ectes-2024-eposter-hintergrund-660bca90303c0212783071.jpg

ectes-2024-eposter-logo-660bcc1ca0874706891033.svg

ectes-2024-eposter-start-660bc6df45fbd927741591.jpg

23rd European Congress of Trauma & Emergency Surgery

Damage control in maxillofacial ballistic trauma: Team approach makes the difference

Visceral trauma

Trauma and Emergency surgery | Miscellaneous

Case history Ballistic facial trauma is potentially life-threatening due to airway compromise, bleeding, or both. Multidisciplinary team approach, swift transfer to the operating (OR) and damage control strategies can improve outcomes. We present a case of a 77-year-old male patient with a severe ballistic facial trauma (suicide attempt) managed at a level 1 trauma center. Pre-hospital information prompted trauma team activation. Clinical findings On primary survey the patient had a compromised airway due to complex facial trauma with avulsion of a large portion of the mandible and soft tissue injury, with massive bleeding. Investigation/Results The team decided to take the patient to the OR for early intubation and control of hemorrhage in a safe environment with more resources. With the surgical team prepared for a surgical airway, successful orotracheal intubation was achieved. Then a damage control procedure, consisting of nasal and oral cavity packing to stop the bleeding, was performed by the maxillofacial surgery team. Diagnosis, Therapy and Progressions After initial stabilization, the patient was moved from the OR to the CT scan for imaging. After this he returned to the OR for second-look surgery with tracheotomy, wound closure, and placement of a reconstruction plate in the mandible to be used in later definitive reconstruction. Comments Airway compromise and massive hemorrhage are critical issues in ballistic maxillofacial trauma. Prior planning, expert decision-making in a multidisciplinary setting and intraoperative management allows for optimal resource allocation. Prompt surgical support and immediate bleeding control were keys to success in this case and early operative management in a damage control strategy proved essential.No.

Poster

Thyroid gland rupture due to blunt trauma: A rare surgical emergency

Polytrauma

I: Thyroid gland rupture is a rare cause of emergency surgery. It is most frequent in pathological glands with preexisting conditions (goiter, nodule). The main reason for surgical management is airway compromise, followed by active bleeding. Non operative treatment is an alternative in stable patients with permeable airway and close follow-up. We present a case of severe blunt neck trauma requiring emergency cervicotomy due to airway obstruction and active bleeding. P&amp;M A 65-year-old female, whit past medical history of psychiatric disorders, is brought by the out-of-hospital care after falling form a third floor. The patient arrives intubated, with diminished left breath sounds, hemodynamically unstable, FAST negative, and with multiple orthopedic injuries. After aggressive reanimation and left chest tube drain placement, hemodynamic stability was achieved, and a CT body was performed. R: Active bleeding of the left hemithyroid gland with tracheal deviation was described along with suspected carotid dissection and left flail chest. Also, a suspected image of middle avulsion of the left hemidiphragm was seen. After a multidisciplinary evaluation, cervicotomy and exploratory laparotomy was decided. Left hemithyroidectomy was necessary due to intraparenquimatous hematoma whit macroscopic preservation of the left recurrent laryngeal nerve. No diaphragmatic hernia was seen during the abdominal time. Torpid postoperative evolution due to extubation failure related to inadequate ventilatory mechanics requiring surgical traqueostomy at eight postoperative days. At 13 postoperative days, withdrawal from artificial ventilatory support with spontaneous ventilation. No abdominal or cervical complications were reported. C: Thyroid gland rupture is a surgical emergency due to its potential compromise of the airway patency. In the literature, a few cases of successful non-operative management are reported, but the airway comprised is always an indication for surgery. No

Prof. Dr.

Evaluation of computed tomography-detected hemothorax after blunt chest trauma: Does everyone need an intervention?

Background Diagnoses of Hemothorax, especially occult hemothorax, have increased after widespread use of computed tomography (CT) for imaging trauma patients. However, the need for chest tube insertion remains controversial. We aimed to study the management of hemothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, at Hamad level one trauma center. METHODS Patients with blunt chest trauma treated from June 2014 and January 2020 were e retrospectively studied. Variables on demographics, injury mechanism, severity, associated chest injuries, indications for tube thoracostomy, mechanical ventilation, hospital LOS, complications, and outcome were reviewed. RESULTS During the study period, 254 patients with hemothorax were studied. The majority of patients (79.1%) were successfully observed and tube thoracostomy was required in 20.9%. Hemithorax volume of less than 300 cc associated with successful observation (P value 0.001). Indications for chest tube insertion included progression of hemothorax on follow-up chest x-ray (15), desaturation (6), hemodynamic instability (2), and at the discretion of the physician (13). There were no complications related to delayed chest tube insertion. CONCLUSION Conservative treatment was safe and sufficient for most patients with hemothorax volume of less than 300 cc. Quantitative evaluation of hemothorax volume on CT scan should be considered in decision-making regarding tube thoracostomy insertion.No

A retrospective study describing the experiences in surgical stabilization of rib fractures at a level 1 trauma centre

Introduction Thoracic wall trauma could present with a simple rib fracture to multiple rib fractures to deadly flail chest or a stove in chest. Studies have demonstrated usefulness of SSRF in dealing with flail segment with regards to pain and hospital stay [1]. However, they have been limited in the Indian subcontinent. We describe here a case series of 14 patient where patient underwent surgical fixation of ribs. Aims To determine the benefits and outcomes in cases of surgical stabilization of rib fractures Materials and Methods A retrospective case series was done at a level 1 trauma centre in Bihar, India from August 2022 to August 2023. After ethical clearnce, data was collected from the hospital medical records. All adult patients that underwent rib plating at our centre were included. Statistics of patient demographics, injuries and pre and post operative VAS score were prepared. The prepared data was analysed. Patients were followed up in outpatient department and telephonically up to 3 months after the discharge with regards to impact on daily life. Results- Total 14 patients underwent SSRF in 1 year. In all cases, patients showed improvement in their pain as assessed by VAS scale. On follow up, all patients showed improved respiratory function. 11 out of 14 patients had returned to work and could resume with their daily activities normally. Conclusion- SSRF is a novel method of rib fixation that has been shown to have a greater benefit with regards to outcomes in displaced rib fractures and flail chest. More studies and cost-benefit analysis, especially in LMICs will help in standardization of the practice in such cases. References- 1] Coughlin TA, Ng JW, Rollins KE, Forward DP, Ollivere BJ. Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials. Bone Joint J. 2016;98-B:1119-1125No

Prof.

Diaphragmatic rupture with splenic and gastric injury after blunt thoraco-abdominal injury: Management with damage control

Case history: 23-year-old man victim of a road accident with closed thoraco-abdominal trauma, transferred to our Level I trauma center Clinical findings: received intubated and under invasive mechanical ventilation. In the assessment of B, symmetrical chest movements are present and a left thoracic drain had already been placed with 200cc of hematic content; peripheral O2 saturation of 100%. In terms of C, on vasopressor support, tachycardic but with mean arterial pressures of 75 mmHg. Neurologically, the pupils were isochoric and no motor lateralization was detected. There were no open fractures/deformities Results: trauma protocol CT scan shows 7-10th rib fracture and rupture of the left hemidiaphragm with abdominal herniation; splenic laceration and pneumoperitoneum were identified Diagnosis: diaphragmatic rupture with splenic laceration and hollow visceral perforation Therapy and Progression: exploratory laparotomy confirms a grade IV (AAST) rupture of the left hemidiaphragm (herniation of the stomach, spleen and colon), grade IV (AAST) splenic laceration and grade II (AAST) stomach perforation. A damage control procedure was performed: splenectomy, atypical gastrectomy and primary diaphragmatic repair with vacuum-assisted abdominal closure. A 2nd look laparotomy confirmed an intact gastric suture and the definitive abdominal closure was performed on PO4. The postoperative period was complicated by thoracic empyema and surgical site infection, treated with antibiotic and negative pressure therapy (Dindo-Clavien II). He was discharged on the 38th day and the 3 months follow-up appointment showed a god recovery Comment: traumatic diaphragm injuries are rare but potentially fatal situations. The approach should be early and directed at restoring herniated content to improve respiratory physiology and control bleeding and contamination. Immediate laparotomy in a damage control strategy is warranted for unstable patients and was the key to success in this caseNo

Case report: Double penetrating stabwound with a grade-V splenic lesion and zone-II left retroperitoneal hematoma

We present an otherwise healthy 46 year old man, that came to the emergency department after suffering multiple stabwounds located on posterior thorax, and left hemiabdomen. The patient was received in emergency department hemodynamically unstable, a complete polytrauma radiographs series were taken without evidence of an evident pneumothorax. Following ATLS protocols, an abdominal and thoracic tomography was taken, reporting a 2 cm lesion located on left posterior diaphragm with intestinal content inside thoracic cavity. The patient was managed preoperative with crystalloids and following a 1:1 fixed ratio of transfusion protocol was afterwards admitted to the operating room. A complete abdominal laparotomy was performed, a 2 cm lesion on both sides of spleen with an evident hematoma inside zone II retroperitoneum was found with approximately 500 cc of hemoperitoneum. A complete splenectomy and diaphragm repair, exploration of zone II retroperitoneum while exploring both sides of colonic and small intestine mesenteric and antimesenteric spaces, without overexisting lesion. Double penetration wounds into thorax and abdomen are a rare case of acute abdomen in the polytraumatic pacient. Recent data suggests that any lesion of stabwound below 5th intercostal space without evidence of symptoms of acute abdomen must always be studied and complete follow up and 24 hour vigilance of the patient, any data of acute abdomen, must be followed by abdominal CT or exploratory laparoscopy. This patient was sent directly into operating room because of the hemodynamically unstable condition, with suspicion of a double penetrating wound. Teh patient underwent 5-day antibiotic treatment and was sent to follow-up with external consult and sent to complete vaccination post splenectomy. Peter Arnold, Jessica Belchos, Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication,Journal of Surgical Research,Volume 280,2022,Pages 35-43, No

Failure rate and complications of transarterial splenic artery embolization following blunt splenic trauma: A meta-analysis and systematic review of the literature

Background: For the past few decades, spleen angioembolization (SAE) as an adjunct to non-operative management (NOM) has been a distinguished intervention for patients with blunt splenic injuries (BSI). SAE evidently improves patient outcomes, salvages the spleen, and avoids complications related to operative splenectomy. The aim of this systematic review and meta-analysis was to assess the failure rate of blunt trauma patients who underwent SAE as well as the complications associated with this treatment modality. Methods: A systematic literature search (PubMed, SCOPUS, and Cochrane Library) was performed describing splenic angioembolization in the setting of blunt trauma. Articles that fulfilled the predetermined inclusion criteria were included. This article analyzes the indications, outcomes, failure rate, and major and minor complications. Results: Thirty-three of five hundred and ninety-nine identified articles met the inclusion criteria. Of these studies, 29 were retrospective, 3 were prospective, and 1 was a randomized control trial. 25,521 patients were admitted with BSI and 3,835 embolized patients were reviewed. The overall failure rate of SAE was 5.3%. The most frequently reported major complications were rebleed (4.8%), infarction (4.6%), and abscess formation (4%). Minor complications included fever (18.4%), pleural effusion (13.1%) and coil migration (3.9%). Other complications included splenic atrophy, splenic cyst, hematoma, and access site complications like splenic/femoral dissection. Overall post embolization spleen-related mortality was 0.08%. Conclusion: SAE is a valuable component in the management of BSI with a favorably low failure rate of 5.3%. However, this treatment modality is not without the risk of serious life-threatening complications and mortality.No

Quantity of hemoperitoneum by a modified Federle score-not grade of injury-predicts the need for splenectomy in patients with blunt splenic injury

Research

Introduction: Among patients with blunt splenic injury (BSI), American Association for the Surgery of Trauma (AAST) injury grade and presence of hemoperitoneum (HP) are among the factors used to predict the need for intervention, defined as splenic artery embolization (SAE) or splenectomy. This study evaluated whether the amount of HP assessed by a modified Federle Score (mFS = sum of compartments with blood: perisplenic, perihepatic, hepatorenal fossa/Morrison pouch, right and left paracolic gutter, intraperitoneal pelvis, and floating bowel) was more predictive of need for intervention than AAST grade. Methods: This was a multi-center, retrospective analysis of 62 adult patients with BSI and HP, 2019-2022. Data included demographic, hemodynamic variables, Injury Severity Score (ISS), AAST grade, and mFS obtained by review of CT scans. Results: Among 62 patients, 47 (75.8%) were managed successfully with NOM and 15 (24.2%) required splenectomy. There was a correlation between AAST grade and mFS (r=0.536, p&lt;0.01. In the univariate analysis both the ISS and mFS score were predictive of splenectomy, however, only the mFS remained predictive of splenectomy in the binary logistic regression (OR 1.739, 95% CI 0.50-2.879, p &lt; 0.05). AAST grade was not associated with need for SAE or splenectomy (Figure 1). Conclusions: Based on our results, we conclude that amount of HP by the mFS is more predictive than AAST grade for need for splenectomy in BSI, therefore, it should be incorporated in treatment algorithms.No.

Long term outcomes of splenic trauma in a UK major trauma centre: A 5 year observational study

Background Splenic preservation after injury has increased over the last 30 years (Zarzaur 2017). Selective non-operative management (SNOM) of splenic injuries is the favoured option for patients without haemodynamic compromise (Stassen 2012), with short term benefits in mortality (Crichton 2017). Whilst splenectomy carries long term risk of infection (Sinwar 2014), the long-term outcomes following SNOM are less well understood. A single study from the USA showed no long-term problems in a large US cohort but no equivalent UK or European studies have been conducted (Zarzaur 2015). Aims To investigate splenectomy and to determine the 2-year outcomes for splenic injury in patients managed by surgery and SNOM at a large UK Major Trauma Centre (MTC). Patients &amp; Methods An observational study at an MTC in Birmingham, UK included patients with splenic injury in a 5-year period (2015-2019). Demographics, clinical data, management strategy, 2-year outcome were recorded. Multivariable logistic regression was used to determine the factors associated with splenectomy. Results There were 138 patients, 22/138 (16%) had splenectomy. Overall mortality was 11.6%. No patients had 2-year spleen-related complications. A multivariable logistic regression model adjusted for systolic blood pressure and grade of injury demonstrated that patients were more likely to have surgery with higher injury severity score and higher lactate. Conclusion We found no long-term complications related to our current management of splenic injuries. Limitations of this study include small numbers and single institution. Further large multi-centre studies are warranted. References Zarzaur &amp; Rozycki. Trauma Surg Acute Care Open. 2017 Jun 9;2(1) Stassen et al. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S294-300. Crichton et al. J Trauma Acute Care Surg. 2017 Nov;83(5):934-943. Sinwar. Int J Surg. 2014: 12(12):1314-1316.No

Self-inflicted penetrating abdominal trauma by an angle grinder blade

Emergency surgery

Introduction Penetrating abdominal injury is often a life-threatening condition, which is mainly associated with inflicted injuries. Angle grinders are a handheld power tool with a circular saw blade used at home or in workplaces, that can cause penetrating injuries due to shattered rotating discs. 2. Objectives To report the case and the surgical management of a penetrating abdominal trauma with intestinal injury after a domestic accident. 3. Materials and Methods An 80-year-old male is brought to the emergency room with omental and bowel evisceration after a penetrating abdominal trauma at home caused by a broken angle grinder blade. At initial assessment, there was no massive external bleeding, airway and breathing were not threatened and the circulatory state was normal. Exposure confirmed bowel evisceration and perforation [Image 1]. After blood typing and crossmatch the patient was immediately taken to the operating room for emergent surgical exploration 4. Results Abdominal inspection revealed a left paramedian penetrating wound about 10 cm long. A perforation of the small bowel was encountered 130 centimeters after the duodenojejunal flexure, with no other traumatic organ injuries found. A segmental enterectomy with primary anastomosis was performed and the traumatic wound was debrided and closed. The post-operative period was uneventful, and the patient was discharged 7 days after surgery. 5. Conclusion Penetrating abdominal injuries usually involve violation of the peritoneal cavity and small bowel is the most commonly injured intraperitoneal viscera, mandating abdominal exploration, usually through laparotomy. We present a uncommon mechanism of injury with an angle grinder blade, which should prompt the development of safety measures for this highly disseminated power tool.No

Just a little gunshot wound in the abdomen

Case A 30-year-old man with no significant medical history was admitted to the emergency department with a gunshot wound on the left flank, without exit wound. Clinical On arrival the patient was intoxicated, with pallor, unrest. He was hemodynamically stable with BP of 123/72 mmHg, heart rate of 100 beats/min and oxygen saturation of 96%. At physical examination presented with diffuse abdominal pain and rebound tenderness, single left flank infracentimetric gunshot wound without active hemorrhage. Investigation Blood work up showed hemoglobin 12,2 g/dl, WBC at 10700/mm³, platelets 19500. Thoraco-abdominal TC revealed minor hemopneumoperitoneum and a projectile near the lower edge of the right ribs. Therapy An emergency laparotomy revealed active bleeding from a greater omentum vessel, 2cm transverse colon serosa injury, retroperitoneal hematoma on the right and perforation wound in ascending colon (1), ileum (3), jejunum (1) and stomach (3). An segmental ileum resection with primary anastomosis was performed. For the other lesions primary two-lawyers suture with long-length absorbable coat was performed. Two drains were placed: one in the right paracolic and stomach, the second in ileal anastomosis. Maintained nasojejunal feeding tube for 3 days, with an uneventful post-operative. The bullet was removed at 9th postoperative day with local anesthesia after skin abcess. The patient was discharged on the 12th post-operative day. Comments The pathway of gunshot wound is unpredictable. These lesions could result in multiple injuries of the hollow viscera with high morbidity and mortality. For hemodynamically stable patients, in combination with physical examination, CT is the most sensitive examen for identifying gastrointestinal injury. Evidence of hemodynamic instability, peritonitis or evisceration are the main indications for emergent exploratory laparotomy. The intraoperative management depends on severity, location of the injury and the patient status.No

Complex pelvic trauma: Open fracture with bladder evisceration – General surgery and orthopedics assembled

Case History 67 year-old Female patient, no relevant known history, is brought to the ER after being run-over by a tractor. Clinical Findings At first evaluation, airway and ventilation were normal. She was slightly tachycardic but with normal blood pressure. A suprapubic open wound was found with active bleeding, initially managed with compression, with bone fragments and bladder evisceration. The patient responded to initial resuscitation. Investigations / Diagnosis Full body trauma CT showed a complex open pelvic fracture, with significant comminution of the iliac and isquiopubic bones, as well as emphysema of the soft tissue with significant laceration and anterior bladder evisceration due to abdominal wall injury. There was no posterior arch injury. Therapy and Progressions Initial damage control with pelvic packing was followed at 48hours later with open reduction and realignment of anterior pubic bone fragments as well as correction of the bladder herniation with an underlay polygactin mesh. She was discharged after 18 days, without signs of bone or soft tissue infection. Recovery was uneventful and two months post op, the patient walked with walker support without significant complaints and no apparent incisional herniation. Comments Open pelvic fractures are rare but carry a high mortality, up to 50%. Exsanguination is an immediate concern and late complications due to pelvic sepsis are also frequent. As such, successful management relies on swift multidisciplinary approach. An initial damage control approach followed by definitive treatment with a multidisciplinary team was the key in managing this challenging case, with low morbidity/mortality and good functional results.No

The use of an emergency department observation unit in the management of patients with significant blunt trauma

Introduction Often patients presenting to the Emergency Department (ED) after significant trauma do not have injuries requiring hospital admission identified on initial evaluation, however, they run risks of having potential injuries that will only be apparent later after observation, serial examinations and further tests. A period of evaluation in an Emergency Department Observation Unit (EDOU) would provide a good bridge in care. EDOUs have grown in utility over the years, with multiple studies demonstrating shorted length of stay, lower costs and better patient satisfaction. Despite this, EDOU use for traumatic injuries is rarely described in the literature. Materials &amp; Methods In our 125,000 visits/year ED at a level one trauma center, a Blunt Injury Protocol (BIP) was implemented in the EDOU. A retrospective chart review was performed on all patients admitted to the BIP over a 1-year period. All data pertaining to patient characteristics, disposition, interventions, adverse events, inpatient admission rates and ED re-attendance rates were captured, with objectives to evaluate the safety and efficacy of our BIP. Results 102 BIP patients were captured during the study period ranging from 16 to 90 years old, with 72% of them Males. 81% were conveyed to the ED via ambulance. 45% were triaged as "P1" and seen in a monitored area within 15 minutes of arrival by a specialist. There were no deaths, intubations or other adverse events. The average length of stay was 14.68 hrs. 12% of patients were admitted to inpatient units from the EDOU, which are within acceptable ranges reported in literature. 9 patients re-attended to the ED for complaints related to initial trauma after discharge from the EDOU. None of them required re-admission. Conclusion EDOUs are a safe alternative to inpatient admission for evaluation of stable trauma patients with significant mechanisms of injury. References(DOI): -10.1016/j.ajem.2011.10.012 -10.7759/cureus.39447No

Protocolizing venous thrombo-embolism prophylaxis using Anti Xa in trauma: Experience from the national trauma center in Qatar﻿

Introduction: Venous Thromboembolism (VTE) in trauma carries a significant mortality and morbidity. Even tough low molecular weight heparin (LMWH) is the standard for VTE prophylaxis, the timing of LMWH initiation, optimal dosing, and anti Xa monitoring remain controversial. Objectives: : To determine the impact of a VTE prophylaxis protocol recommending early LMWH initiation, twice daily dosing, and anti-Xa based dose adjustment on VTE in trauma. Methods: all adult trauma patients admitted to the Trauma ICU in a Level 1 Trauma Center, 10 months before and after implementation of a VTE protocol were included. Outcome was VTE rate and bleeding episodes in the post implementation group. Protocol mandated Enoxaparin 30 mg twice daily starting 24-36h post admission with peak anti Xa activity measured 4h after 3rd dose. Dosing was adjusted according to BMI, glomerular filtration rate, traumatic brain injury (TBI), age (&gt;65), and a anti Xa level between 0.2-0.4 IU/ml. Berne-Norwood criteria was used in initiating prophylaxis in TBI. Results: Protocol implementation was associated with a significant reduction in VTE, pre-implementation 4.7% (17 of 362 patients), post-implementation 1.6% (7/438). Data adjustment and multivariate analysis further revealed protocol introduction significant association with less VTE (adjusted odds ratio: 0.27 (0.088-0.882), p= 0.03). All 8 patients (1.8 %) who bled while on prophylaxis were audited. In 7 (87.5%), the bleeding was considered unrelated to the LMWH and the anti Xa levels Below 0.4 (median 0.29 IU/ml (0.15-0.52). Only one patient had anti Xa level 0.52IU/ml. Median initiation time for these 8 patients was 27hrs. (19-60) Conclusion: Instituting a protocol for VTE prophylaxis (described above), in traumatized adult patients admitted to ICU, resulted in substantial reduction in VTE rates. Dose adjustment according to anti Xa levels may prove to be safe and improve outcomes. Further studies are warranted.No

Poster session 14
Visceral trauma 1

Appointment

Chairs

Topic

Programme

Poster session 14Visceral trauma 1

Appointment

Chairs

Topic

Programme

Poster session 14
Visceral trauma 1