from 7 Level-1 trauma centers. Patients with CT scans were included. Demographics, injury and imaging characteristics, and interventions were reviewed. We assessed compliance with obtaining excretory phase CT and its timing (9 minutes delay considered as adequate), and the rate of interventions for UE. We defined UE information as Ux (unknown/excretory imaging not done), U0 (no UE in excretory imaging), and U1 (UE present). RESULTS: We reviewed data from 550 patients with HGRT (grades III: 284 [51.5%]; IV: 250 [45.5%]; V: 16 [3%]) according to the 2018 AAST grading system. Only 324 (59%) had excretory phase images available within the initial CT to assess for UE with compliance rates between 26% to 100% between different centers. The median time between the arterial and delayed phase was 8 minutes (IQR: 4–11); 51% of the excretory images were inadequately timed (<9 minutes). Overall, 94 (17%) were diagnosed with UE either initially (n=62) or in follow up images (n=32). Of these, 22 (23%) underwent ureteral stent placement and 5 (5%) received peri-renal drains. Of the 262 with U0, 21 had UE diagnosed in follow up studies (8% missed UE with initial excretory imaging). Of the 226 with Ux, 11 were diagnosed with UE in follow up imaging (5% missed UE without initial excretory imaging). 59 of 94 patients with UE (63%) would have been grade IV only due to UE. Compared to the other patients with UE, these had lower rates of bleeding interventions (8% vs. 31%), active bleeding, and had smaller hematoma and lacerations sizes. CONCLUSIONS: About 40% of those with HGRT did not undergo excretory phase imaging in the initial assessment. The compliance in obtaining these images and the timing were variable and suboptimal. These can lead to inaccurate and incomplete grading of renal injuries in regards to UE. UE status can be provided as separate information or be included under grade III renal injuries. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e400 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sorena Keihani More articles by this author Douglas Rogers More articles by this author Sherry Wang More articles by this author Joel Gross More articles by this author Ryan Joyce More articles by this author Judith Hagedorn More articles by this author J. Patrick Selph More articles by this author Rachel Moses More articles by this author Rachel Sensenig More articles by this author Joshua Broghammer More articles by this author Shubham Gupta More articles by this author Nima Baradaran More articles by this author Jeremy Myers More articles by this author Expand All Advertisement PDF downloadLoading ...

CLINICAL STUDY ON CONSERVATIVE MANAGEMENT OF BLUNT SPLENIC INJURY

Background: Spleen is the most common intra-abdominal organ to be injured in blunt abdominal trauma and currently most cases are treated nonoperatively. Aim of this study was to evaluate the efcacy of Non-Operative Management (NOM) of blunt splenic injury and to point out the predictors of failure of NOM. Methods: Over a 12 month period (June 2021- May 2022), 16 hemodynamically stable patients with blunt splenic injury admitted in Department of General Surgery in Silchar Medical College and Hospital were evaluated prospectively. Association of various factors were analysed using SPSS statistical software version 22 to nd out efcacy of NOM as well as to point out predictors of NOM. Results: NOM was successful in 81.3% of patients and 18.8% were converted to operative management (NOM failure). Statistical analysis showed that Systolic BP and Haemoglobin at the time of admission, Number of blood transfused, Injury Severity Score (ISS), USG nding of grade of hemoperitoneum, American Association for Surgery of Trauma (AAST) grade of splenic injury, Duration of hospital stay were signicantly associated with the outcome of NOM success (P value &lt; 0.05). Age, Sex, Mode of injury, Pulse rate at the time of admission had no signicant relation with the outcome. AASTgrade IV splenic injury or higher, Massive hemoperitoneum, ISS &gt; 25, Haemoglobin &lt;8 gm%, Requirement of 4 or more units of blood and New-onset hemodynamic instability were independent predictors of failure of conservative management. Conclusion: Conservative management of blunt splenic injury is safe and effective as long as patients are selected based on strict inclusion/exclusion criteria

Splenic Artery Embolization for Unstable Patients with Splenic Injury: A Retrospective Cohort Study

PurposeTo compare the outcomes of splenic artery embolization (SAE) for acute splenic injury (ASI) between patients who are hemodynamically stable (HDS) and hemodynamically unstable (HDU). Nonoperative management with SAE has become an accepted practice for patients who are HDS with ASI; however, SAE for the treatment of patients who are HDU with ASI has not been well studied. Materials and MethodsA retrospective cohort study was performed, including 52 patients who were HDU and HDS who underwent SAE for ASI at a Level 1 trauma center. HDU was defined as the lowest recorded systolic blood pressure prior to intervention <90 mm Hg. Utilizing the American Association for Surgery of Trauma (AAST) splenic injury scale, AAST Grades 1–3 were defined as low grade, and Grades 4–5 were defined as high grade. The primary outcomes were survival at 30 days and the need for subsequent splenectomy. ResultsSeventy-five percent (n = 39) of the patients were HDS, and 25% (n = 13) were HDU. The majority (69%) of patients who were HDU who underwent SAE did not require splenectomy, compared with 95% of patients who were HDS (P = .03). No significant difference in 30-day survival between patients who were HDU and HDS was noted. No major adverse events were recorded. There was no significant difference in 30-day patient survival or the rate of subsequent splenectomy between high-grade and low-grade splenic injuries. ConclusionsIn this retrospective cohort study, there was no statistically significant difference in the adverse events or 30-day post-SAE survival rates between patients who were HDS and HDU with ASI. The authors conclude that SAE can be a safe and effective treatment option for patients who are HDU with ASI, including high-grade splenic injury.

Splenic trauma after colonoscopy: Management and treatment

Colonoscopy is an increasingly used diagnostic-therapeutic technique. Although it is a safe procedure, it is not exempt from complications, which are rare but potentially serious. We present the case of a 54-year-old woman who came to the emergency room for abdominal pain after a diagnostic colonoscopy, with anemia in blood test. In CT angiography, was detected a grade III splenic injury according to the classification of the American Association for Surgery of Trauma (AAST), without active bleeding. Due to clinical stability, a non-operative management was decided, with good evolution. Possible causes of splenic rupture are direct trauma to the spleen or excessive traction on the colonic mucosa during biopsy. Symptoms usually appear in the first 24-72 hours after the procedure and are usually abdominal pain and peritoneal irritation, as well as anemia. Abdominal CT is recommended as the imaging test of choice (Figure 1). Treatment of these patients can be extrapolated to management for traumatic splenic injuries. Based on the AAST classification, hemodynamically stable patients may benefit from non-operative management, although in grades IV and V an angiography would be recommended to rule out active bleeding and perform prophylactic angioembolization. Therapeutic angioembolization would be indicated in stable patients with active bleeding. In the case of instability or signs of peritonism, urgent laparotomy is the treatment of choice. Some authors recommend performing control CT for the diagnosis of associated non-hemorrhagic vascular lesions, such as pseudoaneurysms. In conclusion, post-colonoscopy splenic rupture is a serious but infrequent complication, whose treatment will be determined by the stability of the patient and the presence of active bleeding in an imaging test.

Evaluation of urinary extravasation after non-operative management of traumatic renal injury: a multi-center retrospective study

PurposeUrinary extravasation is one of the major complications after non-operative management of traumatic renal injury and may lead to urinary tract infection and sepsis. The purpose of this study was to evaluate these factors in patients with traumatic renal injury.MethodsThis was a multi-center, retrospective, observational study performed at three tertiary referral hospitals in Osaka prefecture. We included patients with traumatic renal injury transported to the centers between January 2008 and December 2018. We excluded patients who either died or underwent nephrectomy within 24 h after admission. We investigated the occurrence of urinary extravasation and the related factors after traumatic renal injury using multivariable logistic regression analysis.ResultsIn total, 146 patients were eligible for analysis. Their median age was 44 years and 68.5% were male. Their median Injury Severity Score was 17. Renal injuries were graded as American Association for Surgery of Trauma (AAST) grade I in 33 (22.6%), II in 27 (18.5%), III in 38 (26.0%), IV in 28 (19.2%), and V in 20 (13.7%) patients. Urinary extravasation was diagnosed in 26 patients (17.8%) and was statistically significantly associated with AAST grades IV–V (adjusted odds ratio, 33.8 [95% confidence interval 7.12–160], p < 0.001).ConclusionWe observed urinary extravasation in 17.8% of patients with non-operative management of traumatic renal injury and the diagnosed was made in mostly within 7 days after admission. In this study, the patients with AAST grade IV–V injury were associated with having urinary extravasation.

Scrotal self-inflicted gunshot injuries: report of two consecutive cases and literature review

BackgroundIsolated scrotal gunshot injuries are uncommon. Even more so when they are self-inflicted. The extent of the injury is determined by the caliber of the weapon. Established management protocols when followed yields excellent results. Case presentationsWe present two male patients, aged 41 and 51 years old, who sustained gunshot injuries to the scrotum following accidental discharges from hand guns stored in their trouser pockets. The first (41 years) sustained grade 5 American Association for Surgery of Trauma (AAST) left testicular injury and was managed by unilateral orchidectomy. The second (51 years old) sustained bilateral grade 4 AAST testicular injuries and had both testes salvaged by primary repair after meticulous debridement.ConclusionIsolated scrotal gunshot injuries can occur when low velocity guns are placed adjacent to the genitalia and accidentally discharged. The testes are endangered and can be devitalized requiring orchidectomy or salvaged by meticulous debridement and primary repair when viability is not compromised.

Importance of a Follow-Up Ultrasound Protocol in Monitoring Posttraumatic Spleen Complications in Children Treated with a Non-Operative Management.

Background and objectives: For the last three decades, non-operative management (NOM) has been the standard in the treatment of clinically stable patients with blunt spleen injury, with a success rate of up to 95%. However, there are no prospective issues in the literature dealing with the incidence and type of splenic complications after NOM. Materials and methods: This study analyzed 76 pediatric patients, up to the age of 18, with blunt splenic injury who were treated non-operatively. All patients were included in a posttraumatic follow-up protocol with ultrasound examinations 4 and 12 weeks after injury. Results: The mean age of the children was 9.58 ± 3.97 years (range 1.98 to 17.75 years), with no statistically significant difference between the genders. The severity of the injury was determined according to the American Association for Surgery of Trauma (AAST) classification: 7 patients had grade I injuries (89.21%), 21 patients had grade II injuries (27.63%), 33 patients had grade III injuries (43.42%), and 15 patients had grade IV injuries (19.73%). The majority of the injuries were so-called high-energy ones, which were recorded in 45 patients (59.21%). According to a previously created posttraumatic follow-up protocol, complications were detected in 16 patients (21.05%). Hematomas had the highest incidence and were detected in 11 patients (14.47%), while pseudocysts were detected in 3 (3.94%), and a splenic abscess and pseudoaneurysm were detected in 1 patient (1.31%), respectively. The complications were in a direct correlation with injury grade: seven occurred in patients with grade IV injuries (9.21%), five occurred in children with grade III injuries (6.57%), three occurred in patients with grade II injuries (3.94%), and one occurred in a patient with a grade I injury (1.31%). Conclusion: Based on the severity of the spleen injury, it is difficult to predict the further course of developing complications, but complications are more common in high-grade injuries. The implementation of a follow-up ultrasound protocol is mandatory in all patients with NOM of spleen injuries for the early detection of potentially dangerous and fatal complications.

Renal artery angiography in pediatric trauma using a national data set

With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking. This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions. All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement. 536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n=9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements. The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography. Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.

New opinion on radiological grade and conservative treatment of children splenic injury

Objective Radiological grade of splenic injury was seldomly used in China trauma center now, though it had been established in 1994 by American Association for Surgery of Trauma (AAST) and widely used.The present study is aimed to analyze the imaging grade and clinical characteristics of traumatic splenic rupture in children, discuss the feasibility of conservative treatment, and the role of radiographic grading during clinical treatment. Methods Information (including age, gender, severity based on radiological findings, treatment strategies, and clinical outcome) regarding 59 hospitalized splenic injury patients whose injuries occurred between 2008 and 2014 was retrospectively analyzed. Results Between 2008 and 2014, 59 pediatric patients with splenic injury were treated in our institution.Median age was 9.5 years (range, 3 months to 16 years). Of all patients, 41 (69.5%) were male.The injuries were primarily caused by traffic crash (45.7%), stumbling/falling from a height (38.9%). According to AAST, 5 cases were grade Ⅰ, 26 patients grade Ⅱ (44.1%), and 21 cases grade Ⅲ (35.6%), 6 over grade Ⅳ, and only one was unclear.Of all patients, 25 cases were with the other organs complications.All patients underwent fasting, bed rest, and antibiotics.Only 1 case was transferred to operation during the conservative treatment.Forty-nine patients underwent with CT scan over 2 times. Conclusion Imaging classification helps guide clinical treatment.Conservative treatment is feasible for traumatic splenic injury in children.Early imaging classification of splenic injury may be helpful in clinical judgment, and reduce children radiation exposure. Key words: Children; Splenic injury; Conservative therapy; Radiation exposure,

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

Conservative and surgical management of pancreatic trauma in adult patients.

The management of pancreatic trauma is complex. The aim of this study was to report our experience in the management of pancreatic trauma. All patients hospitalized between 2005 and 2013 for pancreatic trauma were included. Traumatic injuries of the pancreas were classified according to the American Association for Surgery of Trauma (AAST) in five grades. Mortality and morbidity were analyzed. A total of 30 patients were analyzed (mean age: 38±17 years). Nineteen (63%) patients had a blunt trauma and 12 (40%) had pancreatic injury ≥ grade 3. Fifteen patients underwent exploratory laparotomy and the other 15 patients had nonoperative management (NOM). Four (13%) patients had a partial pancreatectomy [distal pancreatectomy (n=3) and pancreaticoduodenectomy (n=1)]. Overall, in hospital mortality was 20% (n=6). Postoperative mortality was 27% (n=4/15). Mortality of NOM group was 13% (n=2/15) in both cases death was due to severe head injury. Among the patients who underwent NOM, three patients had injury ≥ grade 3, one patient had a stent placement in the pancreatic duct and two patients underwent endoscopic drainage of a pancreatic pseudocyst. Operative management of pancreatic trauma leads to a higher mortality. This must not be necessarily related to the pancreas injury alone but also to the associated injuries including liver, spleen and vascular trauma which may cause impaired outcome more than pancreas injury.

Simple repair is sufficient for most injuries to the duodenum - a case series of 23 patients

Background: Duodenal injury is the most important hollow viscus injury in the abdomen. The study analysed the outcome of duodenal injuries at the unit. Patients &amp; Methods: Prospectively collected data on a case series involving 23 patients over 3 years. It involved demographic details, part of duodenum injured, injury severity according to the AAST, injury-operation time lag, mode of repair, and the extent of significant associated injuries. Results: M:F ratio was 4.75:1. Mean age 33yrs. Patients with non-perforating injury were excluded. All were operated by a senior registrar or senior. 7/23 were blunt, 13/23 firearm &amp; 3/23 stab injuries. D2 was involved in 87%. Injury severity was graded according to AAST (American Association for Surgery of Trauma). 17/23 were Grade II/III, 3 Grade IV &amp; 3 Grade V injuries. Four had injury-operation lag of &gt;18hrs. Two injuries were missed. All injuries up to Grade IV had simple repair. Two of them had T-tube duodenostomy. None had pyloric exclusion. Complex repairs wer e required for 3/23 patients. Five patients died, as a result of associated insults. One delayed repair developed duodenal fistula. Intra-abdominal abscess, septicaemia and wound dehiscence were seen in two patients each. Duodenum-related mortality was zero. Adverse prognostic factors towards morbidity were injury severity &gt;GIII and injury-operation lag &gt;18hrs. The mortality was related to associated injuries. Conclusion: Primary repair is sufficient for most non-resectional duodenal injuries.

Surgical management of AAST grades III-V hepatic trauma by Damage control surgery with perihepatic packing and Definitive hepatic repair-single centre experience.

BackgroundSevere liver injury in trauma patients still accounts for significant morbidity and mortality. Operative techniques in liver trauma are some of the most challenging. They include the broad and complex area, from damage control to liver resection.Material and methodThis is a retrospective study of 121 trauma patients with hepatic trauma American Association for Surgery of Trauma (AAST) grade III–V who have undergone surgery. Indications for surgery include refractory hypotension not responding to resuscitation due to uncontrolled hemorrhage from liver trauma; massive hemoperitonem on Focused assessment by ultrasound for trauma (FAST) and/or Diagnostic peritoneal lavage (DPL) as well as Multislice Computed Tomography (MSCT) findings of the severe liver injury and major vascular injuries with active bleeding.ResultsNon-survivors have significantly higher AAST grade of liver injury and higher Injury Severity Score (ISS) (p = 0.000; p = 0.0001). Non-survivors have significant hypotension on arrival and lower Glasgow Coma Scale (GCS) on admission (p = 0.000; p = 0.0001). Definitive hepatic repair was performed in 62(51.2 %) patient. Damage Control, liver packing and planned re-laparotomy after 48 h were used in 59(48.8 %). There was no statistically significant difference in terms of the surgical approach. There was significant difference in the amount of red blood cells (RBC) transfusion in the first 24 h between survivors and non-survivors (p = 0.001). Overall mortality rate was 33.1 %. Regarding complications non-survivors had significantly prolonged bleeding and higher rate of Acute respiratory distress syndrome (ARDS) (p = 0.0001; p = 0.0001), while survivors had significantly higher rate of pleural effusion (p = 0.0001).ConclusionAll efforts in the treatment of severe liver injuries should be directed to the rapid and effective control of bleeding, because uncontrollable hemorrhage is the cause of early death and it requires massive blood transfusion, all of which contributes to the late fatal complication.

The incidence of long-term hypertension in children after high-grade renal trauma

IntroductionIt is generally accepted that there is a risk of hypertension after renal trauma, particularly in high-grade and devascularizing injuries. Hypertension following renal trauma is estimated to occur in five percent of adults, however, the incidence is unknown in the pediatric population. Materials and methodsWe performed a retrospective review of all pediatric trauma patients at Primary Children’s Hospital in Salt Lake City, Utah between 2002 and 2012. We included all children age ≤17years old with American Association for Surgery of Trauma (AAST) grade 3–5 renal injury. Hypertension was defined as persistent hypertension that required anti-hypertensive medications. Our primary outcomes were incidence of hypertension during the acute trauma and in long-term follow. ResultsA total of 62 children were identified with AAST grade 3–5 renal injuries during our study period. Follow up blood pressures were recorded in 36 (58%) of these children with a median follow of 4.1years (IQR 2.1–5.1years) after trauma. Four children (6.5%) were identified to have some degree of hypertension while hospitalized after trauma and started on anti-hypertensive medication. Two out of these four children remained on hypertensive medication at follow up, while the remaining two children’s hypertension resolved. No children who were normotensive in the immediate post-trauma period, developed delayed hypertension during long-term follow up. ConclusionsThere is a low risk of developing hypertension following severe renal trauma in the pediatric population. Patients who develop long-term problems with hypertension after renal trauma manifest it during the initial hospitalization, rather than subsequently during the long-term.

Initial multidetector computed tomography of blunt splenic injury: Impact on management

PurposeThis study aimed to assess the role of MDCT in evaluation and management of blunt splenic injury. Patients and methodsWe retrospectively traced clinical data of patients who underwent MDCT for suspected blunt traumatic intra-abdominal injuries and were admitted in general surgery department of Nizwa Hospital, Oman, during period from March 2012 to February 2013. 44 patients were found to have splenic injuries that were verified either during laparotomy or with clinical notes during hospital stay. The initial MDCT findings were correlated with the final diagnosis and management of the patients. ResultsThe 44 splenic injuries were classified according to American Association for Surgery of Trauma (AAST) grading scales, and 32 of them (72.7%) underwent non-operative management. Of the 7 patients with contrast material extravasation (CME), all underwent spleen-related laparotomy (100%) and demonstrated active bleeding during surgery. Only 5 of the remaining 37 patients without CME (13.5%) required spleen-related laparotomy. The difference was statistically significant (p<0.01). ConclusionMDCT evaluation of blunt splenic injuries provides accurate diagnosis which is helpful in determining the proper plan for successful management strategy.

High-grade renal injuries are often isolated in sports-related trauma

IntroductionMost high-grade renal injuries (American Association for Surgery of Trauma (AAST) grades III–V) result from motor vehicle collisions associated with numerous concomitant injuries. Sports-related blunt renal injury tends to have a different mechanism, a solitary blow to the flank. We hypothesized that high-grade renal injury is often isolated in sports-related renal trauma. Material and methodsWe identified patients with AAST grades III–V blunt renal injuries from four level 1 trauma centres across the United States between 1/2005 and 1/2014. Patients were divided into “Sport” or “Non-sport” related groups. Outcomes included rates of hypotension (systolic blood pressure <90mm Hg), tachycardia (>110bpm), concomitant abdominal injury, and procedural/surgical intervention between sports and non-sports related injury. Results320 patients met study criteria. 18% (59) were sports-related injuries with the most common mechanisms being skiing, snowboarding and contact sports (25%, 25%, and 24%, respectively). Median age was 24 years for sports and 30 years for non-sports related renal injuries (p=0.049). Males were more commonly involved in sports related injuries (85% vs. 72%, p=0.011). Median injury severity score was lower for sports related injuries (10 vs. 27, p<0.001). There was no difference in renal abbreviated injury scale scores. Sports related trauma was more likely to be isolated without other significant injury (69% vs. 39% (p<0.001)). Haemodynamic instability was present in 40% and 51% of sports and non-sports renal injuries (p=0.30). Sports injuries had lower transfusion (7% vs. 47%, p<0.001) and lower mortality rates (0% vs. 6%, p=0.004). There was no difference in renal-specific procedural interventions between the two groups (17% sports vs. 18% non-sports, p=0.95). ConclusionsHigh-grade sports-related blunt renal trauma is more likely to occur in isolation without other abdominal or thoracic injuries and clinicians must have a high suspicion of renal injury with significant blows to the flank during sports activities.

Readability of patient education materials on the american association for surgery of trauma website.

Background:Because the quality of information on the Internet is of dubious worth, many patients seek out reliable expert sources. As per the American Medical Association (AMA) and the National Institutes of Health (NIH) recommendations, readability of patient education materials should not exceed a sixth-grade reading level. The average reading skill of U.S. adults is at the eighth-grade level.Objectives:This study evaluates whether a recognized source of expert content, the American Association for Surgery of Trauma (AAST) website’s patient education materials, recommended readability guidelines for medical information.Materials and Methods:Using the well-validated Flesch-Kincaid formula to analyze grade level readability, we evaluated the readability of all 16 of the publicly-accessible entries within the patient education section of the AAST website.Results:Mean ± SD grade level readability was 10.9 ± 1.8 for all the articles. All but one of the articles had a readability score above the sixth-grade level. Readability of the articles exceeded the maximum recommended level by an average of 4.9 grade levels (95% confidence interval, 4.0-5.8; P < 0.0001). Readability of the articles exceeded the eighth-grade level by an average of 2.9 grade levels (95% confidence interval, 2.0-3.8; P < 0.0001). Only one of the articles had a readability score below the eighth-grade level.Conclusions:The AAST’s online patient education materials may be of limited utility to many patients, as the readability of the information exceeds the average reading skill level of adults in the U.S. Lack of patient comprehension represents a discrepancy that is not in accordance with the goals of the AAST’s objectives for its patient education efforts.

Renal trauma imaging: Diagnosis and management. A pictorial review.

SummaryBackgroundThe purpose of this review is to illustrate and discuss the spectrum of imaging findings, particularly computed tomography (CT), of blunt and penetrating renal trauma, based on our own materials, according to the American Association for Surgery of Trauma (AAST) renal injury grading scale. The article also indicates the conditions in which interventional radiology procedures can be applied for the management of renal trauma.Material/MethodCases for this pictorial review were selected from the imaging material collected at the Radiology Department of Hamad Medical Corporation during a 14-year period from 1999 to 2012. The material includes 176 cases (164 males and 12 females) with confirmed blunt or penetrating renal trauma. Following abdominal trauma, all patients had a CT examination performed on admission to the hospital and/or during hospitalization. The most representative and illustrative cases of renal trauma were reviewed according to CT findings and were categorized according to the AAST grading system.DiscusionThe review describes a spectrum of imaging presentations with special emphasis on the 5 grades of renal injury on a CT according to the AAST scale.The most representative cases were illustrated and discussed with indications of possible interventional radiology treatment. Two groups of patients not included in the AAST grading system were presented separately: those with preexisting renal abnormalities and those with sustained iatrogenic renal injury.ConclusionsProper application of renal trauma grading scale is essential for selecting the patients for conservative treatment, surgery or interventional radiology procedure.

Grade 4 renal injury: current trend of management and future directions

The management of blunt renal trauma has been evolving. The past management largely based on American Association for Surgery of Trauma (AAST) grading system, i.e. necessitated a computed tomography (CT) scan. Although the CT scan use is increasing and becomes the standardized mode of investigation, AAST grading no longer plays the sole role in the decision of surgical interventions. Two case reports of blunt renal trauma managed successfully by conservative methods are presented. Case one was an 18 year-old boy who had a fall when riding a motorbike at 20 km/h with a helmet and full protective equipments. He was landed by his left flank onto a rock. Contrast abdominal CT revealed a 4 cm, grade III splenic tear and a grade IV left kidney injury with large perirenal haematoma. His international severity score (ISS) was 34. He was managed conservatively with bed rest and frequent serum haemoglobin monitoring. Subsequent CT with delayed contrast revealed stable perirenal haematoma with urine extravasation which was consistent with a grade IV renal injury. Case two was a 40 year-old male who had a motor bike accident on a racetrack when he was driving at 80 to 100 km/h, wearing a helmet. He lost control and hit onto the sidewall of the racetrack. Contrast abdominal CT revealed a grade IV left renal injury with a large urine extravasation. His renal injury was managed conservatively with interval delayed phase CT of the abdomen. A repeat CT on abdomen was performed five months after the initial injury which revealed no residual urinoma. In this study, moreover, a review of the literature to the management of blunt renal trauma was conducted to demonstrate the trend of increasing conservative management of such traumas. Extra radiological parameters may guide future decision making. However, the applicability of data may be limited until randomized trials are available.