22nd European Congress of Trauma & Emergency Surgery

Chairs

Complex pelvic trauma – A rare case of delayed ano-rectal perforation with scrotal involvement and resultant pelvic sepsis

Polytrauma

Emergency surgery

Abstract text (incl. references and figure legends) A motorcyclist presented to our trauma unit after colliding with a car and flung. He sustained an open book pelvic fracture as well as right scrotal hematoma and laceration. After stablisation, he underwent open reduction and internal fixation of the pelvic fracture primary closure of the scrotal laceration on day 3 of admission. 2 days later, he was found to have per-rectal bleeding. He was febrile and tachycardic. On per-rectal examination, there was an mucosal defect suspicious for an ano-rectal laceration at the superior aspect of the anal canal. Interval computed tomography scan revealed new air-fluid levels within the scrotal sac and extensive subcutaneous emphysema involving the bilateral inguinal regions. This was concerning for a delayed anoectal perforation with resultant pelvic sepsis. He underwent wound debridement of the scrotal wound and sigmoid colostomy creation. There was a full thickness 3cm long anorectal laceration communicating with the scrotum with large amounts of clots. He had another surgery one week later for repeat pelvic and scrotal wound debridement due to wound infection. He did not require removal of the implants. He completed a 6 week course of antibiotics whilst undergoing aggressive rehabilitation. He underwent closure of his stoma once the anorectal laceration and scrotal wounds have completely healed. Our postulation is that a micro-tear in the anal mucosa was likely present initially which was converted to a full thickeness perforation due to increased pressure and a mass effect caused by expansion of the scrotal hematoma. This illustrates a unique case of a delayed anorectal perforation with involvement of the scrotum resulting from a complex pelvic trauma. References 1. Trauma to the pelvis:Injuries to the Rectum and Genitourinary Organs.Curr Trauma Rep(2015)1:8-15 2. Management of anorectal wounds.J Indain Med Assoc 2021;119(5):89-94 3. Care of the patient with anorectal trauma.Clin Colon Rectal Surg 2012;25:210–213 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

Poster

Prof.

Full recovery of an extreme thermal-crush trauma with nerve injury after aggressive debridement and plastic reconstruction: The essential role of timely cooperation between trauma and plastic surgeon

Abstract text (incl. references and figure legends) A 26 year-old man was referred to our Centre after an industrial thermal-crush trauma due to a heat press on his thorax, right arm and face. At the first evaluation in the Emergency Department, main findings were third-degree burns of right ear, right hemithorax and arm, associated with extensive traumatic soft tissue loss (Fig.1A). A total body CT scan revealed sternum fracture, right rib fractures (II-IX) with ipsilateral pulmonary contusion and small pneumothorax. The patient was resuscitated in the ICU. An extended debridement was performed within 24 hours from admission. We found necrosis of right Latissimus dorsi, Biceps brachii, Teres major, and complete high Median, Ulnar, and Muscolocutaneous nerves transections (Fig.1B). The reconstructive surgery was performed four days later. An autologous right sural nerve grafting was used to bridge the gap of the Ulnar and Musculocutaneous nerve. The reconstruction of the Median nerve was not performed because its distal end was undetectable. A free anterolateral thigh (ALT) flap was moved to cover the exposed vessel-nerve bundle in the right axillary area. Artificial dermis (INTEGRA) and multiple skin autografts were subsequently applied to cover the thoraco-dorsal region and arm. The exposed auricular cartilage of the ear was buried in a retroauricular skin pocket. The post-operative course was complicated by surgical site infection and sepsis requiring long-term antibiotics and surgical drainage of purulent collections. The patient was discharged two months after admission. During the following weeks he underwent physical therapy. At present, 8 months post-injury, the skin loss is covered (Fig.1C) and 90° abduction and flexion-extension have been restored. By contrast, the recovery of pronation-supination elbow movements is not complete and fingers movements have not been restored yet. Fig.1. A: injury at admission; B: injury after the debridement; C: 8-month follow upDisclosure: 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

Surgical approach to major vascular injury after severe blunt trauma: Traumatic superior vena cava pseudoaneurysm with unstable pelvis fracture

Visceral trauma

Abstract text (incl. references and figure legends) An 80 year old woman was taken to the emergency department after a run over, with severe thoracoabdominal blunt trauma. She was haemodynamically unstable, with systolic blood pressure of 60mmHg, heart rate 130bpm, oximetry 88%, Glasgow coma scale 8/15, at arrival. Orotracheal intubation was performed, fluid resuscitation, and vasoactive drugs were provided, and external compression device was set to pelvic fixation. Massive transfusion protocol was triggered. Chest and pelvic X-ray showed a mediastinal widening and an unstable pelvic fracture. Transient response to resuscitation allowed to perform a CT scan, showing: pseudo-aneurysm of superior vena cava (SVC) with no active bleeding, mediastinal hematoma, bilateral haemopneumothorax and pulmonary contusion, pneumopericardium and pelvic fracture with venous bleeding. Emergency surgery was decided. External pelvic fixation over the iliac crest and extraperitoneal pelvic packing was performed, followed by a median sternotomy for SVC repair. A pseudoaneurysm of the SVC with profuse bleeding was identified and emergent cardiopulmonary bypass was stablished. After vessel control, SVC burst ruptured was identified, making impossible primary repair. Azygos vein was ligated and a 10mm Dacron graft was sewn for SVC substitution. A temporary closure was carried out. A second-look surgery was scheduled 72 hours later, and in the absence of bleeding, chest and abdomen were both definitely closed. After a prolongated ICU stay with several complications, the patient was finally discharged to a rehabilitation hospital. Major vascular injuries are associated to a high mortality rate. There is not much evidence of traumatic pseudoaneurysm SVC management, but achieving an early vessel control is imperative to prevent exsanguination, and may require complex cardio-thoracic surgery. Fig1. CT scan showing a SVC pseudo-aneurysm. Fig2. SVC ruptured. Naidoo S, et al. Traumatic injury to the great vessels of the chest. Doi: 10.21037/med-21-15.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.

Blunt liver trauma and bile leakage

Abstract text (incl. references and figure legends) CASE HISTORY: A 55-year-old male presented with acute abdominal pain at the ER following a work accident. He fell from a 3m height and injured his right hemithorax. Patient was haemodynamically unstable. BP=70/40 mmHg, HR=120 bpm, SpO2=96%, GCS=14/15. CLINICAL FINDINGS: Abdominal examination revealed tenderness in the right upper quadrant. No other significant injuries identified. INGESTIGATION/RESULTS: U/S FAST was positive for free intraperitoneal fluid collection. Following resuscitation, CT scan showed grade IV-V multiple liver lacerations at segments V-VI-VII-VIII with extravasation of contrast in the venous and delayed phases. DIAGNOSIS: The diagnosis set was blunt liver trauma. THERAPY AND PROGRESSIONS: The patient underwent urgent laparotomy which showed grade IV-V lacerations in the right posterior liver lobe. Liver packing was initially performed. The patient underwent three subsequent urgent laparotomies during the first 24 hours. Finally, right hepatic artery ligation took place. The patient was admitted in the ICU. The second look operation included liver packing removal and cholecystectomy. On the 5th post-operative day, bile leakage was identified. On the 34th post-operative day the patient underwent ERCP and CBD stenting. He was discharged from the hospital on the 44th post-operative day completely recovered. COMMENTS: The patient initially presented a bilious drainage of 200-300 ml/24h. Following ERCP, the patient was discharged with a bilious drainage of less than 20 ml/24h. REFERENCES: Afifi I, Abayazeed S, El-Menyar A, Abdelrahman H, Peralta R, Al-Thani H. Blunt liver trauma: a descriptive analysis from a level I trauma center. BMC Surg. 2018 Dec;18(1):42 Oo J, Smith M, Ban EJ, Clements W, Tagkalidis P, Fitzgerald M, et al. Management of bile leak following blunt liver injury: a proposed guideline. ANZ Journal of Surgery. 2021 Jun;91(6):1164–9 FIGURE 1: Pre-operation CT scan FIGURE 2: ERCP pre-stentingDisclosure: 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

Prof. Dr.

Case series of destructive penetrating airbag injuries at a level 1 trauma center in Qatar

Education

Abstract text (incl. references and figure legends) Case history 6 patients were involved in motor vehicle collisions (MVC) with deployment of airbag. Clinical findings One patient was in cardiac arrest, was revived but had no brain activity. She had a large foreign body in the hard palate with fracture of the mandible. One patient had fractured mandible and zygoma. One patient had a penetrating wound in the neck. Three patients had penetrating chest injuries. Investigation/Results CT imaging of all patients showed a hyperdense rounded foreign body lodged within the site of impact. (Fig.1) Diagnosis Case 1 – Traumatic brain (TBI), cervical spine injury and death Case 2 – TBI, facial bone fractures Case 3 – Left lung laceration Case 4 – Right lung laceration Case 5 – TBI and zone 2 penetrating neck injury Case 6 – Right chest wall injury Therapy and Progressions The patient with cardiac arrest expired in the ICU within a week due to severe TBI. The patient with left chest injury underwent exploration in the operating room (OR), he developed respiratory failure and is currently on ECMO. The rest of the patients underwent exploration in OR and had uneventful recovery. Comments All the patients suffered from injuries caused by the same component of the airbag inflator after deployment. (Figure 2). The National Highway Traffic Safety administration estimates that nearly 50,000 lives have been saved by airbags since 1987. (1) Recent reports of significant injuries and deaths due to airbags have been reported including a global recall of millions of vehicles due to malfunctioning airbags. (2) This highlights the potential dangers of a supposed safety measure which may result in devastating consequences. References 1- Newer cars are safer cars. NHTSA. (n.d.). https://www.nhtsa.gov/newer-cars-are-safer-cars 2- Jothee S. Fatal penetrating neck injury due to defective airbag inflator. Forensic Sci Int. 2018 Oct;291:e4-e7 Fig 1. Case 1 &amp; Case 2: TBI, C-spine &amp; facial fractures. Fig 2. Inflator component 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

A floating knee with bilocular open fractures of femur, tibia and patella

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) Introduction. Floating knee injuries are a result of high energy trauma and may be associated with life-threatening injuries. Frequently the fractures patterns are complex with serious injuries of the soft tissues. Management of associated life-threatening injuries should take precedence over the orthopedic injury. A risk adapted damage control orthopedics should be apply to all polytrauma patients with floating knee depending on their age ISS, GCS and the soft tissue status of the extremities. Case history and clinical findings. The patient is a 29 years old male, admitted in the emergency after a motorcycle accident. The orthopedic examination and the ex-rays revealed a Gustillo-Anderson/GA/ II bilocular open fracture of the right femur/AO/ASIF 31.B2+32.B3/, a GA II fracture of the right tibial plateau/ Schatzker V/, a patella multifragmented fracture and fracture of the right distal tibia and fibula / AO/ASIF 43.A1/ and injury of n. Peroneus. Therapy and Progressions. After wound debridement and temporary stabilization of the fractures the patient was transferred to the ICU. With improvement of the general condition, 7 days after the accident all fractures were stabilized in one stage: anterograde intramedullary nail for the femur fractures, plate fixation for tibia and fibula, and screw and cerclage fixation for patella. Compression from the foot orthesis in the area of fibula fracture and the loss of sensation led to operative wound dehiscentio and deep infection. The latter was treated with multiple debridements, i.v. antibiotics, application of V.A.C and dermal flap. RESULTS: All fractures healed between the 3rd and 5th postoperative month.Full recovery of nerve function is assessed 5 months post injury. According to Karlstrom and Olerud functional scale excellent result is assessed. 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.) I have no financial interest.

Fall from 10 meters high, what happens next?

Abstract text (incl. references and figure legends) Female, 26YO. Suicide attempt witnessed by civilians: fall from about 10 meters high. Found on the public road in prone position. Upon admission to the emergency room, the airway was patent and permeable, with tachypnea and decreased breath sounds bilateral. Tachycardia with hypotension. Cold ends. GCS of 14, with iscochoric pupils. No hip instability. Deformity of the right humerus and left femur.Chest x-ray:left pneumothorax + bilateral contusion. A 30Fr drain on left hemithorax was placed with the exit of air and some blood.After 10 min of being in the emergency room, her neurological status worsens–GCS 9.Intubation and invasive ventilation was done. Performed TC-TAP: thoracic trauma: fracture of the 1st left costal arch + bilateral pneumothorax + bilateral pulmonary contusions- Abdominal trauma: traces of left kidney fracture- limb trauma: fracture of the right humerus (immobilized with plaster), fracture of the left femur (immobilized for deferred surgical treatment)- spinal trauma: C1 anterior arch+ C4 right lamina+ D12+ dorsal and lumbar left transverse apophyses fractures, L2+ sacral fractures of the left iliopubic branch. Admission to the Intensive Care Unit.She remained hospitalized for 56 days, during which she was operated on by orthopedics for surgical treatment of spinal, femur and humerus injuries. She remained intubated and ventilated for 30 days because of a ventilator-associated pneumonia. She was successfully extubated, and was discharged from intensive care on the 35th day.She was diagnosed with ASIA A vertebromedullary injury.On the 56th day,due to abdominal pain, a TC was performed: pneumoperitoneum due to perforation of the cecum. She was operated: ileocolic resection, terminal ileostomy and lateral transverse colostomy. She keeps doing her fisical rehabilitation on our hospital, waiting for a vacancy in a specialized rehabilitation center. References: ATLS, 9Th Edition, ACS; DSTC, 5th edition, IATSIC. 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

Walking dead – An accurate triage is a must

Abstract text (incl. references and figure legends) In pre-hospital units, there is a need to examine and identify injured patients as quickly and as accurately as possible to resolve potentially fatal conditions. We are prepared for the worst possible scenario every time right from the dispatch call. But what about when the patient comes to the medical unit on foot? Triage is an extremely important part of patient treatment, which can be quickly forgotten when the patient is talkative and mobile. A 56-year-old male came on foot, alone, to the entrance of the Litija Primary care health. Because of bleeding, he was sent to the ER department. At first assessment, we noticed massive bleeding from the mouth and a wound on his lower lip. When taking an anamnesis, the patient was evasive and claimed that he had fallen off a ladder. On arrival, his BP was 102/50 mmHg, HR 110/min, SpO2 90%. Given the condition, the suspicious circumstances of an accident (which later turned out to be fabricated), we acted quickly. A more detailed examination showed a suspicion injury of mandibula, right hemithorax and the lumbar spine. His front teeth were avulsed. After spinal immobilisation, he became responsive only to pain. His BP dropped to 70/45 mmHg, saturation was still 90%, he was breathing sufficiently. Two IV lines were applied, 1000 mL NaCl 0.9% and 100% oxygen through a high flow oxygen mask were administered. Immediately after the initial care HEMS was activated for transport to the trauma centre. From the moment the patient entered the ER to the arrival of HEMS, lasted 45 minutes. Since the patient was a middle-aged man, without associated diseases and in good physical condition, his body was able to compensate for a longer period of time, which could mislead us. An accurate triage with efficient and fast treatment played a significant role in the further care 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

Traumatic tram tragedy – A case report on a polytraumatised patient

Abstract text (incl. references and figure legends) Traumatic pelvic injuries contribute to the mortality rate in polytrauma patients. A 66-year-old male cyclist had a traumatic collision with a tram. In the prehospital phase, he was responsive and treated as per local EMS-protocol. Upon admission to the ED, he was conscious, tachypneic, tachycardic, hypotensive and deteriorating. Polytrauma CT showed ribs and sternum fractures, bilateral pneumothorax, numerous unstable pelvic fractures, paraspinal muscles blunt injury and retroperitoneal bleeding. An external pelvic stabilization splint was established. Rescue transfusion for hemorrhage as well as external heating was initiated. The patient was first qualified for an orthopedic external pelvic stabilization surgery. Due to the worsening shock with the unclear focus of bleeding resulting in the patient falling into transient cardiac arrest, plans for surgery were abandoned. The repeated FAST-USG was negative for any visible intraperitoneal bleeding, cardiac tamponade or other cardiac injuries. Priority was switched to radiological intervention. Three arteries: right obturator artery, left internal iliac artery, and the right intercostal artery were found actively bleeding and embolized 3 hours after ED admission. The patient was then admitted in the ICU where he continued to deteriorate with signs of irreversible phase of shock with multiple organ failure. The patient died the day after the accident. In case of traumatic pelvic fractures, it is crucial to suspect bleeding from adjacent vessels since shock symptoms can be occult on the onset. The "golden hour" rule in the prehospital phase is cardinal. Once haemorrhagic shock is suspected, it is critical to prevent "the death triad"- coagulopathy, acidosis and hypothermia. If the patient hemodynamically deteriorates with negative POCUS/CT, suspect retroperitoneal/GI bleeding. Endovascular intervention in high-energy pelvic trauma patients with shock can be life saving as the late phase of shock is irreversible.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 emphysema and soft tissue swelling following traumatic pneumothorax

Abstract text (incl. references and figure legends) Case history A fit-and-well 46-year-old male patient presented in our emergency room with increasing pain and swelling of his left thoracic wall after falling down an entire staircase around 11 hours previously. Clinical findings In the emergency room the patient presented in full consciousness, spontaneously breathing and hemodynamically stable. Swelling of the neck, chest, scrotum and left upper leg were found upon physical examination with crackling skin as found in emphysema. The airway was not compromised, but there was a B problem detected, as the patient presented with left chest hypoventilation. There were no C, D or E problems present. Investigations/Results A trauma CT scan was performed, which revealed a massive pneumothorax on the left side as well as massive subcutaneous emphysema. Fractures of the sixth and seventh left rib as well as of the left scapula were detected. Diagnosis The patient suffered a pneumothorax with massive subcutaneous emphysema as well as fractures of the sixth and seventh left rib and scapula after falling down the stairs eleven hours previously. Therapy and Progressions Immediately after performing the CT scan a chest drain was placed in the left chest. X-ray was performed to control the correct position of the tube, in which the massive emphysema was still visible(Figure 1). Afterwards, the patient was transferred to the intensive care unit. A few days later, pneumothorax as well as the emphysema had completely resolved, and the chest drain was removed. Comments This case study presents the story of a patient, who suffered a severe trauma resulting in a potentially life-threatening injury. As the pneumothorax was not treated immediately after trauma, subcutaneous emphysema could develop, with swelling of the neck, chest and even lower body including the scrotum. If this swelling due to emphysema had continued, airway obstruction or obstruction of blood vessels could have resulted, potentially leading to death.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

Multidisciplinary approach to a patient with AAST Grade 5 blunt liver trauma – A case report

Abstract text (incl. references and figure legends) Case history. 22-years old male felt from 10 meters high. First responders assessed a patient and decided that there is high probability of severe blunt abdominal trauma. At arrival patient was present with signs of hypovolemic shock. FAST ultrasound showed a massive hematoperitoneum with lacero-contusion of right hemi liver. Massive transfusion protocol was activated. Clinical findings. Intraoperative finding showed severe lacero-contusion of right hemi liver with active bleeding. Partial avulsion of right kidney and bleeding from retroperitoneum. Investigation/Results. Abdominal computer tomography (CT) scan - Grade 5 AAST right hemi liver injury. Diagnosis: AAST Grade 5 right hemi liver injury Therapy and Progressions. Complete medial laparotomy and perihepatic packing was done, however it was not successful in providing adequate haemostasis. With use of Pringle manoeuvre we performed vascular exclusion of right hemi liver with right portal and hepatic vein and artery ligation. Combining vascular exclusion of right hemi liver and perihepatic packing we succeeded in reasonably good level of a haemostasis. Whole body CT was done and patient was transferred to intensive care unit (ICU). Hours later sings of active bleeding were noticed. CT scan and embolization of small arterial hepatic pseudoaneurysm were performed. After interventional procedure second operation was performed with additional haemostasis and perihepatic packing. In third operation local situation allowed complete mobilisation of right hemi liver and suture of thorn retro hepatic veins and vena cava. Signs of toxic shock prompt early surgical intervention (after 24h) with a right hepatectomy. No other surgical or invasive interventions were needed afterwards. He was transferred to ward on day 26 and was discharged on day 44 to rehabilitation centre. Comments. In our case report we show importance of multidisciplinary approach in a patient with blunt abdominal trauma and AAST grade 5 liver injury.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.

Cervical bleeding injury after motorcycle road accident management in polytrauma patient

Abstract text (incl. references and figure legends) Case history: A 49-year-old male victim of a motorcycle crash into another vehicle, brought by pre-hospital emergency to our hospital with a cervical wound and laceration of the left external jugular vein (LEJV). Clinical findings: He presented hemodynamically stable, with cervical bleeding controlled by external compression and cervical immobilization. Airway was apparently not compromised and orotracheal intubation was performed maintaining manual cervical traction after removing cervical collar and excluding tracheal injury and other cervical injuries. He also had pubic region swelling and was stabilized with a pelvic binder. Results: CT scan showed preservation of the carotid vascular axis, fractures of the spinous process of C6 and transverse processes of C6-T1, left clavicle, virtually all left ribs and diastasis of the pubic symphysis and right sacroiliac joint. Diagnosis: Polytrauma with cervical, clavicular and rib fractures, pelvic APC III fracture and cervical injury with laceration of LEJV. Therapy and progressions: Surgical exploration of the cervical wound was performed, with ligation of the LEJV extremities. The patient was admitted to the intensive care unit. Pelvic ring fracture was initially managed by osteotaxis with external fixator to the iliac crests and deferred definite treatment with osteosynthesis of sacroiliac fracture was performed at day 5 and pubic symphysis with plate and screws at day 15. Cervical immobilization was maintained until surgical arthrodesis at day 19. The other fractures were managed with a conservative approach and a left erector spinae plane block catheter was placed for better pain control. The patient was discharged from ICU on day 25, fully awake and conscious, breathing on room air, with a sensory-motor deficit on the left arm due to left brachial plexus injury and no other neurological deficits. Comments: This case highlights the importance of damage control, prioritizing the approach of different injuries in polytrauma patients, with deferred definitive treatment after stabilization. Airway protection is also important and special care should be taken in its management, given the cervical trauma.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

Poster Session 16
Polytrauma 5

Appointment

Chairs

Programme

Poster Session 16Polytrauma 5

Appointment

Chairs

Programme

Poster Session 16
Polytrauma 5