Endovascular thrombectomy and repair of suprarenal inferior vena cava thrombosis: A case series

Objectives The objective of this study is to document the combined use of catheter-based thrombectomy/thrombolysis with endovascular repair of high-risk segments of the inferior vena cava in the setting of iatrogenic and traumatic injuries. While the use of endovascular techniques to treat caval thrombosis is well documented and often preferred due to its minimally invasive nature, there is still little literature that focuses on the nuances related to injury of high mortality areas of the IVC as a result of major trauma, transplant, and other surgical interventions. Methods An IRB-approved retrospective review of all patients undergoing IVC thrombectomy was performed at a single tertiary care academic center between January 2018 and July 2021. Cases were subsequently selected based on those who underwent primary mechanical thrombectomy followed by endovascular stenting (or angioplasty). Among this cohort, four patients who underwent this procedure in the context of iatrogenic and traumatic injuries were included. Results All four patients undergoing primary mechanical thrombectomy followed by endovascular stenting (or angioplasty) due to IVC thrombus and/or stenosis were technically successful with immediate positive clinical outcomes. Conclusions Mechanical thrombectomy in conjunction with IVC recanalization via stenting may be a useful intervention with promising technical success and positive clinical outcomes for occlusive thrombosis and IVC stenosis.

Age and injury size influence the magnitude of fecal dysbiosis in adult burn patients

Clinical studies have demonstrated that age ≥ 50 years old is an independent risk factor associated with poor prognosis after burn injury, the second leading cause of traumatic injuries in the aged population. While mechanisms driving age-dependent post-burn mortality are perplexing, changes in the intestinal microbiome however may contribute to the heightened, dysregulated systemic response seen in aging burn patients. The fecal microbiome from 22 patients admitted to a verified burn center from July 2018 to February 2019 were stratified based on age of 50 years and total burn surface area (TBSA) size of ≥10%. Significant differences (P = 0.014) in overall microbiota community composition (i.e., beta diversity) were measured across the four patient groups, young <10% TBSA, young ≥10% TBSA, older <10% TBSA, and older ≥10% TBSA. Differences in beta diversity were driven by %TBSA (P = 0.013) and trended with age (P = 0.087). Alpha diversity components, richness, evenness, and Shannon diversity were measured. We observed significant differences in bacterial species evenness (P = 0.0023) and Shannon diversity (P = 0.0033) between the groups. There were significant correlations between individual bacterial species and levels of SCFA. Specifically, levels of fecal butyrate correlated with the presence of Enterobacteriaceae, an opportunistic gut pathogen, when elevated in burn patients lead to worsen outcomes. Overall, our findings reveal that age-specific changes in the fecal microbiome following burn injuries may contribute to immune system dysregulation in patients with varying TBSA burns and potentially lead to worsen clinical outcomes with heightened morbidity and mortality.

Epidemiological Characterization of Tibial Plateau Fractures in Five Colombian Clinics

Background: Tibial plateau fractures are traumatic injuries with severities ranging from nondisplaced to complicated fractures. This study describes the epidemiological characteristics of patients with tibial plateau fractures treated in five trauma clinics.Methods: This retrospective, cross-sectional study included 1,165 patients with tibial plateau fractures treated between December 2015 and May 2017. Subjects were selected from the medical records of five institutions based on the inclusion and exclusion criteria. Age, sex, laterality, fracture type, trauma mechanism, vehicle type, classification, and associated injuries were assessed via univariate and bivariate analyses. Results: In total, 23.3% of patients with tibial fractures treated during the study period had tibial plateau fractures. Of those affected, 73% were men and 50% were younger than 40 years. Furthermore, 95.7% of fractures were caused by traffic accidents, 82.6% of which involved motorcycles. Fractures were closed in 93.1% of cases, and 78% of subjects had associated injuries. The most common fractures, according to Schatzker classification, were type VI (23%) and V (19.1%) fractures.Conclusions: Tibial plateau fractures are frequent injuries in our setting and mostly occur in men in their 30s and 40s. These fractures are typically caused by motorcycle traffic accidents. Level of Evidence: IV

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist’s expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

Operative Management Considerations in a Patient With Multiple Occult Penetrating Cardiac Injuries

Penetrating cardiac injury remains one of the deadliest traumatic injuries. Early identification and definitive operative management are critical tenets for patient survival; however, variable clinical presentations can obscure the diagnosis. Here, we present the case of a 58-year-old obese man who presented to an urban level 1 trauma center with multiple stab wounds to the epigastrium and lateral left chest in the axillary line with an unknown weapon. The patient was taken emergently to the operating room for exploratory laparotomy, median sternotomy, and attempted repair of multiple full-thickness lacerations of the right ventricle and left and right atrium. This case demonstrates several instructive points. First, a high index of suspicion for penetrating cardiac injury is needed, especially during triage of multiple injuries. Second, careful release of cardiac tamponade is critical. Finally, there are several indications for cardiopulmonary bypass, which include multichambered injuries, uncontrollable hemorrhage, and concern for intracardiac injury.

A retrospective observational study to investigate the effect of frailty on outcomes of older adults admitted with major trauma.

The majority of major injuries admitted to hospital are now in older people, with a fall from standing height being the most common reason for injury. Our study will look at older adults admitted to hospital with serious traumatic injuries across England. It will aim to work out firstly if there is an effect of frailty on peoples' survival after injury. Frailty is the reserve a person has to cope with illness and is a measure of a person slowing down over time usually due to the collection of lots of health problems. Secondly, we will look at if being seen by an old age specialist (geriatrician) has an effect on a person's chances of surviving their injuries. The records we will look at are held collected routinely and held by a national database run by the Trauma and Audit Research Network (TARN) from the University of Manchester. They collect information from the 22 centres of major trauma excellence around the country and help researchers to work with them to access the anonymous data for specific research questions. We aim to use these results to help clinicians and health systems to improve how the fund and deliver care for older people.

Current Concepts about Managing of Trauma Patients.

Background: Managing principles for traumatized patients have continued to evolve with advances in technology. Hemorrhage remains the leading cause of morbidity and mortality in trauma, pre-hospital management by well-trained and well-equipped medical teams at the scene as well as in hospitals have continued to improve treatment outcomes. Although new treatment options continue to be evidence, as well as the implementation of concepts related to the optimal time for the operation. Although the preliminary assessment was performed using the Injury Significance Score (ISS) as an assessment and prognostic element to determine the timing of the intervention The current consensus argues that unnecessary delays in fracture care should be avoided while respecting the complex physiology of certain groups of patients who may remain at increased risk for complications. Using innovative techniques and understanding concepts such as the anatomy of traumatic injuries, the optimal approach to the polytrauma patient continues to evolve day by day.

Trauma and COVID-Induced Severe Rhabdomyolysis

The novel coronavirus COVID-19 has been implicated in a number of extra-pulmonary manifestations including rhabdomyolysis. It is hypothesized to be secondary to direct muscle damage from the virus. The usual treatment of rhabdomyolysis is resuscitation with aggressive fluid management to prevent acute renal failure. However, the combination of blunt thoracic trauma and COVID pneumonia has posed additional challenges for critical care management. A 68-year-old male presented to our institution after being found down for an unknown duration of time. He was diagnosed symptomatic COVID pneumonia. His traumatic injuries included 4 rib fractures, a rectus sheath hematoma, and rhabdomyolysis with a creatinine kinase (CK) level of 16,716 U/L. He was initially treated with steroids, prone positioning, and aggressive fluid administration. Despite treatment his CK level peaked at 146,328 U/L. Here we present the case of trauma and COVID-induced rhabdomyolysis with an extremely elevated CK level.

Injuries in Medium to Long-Distance Triathlon: A Retrospective Analysis of Medical Conditions Treated in Three Editions of the Ironman Competition

Triathlon’s popularity is rapidly increasing, and epidemiological data relating to its related medical conditions is crucial to the development of proper medical plans and safety guidelines for it. This study examined the data from the medical reports collected during three consecutive editions of Ironman Italy, from 2017 to 2019. Out of 10,653 race-starters, 3.3% required medical attention sustaining 472 medical conditions. A significantly higher injury risk was found for females versus males (χ2 = 9.78, p = 0.02) and in long-distance (IR: 4.09/1,000hours) rather than in Olympic/middle distance races (IR: 1.75/1,000hours). Most (68.4%) conditions (including muscular exhaustion, hypothermia, and dehydration) were systemic, whilst only 10.2% were acute traumatic injuries. Of a total of 357 triathletes requiring medical assistance, 8.1% were a candidate for hospitalisation. The equipment and personnel that are required for the medical assistance in future triathlon events were estimated based on Maurer’s algorithm, and ten practical recommendations for triathlon medical support were formulated.