Surgery in Traumatic Injury and Perioperative Considerations

AbstractA severely injured patient presents several unique challenges to an admitting trauma team. Not only must the extent of the patient's injuries, particularly those that are life-threatening, be determined within minutes of hospital arrival, but also the trauma team needs to be able to assess whether the patient is bleeding and/or has an attendant coagulopathy. Early management of trauma patients is dictated by the presence (or absence) of significant bleeding. Standard definitive surgical procedures can be conducted in hemodynamically stable patients, but those in hemorrhagic shock should be treated according to damage control resuscitation (DCR) principles. DCR is a practice that has evolved over the last two to three decades, combining limited surgical techniques, which provide early hemorrhage control, and balanced transfusion resuscitation strategies, which mitigate (and ideally) treat trauma-induced coagulopathy (TIC). This review describes the contemporary perioperative management of trauma patients who have significant bleeding and/or TIC and sets out the evidence around the current approach for hemostatic resuscitation in these patients.

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A Contemporary Analysis of Delayed Diagnoses After Traumatic Injury

The American Surgeon ◽

10.1177/0003134820951458 ◽

2020 ◽

pp. 000313482095145

Author(s):

Justin S. Hatchimonji ◽

Catherine E. Sharoky ◽

Elinore J. Kaufman ◽

Lucy W. Ma ◽

Anna E. Garcia Whitlock ◽

...

Keyword(s):

Regression Analysis ◽

Injury Severity ◽

Traumatic Injury ◽

Trauma Team ◽

Trauma Patients ◽

Extremity Injury ◽

Factors Associated ◽

Common Category ◽

Multivariable Regression Model ◽

Multivariable Regression

Background Factors associated with delayed injury diagnosis (DID) have been examined, but incompletely researched. Methods We evaluated demographics, mechanism, and measures of mental status and injury severity among 10 years’ worth of adult trauma patients at our center for association with DID in a multivariable regression model. Descriptions of DID injuries were reviewed to highlight characteristics of these injuries. Results We included 13 509 patients, 89 (0.7%) of whom had a recognized DID. In regression analysis, ISS (OR 1.04 per point, 95% CI 1.02-1.06) and number of injuries (OR 1.08 per injury, 95% CI 1.04-1.11) were associated with DID. Operative patients had twice the odds of DID (OR 2.02, 95% CI 1.18-3.44). The most common category of DID was orthopedic extremity injury (22/89). Conclusion DID is associated with injury severity and operative intervention. This suggests that the presence of an injury requiring operation may distract the trauma team from additional injuries.

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A systematic approach to the injured patient

10.1093/med/9780199600830.003.0332 ◽

2016 ◽

Author(s):

Clay Cothren Burlew ◽

Ernest E. Moore

Keyword(s):

Cause Of Death ◽

Injured Patient ◽

Trauma Team ◽

Detailed Examination ◽

Simultaneous Treatment ◽

Common Cause ◽

Primary Survey ◽

Life Threatening ◽

Secondary Survey ◽

Injured Patients

Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years, and is the third most common cause of death regardless of age. It is also the leading cause of years of productive life lost. However, death rate underestimates the magnitude of the societal toll. Organized trauma systems have improved mortality by providing timely and expert care to severely-injured patients. Patient management consists of rapid primary survey, which should focus on the identification and simultaneous treatment of immediately life-threatening injuries. A classical ABC (airway, breathing, circulation) approach is recommended and is best carried out by a trained and practiced trauma team. The primary survey is followed by a more detailed examination, the secondary survey, which consists of a head-to-toe examination to identify all specific injuries. The secondary survey should be followed by investigation and definitive care.

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Predictive Factors for Massive Transfusion in Trauma: A Novel Clinical Score from an Italian Trauma Center and German Trauma Registry

Journal of Clinical Medicine ◽

10.3390/jcm9103235 ◽

2020 ◽

Vol 9 (10) ◽

pp. 3235

Author(s):

Sara Giulia Cornero ◽

Marc Maegele ◽

Rolf Lefering ◽

Claudia Abbati ◽

Shailvi Gupta ◽

...

Keyword(s):

Trauma Registry ◽

Massive Transfusion ◽

Damage Control ◽

Area Under The Curve ◽

Clinical Score ◽

Limb Amputation ◽

Predictive Score ◽

Trauma Patients ◽

Early Management ◽

Critical Bleeding

Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who did not (MT−). Hemodynamics, Glagow Coma Score (GCS), diagnostics and blood tests were evaluated. Using multivariate analysis, we created and validated a predictive score for MT+ patients. The predictive score was validated on a matched cohort of patients of the German Trauma Registry TR-DGU. One hundred thirty-nine patients were included. Independent predictors of MT+ included a prehospital (PH) GCS of 3, PH administration of tranexamic acid, hypotension and tachycardia upon admission, coagulopathy and injuries with significant bleeding such as limb amputation, hemoperitoneum, pelvic fracture, massive hemothorax. The derived predictive score revealed an area under the curve (AUC) of 0.854. Massive transfusion is essential to damage control resuscitation. Altered GCS, unstable hemodynamics, coagulopathy and bleeding injuries can allow early identification of patients at risk for critical hemorrhage.

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Management of Destructive Colon Injuries after Damage Control Surgery

Clinics in Colon and Rectal Surgery ◽

10.1055/s-0037-1602178 ◽

2017 ◽

Vol 31 (01) ◽

pp. 036-040 ◽

Cited By ~ 3

Author(s):

Priya Prakash ◽

William Symons ◽

Jad Chamieh

Keyword(s):

World War Ii ◽

Damage Control ◽

Damage Control Surgery ◽

Standard Of Care ◽

Fecal Diversion ◽

Trauma Patients ◽

Stoma Formation ◽

Diverting Stoma ◽

Life Threatening ◽

Colon Injuries

AbstractAfter the World War II, fecal diversion became the standard of care for colon injuries, although medical, logistic, and technical advancements have challenged this approach. Damage control surgery serves to temporize immediately life-threatening conditions, and definitive management of destructive colon injuries is delayed until after appropriate resuscitation. The bowel can be left in discontinuity for up to 3 days before edema ensues, but the optimal repair window remains within 12 to 48 hours. Delayed anastomosis performed at the take-back operation or stoma formation has been reported with variable results. Studies have revealed good outcomes in those undergoing anastomosis after damage control surgery; however, they point to a subgroup of trauma patients considered to be “high risk” that may benefit from fecal diversion. Risk factors influencing morbidity and mortality rates include hypotension, massive transfusion, the degree of intra-abdominal contamination, associated organ injuries, shock, left-sided colon injury, and multiple comorbid conditions. Patients who are not suitable for anastomosis by 36 hours after damage control may be best managed with a diverting stoma. Failures are more likely related to ongoing instability, and the management strategy of colorectal injury should be based mainly on the patient's overall condition.

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Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient

10.25100/cm.v51i4.4362 ◽

2020 ◽

Author(s):

Carlos Alberto Ordoñez ◽

Michael Parra ◽

Alfonso Holguín ◽

Carlos Garcia ◽

Monica Guzmán-Rodríguez ◽

...

Keyword(s):

Computed Tomography ◽

Decision Making ◽

Damage Control ◽

Hemodynamic Instability ◽

Whole Body ◽

Trauma Patients ◽

Severely Injured ◽

Hemostatic Resuscitation ◽

Whole Body Computed Tomography ◽

Technological Advances

Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of Damage Control Trauma Care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of Whole Body Computed Tomography as a potentially safe, effective, and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a Whole-Body Computed Tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.

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Damage control surgery: it's evolution over the last 20 years

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/s0100-69912012000400012 ◽

2012 ◽

Vol 39 (4) ◽

pp. 314-321 ◽

Cited By ~ 52

Author(s):

Brett H Waibel ◽

Michael MF Rotondo

Keyword(s):

Damage Control ◽

Damage Control Surgery ◽

Primary Treatment ◽

Trauma Patients ◽

Permissive Hypotension ◽

Visceral Injury ◽

Core Concepts ◽

Life Threatening ◽

Surgical Conditions ◽

Original Application

In less than twenty years, what began as a concept for the treatment of exsanguinating truncal trauma patients has become the primary treatment model for numerous emergent, life threatening surgical conditions incapable of tolerating traditional methods. Its core concepts are relative straightforward and simple in nature: first, proper identification of the patient who is in need of following this paradigm; second, truncation of the initial surgical procedure to the minimal necessary operation; third, aggressive, focused resuscitation in the intensive care unit; fourth, definitive care only once the patient is optimized to tolerate the procedure. These simple underlying principles can be molded to a variety of emergencies, from its original application in combined major vascular and visceral trauma to the septic abdomen and orthopedics. A host of new resuscitation strategies and technologies have been developed over the past two decades, from permissive hypotension and damage control resuscitation to advanced ventilators and hemostatic agents, which have allowed for a more focused resuscitation, allowing some of the morbidity of this model to be reduced. The combination of the simple, malleable paradigm along with better understanding of resuscitation has proven to be a potent blend. As such, what was once an almost lethal injury (combined vascular and visceral injury) has become a survivable one.

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Principles of Initial Trauma Management and Evaluation

DeckerMed Surgery ◽

10.2310/surg.8170 ◽

2018 ◽

Author(s):

Shelby Resnick ◽

Brian Smith ◽

Patrick Reilly

Keyword(s):

Trauma Patient ◽

Damage Control ◽

Penetrating Trauma ◽

Injured Patient ◽

The United States ◽

Rapid Sequence Intubation ◽

Multidisciplinary Teams ◽

Rapid Sequence ◽

Life Threatening ◽

Secondary Survey

Trauma accounts for almost 10% of deaths worldwide and is the fourth most common cause of death in the United States. Treatment of the injured patient requires multiple unique resources, including multidisciplinary teams, surgical subspecialties, and dedicated resuscitation areas. Evaluation and initial management of the trauma patient is performed systematically to quickly identify and treat life-threatening injuries. This review serves as an introduction to care for the critically injured patient. It covers the initial steps for evaluation, resuscitation, diagnosis and treatment of the trauma patient and provides a brief overview of various injury patterns resulting from both blunt and penetrating trauma. This review contains 6 figures, 6 tables and 49 references Key Words: blunt trauma, damage control resuscitation, FAST exam, lateral canthotomy, penetrating trauma, primary survey, rapid sequence intubation, secondary survey, trauma systems

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Principles of Initial Trauma Management and Evaluation

10.2310/7ccsp.8170 ◽

2018 ◽

Author(s):

Shelby Resnick ◽

Brian Smith ◽

Patrick Reilly

Keyword(s):

Trauma Patient ◽

Damage Control ◽

Penetrating Trauma ◽

Injured Patient ◽

The United States ◽

Rapid Sequence Intubation ◽

Multidisciplinary Teams ◽

Rapid Sequence ◽

Life Threatening ◽

Secondary Survey

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Principles of trauma management

Current Surgical Guidelines ◽

10.1093/med/9780198794769.003.0017 ◽

2018 ◽

pp. 151-160

Author(s):

Abdullah Jibawi ◽

Mohamed Baguneid ◽

Arnab Bhowmick

Keyword(s):

Major Trauma ◽

Trauma Team ◽

Trauma Patients ◽

Trauma Management ◽

Economic Output ◽

Specific Organ ◽

Life Threatening ◽

Clinically Significant ◽

The Impact

Major trauma is defined as an injury or a combination of injuries that are life-threatening and could be life changing because it may result in long-term disability. The impact of trauma is huge. Injuries from accidental trauma worldwide causes moderate to severe disability in > 45m people each year. Trauma is the biggest killer of people age < 45y. UK annual trauma cost is ~£0.35b in immediate treatment; subsequent financial costs are unknown. UK annual lost economic output due to major trauma is ~£3.5b. Trauma management is challenging. Up to 40% of trauma patients have injuries that are initially missed, and up to 20% of these are clinically significant. The trauma team should be appropriately formed to achieve the assigned level of care and prioritize management. Guidelines for specific organ trauma management should be followed and practice standardized to ensure the best outcome.

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P043: Trauma team leaders in Canada: A national survey

CJEM ◽

10.1017/cem.2019.234 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S78

Author(s):

V. Belhumeur ◽

C. Malo ◽

A. Nadeau ◽

S. Hegg ◽

A. Gagné ◽

...

Keyword(s):

Prehospital Care ◽

Injured Patient ◽

Trauma Team ◽

Initial Assessment ◽

Trauma Patients ◽

Lack Of Information ◽

Level 1 ◽

Patient Prognosis ◽

Activation Criteria ◽

Early Trauma

Introduction: It was demonstrated that the early trauma team activation (TTA) could improve younger trauma patients outcomes and mortality rates. However, the link between older patient prognosis improvement and the activation / effectiveness of the Trauma team (TT) is still unclear. There is also a lack of information about the exact and optimal structure of TTs and their activation criteria, which may differ across centers. The main objective of this study is to provide a description of the current TT available in level 1 and 2 centres across Canada. Methods: In 2017, a survey using a modified Dillman technique was sent to 210 health professionals scattered across all Canadian trauma care facilities. The survey included questions regarding 1) the presence and the composition of a TT, 2) the established TT activation criteria, and finally 3) the initial patient care. Results: A total of 107 (57%) completed surveys were received. Among them, only 22 (11.7%) were from level 1 or 2 centres and were therefore considered for analyses. Seventeen respondents had a TT in their centre, and they all shared their TT activation criteria (1 to 27 different indications). Most frequently mentioned criteria were: suspected injuries (58.8%), judgment of the emergency physician (41.2%), systolic blood pressure (47.1%), Glasgow Coma score (35.3%) and respiratory rate (28%). In presence of a prehospital care warning trauma, the initial assessment of a severely injured patient is exclusively completed by a member of the TT for only 35.1% of the respondents. For 11.8% of respondents, TT coordinates airway management. For 64.7% of participants, the TT leader is the dedicated care provider to accompany patients until final orientation. Conclusion: These results suggest a great variability across Canada regarding the roles assumed by the TT, but also regarding the activation criteria leading them to take action.

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