Validity of no-zone approach for management of isolated penetrating neck injuries in hemodynamically stable patients

Background: Routine neck exploration for isolated penetrating neck injuries (PNIs) in hemodynamically stable patients increases the frequency of unnecessary interventions and complications. Current management protocol involves the no zone approach which uses physical examination and computerized tomographic angiography (CTA) to guide treatment. The aim was to assess the validity of the no-zone approach in the management of isolated PNIs in hemodynamically stable patients.Methods: This retrospective study included patients with isolated PNIs with soft signs who were hemodynamically stable. They were classified into patients with negative CTA findings and were managed conservatively and patients with positive CTA findings suspecting aerodigestive tract injuries (ADTIs) who were submitted to further selective investigations to confirm or rule out these injuries. Detected injuries were managed accordingly.Results: This study included 106 PNIs patients who had soft signs and were hemodynamic stable. 37 cases (34.9%) had negative CTA findings and were managed conservatively. Sixty nine patients (65.1%) had positive CTA findings and were subjected to subsequent selective investigations and revealed 3 patients with negative endoscopic findings who passed without need for any surgical intervention. Therefore, 40 (37.7%) patients were saved from surgery with no missed injuries. Patients with definitive injuries (66 patients) underwent neck exploration and managed accordingly. No missed injuries were recorded in this study. Complications were detected in 6 cases (5.7%) while death was recorded in 2 cases (1.9%).Conclusions: No-zone approach offers a safe management protocol for isolated PNIs in hemodynamically stable patients. It provides no missed injuries, negligible rates of negative exploration and minimal complications and mortality.

1270 Secondary Survey Documentation in Trauma Patients - A Review Following Implementation of a Dedicated Trauma Ward

Introduction A secondary survey is a detailed head to toe assessment performed in trauma patients following initial primary survey and patient stabilisation. It forms part of the ATLS guidelines and is an important tool in the recognition of patient injury. We performed an audit within the Regional Trauma Unit to assess the standard of documentation of secondary surveys in trauma admissions. We then repeated this audit following staff teaching and the implementation of a dedicated Trauma Ward, with an aim of improving secondary survey documentation and the early recognition and management of associated injuries. Method Admission notes for all trauma patients admitted in the three months prior to the opening of the dedicated Trauma Ward were reviewed for documentation of a secondary survey (n = 30), with the incidence of any missed injuries on follow up recorded. A further audit loop was then performed on all trauma admissions following the opening of the Trauma Ward and trauma staff teaching (n = 52). Results Complete documentation of a full secondary survey improved from 10% to 98% for trauma patient admissions. This also improved early identification of initially missed injuries from the primary survey including extremity fractures, chest trauma, and multi-ligament knee injuries. Conclusions Secondary surveys are an important tool in assessing trauma patients and can help identify significant injuries. The implementation of a dedicated Trauma Ward along with teaching to the trauma staff has led to an improvement in performance of secondary surveys with a direct improvement in identifying associated injuries in trauma patients.

Effectiveness of laparoscopy in management of patients with penetrating and blunt abdominal trauma.

Objectives: To study the role of laparoscopy in reducing the incidence of non-therapeutic Laparotomies in abdominal trauma, and management of penetrating (PAT) and blunt (BAT) abdominal trauma. Study Design: Prospective Experimental study. Setting: Department of Surgery DHQ Hospital Rawalpindi. Period: January 2018 to June 2018. Material & Methods: All Patients (n=50) were admitted through emergency and were allocated to one of two groups Laparoscopy or Laparotomy group (25 in each) by lottery method according to the inclusion criteria of haemodynamically stable patients with systolic BP>90 mm of Hg. Patients in the Laparotomy group were managed according to the conventional protocol and decision of laparotomy was based on clinical examination, imaging and laboratory investigations. Where as in Laparoscopy group after clinical examination and chemical labortary. Reports diagnostic laparoscopy (screening tool) was done to identify injuries and decide whether patient needs laparotomy or not. Forward viewing 0 degree 10 mm laparoscope was used in all the cases following standard protocols for laparoscopy. Data analysis was done by SPSS 20. P-Value was set at 0.05. Results: Out of total 50 selected haemodynamically stable abdominal trauma patients (n=50) there were 77% males and 23% females. Average age of the patients was 37 years. Overall out of total of 50 patients 30 (60%) patients presented with PAT and 20 (40%) patients presented with BAT. Diagnostic laparoscopy was able to identify abdominal injuries in 96% (24 out of 25) patients. There were no missed injuries in both groups. Similarly there were no non-therapeutic laparotomies in Laparoscopy group where as in Laparotomy group 6 (24%) non-therapeutic laparotomies were done. Conclusion: Laparoscopy reduces the incidence of non-therapeutic laparotomies and missed injuries. It correctly identifies the injuries depending upon the experience of surgeon in selected stable trauma patients.

Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk

Purpose Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries. Methods In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed. Results In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053). Conclusion Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey. Level of evidence Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).

Missed Injuries in Trauma Patients; The Value of a Diagnostic Thoracotomy or Thoracoscopy During Surgical Stabilisation of Rib Fractures.

PurposeOver the last decade Surgical Stabilisation of Rib Fractures (SSFR) gained popularity in our hospital. With increased numbers, we noted that frequently injuries were missed during primary/secondary survey and radiological imaging, that were found during the surgical procedure. With this observation, the research question was formulated: What is the value of diagnostics thoracotomy or thoracoscopy during surgical stabilisation of rib fractures?MethodsIn a single centre, retrospective study between February 2010 till December 2019, trauma patients who underwent Surgical Stabilization of Rib Fractures (SSFR) and an inspection thoracotomy were included. All radiological injuries were compared with intraoperative findings. Missed injuries that were discovered during the surgical procedure that weren’t analysed during primary/secondary survey or on radiological imaging were recorded and retrospectively analysed by an independent radiologist. Results51 patients were included. Eight patients had additional injuries; all had a diaphragmatic rupture, one patient had an attending stomach laceration, another patient had an attending significant lung laceration in need of surgical repair. Only 13 out of 56 diaphragm rupture CT-signs were confirmed, therefore still 77% of signs could not be confirmed by initial radiological findings.Conclusion With the recent shift towards surgical stabilisation of rib fractures, an inspection thoracoscopy or thoracotomy during SSFR should be considered to minimize the incidence of missed intrathoracic injuries requiring early or late surgical treatment.

738 Missed Injuries in Trauma Patients Attending a London Trauma Centre

Introduction Patients attending following trauma present a diagnostic challenge. Missed injuries may lead to increased morbidity, mortality and length of hospital stay. We reviewed the incidence of and contributing factors to missed injuries in trauma patients attending a London Trauma Centre. Method The records of all trauma patients admitted to a London Trauma Centre during September 2019 were studied to determine the extent and type of missed injuries. Missed injuries were classified as: Type 1 – missed during initial management (on primary and secondary survey) or Type 2 – missed on primary, secondary, and tertiary survey, but detected prior to discharge. Results Forty-two (42.4%) of 99 patients (24 Female, 75 Male) had 63 missed injuries (an average of 1.5 missed injuries per patient). Thirty-seven type 1 missed injuries occurred (5 fractures, 28 soft tissue injuries, 4 neurological injuries). Twenty-six type 2 missed injuries occurred (13 fractures, 7 soft tissue injuries, 3 neurological injuries and 3 visceral injuries). Conclusions Significant injuries can be missed despite primary, secondary, and tertiary surveys in trauma patients. Clinicians involved in the care of trauma patients should therefore remain alert to evolving/new injuries throughout hospital admission.

A tailored protocol in management of penetrating neck injuries: experience at a level 1 trauma centre

Background: The management of penetrating neck injuries (PNIs) evolved markedly over last year’s towards more conservative approaches. Recent improvements in imaging modalities as multi-detector CT-angiography (MDCT-A) produced a paradigmatic shift towards 'no-zone' approach. In this study, we adopted a tailored protocol to deal with such injuries with less dependency on zone classification.Methods: This prospective study included patients with PNIs from February 2012 to January 2014. Unstable patients and patients with hard signs in zone-II were managed by immediate exploration. Patients with hard signs in zones-I and III had MDCT-A to check feasibility of endovascular intervention. However, all patients with soft signs and asymptomatic patients underwent MDCT-A regardless the zone affected to determine the need for therapeutic intervention. Complementary investigations were added in some cases with equivocal MDCT-A results.Results: Our study included 85 patients. Majority were males (94%; n=80) with mean age 27±4. Stabs were the main causative injury (51%; n=43). 63 (74%) patients were stable; with majority (64%; n=40/63) were symptomatic (18 presented with hard signs and 22 presented with soft signs). 53 (62%) patients had MDCT-A with sensitivity, specificity of 77%, 97% respectively and significant p value <0.05. After applying this protocol, we avoided 37% (31/85) non-therapeutic neck exploration, with only 4 (7.4%) negative cases on exploration. We experienced no missed injuries in the conservative group, yet 2 (3.7%) missed nerve injuries were encountered in intervention group.Conclusions: Zones-classification is losing popularity nowadays and shouldn't be the cornerstone of the new management protocols in PNIs. This selective tailored approach can be effectively used in management of PNIs. It avoids missed injuries and unnecessary explorations significantly.

Impact of Implementation of Sequential Trauma Education Programs (STEPs) Course on Missed Injuries in Emergency Polytrauma Patients, Ismailia, Egypt

IntroductionTrauma deaths account for 8% of all deaths in Egypt. Patients with multiple injuries are at high risk but may be saved with a good triage system and a well-trained trauma team in dedicated institutions. The incidence of missed injuries in the Emergency Department (ED) of Suez Canal University Hospital (SCUH) was found to be 9.0% after applying Advanced Trauma Life Support (ATLS) guidelines. However, this rate is still high compared with many trauma centers.AimImprove the quality of management of polytrauma patients by decreasing the incidence of missed injuries by implementing the Sequential Trauma Education Programs (STEPs) course in the ED at SCUH.MethodsThis interventional training study was conducted in the SCUH ED that adheres to CONSORT guidelines. The study was conducted during the 1-month precourse and for 6 months after the implementation of the STEPs course for ED physicians. Overall, 458 polytrauma patients were randomly selected, of which 45 were found to have missed injuries after applying the inclusion and exclusion criteria. We assessed the clinical relevance of these cases for missed injuries before and after the STEPs course.ResultsOverall, 45 patients were found to have missed injuries, of which 15 (12%) were pre-STEPs and 30 (9%) were post-STEPs course. The STEPs course significantly increased adherence to vital data recording, but the reduction of missed injuries (3.0%) was not statistically significant in relation to demographic and trauma findings. However, the decrease in missed injuries in the post-STEPs course group was an essential clinically significant finding.ConclusionSTEPs course implementation decreased the incidence of missed injuries in polytrauma patients. Thus, the STEPs course can be considered at the same level of other advanced trauma courses as a training skills program or possibly better in dealing with trauma patients. Repetition of this course by physicians should be mandatory to prevent more missed injuries. Therefore, the validation of STEPs course certification should be completed at least every 2 years to help decrease the number of missed injuries, especially in low-income countries and low-resource settings.Trial RegistrationProject manager for the Pan African Clinical Trial Registry (www.pactr.org) database has been accepted with the date of approval:18/11/2020. Current Controlled Trials number for the registry is PACTR202011853914203. Please note that the article state Retrospectively registered that my study adheres to CONSORT guidelines.

Missed orthopaedic injuries in adult trauma patients at a major trauma centre

IntroductionDespite advances in trauma care, missed injury remains a significant cause of morbidity and mortality in trauma worldwide. In England, few have published their missed injury rates and there are no recent data for London. In 2010 London trauma networks were restructured and the impact on missed injury rates is not known. This study aimed to determine the incidence of missed orthopaedic injury for adult trauma patients at St George’s Hospital, London, and to analyse missed injuries and comment on risk factors.MethodTrauma patients were recorded prospectively at the daily trauma meeting from July to September 2012. The researcher attended clinical activities and reviewed the patient notes and radiology reports daily whilst each patient was an inpatient until discharge. Missed injuries were defined as fractures or dislocations discovered more than 12 h after arrival in the emergency department. The notes for missed injury patients were reviewed again at six months. Missed injury details were recorded/analysed.ResultsThree hundred and forty three adult trauma patients were referred to trauma and orthopaedics in the three-month study period; 5 (1.5%) had a missed injury and 148 (43.1%) had an ISS&gt;15. All missed injuries occurred in these major trauma patients, giving an incidence of 5/148 (3.4%). Four were extremity injuries and one was cervical. All missed injury patients had a GCS of 15/15, were admitted outside normal working hours, were direct admissions and had whole-body CT.ConclusionsAt 3.4% our missed injury incidence is comparable to those published from similar major trauma centres. This provides recent London data following the restructuring of trauma networks.