Management Of Blunt Trauma Research Articles

Pediatric Trauma Verification Status Is Associated with Decreased Complications in the Management of Blunt Trauma with Duodenal Injury in Children

Pediatric Trauma Verification Status Is Associated with Decreased Complications in the Management of Blunt Trauma with Duodenal Injury in Children

CT Imaging and Management of Blunt Splenic Trauma: Lessons for Today and Tomorrow

CT Imaging and Management of Blunt Splenic Trauma: Lessons for Today and Tomorrow

English

BACKGROUND Blunt trauma is one of the most serious and most common causes of death in youth. Specifically, liver is one of the most frequently injured organs during abdominal trauma. During the last two decades, management of blunt trauma to the liver has changed from mainly operative intervention, to the current practice of selective operative and non-operative management (NOM). Avoidance of a laparotomy with its short- and long-term risks is of great benefit to the patient. Majority of patients admitted for liver injury have grade I, II and III injuries and are successfully treated with non-operative management. METHODS We conducted a prospective observational study over a period of 24 months between August 2017 and August 2019 among a total of 48 patients, in the Department of General Surgery, Government Medical College, Srinagar, and associated hospitals who were haemodynamically stable with isolated blunt hepatic trauma. RESULTS As liver trauma occurs more frequently in men, we found that male to female ratio was 3 : 1. In our study, 97 % of patients with isolated blunt hepatic trauma were haemodynamically stable, rest 3 % patients stabilized after initial resuscitation. Most of the complications 14.58 % occurred in higher grade injuries (grade IV and V). The complication rate in our study group was 18.75 %. CONCLUSIONS About 90 % of haemodynamically stable patients with isolated blunt hepatic injury can be managed successfully by non-operative management and nonoperative management is the treatment of choice irrespective of the grade of injury, mode of blunt trauma, age, and gender. KEYWORDS Non Operative Management, Hepatic Trauma

Blunt and Penetrating Liver Trauma have Similar Outcomes in the Modern Era

The trend in liver trauma management has progressively become increasingly conservative. However, a vast majority of literature focuses heavily on the management of blunt trauma. This study reviews the management of hepatic trauma at a major trauma center in a developing world setting, in order to compare blunt and penetrating liver trauma and to define current management algorithms and protocols. All patients who sustained liver trauma between 2012 to 2018 were identified in the Hybrid Electronic Medical Registry and extracted for further analysis. A total of 808 patients with hepatic trauma were managed by our trauma center. There were 658 males and 150 females. The mean age was 30 years (standard deviation 13.3). A total of 68 patients died (8.2%) and a total of 290 (35%) patients required intensive care unit admission. The mean presenting shock index was 0.806 (standard deviation 0.67-1.0), the median Injury Severity Score was 18 (interquartile range 10-25) and the mean Revised Trauma Score was 12 (standard deviation 11-12). There were 367 penetrating and 441 blunt liver injuries. The age distribution was similar in both groups. There were significantly less females in the penetrating group. The shock index and the Injury Severity Score on presentation were significantly worse in the blunt group, respectively: 0.891 (standard deviation 0.31) versus 0.845 (standard deviation 0.69) (p < 0.001) and score 21 (interquartile range 13-27) versus 16 (interquartile range 9-20) (p < 0.01). The opposite applied to the Revised Trauma Score of 11.75 (standard deviation 0.74) versus 11.19 (standard deviation 1.3) (p < 0.001). There were significantly more associated intra-abdominal injuries in the penetrating group than the blunt group, in particular that of hollow organs, and 84% of patients with a penetrating injury underwent a laparotomy while only 33% of the blunt injuries underwent a laparotomy. The mortality rate was comparable between both groups. Hepatic trauma is still associated with a high morbidity rate, although there have been dramatic improvements in mortality rates over the last three decades. The mortality rates for blunt and penetrating liver trauma are now similar. Non-operative management is feasible for over two-thirds of blunt injuries and for just under 20% of penetrating injuries.

The impact of early administration of vasopressor agents for the resuscitation of severe hemorrhagic shock following blunt trauma

BackgroundWhen resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock.MethodsIn this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25–75% interquartile range) or number.ResultsForty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36–48) vs 45 (34–51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12–0.48] vs 0.21 [0.08–0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680–9320] vs 6540 [4550–7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0–4] vs 14 [10–18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4–26] vs 34 [10–74] hours; p = 0.026) in survivors.Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71–121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90–58.5; p = 0.005) indicated significant higher risk of death in this study.ConclusionVasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.

263 Utility of Computed Tomography Pan-Scan Strategy in Elderly Patients With Isolated Head Injury and Normal Mental Status

CT pan-scan (CTPS) describes whole body CT imaging strategy used in blunt trauma management. CTPS includes imaging of chest, abdomen and pelvis in addition to CT head and cervical spine. Utilization of this strategy in patients with multiple injuries and altered mental status is widely accepted. Elderly trauma patients have high rates of morbidity and mortality from traumatic injuries. The purpose of this study is to ascertain if CTPS strategy is indicated in elderly patients with normal mental status and isolated head injury without signs or symptoms of trauma to chest, abdomen and pelvis (AP). This was a retrospective study of ED patients in an urban American College of Surgeons certified Level 1 Trauma center. We conducted a chart review of elderly trauma patients with a head injury and trauma activation in the emergency department between the dates of January 1st 2014 and December 31st 2016. Patients were included if they were 65 years or older, had an isolated head injury, Glasgow Coma Scale (GCS) ≥ 14, had a normal physical exam of the chest, AP, and a CTPS ordered within 3 hours of arrival. CTPS was considered positive (+CTPS) if there was a presence of a fracture to musculoskeletal (MSK) spine (MS), MSK thoracic (MT), MSK pelvis (MP), MSK extremity (ME) and/or splenic (S), vascular (V), pulmonary (P), or bowel (B) injuries. During the study period, 296 patients with isolated head injury and GCS ≥ 14 obtained a CTPS. Average age of patients included was 80.2 years [8.49]. Most common mechanism of blunt injury was a fall (91.8%). Average shock index (SI) was 0.57, while 19 (6.4%) patients had SI > 0.9. Out of the total 296 patients included in the study, 73 (24.6%) had a +CTPS. Among patients with SI > 0.9, 6 (31%) had +CTPS. Head CT was positive for acute intracranial hemorrhage in 80 (27%) patients. Out of these 80 patients, 22 (27.5%) had a +CTPS. Out of total 296 patients, 215 had both initial negative Chest X-ray (CXR) and pelvic X-ray. Of these 215 patients, 36 (16.2%) had a +CTPS. Among patients with negative plain films, types of injuries were as follows: MT -19, MS - 12, ME - 5, MP - 4, S - 3, V - 1, P - 1, and B - 1. There was no statistically significant correlation between +CTPS and the presence of anticoagulation and or antiplatelet use. Among ED elderly trauma activation patients with isolated head injury and normal mental status, the rate of +CTPS is significant. MSK injuries were the most common findings on +CTPS. Our study supports the use of this strategy at this time.

Successful management of a gun shot wound to the mandibular condyle by removal of the condylar head with no hard tissue reconstruction - Lessons for blunt trauma management?

Successful management of a gun shot wound to the mandibular condyle by removal of the condylar head with no hard tissue reconstruction - Lessons for blunt trauma management?

The Challenge of Blunt Abdominal Trauma in Children: Report of a Case and Review of Management

Blunt abdominal trauma is the most frequent cause of abdominal injuries in children. The term solid organ injury (SOI) is referred to liver, spleen and kidney. Splenic injuries are the most common. The management of SOI has been motive of discussion for years and has undergone a radical shift in the last decades. Currently, non-operative management is the gold standard of care when circumstances are favorable. In 1977, non-operative management was supported by surgeons in Toronto. Later, the American Pediatric Surgical Association (APSA) pointed that management should be based on imaging findings and CT grading of the American Association for the Surgery of Trauma. However, this caused long stays and unnecessary follow-up imaging. Soon, APSA guidelines were questioned and raised controversy. Finally, hemodynamic status was defined as the main key for taking decisions and ATOMAC guidelines gained support. However, facing a blunt trauma in children is always a challenge. Hemodynamic stability is not easy to define and heart rate and blood pulse are poor markers for stability. This complicates the management of blunt trauma in children. As consequence, it is important that these children are treated in pediatric centers. We report a case of a 15-year-old male who suffered from a blunt abdominal trauma with splenic and renal injuries treated by adult surgeons when playing football. We review the current recommendations for blunt abdominal trauma in children and the differences with adult management. J Med Cases. 2017;8(11):340-346 doi: https://doi.org/10.14740/jmc2901w

Whole-body computed tomography is associated with decreased mortality in blunt trauma patients with moderate-to-severe consciousness disturbance

Whole-body computed tomography (WBCT) has become commonly used in the management of blunt trauma (BT) in high-income countries, but its indications are controversial. Advanced trauma life support recommends conducting head CT for traumatized patients with a Glasgow Coma Scale (GCS) score of 3 to 12. This nationwide study was conducted to verify that WBCT is also beneficial for these patients. The Japan Trauma Data Bank (2007-2010) was used to identify BT patients with systolic blood pressure of greater than 75 mm Hg having a GCS score of 3 to 12. Because the probability of survival (Ps) by the Trauma and Injury Severity Score (TRISS) method was used for severity adjustment, 5,208 patients not lacking variables necessary for TRISS Ps calculation were analyzed. WBCT was defined as CT including all of the head, neck, chest, abdomen, and pelvis during initial trauma management, and the WBCT group was compared with patients who did not undergo CT of one or more of the body regions (non-WBCT). No significant difference in TRISS Ps was observed between the groups. However, the recorded mortality proportion was significantly lower (p = 0.0002) in the WBCT group (0.24; 95% confidence interval, 0.22-0.26) than in the non-WBCT group (0.28; 95% confidence interval, 0.27-0.30). In Japan, integration of WBCT into initial trauma management may decrease mortality in BT patients with a GCS score of 3 to 12 for whom head CT is indicated.

A Conservative Approach to Testicular Rupture in Adolescent Boys

Management for blunt trauma with breach of the renal capsule or bladder (extraperitoneal) has largely become nonsurgical since a conservative approach proved to be effective and safe. Currently the recommendation for managing testicular rupture is surgical exploration and débridement or orchiectomy. We report outcomes in boys diagnosed with testicular rupture and treated without surgical intervention. In the last year we conservatively treated 7 consecutive boys with delayed presentation of testicular rupture after blunt scrotal trauma. Patients were treated with scrotal support, antibiotics to prevent abscess, rest, analgesics and serial ultrasound. We report clinical information and outcomes. The 7 boys were 11 to 14 years old and presented 1 to 5 days after injury. Trauma was to the left testis in 3 cases and to the right testis in 4. Patients presented with mild to moderate pain and similar scrotal swelling. Ultrasound findings consistently revealed hematocele and increased echogenicity. Blood flow was present in the injured portion of the testes in 3 cases and to the remainder of the affected testicle in 6 of the 7 boys. In the remaining boy an adequate waveform was not seen in either testicle, which the radiologist thought was secondary to prepubertal status. Other findings included scrotal edema, irregular contour and seminiferous tubule extrusion. Followup was greater than 6 months in all cases. Five boys were seen at the office and the 2 remaining had telephone followup. In all cases hematocele resolved, testicular size stabilized without atrophy and echogenicity normalized in the 5 patients with followup ultrasound. One patient required surgical repair of hydrocele 4 months after trauma but no other patient needed surgical exploration. No abscess or infection developed. A conservative approach in a select group of adolescent boys with testicular rupture can result in resolution of the fracture and maintenance of testicular architectural integrity.

Abstract No. 150: Non Operative Management of Blunt Trauma to the Liver by Transcatheter Embolization: Risk Factors for Late Rebleeding

Abstract No. 150: Non Operative Management of Blunt Trauma to the Liver by Transcatheter Embolization: Risk Factors for Late Rebleeding

Treatment in Pediatric Renal Trauma: A Conservative Management Approach

Purpose: The management of pediatric trauma is substantially derived from the results of adult trauma patient. Despite the increasing of pediatric renal trauma, the management of them still remains controversial. The aim of this study is to evaluate our experience with the expectant conservative management of blunt trauma in children. Materials and Methods: We retrospectively studied 45 pediatric patients with renal trauma between 1995 and 2007. We reviewed medical records for clinical symptoms, mechanism of injury, assigned grade of renal injury, associated injuries, indication of surgery, and treatment outcomes. We graded renal injuries according to the American Association for the Surgery of Trauma Organ Injury Scale. Results: All patients of grade I, II, III, and IV were managed conservatively at beginning, if the hemodynamic state is stable. Among them, 2 patients of grade IV were done delayed operation. One patient underwent delayed renorrhaphy for persistent anemia and hypotension, and the other patient needed delayed nephrectomy because of persistent fever and worsening abdominal pain with significant urinary extravasation. All patients of grade V were undergone early nephrectomy. Conclusions: Except for persistent fever with significant extravasation and grade V injury, initial conservative management of blunt renal trauma in children is effective and recommendable at beginning, if the hemodynamic state is stable. Prospective larger randomized controlled trials will be needed. (Korean J Urol 2009;50:1125-1132) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Nonoperative management of blunt trauma in abdominal solid organ: a prospective study to evaluate the success rate and predictive factors of failure

Over the past several years, nonoperative management (NOM) has increasingly been recommended for the care of selected blunt abdominal solid organ injuries. No prospective study has evaluated the rate of NOM of blunt abdominal trauma in the northwest of Iran. The objective of our study was to evaluate the success rate of this kind of management in patients who do not require emergency surgery.

Combined head and abdominal computed tomography for blunt trauma: which patients with minor head trauma benefit most?

The widespread availability of computed tomography (CT) in the diagnosis and management of blunt trauma has created the possibility of overuse without clear indications. Some clinicians believe that patients with head injury, intoxication, and/or distracting injury have an unreliable abdominal examination and should undergo combined head and abdomen CT. The objective of this study was to evaluate which patients with minor head trauma benefit most from combined head and abdomen CT. Consecutive blunt trauma patients, with a Glasgow coma scale (GCS) of 14 or 15, who underwent concomitant head and abdomen CT upon admission to a level I trauma center over a 2-year period were retrospectively reviewed. Patient demographics, mechanism of injury, physical exam, hospital course, and radiological and laboratory findings were recorded. Patients were divided into four subgroups based upon the presence or absence of intracranial and/or intraabdominal injury detected by CT. Among the 1,478 blunt head trauma patients, only 18 (1%) patients had both head and abdominal injuries detected by combined CT. One-hundred twelve (8%) patients had only head injuries, and 131 (9%) had only intraabdominal injuries detected. Patients with a GCS of 14 were more likely to have isolated head injury [odds ratio (OR) 3.1, P=0.001], while those with loss of consciousness were more likely to have combined head and intraabdominal injury (OR 6.8, P=0.03) or isolated head injury (OR 1.7, P=0.02). Abdominal tenderness was associated with increased risk of isolated intraabdominal injury (OR 1.8, P=0.0015). Hematuria was associated with increased risk of combined head and intraabdominal injury (OR 8.3, P=0.0004) or isolated intraabdominal injury (OR 7.9, P=0.0001). Patients with loss of consciousness and/or GCS of 14 frequently undergo head CT. The addition of an abdomen CT scan in this patient population should be based on objective clinical criteria such as presence of abdominal tenderness and/or hematuria.

Laparoscopy in a case of pediatric blunt abdominal trauma

The use of laparoscopy in the assessment and treatment of blunt abdominal trauma has been reported for both adults and children. With increasing surgical experience and improvements in equipment, an expanding range of therapeutic interventions is available. The management of a 7-year-old boy who sustained blunt abdominal trauma during a fall from a bicycle is described. He was hemodynamically stable, but his abdomen remained tender, with guarding in the right upper quadrant. Serial ultrasound scans showed a thick-walled gallbladder and increasing intraabdominal fluid. Laparoscopy was used both as a diagnostic tool, and then as a therapeutic method. Diagnostic laparoscopy showed a ruptured gallbladder treated by laparoscopic cholecystectomy. A 3-cm grade 1 liver laceration also was identified, which required no intervention. Free bile was aspirated and the peritoneal cavity thoroughly lavaged. The child made a rapid postoperative recovery. The ultimate aim in the management of blunt trauma is to avoid unnecessary laparotomy while preventing undue delay in the detection of significant intraabdominal pathology. Computed tomography scanning, ultrasound scanning, and diagnostic peritoneal lavage all have strengths for detecting different injury types, but they also have a low specificity in determining the need for laparotomy. The advantages and limitations of laparoscopy in hemodynamically stable children who have sustained injuries from blunt trauma are discussed. The authors recommend laparoscopy in experienced hands as an additional tool for the optimal management of selected trauma cases.

Management of Blunt Trauma

Management of Blunt Trauma

Integration of Emergency Medical Services and Special Weapons and Tactics (SWAT) Teams: The Emergence of the Tactically Trained Medic

The emphasis of training for paramedics that function in the civilian sector in the United States has focused on the management of blunt trauma. The personal risks they face generally are the result of accidents or public health threats. The management of penetrating trauma under the threat of intentional personal harm is a different matter.Law enforcement agencies have responded to the threat of apprehending heavily armed felons by forming special units highly trained in military-style, small-unit tactics. To provide care in this special environment, and support a special weapons and tactics (SWAT) team in fulfilling its mission, there is a requirment for a unique body of knowledge and special skills. (Prehospital care providers with at least emergency medical technician [EMT] skills and SWAT training will be referred to as tactical medics.).

Book Review: Management of Blunt Trauma

Book Review: Management of Blunt Trauma

Management of Blunt Trauma

Management of Blunt Trauma

Management of Blunt Trauma

Management of Blunt Trauma