American Association For The Surgery Of Trauma-Organ Injury Scale Research Articles

Proposed revision of the American Association for Surgery of Trauma Renal Organ Injury Scale: Secondary analysis of the Multi-institutional Genitourinary Trauma Study.

This study updates the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. This was a secondary analysis of a multicenter retrospective study including patients with high-grade renal trauma from seven level 1 trauma centers from 2013 to 2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed-effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST OIS. Based on the 2018 OIS grading system, we included 549 patients with AAST grades III to V injuries and computed tomography scans (III, 52% [n = 284]; IV, 45% [n = 249]; and V, 3% [n = 16]). Among these patients, 89% experienced blunt injury (n = 491), and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded, and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from grade IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC, 0.805; revised AUC, 0.883; p = 0.001) and number of units of packed red blood cells transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. Diagnostic Test/Criteria; Level III.

The Role of Dual-Energy CT in Solid Organ Injury.

The liver, spleen, and kidneys are the commonest injured solid organs in blunt and penetrating trauma. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted system for categorizing traumatic injuries. Grading systems allow clear communication of findings between clinical teams and assign a measurable severity of injury, which directly correlates with morbidity and mortality. The 2018 revised AAST OIS emphasizes reliance on CT for accurate grading; in particular regarding vascular injuries. Dual-Energy CT (DECT) has emerged as a promising tool with multiple clinical applications already demonstrated. In this review article, we summarize the basic principles of CT attenuation to refresh the minds of our readers and we scrutinize DECT's technology as opposed to conventional Single-Energy CT (SECT). This is followed by outlining the benefits of various DECT postprocessing techniques, which authors of this article refer to as the 3Ms (Mapping of Iodine, Material decomposition, and Monoenergetic virtual imaging), in aiding radiologists to confidently assign an OIS as well as problem solve complex injury patterns. In addition, a thorough discussion of changes to the revised AAST OIS focusing on definitions of key terms used in reporting injuries is described.

Shattered Kidney After Renal Trauma: Should It Be Classified As an American Association for the Surgery of Trauma Grade V Injury?

To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions. We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups. From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P=.01). Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE.

Splenic Artery Embolization in Conservative Management of Blunt Splenic Injury Graded by 2018 AAST-OIS: Results from a Hospital in Vietnam.

This study was conducted to evaluate the results of conservative management of blunt splenic trauma according to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) in 2018 by embolization. This observational study included 50 patients (42 men and 8 women) with splenic injury who underwent multidetector computed tomography (MDCT) and embolization. According to the 2018 AAST-OIS, 27 cases had higher grades than they did according to the 1994 AAST-OIS. The grades of two cases of grade II increased to grade IV; those of 15 cases of grade III increased to grade IV; and four cases of grade IV increased to grade V. As a result, all patients underwent successful splenic embolization and were stable at discharge. No patients required re-embolization or conversion to splenectomy. The mean hospital stay was 11.8±7 days (range, 6-44 days), with no difference in length of hospital stay among grades of splenic injury (p >0.05). Compared with the AAST-OIS 1994, the AAST-OIS 2018 classification is useful in making embolization decisions, regardless of the degree of blunt splenic injury with vascular lacerations visible on MDCT.

Operative Management of Penetrating Colon Injury: Gone Are the Days of the Diverting Colostomy

INTRODUCTION: There is continued controversy regarding the optimal operative management of penetrating colon injury (PCI). The aim of our study is to compare outcomes of initial diverting operation (DO) vs primary repair and anastomosis (PRA) for PCI. METHODS: A 2017-2018 American College of Surgeons TQIP analysis. All adult trauma patients with operatively managed PCI were included. Transferred, dead ≤24 hours, or burn patients were excluded. Patients were stratified into DO or PRA. Outcomes measures were superficial and deep operative site infection (SSI) rate, intraabdominal abscess, sepsis, infectious complication, and failure of operative management (FOM; unplanned operating room return or subsequent diversion), hospital and ICU length of stay (LOS), and mortality. Multivariate regression was performed to identify predictors of infectious complication. RESULTS: A total of 4,504 patients were identified, of whom 357 (8%) underwent DO and 4,147 (92%) PRA. Mean age was 34 ± 13 years, 4,029(90%) were men, median Injury Severity Score was 16 [9-25]. The most common mechanism of injury was firearm (82%). Left-sided colon was most commonly affected (38%), and 56% had an American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade III PCI or higher. A total of 599b(13%) patients had an infectious complication. DO group had higher superficial SSI rate (5.0% vs 2.4%; p = 0.003) and infectious complication (19.0% v s12.8%; p < 0.001), but no difference in deep SSI rate, intra-abdominal abscess, sepsis, FOM, mortality, hospital and ICU LOS between both groups (p > 0.05). Independent predictors of infectious complication are described in the Table. CONCLUSION: One in 7 patients with PCI developed an infectious complication, most commonly an intra-abdominal abscess. DO is independently associated with increased risk of infectious complication, along with left-sided PCI, concomitant gastric or small intestinal injuries, firearm injury, and AAST-OIS grade of PCI. PRA should be the preferred operative management for PCI.Table

Kardiyak Travmada Cerrahi Tedavi Deneyimi: Tek Merkezli Çalışma

Objective: Cardiac trauma has a high mortality rate and requires emergency diagnosis and surgical treatment. This retrospective study was planned to evaluate outcomes of patients who underwent urgent surgical treatment for cardiac trauma using valuable injury scoring systems.Material and Methods: All traumatic patients who applied to our emergency service and performed surgical operations due to cardiac trauma between January 1985 and November 2021 by cardiovascular surgeons, were analyzed retrospectively. The patients with iatrogenic cardiac trauma after the percutaneous intervention were also included in the study population. Cardiac injury scales such as physiological index (PI), penetrating cardiac trauma index (PCTI), penetrating thoracic trauma index (PTTI), and American Association for the Surgery of Trauma/Organ Injury Scale (AAST/OIS), were calculated in all patients for clinical severity.Results: In this study, 39 patients were enrolled. 24 patients (61.6%) had penetrating, 13 (33.3%) iatrogenic, 2 (5.1%) blunt cardiac injuries. 15 patients (38.5%) had penetrating stab wounds, and 9 (23.1%) had gunshot wounds. The mean age of the patients was 48.3±19.0 (min: 6-max: 87) years, and 79.6% were male. The most frequently injured cardiac chambers were right ventricle (RV) (46.2%), left ventricle (LV) (25.6%), right atrium (RA) (10.3%), and coronary arteries (10.3%), respectively. While the number of patients with cardiac tamponade was 25 (64.1%), additional abdominal injuries were detected in 6 (15.4%) patients. 80% of the patients with cardiac tamponade survived (p=0.006). The mortality rate was 35% for penetrating injuries in this study.Conclusion: This study, which included patients with cardiac trauma from a single-center, draws attention in terms of showing the negative effect of cardiac tamponade on mortality. Our study outcomes also do not support the old dictum that left ventricular injuries have higher mortality.

Management of pancreatic trauma-a single center experience

Background: Traumatic injury to the pancreas is rare and frequently overlooked. High index of suspicion is required in diagnosing pancreatic injury and management is challenging even with experienced trauma surgeons. The aim of this study was to report our experience in the management of pancreatic injuries.Methods: We analyzed 39 patients with pancreatic injury managed in our center from January 2016- December 2021. Data regarding patients’ demographics, mode of injury, American association for the surgery of trauma-organ injury scale (AAST-OIS) grade of pancreatic injury, associated injuries, management, morbidity and mortality were collected for analysis.Results: The study included 39 patients who presented with blunt injury abdomen (AAST-OIS grading: grade 2 (n=6), grade 3 (n=29), grade 4 (n=4)) with mean age 28.9 years. Associated injuries were present in 41% of patients (n=16). Thirteen patients had non-operative management-5 of them were managed conservatively without any intervention; 8 of them had non-surgical intervention in the form of Percutaneous Drainage or Endoscopic Retrograde Cholangio Pancreatography with Pancreatic duct stent for peri-pancreatic collection or ductal injury. But the rate of readmission for recurrent pancreatitis and reintervention for peri-pancreatic collection was 46% and 38% respectively in these patients. Twenty-six patients underwent surgery-distal pancreato splenectomy, laparotomy and external drainage, Roux-en Y pancreaticojejunostomy.Conclusions: Management of high-grade pancreatic injuries needs technical expertise. Early diagnosis and appropriate surgical management in high-grade pancreatic injuries carries favorable outcomes. Delayed presentation with sepsis is associated with high mortality.

Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS

BackgroundThis study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE).MethodsWe conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE.ResultsIn total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate.ConclusionsOur data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.Graphical abstract

Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention.

Computed tomography volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research. BACKGROUND Several ordinal grading systems are used in deciding whether to perform angioembolization (AE) or splenectomy following blunt splenic injury (BSI). The 2018 American Association for the Surgery of Trauma (AAST) Organ Injury Scale incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision making. PURPOSE The purpose of this study is to compare performance of computed tomography (CT) volumetry-based quantitative modeling to the 1994 and 2018 AAST Organ Injury Scale and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or AE. MATERIALS AND METHODS Adult BSI patients (age ≥18 years) scanned with dual-phase CT prior to intervention at a single Level I trauma center from 2017 to 2019 were included in this retrospective study (n = 174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included (1) SPY and (2) the composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. Area under the receiver operating characteristic curve (AUC) for ordinal systems and volumetric models were compared. RESULTS Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85—SPY, 0.82—composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p = 0.66, 0.14) for both endpoints and were significantly improved over Thompson scoring (0.76, p = 0.02; 0.77, p = 0.04). CONCLUSION Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.

Efficacy of Minimal Invasive Methods in Management of Traumatic Pancreatic Injury

Introduction Isolated pancreatic injury is relatively uncommon due to its mostly retroperitoneal location. However, if present, it is associated with other visceral injuries and causes serious complications if expected management is delayed. Cases In this report we have discussed about the different minimal invasive management approaches in two cases of pancreatic injury. The first case had American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade IV pancreatic injury with late presentation who underwent ultrasound-guided percutaneous drainage of pseudocyst with video assisted lavage of cavity, followed by endoscopic retrograde cholangiopancreatography (ERCP) guided pancreatic duct stenting. Second case had AAST-OIS grade II pancreatic injury which was managed with serial percutaneous drainage. Conclusion Management of pancreatic injury is complex. Evolving trend of minimal invasive techniques of management for selected patients with higher grade pancreatic injury is associated with better outcomes.

Early pancreaticogastrostomy: a better and novel approach for high grade traumatic pancreatic injuries - case report from tertiary care centre in India

Traumatic pancreatic injury is a rare entity which is associated with severe morbidity and mortality. The management varies according to the American association for the surgery of trauma-organ injury scale (AAST-OIS) grading of injury, hemodynamic status and time of definitive diagnosis. Non-operative versus operative management has potential risks and benefits and long term debate on the ideal management is still ongoing. A 19-year boy, with severe, generalised pain abdomen was admitted after road traffic accident. Upon admission, the investigations: ultrasonography (USG) and computed tomography (CT) scan abdomen, showed traumatic pancreatic injury (AAST-OIS, grade V), was taken for exploratory laparotomy which revealed lacerated head of pancreas along with normal distal segment of pancreas with no associated injury to nearby hollow viscera, vascular structures. He underwent primary closure of head of pancreas with distal segment pancreaticogastrostomy. Postoperatively he recovered well with no complications. In the present case, as he had traumatic pancreatic injury (AAST-OIS, grade V) and there was no involvement of hollow viscera and vascular structures, the operative intervention can decrease morbidity as by pancreaticogastrostomy we have diverted the pancreatic fluid into stomach, subsequently decreasing the chances of pseudocyst, fistula, necrosis of pancreas. Thus we conclude, high grade blunt traumatic abdomen injuries should be managed with adequate resection and subsequent reconstruction and/or drainage procedure. Pancreaticoduodenectomy, distal pancreatectomy, pancreaticogastrostomy, pancreaticojejunostomy are the available options to be used according to the grading of injury and associated injuries.

Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience

IntroductionWe aimed to compare outcomes of pancreatic resection with that of peripancreatic drainage for American Association for the Surgery of Trauma–Organ Injury Scale (AAST-OIS) grade IV blunt pancreatic injury in order to determine the optimal treatment method. Materials and methodsNineteen surgical patients with AAST-OIS grade IV blunt pancreatic injury between 1994 and 2016 were retrospectively studied. ResultsAmong the 19 patients, 14 were men and 5 were women (median age: 33 years). Twelve patients underwent pancreatic resection (spleen-sacrificing distal pancreatectomy, n = 6; spleen-preserving distal pancreatectomy, n = 3; and central pancreatectomy with Roux-en-Y anastomosis, n = 3), and seven underwent peripancreatic drainage. After comparing these two groups, no significant differences were found in terms of gender, shock at triage, laboratory data, injury severity score, associated injury, length of hospital stay, and complication. The only significant difference was that in the drainage group, the duration from injury to surgery was longer than that from injury to resection (median, 48 hours vs. 24 hours; P = 0.036). In the drainage group, three patients required reoperation, and another three required further pancreatic duct stent therapy. ConclusionsIn the surgery of the grade IV blunt pancreatic injury, pancreatic resection is warranted in early, conclusive MPD injury; if surgery is delayed or MPD injury has not been clearly assessed, peripancreatic drainage is an alternative method. However, peripancreatic drainage alone is not adequate and further pancreatic duct stent or reoperation is required. Further studies should be conducted to confirm our conclusions.

Traumatic pancreatic transection - Case reports

Pancreatic injury following blunt trauma abdomen is presentation with significant morbidity and mortality. Our first case here is the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade V pancreaticoduodenal injuries following penetrating injury managed with pancreaticoduodenectomy and the second case is blunt trauma to the abdomen with pancreatic tail transection which is American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade III that was managed with Endoscopic Retrograde Cholangiopancreaticography (ERCP) and pancreatic duct stenting. The outcome depends on early diagnosis and needs a high index of suspicion due to subtle clinical and radiological findings initially. Hemodynamically unstable patients may have other associated visceral and vascular injuries, and damage control strategy will be a suitable option. Same sitting resection procedures like pancreaticoduodenectomy are rarely performed. Pancreatic injuries can often be managed non-operatively with percutaneous drainage and pancreatic duct stenting.

The American Association for the Surgery of Trauma Organ Injury Scale 2018 update for computed tomography-based grading of renal trauma: a primer for the emergency radiologist.

The most widely used trauma injury grading system is the Organ Injury Scale (OIS) by the American Association for the Surgery of Trauma (AAST). The AAST OIS for renal trauma was revised in 2018 to reflect necessary updates based on decades of experience with computed tomography (CT)-based injury diagnosis and, specifically, to better incorporate vascular injuries, which were not comprehensively addressed in the original OIS. In this review article, we describe CT findings of the AAST OIS for the kidney according to the 2018 revision, with an emphasis on real-world application, and highlight important differences from the prior grading scheme. Routine use of this grading system allows for a standardized classification of the range of renal injuries to aid in management, adding value in the imaging care of trauma patients.

Influence of postoperative hepatic angiography on mortality after laparotomy in Grade IV/V hepatic injuries.

Mortality rate for severe liver injuries remains high. As an adjunct to surgery, postoperative hepatic angiography (PHA) may have a positive impact on outcomes. This study sought to compare outcomes following surgical management of severe liver injuries with and without PHA using propensity score matching analysis. Data from the National Trauma Data Bank from 2007 to 2014 were analyzed. The study population consisted of patients older than 18 years, sustaining severe liver injuries (i.e., American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade IV or V) who underwent surgery. Patients were divided into two groups. The PHA group consisted of those undergoing surgery followed by PHA. In the surgery-only group, no angiography was performed. To determine the impact of PHA on outcomes, propensity score matching analysis (1:3) was used. A total of 3,871 patients met inclusion criteria. Of those, 205 (5.3%) patients underwent PHA. Prior to matching, patients in the PHA group had higher severity, but overall in-hospital mortality was found to be similar between the two groups. After 1:3 propensity-score matching, 196 patients in the PHA group were matched with 588 in the surgery-only group with well-balanced baseline characteristics. The in-hospital mortality was significantly lower in the PHA group compared with the surgery-only group (24.5% vs. 35.9%; odds ratio, 0.58; 95% confidence interval, 0.40-0.84). However, hospital length of stay was longer (16.0 [7.0-29.8] vs. 11 [1.0-25.0] days, p = 0.001), and the incidence of deep and organ/space surgical site infection (3.6% vs. 1.2%, 8.2% vs. 3.5%, respectively) was higher in the PHA group. The use of PHA was associated with decreased mortality rates. A multimodality approach using both surgical intervention followed by PHA appears to identify patients that may benefit from arterial embolization, leading to decreased mortality of severe liver injuries. Therapeutic study, level IV.

Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma

BackgroundPenetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to...

Perinephric Hematoma Size is Independently Associated with the Need for Urological Intervention in Multisystem Blunt Renal Trauma

We examined radiographic predictors of intervention for blunt renal trauma independent of AAST-OIS (American Association for the Surgery of Trauma-Organ Injury Scale). A total of 328 patients with blunt renal trauma from October 2004 to December 2014 were identified for analysis. Hospital records and diagnostic imaging were reviewed to identify the need for urological intervention, including angiographic embolization, nephrectomy, renorrhaphy, ureteral stenting or percutaneous drainage. Factors examined included patient age, gender, length of stay, ISS (Injury Severity Score), AAST-OIS, laceration location, length and number, perinephric hematoma characteristics, intravascular contrast extravasation and devitalized segment status. Descriptive statistics and binary logistic regression were performed as appropriate. Mean patient age was 37.0 years and mean ISS was 31.7. A total of 31 urological interventions were required in 27 patients (8.2%), including ureteral stenting in 38.7%, angiographic embolization in 32.3%, nephrectomy in 22.6%, renorrhaphy in 3.2% and percutaneous drainage in 3.2%. On univariate analysis AAST-OIS, hematoma diameter, hematoma area, intravascular contrast extravasation, laceration length, laceration number, degree of devitalization and devitalized fragment presence were associated with the need for intervention (each p <0.001). On multivariate analysis only AAST-OIS grade (OR 69.4, 95% CI 6.4-748.3, p <0.001) and hematoma diameter (OR 1.5, 95% CI 1.1-1.9, p = 0.004) or area (OR 1.03, 95% CI 1.01-1.06, p = 0.012) remained associated with urological intervention. Although AAST-OIS is strongly associated with the need for urological intervention, perinephric hematoma size is also independently associated with this occurrence. Perinephric hematoma diameter should be considered during clinical decision making and incorporated into a revised injury grading system.

Blunt Pancreatic Injury in Major Trauma: Decision-Making between Nonoperative and Operative Treatment

Blunt trauma injuries to the pancreas are rare but are associated with significant overall mortality and a high complication rate. Motor vehicle collisions are the leading cause of blunt pancreatic trauma, followed by falls, and sports injuries. We discuss the decision-making process used during the clinical courses of 3 patients with life-threatening blunt pancreatic injuries caused by traumatic falls. We also discuss the utility of the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS), which provides a system for grading pancreatic trauma. Retrospectively, the cases reviewed were classified as AAST-OIS grade II, III, and IV in each one patient. Although the nonoperative approach was initially preferred, surgery was required in each case due to pseudocyst formation, pancreatic necrosis, and posttraumatic pancreatitis. In each case, complete healing was achieved through exploratory laparotomy with extensive lavage and placement of abdominal drains for several weeks postoperatively. These cases show that nonoperative management of pancreatic ductal trauma results in poor outcomes when initial therapy is less than optimal.

Reliability and reproducibility of the American Association for the Surgery of Trauma scaling for renal injury and impact on radiologic follow-up

The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most used classification for renal trauma. It determines the radiologic monitoring, only recommended for high-grade injuries. The aim of this study was to assess the subjectivity of AAST scaling and its impact on short-term follow-up. We retrospectively reviewed all patients with blunt renal injuries admitted at a university hospital between 2010 and 2015. Computed Tomography (CT) scan were analyzed and injuries graded according to AAST OIS independently by a senior radiologist, a senior urologist who was blind to clinical data and a resident urologist. Grading disagreements were analyzed collegially to obtain a final rating. The agreement of AAST scaling was evaluated through the Cohen's Kappa coefficient. Ninety-seven patients had 101 renal injuries: low grade in 58.4% (11.9% grade I, 17.8% grade II, 28.7% grade III) and high grade in 41.6% of cases (23.6% grade IV and 17.8% grade V). The agreement was fair with Kappa coefficient at 0.36. The agreement was moderate in severity sub-division analysis (low or high grade): Kappa coefficient at 0.59. There was a disagreement in 49.5% between the senior urologist's and the senior radiologist's ratings. Those differences brought to a severity group change and radiologic follow-up modification in 34% (n=17). AAST OIS for renal trauma suffers from subjectivity but is improved by severity sub-group analysis. This subjectivity influences the radiologic follow-up but could be reduced by collegiate rating. 4.

Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries.

Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management. This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression. 101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97±47, mean HR 92±47, and mean admission pH 7.22±0.17. Mean RTS 6.25±2.7, mean ISS 36±22. The mean estimated blood loss (EBL) was 5277±4955mls. Predictors of outcome are: admission pH (p=0.0014), admission base deficit (p<0.0001), packed red blood cells (PRBCs) transfused (p=0.023), whole blood transfused (p<0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p=0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p<0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p=0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p=0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p=0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome. Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.