WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

Kuala Lumpur train collision during the COVID-19 pandemic

Background Two city trains collided in an underground tunnel on 24 May 2021 at the height of COVID-19 pandemic near the Petronas Towers, Kuala Lumpur, Malaysia, immediately after the evening rush hours. We aim to evaluate the management of this mass casualty incident highlighting the lessons learned to be used in preparedness for similar incidents that may occur in other major cities worldwide. Methods Information regarding incident site and hospital management response were analysed. Data on demography, triaging, injuries and hospital management of patients were collected according to a designed protocol. Challenges, difficulties and their solutions were reported. Results The train's emergency response team (ERT) has shut down train movements towards the incident site. Red zone (in the tunnel), yellow zone (the station platform) and green zone (outside the station entrance) were established. The fire and rescue team arrived and assisted the ERT in the red zone. Incident command system was established at the site. Medical base station was established at the yellow zone. Two hundred and fourteen passengers were in the trains. Sixty-four of them were injured. They had a median (range) ISS of 2 (1–43), and all were sent to Hospital Kuala Lumpur (HKL). Six (9.4%) patients were clinically triaged as red (critical), 19 (29.7%) as yellow (semi-critical) and 39 (60.9%) as green (non-critical). HKL's disaster plan was activated. All patients underwent temperature and epidemiology link assessment. Seven (10.9%) patients were admitted to the hospital (3 to the ICU, 3 to the ward and 1 to a private hospital as requested by the patient), while the rest 56 (87.5%) were discharged home. Six (9.4%) needed surgery. The COVID-19 tests were conducted on seven patients (10.9%) and were negative. There were no deaths. Conclusions The mass casualty incident was handled properly because of a clear standard operating procedure, smooth coordination between multi-agencies and the hospitals, presence of a 'binary' system for 'COVID-risk' and 'non-COVID-risk' areas, and the modifications of the existing disaster plan. Preparedness for MCIs is essential during pandemics.

Differentiating necrotizing soft tissue infections from cellulitis by soft tissue infectious fluid analysis: a pilot study

Background We conducted this study to evaluate the characteristics of the infectious fluid in soft tissue infection and investigate the utility of the biochemical tests and Gram stain smear of the infectious fluid in distinguishing necrotizing soft tissue infection (NSTI) from cellulitis. Methods This retrospective cohort study was conducted in a tertiary care hospital in Taiwan. From April 2019 to October 2020, patients who were clinically suspected of NSTI with infectious fluid accumulation along the deep fascia and received successful ultrasound-guided aspiration were enrolled. Based on the final discharge diagnosis, the patients were divided into NSTI group, which was supported by the surgical pathology report, or cellulitis group. The t test method and Fisher’s exact test were used to compare the difference between two groups. The receiver–operator characteristic (ROC) curves and area under the ROC curve (AUC) were used to evaluate the discriminating ability. Results Total twenty-five patients were enrolled, with 13 patients in NSTI group and 12 patients in cellulitis group. The statistical analysis showed lactate in fluid (AUC = 0.937) and LDH in fluid (AUC = 0.929) had outstanding discrimination. The optimal cut-off value of fluid in lactate was 69.6 mg/dL with corresponding sensitivity of 100% and specificity of 76.9%. The optimal cut-off value of fluid in LDH was 566 U/L with corresponding sensitivity of 83.3% and a specificity of 92.3%. In addition, albumin in fluid (AUC = 0.821), TP in fluid (AUC = 0.878) and pH in fluid (AUC = 0.858) also had excellent diagnostic accuracy for NSTI. The Gram stain smear revealed 50% bacteria present in NSTI group and all the following infectious fluid culture showed bacteria growth. Conclusions The analysis of infectious fluid along the deep fascia might provide high diagnostic accuracy to differentiate NSTI from cellulitis.

Rethinking preparedness planning in disaster emergency care: lessons from a beyond-surge-capacity event

Background Large-scale burn disasters can produce casualties that threaten medical care systems. This study proposes a new approach for developing hospital readiness and preparedness plan for these challenging beyond-surge-capacity events. Methods The Formosa Fun Coast Dust Explosion (FFCDE) was studied. Data collection consisted of in-depth interviews with clinicians from four initial receiving hospitals and their relevant hospital records. A detailed timeline of patient flow and emergency department (ED) workload changes of individual hospitals were examined to build the EDs' overload patterns. Data analysis of the multiple hospitals' responses involved chronological process-tracing analysis, synthesis, and comparison analysis in developing an integrated adaptations framework. Results A four-level ED overload pattern was constructed. It provided a synthesis of specifics on patient load changes and the process by which hospitals' surge capacity was overwhelmed over time. Correspondingly, an integrated 19 adaptations framework presenting holistic interrelations between adaptations was developed. Hospitals can utilize the overload patterns and overload metrics to design new scenarios with diverse demands for surge capacity. The framework can serve as an auxiliary tool for directive planning and cross-check to address the insufficiencies of preparedness plans. Conclusions The study examined a wide-range spectrum of emergency care responses to the FFCDE. It indicated that solely depending on policies or guidelines for preparedness plans did not contribute real readiness to MCIs. Hospitals can use the study's findings and proposal to rethink preparedness planning for the future beyond surge capacity events.

A clinical predictive model for risk stratification of patients with severe acute lower gastrointestinal bleeding

Background Lower gastrointestinal bleeding (LGIB) is a common presentation of surgical admissions, imposing a significant burden on healthcare costs and resources. There is a paucity of standardised clinical predictive tools available for the initial assessment and risk stratification of patients with LGIB. We propose a simple clinical scoring model to prognosticate patients at risk of severe LGIB and an algorithm to guide management of such patients. Methods A retrospective cohort study was conducted, identifying consecutive patients admitted to our institution for LGIB over a 1-year period. Baseline demographics, clinical parameters at initial presentation and treatment interventions were recorded. Multivariate logistic regression was performed to identify factors predictive of severe LGIB. A clinical management algorithm was developed to discriminate between patients requiring admission, and to guide endoscopic, angiographic and/or surgical intervention. Results 226/649 (34.8%) patients had severe LGIB. Six variables were entered into a clinical predictive model for risk stratification of LGIB: Tachycardia (HR ≥ 100), hypotension (SBP < 90 mmHg), anaemia (Hb < 9 g/dL), metabolic acidosis, use of antiplatelet/anticoagulants, and active per-rectal bleeding. The optimum cut-off score of ≥ 1 had a sensitivity of 91.9%, specificity of 39.8%, and positive and negative predictive Values of 45% and 90.2%, respectively, for predicting severe LGIB. The area under curve (AUC) was 0.77. Conclusion Early diagnosis and management of severe LGIB remains a challenge for the acute care surgeon. The predictive model described comprises objective clinical parameters routinely obtained at initial triage to guide risk stratification, disposition and inpatient management of patients.

Impact of the COVID-19 Pandemic on road traffic collision injury patterns and severity in Al-Ain City, United Arab Emirates

Background The COVID-19 Pandemic lockdowns restricted human and traffic mobility impacting the patterns and severity of road traffic collisions (RTCs). We aimed to study the effects of the COVID-19 Pandemic on incidence, patterns, severity of the injury, and outcomes of hospitalized RTCs trauma patients in Al-Ain City, United Arab Emirates. Methods We compared the data of two cohorts of patients which were collected over two periods; the Pandemic period (28 March 2020 to 27 March 2021) and the pre-pandemic period (28 March 2019 to 27 March 2020). All RTCs trauma patients who were hospitalized in the two major trauma centers (Al-Ain and Tawam Hospitals) of Al-Ain City were studied. Results Overall, the incidence of hospitalized RTC trauma patients significantly reduced by 33.5% during the Pandemic compared with the pre-pandemic period. The mechanism of injury was significantly different between the two periods (p < 0.0001, Fisher’s Exact test). MVCs were less during the Pandemic (60.5% compared with 72%), while motorcycle injuries were more (23.3% compared with 11.2%). The mortality of hospitalized RTC patients was significantly higher during the Pandemic (4.4% compared with 2.3%, p = 0.045, Fisher’s Exact test). Logistic regression showed that the significant factors that predicted mortality were the low GCS (p < 0.0001), admission to the ICU (p < 0.0001), and the high ISS (p = 0.045). COVID-19 Pandemic had a very strong trend (p = 0.058) for increased mortality. Conclusions Our study has shown that the numbers of hospitalized RTC trauma patients reduced by 33.5% during the COVID-19 Pandemic compared with the pre-pandemic period in our setting. This was attributed to the reduced motor vehicle, pedestrian and bicycle injuries while motorcycle injuries increased. Mortality was significantly higher during the Pandemic, which was attributed to increased ISS and reduced GCS.

Emergency angiography for trauma patients and potential association with acute kidney injury

Background Angiography has been conducted as a hemostatic procedure for trauma patients. While several complications, such as tissue necrosis after embolization, have been reported, little is known regarding subsequent acute kidney injury (AKI) due to contrast media. To elucidate whether emergency angiography would introduce kidney dysfunction in trauma victims, we compared the incidence of AKI between patients who underwent emergency angiography and those who did not. Methods A retrospective cohort study was conducted using a nationwide trauma database (2004–2019), and adult trauma patients were included. The indication of emergency angiography was determined by both trauma surgeons and radiologists, and AKI was diagnosed by treating physicians based on a rise in serum creatinine and/or fall in urine output according to any published standard criteria. Incidence of AKI was compared between patients who underwent emergency angiography and those who did not. Propensity score matching was conducted to adjust baseline characteristics including age, comorbidities, mechanism of injury, vital signs on admission, Injury Severity Scale (ISS), degree of traumatic kidney injury, surgical procedures, and surgery on the kidney, such as nephrectomy and nephrorrhaphy. Results Among 230,776 patients eligible for the study, 14,180 underwent emergency angiography. The abdomen/pelvis was major site for angiography (10,624 [83.5%]). Embolization was performed in 5,541 (43.5%). Propensity score matching selected 12,724 pairs of severely injured patients (median age, 59; median ISS, 25). While the incidence of AKI was rare, it was higher among patients who underwent emergency angiography than in those who did not (140 [1.1%] vs. 67 [0.5%]; odds ratio = 2.10 [1.57–2.82]; p < 0.01). The association between emergency angiography and subsequent AKI was observed regardless of vasopressor usage or injury severity in subgroup analyses. Conclusions Emergency angiography in trauma patients was probably associated with increased incidence of AKI. The results should be validated in future studies.

Accuracy of the WSES classification system for pelvic ring disruptions: an international validation study

Background In 2017, a novel classification for pelvic injuries was established by the World Society of Emergency Surgery (WSES). We validated its effectiveness using nationwide real-world data. The roles of associated vascular injury and open fracture in this system were also evaluated. Methods Patients with pelvic fractures in the National Trauma Data Bank 2015 dataset were retrospectively studied. First, the mortality rates were compared by WSES classification. Second, independent predictors of mortality were evaluated using a multivariate logistic regression model. Patients with and without associated vascular injuries and the same hemodynamic and pelvic ring stability statuses were compared. Patients with associated vascular injuries were compared to the proportion of nonsurvivors and survivors with unstable pelvic ring injuries. Third, the outcomes were compared between patients with open pelvic fracture and closed pelvic fracture in the mild, moderate and severe WSES classes. Results During the 12-month study period, 44,163 blunt pelvic fracture patients were included. The mortality rates were 1.8%, 3.8% and 10.6% for the mild, moderate and severe WSES classes, respectively (p < 0.001). MLR analysis showed that unstable pelvic ring injury did not significantly affect mortality (p = 0.549), whereas open pelvic fracture and associated vascular injury were independent predictors of mortality (odds of mortality: open pelvic fracture 1.630, p < 0.001; associated vascular injury 1.602, p < 0.001). Patients with associated vascular injuries showed that there was no significant difference in the proportion of patients with unstable pelvic ring injuries between survivors and nonsurvivors (37.2% vs. 32.7%, p = 0.323). In all three classes, patients with open pelvic fractures had significantly higher mortality rates and infection rates than patients with closed fractures (mortality rates: minor 3.5% vs. 1.8%, p = 0.009, moderate 11.2% vs. 3.3%, p < 0.001, severe 23.8% vs. 9.8%, p < 0.001; infection rates: minor 3.3% vs. 0.7%, p < 0.001, moderate 6.7% vs. 2.1%, p < 0.001, severe 7.9% vs. 2.8%, p < 0.001). Conclusions Based on this nationwide study, the WSES guideline provides an accurate and reproducible classification of pelvic fractures. It is recommended that open/closed fractures and associated vascular injuries be evaluated as supplements of the WSES classification.

Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia

Background It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year. Conclusions The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.