Emergency Surgical Intervention Research Articles

Diaphragmatic eventration with impending gangrenous organoaxial volvulus of the stomach: Role of timely intervention

Eventration of diaphragm is a rare entity and often is characterized by a developmental abnormality of the diaphragm musculature. The acute presentation of organoaxial volvulus with impending gangrene of stomach is a life-threatening event and requires emergency diagnosis and surgical intervention. A 45-year-old man visited our hospital for evaluation of upper abdominal discomfort. He had a feeling of fullness and discomfort in the upper abdomen for 3 years. These attacks lasted about 2 hours and were not usually severe but eventually presented with severe abdominal pain. The patient was explored as general condition was deteriorating. On exploration, it was found that there was huge organoaxial stomach volvulus with impending stomach gangrene. Emergency exploration, gastropexy, and plication of diaphragm was done. Early diagnosis and prompt intervention may avoid consequent gastric volvulus and complications,improving the overall outcome and mortality.

Ileal Perforation by Ingested Fishbone

Hollow viscus perforation is one of the most frequent causes of acute gastrointestinal symptoms, but these are rare due to foreign body (FB) ingestion. The majority of ingested FBs that reach the stomach pass uneventfully through the gastrointestinal tract. Hollow viscus perforation following a FB ingestion frequently occurs at the ileum. Fishbones are often ingested by older population, and only a small number of patients can recall an event of swallowing an FB. Here, we present a case of ileal perforation caused by ingesting a fishbone in a 60-year-old man who recovered successfully after receiving emergency surgical treatment.

Impact of COVID-19 on surgical emergency presentations in a tertiary hospital in the developing world


 
 
 BACKGROUND: The COVID-19 pandemic and the institution of measures to contain the spread of the virus have disrupted patients' elective and emergency care, with scarce resources being channeled towards care of emergency presentations and containing the virus. The study aimed to assess the impact of COVID-19 on surgical accidents and emergency presentations in a major teaching hospital.
 METHOD: This was a comparative retrospective study. All presentations between February to July 2019 (non-COVID-19 period) were compared with the same period in 2020 (COVID-19 period). Patients' biodata, including surgical specialty that managed the patient, diagnosis, and treatment offered, were collated and analyzed with IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: I.B.M. Corp.
 RESULTS: We included 3463 patients in the study; 2419 (69.9%) were males, while 1044(30.1%) were females. The mean age of the patients in 2019 was 31.83 ±19.31 years, and that of 2020 was 34.93±19.99 years (P=0.001). During the lockdown period, emergency surgical presentations declined significantly by 17% (1894 versus 1569: P=0.001). There was a general decline in surgical emergency presentations across surgical specialties, with orthopedic and otorhinolaryngology (E.N.T.) having the greatest impact (313 versus 202 P=0.044). Presentation for trauma decreased by 18% (1394 versus 1144 P=0.711). Operative interventions declined by 47% (292 versus 155 P=0.001). There was a decline of 31% in the number of admissions for in-patient care (420 versus 290 P=0.019).
 CONCLUSION: The COVID-19 lockdown in Nigeria was associated with a reduction in the number of surgical emergency presentations and surgical interventions.
 
 

Complications Following Ulnar Artery Catheterization for Coronary Angiography.

Use of radial and ulnar access has increased due to its perceived benefits over femoral access. Ulnar artery catheterization can place patients at risk of significant complications, including pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve injury, and critical hand ischemia. The purpose of this study was to describe complications specific to ulnar artery catheterization. After obtaining institutional review board approval, a retrospective review was performed on all patients who underwent ulnar artery catheterization at our institution between 2019 and 2021. Complications were assessed, and complication rates were compared with previously published studies on ulnar artery catheterization for coronary angiography (percutaneous coronary intervention). A total of 41 patients were available for review with a mean age of 59 years. Of these, 17 patients (41%) sustained complications in the immediate postprocedural period. These complications included hematoma (12 patients, 29%), pseudoaneurysm (1 patient, 2%), ulnar artery thrombosis (1 patient, 2%), ulnar neuropathy (3 patients, 7%), arterial damage requiring repair (2 patients, 5%), transient ischemia (3 patients, 7%), and compartment syndrome (2 patients, 5%). Three of these patients (7%) required operative intervention, and several were admitted to the hospital for an additional period of observation. This series highlights the significant risks associated with ulnar artery catheterization for percutaneous procedures. Complications include pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve damage, and critical hand ischemia. Several of these patients required urgent or emergent surgical intervention, with some patients experiencing ongoing ulnar nerve symptoms.

Traumatologie der Nase

Isolated nasal bone fractures are the most common injuries of the central midface. They can be divided into different fracture types, depending on the exposure and orientation of violence. It is essential to ensure that there is no septal hematoma or abscess, which would require an emergency surgical intervention. Aclosed reposition can be offered if misalignment of the nose can still be observed after the edema swelling has gone down. In case of insufficient aesthetic and functional results, rhinoplasty/septal reconstruction can be performed 6 to 12months after the trauma at the earliest. In children the, the decision for repositioning should be taken carefully in order to protect the nasal growing zone.

Radiological Features for Frailty Assessment in Patients Requiring Emergency Laparotomy.

Introduction: As the number of elderly patients requiring surgical intervention rises, it is believed that frailty syndrome has a greater impact on perioperative course than on chronological age. The aim of this study was to evaluate the efficacy of various imaging features for frailty assessment in patients undergoing emergency laparotomy. Methods: The study included all patients that qualified for emergency surgery with preoperative CT scans between 2016 and 2020 in the Second Department of General Surgery. Multiple trauma patients were excluded from the analysis. The modified frailty index and brief geriatric assessment were used in the analysis. CT images were reviewed for the assessment of osteopenia, sarcopenia, sarcopenic obesity, renal volume and abdominal aorta calcification rate. Results: A total of 261 patients were included in the analysis. Multivariate logistic regression identified every next ASA class (OR: 4.161, 95%CI: 1.672–10.355, p = 0.002), intraoperative adverse events (OR: 12.397, 95%CI: 2.166–70.969, p = 0.005) and osteopenia (OR: 4.213, 95%CI: 1.235–14.367, p = 0.022) as a risk factor for 30-day mortality. Our study showed that every next ASA class (OR: 1.952, 95%Cl: 1.171–3.256, p = 0.010) and every point of the BGA score (OR: 1.496, 95%Cl: 1.110–2.016, p = 0.008) are risk factors for major complications. Conclusions: Osteopenia was the best parameter for perioperative mortality risk stratification in patients undergoing emergency surgical intervention. Sarcopenia (measured as psoas muscle area), sarcopenic obesity, aortic calcifications and mean kidney volume do not predict poor outcomes in those patients. None of the radiological markers appeared to be useful for the prediction of perioperative morbidity.

Longer Hospital Length of Stay and Emergency Surgical Intervention are Associated with Lower Rates of Mortality In Elderly Patients with Ruptured Abdominal Aortic Aneurysm: An Analysis of 7,214 Patients.

We aimed to determine predictors for in-hospital mortality for elderly patients with ruptured abdominal aortic aneurysms (AAA) undergoing emergency admission. This was a retrospective cohort study utilizing the National Inpatient Sample (NIS) Database, 2005-2014, on elderly patients with ruptured AAA undergoing emergency admission. ICD-9 code 441.3 was used to identify patients with ruptured AAA. Male versus female sex, survived versus deceased patients, and operated versus not-operated ones were compared for various patient characteristics. A multivariable logistic regression with backward elimination and a generalized additive model (GAM) were implemented to evaluate the associations between potential risk factors and mortality. A total of 7,214 patients aged 65 and older with ruptured AAA were included. About 31% of total sample, 26% of survived, and 36% of deceased were female. Mortality rate was higher in older patients, females, and those who were not operated on (40.6%) versus those that were (74.5%). Age, sex, healthcare insurance, severity of illness subclass, hospital length of stay, total charges, and several comorbidities had significant association with mortality in univariable models. Multivariable logistic regression with backward elimination confirmed age (odds ratio[OR]=1.04; 95% confidence interval [CI]=1.03-1.05; p<0.001), sex (OR=1.23; 95%CI=1.07-1.41; p=0.004), hospital length of stay (OR=0.87; 95%CI=0.86-0.88; p<0.001), bacterial infection (OR=3.79; 95%CI=3.07-4.68; p<0.001), cardiac disease (OR=1.97; 95%CI=1.71-2.28; p<0.001), liver disease (OR=2.90; 95%CI=2.22-3.77; p<0.001), fluid and electrolyte disorders (OR=1.34; 95%CI=1.18-1.52; p<0.001), and coagulopathy (OR=1.96; 95%CI=1.04-1.37; p=0.01) to be the independent predictors of mortality. Age showed a linear association with mortality; whereas, hospital length of stay had a significant L-shaped association. Elderly patients emergently admitted for ruptured AAA had the lowest risk of mortality with hospital stays greater than seven days (EDF=13.91, p<0.0001). Longer hospital length of stay (>7 days) of emergently admitted elderly patients with ruptured abdominal aortic aneurysm was associated with better outcomes and lower risk of mortality. Surgical intervention was also associated with much lower rate of mortality, while increasing age was associated with higher rate of mortality. In elderly patients admitted for ruptured abdominal aortic aneurysm, every one year older than 65, increased the odds of mortality by 4% and female sex increased the odds of mortality by 23%.

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.

Extravasation: Surgical Management and Prevention

Extravasation is defined as the leakage of fluid from a blood vessel into the surrounding area at the injection site. These accidents occur during injection for diagnostic or therapeutic purposes, carried out through the peripheral or central venous lines (Chemotherapy, metabolites, or contrast agent for radiographic examination). They can be the cause of skin necrosis able to progress to significant functional, cosmetic, and psychological sequelae. The saline washout technique is the emergency surgical treatment of choice for extravasations of certain products, allowing the elimination of the toxicant and the preservation of the skin. In the event of skin necrosis, covering techniques such as directed healing, grafts and flaps allow healing. The difficulty of the therapeutic management of these lesions and their unpredictable evolution, require prevention, by the development of protocols for the installation and monitoring of the venous catheters, and by the continuous training of the nursing staff to know the symptoms of extravasation, and their immediate management. The aim of this work is to present a review of the existing literature, allowing to know the diagnostic criteria, insist on the means of prevention, and propose a protocol of management.

Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study

BackgroundFrailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. MethodsA retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. ResultsWe identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60–0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64–0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. ConclusionsIn patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.

Validation of TWIST score in the diagnosis of testicular torsion in children: A Prospective study

Early diagnosis is key in testicular torsion. This study is to validate the diagnostic value of the “Testicular Workup for Ischemia and Suspected Torsion (TWIST)” score for evaluating acute scrotum in children. Patients from 1 month old to 16 years old presented to Children’s hospital No.1 with acute scrotum between June 1 st, 2020, and May 31 st, 2021 were prospectively studied. General surgeons performed an examination and recorded signs and symptoms in the collection form. After that, all patients had Scrotal Doppler Ultrasound (DUS). We calculated the sensitivity, specificity, positive predictive, and negative predictive values of the TWIST score. The ROC curve was used to find out the optimal cut-off in diagnosing Testicular torsion (TT) in Children. Among 68 children with acute scrotum, 16 cases had TT (23.5%). The median age was 12.5 years in the TT group and 9 years in the non-TT group. None of 32 patients with the TWIST score ≤ 2 had TT and among 20 patients with a score of 3 – 4, only one had TT. More importantly, in the high-risk group with a score ≥ 5, 15 had TT (93.8%). ROC curve revealed an AUC of 0.987 (p&lt;0,001) representing a high diagnostic value. The sensitivity and specificity for TT at 5-point cut-off were 93.7% and 98.1%, respectively. The TWIST scoring system has high sensitivity and specificity values. Therefore, it should be used as a useful tool for the diagnosis of testicular torsion. The score ≥ 5 is an indicator of testicular torsion, hence emergency surgical intervention is required.

502 Emergency Giant Hiatus Hernia Surgery: Experiences with Post-Operative Complications

Abstract Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair is shown to reduce the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study was done looking at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications, and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had symptomatic recurrence of the hiatus hernia that required operative correction either during index admission or a subsequent admission. Median length of hospital stay was 8 days (IQR 5–16). There was a positive correlation between number of complications and length of stay. Post-operative mortality was 9%. Conclusions Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.

Factors associated with an unfavorable clinical course in hospitalized patients with pelvic inflammatory disease: a retrospective cohort study of 117 patients from a Japanese academic institution

BackgroundThis study aimed to determine the factors associated with an unfavorable clinical course (emergency surgery and/or prolonged hospitalization) in patients requiring hospitalization owing to pelvic inflammatory disease (PID).MethodsA retrospective study was performed on 117 patients diagnosed with PID who were admitted to our hospital between January 2014 and December 2018. Multivariate regression analysis was conducted to determine the factors associated with emergency surgical intervention, and prolonged hospitalization in a subgroup of successful expectant management (n = 93).ResultsThe average age (mean ± standard deviation) of the patients was 41.2 ± 12.5 years; 16 (13.7%) were postmenopausal; 81 patients (69.2%) complicated with a tubo-ovarian abscess (TOA) of which 59 (72.9%) had an ovarian endometrioma; and 19 patients (16.2%) had a history of various intrauterine manipulations. Emergency surgery was performed in 24 patients (20.5%), and patients with TOA underwent emergency surgery more often than did patients without TOA (25.9% vs. 8.3%, p = 0.03), and TOA was associated with longer length of hospital stay (17.1 days vs. 8.0 days, p = 0.01). Smoking, postmenopausal status, past medical history of PID, and high C-reactive protein (CRP) level at admission were significantly associated with emergency surgery. In patients with successful expectant management, obesity (body mass index ≥ 30) and high WBC and CRP level at admission were significantly associated with prolonged hospitalization.ConclusionsOf the patients requiring hospitalization owing to PID, TOA was associated with both emergency surgery and prolonged hospital stay. Patients with increased inflammatory markers and obesity should be considered to be at a high risk for unfavorable clinical course in the management of PID.

TU8.9 Emergency Giant Hiatus hernia repair, Single Centre Experience

Abstract Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair reduces the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study looked at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had a symptomatic recurrence of the hiatus hernia that required operative correction during index admission or subsequent admission. The median length of hospital stay was eight days (IQR 5–16). There was a positive correlation between the number of complications and length of stay. Post-operative mortality was 9%. Conclusion Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.

Beneficial effects of Cyclosporine A in combination with Nortriptyline on germ cell-specific apoptosis, oxidative stress and epididymal sperm qualities following testicular ischemia/reperfusion in rats: a comparative study

BackgroundTesticular torsion is a pathological condition which needs emergency surgical intervention. However, after surgical reperfusion, oxidative stress factors cause to germ cell apoptosis. The study was planned to evaluate the efficacy of simultaneous use of Cyclosporine A (CsA) and Nortriptyline (Nort) to repair testicular damages in an experimental torsion/detorsion (T/D) rat model.MethodsMale rats (n = 112) were allocated into 7 groups 16 each in; (Group 1); Control group, (Group 2); T/D group, (Group 3–4); CsA 1 and 5 mg/kg, (Group 5–6); Nort 2 and 10 mg/kg and (Group 7); concurrent group, CsA (1 mg/kg) + Nort (2 mg/kg). Right uni-lateral torsion was inducted by twisting testis 720 degrees in the clockwise direction for 1 h. For short-term and mid-term studies, lipid peroxidation, antioxidant enzyme activities, caspase-3 level, histopathological changes and germ cell apoptosis were evaluated. Moreover, in long-term investigation, semen analysis was performed.ResultsAfter T/D induction, testis abnormalities both functional and structural were appeared. Pre- and post-treatment with CsA and Nort, separately, reduced MDA and caspase-3 levels, normalized antioxidant levels, ameliorate tissue injury and improved sperm criteria.ConclusionThe antioxidant and anti-apoptotic characteristics of CsA and Nort and their protective effects have been shown in our study. Concurrent administration of CsA and Nort in selected low-dose indicated a significant positive effect as compared to the individual drug interventions on the reversal of T/D induced oxidative stress in short-term, apoptosis, and histologic changes in mid-term, as well as semen criteria in the long-term appraisal.

Adverse events associated with the bridge occlusion balloon for lead extraction: A MAUDE database study

Transvenous lead extraction has evolved as an important procedure for the treatment of device infection and the removal of unnecessary leads but can result in complications including superior vena cava (SVC) injury that can be potentially fatal. 1 Brunner M.P. Cronin E.M. Wazni O. et al. Outcomes of patients requiring emergent surgical or endovascular intervention for catastrophic complications during transvenous lead extraction. Heart Rhythm. 2014; 11: 419-425 Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar The bridge occlusion balloon (BOB; Philips, San Diego, CA) helps achieve prompt hemostasis and has been shown to reduce SVC injury–associated mortality. 2 Azarrafiy R. Tsang D.C. Wilkoff B.L. Carrillo R.G. Endovascular occlusion balloon for treatment of superior vena cava tears during transvenous lead extraction: a multiyear analysis and an update to best practice protocol. Circ Arrhythm Electrophysiol. 2019; 12e007266 Crossref PubMed Scopus (17) Google Scholar The safety profile of the BOB has not been previously evaluated, and we analyzed adverse events related to its use reported to the Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database.

Risk factors of reintervention after endovascular treatment of type B acute and subacute aortic dissections

The treatment of type B aortic dissections is not driven by well defined guidelines. At the time of diagnosis these dissections can be complicated by rupture or organ or limb malperfusion, which require an emergency surgical treatment, or not complicated. In these cases, optimal medical care only was recommended in first intention. The ADSORB and INSTEAD-XL studies recently led us to change our therapeutic attitude by showing the superiority of TEVAR associated with the optimal medical care compared to medical care only in terms of aortic remodeling, healing of the false lumen, and mortality related to the pathology aortic. Studies highlighted several risk factors for a poor prognosis at the time of the diagnosis, including the maximum aortic diameter, the laminated aspect of the true lumen, the principal main entry tear size, or the patency of the false lumen, which contributed to define the population needing TEVAR in association with the best medical care. These risk factors were measured at the time of the diagnosis, i.e. before the medical or surgical treatment. The literature also reported 25% - 50% reintervention rates for the patients who survived the acute phase. The aim of our study was to determine the risk factors of survival without secondary aortic intervention of the patients presenting with a type B aortic dissection, complicated or not, and treated in the 90 days of the diagnosis by TEVAR with coverage of the principal main entry tear.

Emergency physician and nurse discretion accurately triage high-risk trauma patients.

Prehospital trauma team activation (TTA) criteria allow for early identification of severely injured trauma patients. Although most TTA criteria are objective, one TTA criterion is subjective: emergency provider discretion. The study objective was to define the ability of emergency department physician and nurse discretion to accurately perform prehospital triage of high risk trauma patients. All highest level TTAs arriving to our American College of Surgeons (ACS)-verified Level 1 trauma center (06/2015-08/2020) were included. Exclusions were undocumented prehospital vitals or discharge disposition. At our institution, TTAs are triggered for standard ACS TTA criteria and age > 70 with traumatic mechanism other than ground level fall. Patients meeting ≥ 1 criterion apart from "Emergency Provider Discretion" were defined as Standard TTAs and patients meeting only "Emergency Provider Discretion" were defined as Discretion TTAs. Univariable/multivariable analyses compared injury data and outcomes. 4540 patients met inclusion/exclusion criteria: 3330 (73%) Standard TTAs and 1210 (27%) Discretion TTAs. Discretion TTAs were younger (34 vs. 37years, p < 0.001) and more frequently injured by penetrating trauma (38% vs. 33%, p = 0.008), particularly stab wounds (64% vs. 29%). Overtriage rates were comparable after Discretion vs. Standard TTAs (33% vs. 31%, p = 0.141). Blood transfusion < 4h (31% vs. 32%, p = 0.503) and ICU admission ≥ 3days (25% vs. 27%, p = 0.058) were comparable between groups. Discretion TTA was independently associated with increased need for emergent surgery (OR 1.316, p = 0.005). Emergency provider discretion accurately identifies major trauma, with comparable rates of overtriage as standard TTA criteria. Discretion TTAs were as likely as Standard TTAs to require early blood transfusion and prolonged ICU stay. After controlling for confounders, Discretion TTAs were significantly more likely to require emergent surgical intervention. Emergency provider discretion should be recognized as a valid method of identifying major trauma patients at high risk of need for intervention.

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma

IntroductionThe management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management. MethodsA retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy. Results181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04–0.49 CI 95%, P < .01). ConclusionBoth level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.

Preoperative clinical application of human fibrinogen in patients with acute Stanford type A aortic dissection: A single-center retrospective study.

To evaluate the perioperative clinical efficacy of preoperative human fibrinogen treatment in patients with acute Stanford type A aortic dissection (ATAAD). Data of 159 patients with ATAAD who underwent emergency surgical treatment in our hospital from January 2019 to December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether human fibrinogen was administered before surgery: patients in group A received fibrinogen before surgery, while those in group B did not. The preoperative clinical data, surgical data, postoperative data, complications related to the coagulation function, and mortality of the two groups were compared and analyzed. The in-hospital mortality was similar in the two groups (2.9% vs. 9.3%, p = .122). However, group A had a significantly shorter operation time (279.24 ± 39.03 vs. 298.24 ± 45.90, p = .008), lower intraoperative blood loss (240.48 ± 96.75 vs. 353.70 ± 189.80, p < .001), and reduced intraoperative transfusion requirement of red blood cells (2.61 ± 1.18 vs. 6.05 ± 1.86, p < .001). The postoperative suction drainage within 24 h in group A was significantly decreased (243.24 ± 201.52 vs. 504.22 ± 341.08, p = .002). The incidence of postoperative acute kidney injury (AKI) in group A was lower than that in group B (3.8% vs. 14.8%, p = .023). Similarly, the incidence of postoperative hepatic insufficiency in group A was lower than that in group B (1.9% vs. 9.3%, p = .045). In group A, the mechanical ventilation time was shorter (47.68 ± 28.61 vs. 118.21 ± 173.16, p = .004) along with reduced intensive care unit stay time (4.06 ± 1.18 vs. 8.09 ± 9.42, p = .003), and postoperative hospitalization days (19.20 ± 14.60 vs. 23.50 ± 7.56, p = .004). Preoperative administration of human fibrinogen in patients undergoing ATAAD surgery can effectively reduce the intraoperative blood loss, amount of blood transfused, operation time, and postoperative complications, and improve the early prognosis of patients. In addition, this procedure is highly safe.