22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof. Dr.

From novelty to the norm: Clinical trial on the safety, efficacy and efficiency of outpatient surgery in uncomplicated appendicitis

Abstract text (incl. references and figure legends) Introduction: Acute appendicitis is the most common cause of surgical acute abdomen in the world. Improvements in the management can represent significant savings for the health system. In recent years, some studies have appeared that propose outpatient surgical management of uncomplicated appendicitis. However, there are currently no works with statistical quality that demonstrate that this strategy is safe, effective and efficient. Methods: A randomized clinical trial was carried out between October 2018 and June 2021where 761 patients with suspected uncomplicated appendicitis were initially evaluated. 300 patients were finally included and randomized into two groups: 149 patients in the outpatient surgery group and 151 patients in the inpatient surgery group. The percentage of success of the strategy in the outpatient surgery group, the reasons for which the patients were admitted, the complications, reintervention and readmission in both groups were analyzed. A satisfaction questionnaire was administered in both groups. A cost analysis was performed. Results: 128/149 patients in the outpatient surgery group (85.9%) were discharged without needing to be admitted. Pain, fear, and insecurity were described as predictors of the need for admission in patients assigned to the outpatient surgery group. Both groups had a similar rate of complications, readmissions and reinterventions. Perceived quality was equally similar in both groups. In the cost study, an increase in costs was observed in the inpatient surgery group (saving in total cost 157 842.67 € / saving per patient 985.71 €). Conclusions: Outpatient surgery in patients with uncomplicated acute appendicitis is effective. No higher number of complications, readmissions or reinterventions have been observed compared to the surgery group with admission. The perceived quality is similar in both groups. There is a significant saving in the surgery group without admission compared to the group with admission.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No disclosure.

Education

Emergency surgery

Quick shot presentation

Association between adult trauma patient volume in intensive care units and hospital mortality in severely injured trauma patients

Abstract text (incl. references and figure legends) Introduction To assess an association between adult trauma patient volume in intensive care units (ICU) and hospital mortality in severely injured trauma patients. Methods A nationwide-registry-based retrospective cohort study utilized data of the Japan Trauma Databank from the year of 2004 to 2018. The study population included trauma patients who aged &gt;15 year old and initially survived to hospitalize in the intensive care unit. An association of the quartile of ICU trauma patients volume and in-hospital mortality was assessed by generalized estimating equation model which was adjusted for individual level covariates consisted of age, gender, the injury severity score, and trauma mechanism and a cluster level covariate as hospital ID. Similary, another analysis estimated a non-linear association between ICU patient volume and in-hospital mortality using a generalized additive mixed effect model adjusting for the same covariates of the generalized estimating equation analysis. Results Of 338,774 patients registered in the JTDB, 170,844 were eligible as the study participants and were further divided into 4 strata (42,067, 43,861, 41,938, and 42,978 patients) according to the quartile of annual institutional ICU trauma patient volume (0 to 92, 93 to 152, 153 to 211, and 212+ patients / year), respectively. The mean age (57, 56, 57, and 55) and mean injury severity score (19, 18, 17, and 16) of the study participants differed across the quantile, respectively. Crude hospital mortality of the strata showed a decreasing trend which comprised 12.7%, 10.1%, 9.7%, and 7.5%, respectively. The association between trauma patient volume and hospital mortality showed a negative correlation both in the analyses with the volume as quartile and a continuous variable after adjustment for the covariates (Figure). Conclusion The association of adult trauma patient volume in the Japanese ICU per year and adjusted hospital mortality risk showed a negative correlation.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Dr. med.

Prof.

Prof. Dr. med.

Introduction of the "Straight-Leg-Evaluation-Trauma-Test" as a rapid assessment for long-bone fractures in a trauma bay setting

Abstract text (incl. references and figure legends) Purpose: Lower extremity long bone fractures can contribute a substantial source of bleeding in the polytraumatized patient. Therfore it should be diagnosed in the primary survey as fast as possible. Standardized clinical assessment tools for fracture detection in the trauma bay, however, are lacking. We propose the "Straight-Leg-Evaluation-Trauma-Test" (SILENT-test) as a rapid assesment tool for the lower extremity. The aim of this prospective diagnostic study was to evaluate the efficacy of this test in a standardized preclinical setting.Methods: Medical professionals with different levels of experience performed clinical fracture diagnotics in four human cadavers with two femur- and two tibia shaft fractures. The SILENT-test (ST) and conventional fracture testing (CS) were performed. A cross-over design was used and participants were randomly allocated and blinded. Accuracy, subjective clinical applicability, and clinical performance of both tests were measured and compared. Results: A total of 440 clinical tests were performed by 55 examiners. For femoral fractures, ST had a positive predictive value (PPV) of 0.97 (95% CI 0.93 to 0.99), a specificity of 0.91 (95% CI 0.80 to 0.97) and a sensitivity of 0.96 (95% CI 0.92 to 0.99). CS had a PPV of 0.97 (95% CI 0.93 to 0.99), a specificity of 0.93 (95% CI 0.82 to 0.98) and a sensitivity of 0.89 (95% CI 0.83 to 0.93). ST was significantly more feasible (8.05 ± 1.48 vs. 5.91 ± 2.09) had a significantly greater certainty (8.32 ± 1.84 vs. 7.89 ± 2.01) and was significantly faster (7.73 ± 6.61 vs 14.50 ± 11.11 seconds). Conclusion: SILENT-test showed equal accuracy compared to conventional fracture testing, while being significantly faster and significantly more clinically applicable.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Disaster and military medicine

Polytrauma

Definitive surgical trauma care (DSTC) &amp; definitive anaesthetic trauma care (DATC) courses: A five-year analysis

Abstract text (incl. references and figure legends) Introduction: DSTC is an IATSIC course with 27 years of history, focused on teaching surgical skills for trauma care. It is an essential course that addresses the &quot;second hour&quot; beyond ATLS. Initially focused on the surgeon, it evolved into a team course, including anesthetists (DATC) and a nursing team (DPNTC). Our objective was to review its worldwide development in the last five years and assess the impact of the COVID-19 pandemic on the program. Methods: The authors designed a descriptive study to analyze DSTC, DATC, and DPNTC registries among 25 countries. The total number of courses delivered from 2018 to August 2022 and the DSTC to DSTC+DATC ratio were studied. Frequency, percentage, and proportion of course types were calculated by country. Additionally, faculty perceptions from Spain, Portugal, and Brazil, were assessed by answering an anonymous online survey regarding content and methodology. Results: 138 DSTC courses were delivered during the studied period, of which 70 (51%) were DSTC + DATC. The authors did not find registries for the DPNTC courses. The five counties with the most DSTC courses offered were: Brazil 18 (13%), Sweden 16 (12%), Australia 12 (9%), Spain 11 ( 8%), and South Africa 10 (7%). The DSTC + DATC to DSTC overall ratio was almost 2:1. The total number of courses delivered worldwide during the COVID-19 outbreak was only 7, representing a reduction of 85% compared with the mean of the two previous years. The faculty survey assessment revealed satisfaction with the course content but identified the need for updates. Most welcomed the inclusion of DATC within the course, promoting a trauma team approach. Conclusions: The current trend is to offer the DSTC course in a DSTC + DATC format promoting trauma team training. Brazil, Sweden, and Australia are the three countries with the most significant number of courses delivered in the last five years. However, the number of courses offered in 2020 was reduced by 85% due to the COVID-19 worldwide restrictions. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Visceral trauma

Captain

Major

Colonel

Commander

Analysing military-civilian partnerships in trauma care delivery – The IMPACT Study

Abstract text (incl. references and figure legends) Objectives Trauma is a leading cause of morbidity and mortality. Military-Civilian Partnerships (MCP) can be mutually beneficial in trauma care delivery and advancement. Nation specific guidelines for developing MCPs in High Income Countries (HIC) exist, but are not globally transferable. The role of MCPs to support developing trauma care in other settings, including Low- and Middle-Income Countries (LMICs), is unclear. The literature was reviewed to identify themes, and to inform an international framework. Methods An extensive scoping review was performed, to identify literature describing Mil-Civ trauma systems integration. Multi-stage screening was then conducted. After inclusion, articles were analysed to delineate whether the response was related to disaster or armed conflict, relevant data was extracted and coded into themes, and the level of integration was assessed. Author affiliation and study location were classified by World Bank income group. Results 8172 studies were screened, 74 met inclusion criteria. Experiences in 22 nations were described. The majority (91.9%) of authors were affiliated with institutions in HICs. Identified themes included: skill sustainment, academic integration, geography, event-based integration, and high-level government support. Level of integration consisted of coordination (16.2%), collaboration with formal agreement (50%), partial (24.3%), and full-integration (9.5%). 18 studies described experiences in LMICs, 17 occurring only in response to an event (14 disasters, 2 conflicts, 1 during both disaster and conflict). Only six (33.3%) papers describing experiences in LMICs included authors from that setting. Conclusion Based on available literature, MCPs largely occur in HICs where partnerships can benefit both sectors. Examples identified in LMICs are limited to event-based partnerships. Further prospective investigation into MCPs in LMICs is needed to identify factors supporting successful integration in those settings.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) We have nothing to disclose.

Off-label use of an external hand fixator for craniomaxillofacial fractures – An anatomical feasibility study

Abstract text (incl. references and figure legends) Background The lack of resources limits the treatment of craniomaxillofacial fractures (CMF) in low-income countries (LIC). Barton bandage and/or interdental wiring are considered being gold standar. The fracture reduction is maintained by permanent occlusion for 6 weeks, which often leads to limited compliance and dissatisfying results. Furthermore, in these conditions the healing of nasopharyngeal fistula is difficult. During humanitarian missions CMF need to be treated by trauma surgeons. The aim of this cadaver-based study is to evaluate the feasibility of the use of an external face fixator (EFF) for the treatment of CMF, its biomechanical values and to define the optimal pin insertion points and angles. Material and methods See Fig. 1. A commercially available AO hand fixator was used. CMF type Le Fort 1-3 with split fracture of the hard palate were treated with EFF on 13 anatomical specimens. The pins were placed in specific anatomical regions. The maximal pull-out force [N] of the pins was analysed by a tensile force gauge. As a reference, Fmax of the mandibular pins was evaluated. Computer tomography (CT) scans were performed on the healthy, fractured and EFF-treated skulls. After reduction and EFF placement an adequate reposition was shown in the CT scans. Results The pull-out forces of the single pins showed good purchase compared to the mandibular pins in the biomechanical pull-out testing. The best drilling angles for the supraorbital pins is between -10 and 35°. Conclusions The operation technique is feasible, and the stability of the EFF is sufficient for maintaining the reduction. The required pins can be safely inserted into the described areas and a good reduction result can be achieved. Fig.2 The EFF offers a feasible alternative to the non-surgical treatment of CMF in LIC. Thus, the gap between the open reduction and internal fixation techniques (mini-plates) used in High-income countries and the Barton bandage used in LIC can be closed.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Hot topics in emergency general surgery research: ESTES members survey 2022

Abstract text (incl. references and figure legends) Introduction: Before this project, it was not known which are the most important topics to be researched within emergency general surgery fields, to date. The section of emergency general surgery of ESTES thought in designing a short survey of it's members to find out the research priorities for the next years and concentrate on developing projects in these directions. Material &amp; Methods: A short survey monkey was designed, comprising of 6 questions and sent to all ESTES members in May 2022. The questions were designed to scope the interest of ESTES members in participating in research projects designed by a working group from EGS section of ESTES and published under collaborative working approach. Also, from a series of common emergency surgery pathologies, the respondents were asked to nominate the most important topic in which they wanted to see more research work published. Results: 84 responses were received from different ESTES members. Vast majority ( around 80% ) were interested to hear/read more about research projects developed by ESTES and a similar number were willing to participate in multi-center research projects as co-authors. From the 15 emergency surgical pathologies proposed for further research in the survey, 5 of them were recognised as important and of immediate interest, these scoring 10% or more of the total number of the members votes. Conclusions: Based on the results of the survey, the section proposed to steer the next projects of research onto the pathologies indicated by the members, as of major interest. References: N/A, members survey using Survey Monkey tool.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) NO

Massive traumatic abdominal wall hernia: a very rare and potentially serious injury. Analysis of a short case series

Abstract text (incl. references and figure legends) Introduction: Traumatic abdominal wall hernias (TAWH) are caused by the disruption of the musculature and fascial structures after a blunt high energy trauma without skin rupture. Because of the its low incidence, diagnosis is difficult and treatment complex and no clear consensus exists on the best moment for surgery. The aim of this study was to analyze our small case series Material and methods: Descriptive and retrospective study from severe trauma database in our center. Patients with a TAWH were studied over a period of 20 years (2001-2020). An analysis of demographic data, mechanisms of injury, type and location of TAWH, associated lesions and treatment were performed. Results: During the study period, 1.226 patients with severe blunt abdominal trauma were included. We identified 6 patients with TAWH, aged between 20-64 years. The injury mechanism was traffic collision, except for one case of bullhorn trauma. The diagnosis was made in 3 patients during the clinical evaluation, and the others were radiological or surgical findings. TAWH were mostly located on the anterior abdominal wall (5 cases) and there was a lumbar hernia. All patients presented with associated injuries, intraabdominal (5 cases), and bone fractures (2 cases). Two patients had a seat-belt sign. Four patients underwent urgent surgery in the first 24 hours; in 2 of them a primary closure of the defect was performed, and the other 2 were reconstructed using meshes. No mortality was recorded and only one early hernia recurrence was observed. Conclusion: TAWH is a rare injury that occurs in less than 1% of blunt trauma cases. Its diagnosis and treatment are challenging. It is important to individualize its management and to evaluate the risk-benefit of urgent vs delayed reconstructions of the abdominal wall, depending on the associated injuries and the clinical status of the patient.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) no

Epidemiological profile of dog attacks to patients under 14 years old assisted at the Pediatric referral emergency unit of a tertiary hospital in Campinas, Brazil

Abstract text (incl. references and figure legends) Introduction: Accidents involving dog attacks are very common, which makes this type of accident a global public health issue. Dog attacks might result in fractures, infections, scars, and psychological traumas. This study aimed to describe the epidemiological profile of dog attacks to children under 14 years old assisted in a pediatric emergency service in Brazil.Methods: The data base of the Information and Toxicological Assistance Center of Campinas was surveyed to identify cases of children under 14 years old assisted after a dog attack in a 9-year period. Demographic data, number and type of lesions, type of exposure, part of the body affected, dog origin and condition, and the accident location and cause were analyzed. The data were presented in a descriptive way and the age groups classified as follows: 0-3 years old, 4-6 years old, and 7-14 years old. The different age groups were compared one to another regarding the markers evaluated using the chi-square test and the Fisher&quot;s exact test. A 0.05 alpha was adopted in all analyses. Results: The number of children assisted in the study period totaled 1,012. The 7-14-year-old group was the most affected (n=498; 49.2%), male patients were also majority (n=660; 65.2%). Most injuries were found on the head/neck area (n=378; 37.4%). However, the older the patients were, the higher the frequency of lesions on upper and lower limbs was, as well as attacks occurred in external environments, thus involving animals that could not be observed. A significant increase in accidents with provoked cause was observed in younger patients. Conclusion: Accidents involving dog attacks are more likely to happen among boys. Younger children run higher risks of becoming victims of these accidents inside homes, being attacked by pets, and showing greater incidence of head and neck lesions. Older children present more injuries on their limbs, which are caused by dogs that cannot be observed.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

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