Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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2023 | January-April | Volume 12 | Issue 1

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Panamerican Journal of Trauma, Critical Care & Emergency Surgery

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:2] [Pages No:vii - viii]

   DOI: 10.5005/pajt-12-1-vii  |  Open Access | 

249

EDITORIAL

Antonio Marttos

Panamerican Journal of Trauma, Critical Care and Acute Care Surgery Editorial: Being Relevant

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:3] [Pages No:1 - 3]

   DOI: 10.5005/jp-journals-10030-1417  |  Open Access |  How to cite  | 

307

CASE REPORT

Carlos Alberto Lozano De Avila, Nayib De Jesus Zurita Medrano, Camilo Viaña Ghisays, Karen Garcia Garcia, Carlos Alberto Borda Venegas, Vanessa Duque

Laparoscopic Management of Perforated Peptic Ulcer Case Report

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:5] [Pages No:4 - 8]

Keywords: Acute abdomen, Helicobacter pylori, Laparoscopy, Nonsteroidal antiinflammatory agents, Omentum, Perforated peptic ulcers, Peritonitis, Pneumoperitoneum

   DOI: 10.5005/jp-journals-10030-1410  |  Open Access |  How to cite  | 

Abstract

A perforated peptic ulcer is the second leading cause of perforation, with an incidence of 2–4% of peptic ulcers. It can be managed with a simple suture or placement of a Graham patch. However, the primary suture with a Graham patch is one of the main preferences of surgeons. The laparoscopic approach offers a great advantage in rapid recovery and a low morbidity rate with respect to conventional open surgery. We present the clinical case of a male patient who was admitted with clinical symptoms of acute abdomen due to perforated peptic ulcer and was taken to emergency surgery for laparoscopic management.

653

ORIGINAL RESEARCH

Victoria Pegna, Alan Askari, Sebastian Chong, Alex Bull, Lauren Kennedy, Shameen Jaunoo, Mansoor Khan

Intervention for Splenic Trauma: An International Consensus Survey

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:7] [Pages No:9 - 15]

Keywords: American Association for the Surgery of Trauma grade, Spleen, Trauma

   DOI: 10.5005/jp-journals-10030-1411  |  Open Access |  How to cite  | 

Abstract

Background: Splenic injury is common in trauma to the abdomen and the management strategies can be varied depending on a variety of clinical and radiological factors. The main aim of this study is to establish consensus on the management of differing grades of splenic trauma and determine which factors influence subsequent choices of operative management (OM), splenic artery embolization (SAE), and non-OM (NOM). Methods: An electronic survey distributed to trauma surgeons and radiologists from across the globe via existing trauma networks and social media surgical groups. The consensus agreement was defined as a 75% agreement. Results: In total, 101 trauma surgeons and interventional radiologists responded to the survey. The consensus was obtained for patients with the American Association for the Surgery of Trauma (AAST) grade I and II splenic injuries to be treated using a NOM approach (grade I—92.1% and grade II—84.2%); however, no consensus was reached for grade III–V injuries in terms of management strategy. Similarly, the need for regional trauma centers that accept tertiary referrals to have the capacity to perform out-of-hours SAE reached a consensus (86.1%). There was near consensus on the following topics—71.3% would proceed to SAE if an established intraparenchymal active extravasation is seen on computed tomography (CT), and 71.3% would not reattempt SAE if unsuccessful and proceed to OM. Most respondents did not change management based on the age of the patient. The number of units of blood transfusions initially would influence the recommendation for SAE and OM in 66.3%, and moderate hemoperitoneum on CT would influence management in 57% of our respondents. Conclusion: The management of splenic trauma is variable across the globe. Although consensus could be made across some decisions, there is still disagreement and particularly with high-grade injuries. With iterative surveys, we aim to reach a consensus on these issues, which will inform future practice.

496

CASE REPORT

Carlos Alberto Lozano de Avila, Carlos Alberto Lozano De Avila, Nayib De Jesus Zurita Medrano, Camilo Viaña Ghisays, Karen Garcia Garcia, Carlos Alberto Borda Venegas, Vanessa Duque

Intestinal Obstruction due to Perforated Jejunal Volvulus Secondary to Diverticulitis

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:4] [Pages No:16 - 19]

Keywords: Acute abdomen, Diverticulitis, Intestinal perforation, Intestinal volvulus

   DOI: 10.5005/jp-journals-10030-1412  |  Open Access |  How to cite  | 

Abstract

Aim: To report a unique case of an elderly female patient requiring urgent surgical intervention for a perforated jejunal volvulus due to diverticulitis. Background: Despite diverticular disease being a common pathology incidentally identified in imaging studies, acute complications are frequent reasons for urgent surgical consultation and surgical intervention. Such decisions are based on individual findings and scientific evidence, which allows for anticípating the possible consequences of each therapeutic option, and the patient's opinion in order to provide the most convenient management for each case. Case description: An old woman was admitted to the emergency department of a third-level hospital for acute abdominal pain associated with nausea and the presence of an indurated mass in the upper abdomen. During the physical examination, signs of peritoneal irritation were found and through a total abdominal ultrasound and a computed tomography (CT) scan, suggestive signs of obstruction and incarceration were evidenced. An exploratory laparotomy was performed and multiple microperforated diverticula were found in the proximal portion of the jejunum. These were successfully resected. Conclusion: The complications of diverticulitis can appear suddenly and compromise the life of the patient in the short-term, which makes it important to consider its existence in the context of acute abdomen, especially given the knowledge of the diagnosis of diverticular disease, and provide a relevant approach. Clinical significance: The case described in this document recalls the importance of timely and prompt attention to acute abdominal pain, as well as, consideration of complications of diverticular disease in cases where it is known, considering that they can become life-threatening.

309

ORIGINAL RESEARCH

Juan P Ramos, Analia Zinco, Jimy S Luna, Pablo Ottolino

Management of Transpelvic Gunshot Wounds in Civilian Trauma

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:5] [Pages No:20 - 24]

Keywords: Damage control surgery, Gunshot wound, Pelvic Trauma, Penetrating trauma

   DOI: 10.5005/jp-journals-10030-1414  |  Open Access |  How to cite  | 

Abstract

Background: Transpelvic gunshot wounds (TGWs) require special attention due to the high density of organs that can be injured within the pelvis, causing associated injuries and a high morbidity and mortality rate. The multiple systems that can be affected make their clinical evaluation difficult and require multiple diagnostic studies. This study aims to describe the demographic, diagnostic, and therapeutic characteristics of patients admitted with TGWs. Patients and methods: Retrospective, cross-sectional, and descriptive study, which included patients older than 15 years of age with a diagnosis of TGW admitted to two hospitals with a high rate of penetrating trauma in a period of 3 years. Results: The cohort was composed of 94 patients with TGWs. 68% of the population arrived with hypovolemic shock [shock index (SI) >0.7]. Trauma evolution time was <12 hours in 91%. Focused assessment with sonography for trauma (FAST) was negative in 91 cases (97%). Among the diagnostic studies, the following predominated: Tomography (65.2%), X-rays (11%), recto-sigmoidoscopy (5%), and urethrocystography (4%). A total of 56 therapeutic laparotomies (73.6%) and nine nontherapeutic (11.8%) were performed. The most frequently injured organs were—the small bowel (36%), colon (21.2%), rectum (13.8%), and bladder (13.8%). Damage control surgery (DCS) was performed in 25 patients (26.5%), and 28 (29.7%) required massive transfusion. The mean hospitalization was 6.7 days, the most frequent complications being surgical wound infection (8.5%), ileum (3.1%), anastomosis leak (2.1%), and wound hematoma (2.1%). Mortality was 8.2%. Conclusions: Transpelvic gunshot wounds (TGWs) must be managed differently from penetrating abdominal trauma. Most of these patients have multiple injuries requiring early surgical treatment, even when admitted stable. Its protocolization is necessary according to the resources of each center for an adequate initial diagnostic evaluation since the physical examination can be uncertain.

455

REVIEW ARTICLE

Sofia Mansilla, Andres Pouy, Noelia Brito, Vanessa Zubiaurre, Santiago Cubas, Nicolas Muniz, Fernando Machado

Nonoperative Management of Retrohepatic Vena Cava Penetrating Trauma

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:5] [Pages No:25 - 29]

Keywords: Nonoperative, Penetrating trauma, Vena cava

   DOI: 10.5005/jp-journals-10030-1409  |  Open Access |  How to cite  | 

Abstract

Background: Despite advances in trauma care, injuries to the inferior vena cava (IVC) continue to have a high mortality rate, up to 75%. An exceptional proportion of patients can be considered for nonoperative management (NOM). They require specific therapeutic management and represent a challenge for the surgical team. Objective: A case report of a 33-year-old patient with penetrating retrohepatic vena cava trauma with successful NOM and literature review is presented. Design and methodology: Bibliographic review was carried out in the PubMed, Cochrane library, Scielo, and Latin American and Caribbean Health Sciences Literature (LILACS) databases. Results: The absolute conditions for NOM of penetrating retrohepatic vena cava trauma are: hemodynamic stability, absence of peritoneal irritation and admission to an intensive care unit with computed tomography (CT) and surgical block available 24 hours. Main questions arise regarding the opportunity for imaging control, absolute rest indication, and thromboprophylaxis. Conclusion: Retrohepatic vena cava injury is associated with fatal outcomes. In a selected group of patients, NOM is a valid therapeutic option. Close monitoring and follow-ups are necessary.

466

ORIGINAL RESEARCH

Pedro J Ruíz-Pérez, Willy Jesús Neumann Ordoñez, Dante Manuel Quiñones-Laveriano, Eduardo Huaman

Results of the Implementation of a Trauma Registry in a Peruvian Low Complexity Hospital: A 2-year Analysis

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:5] [Pages No:30 - 34]

Keywords: Injuries and trauma, Peru, Registration system, Surgery

   DOI: 10.5005/jp-journals-10030-1408  |  Open Access |  How to cite  | 

Abstract

Introduction: Peruvian public health system lacks data collection and processing strategies for patients who arrive at hospitals with traumatic injuries (TI), negatively affecting the provision of health services. The objective of this study was to describe the results of the implementation of a trauma registry in a low complexity hospital in Vitarte, located in the eastern region of Lima, Peru. Materials and methods: An observational, descriptive, and retrospective study was conducted using the Trauma Registry® developed by the Panamerican Trauma Society (PTS) between May 2018 and June 2020. Stata v16 software was used for statistical analysis. Results: A total of 399 records were included. The median age was 27 years, and 72.2% of patients were male. The main primary mechanism was blunt trauma (60.7%), mainly caused by falls and traffic accidents. Nearly 82.5% of TI were related to alcohol intake. Attendances were most frequent between 08:00 and 12:00 hours, on Sundays, in the middle of the month, and in April. The most frequent injuries were minor, according to the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS). In the majority of cases, an Injury Severity Score (ISS) of >15 corresponded to patients requiring transfer to more developed health centers, mainly for traumatic brain injury. Conclusion: Traumatic injuries (TI) in Hospital Vitarte affected mainly young males, with a high frequency of alcohol intake in injured patients. The type of trauma and the mechanism of injury did not follow a specific pattern due to the level of complexity of the hospital. Trauma indices are useful tools to determine the severity of injuries and to predict the need for transfer to a center of a higher level of complexity and resolution capacity. The Trauma Registry® represents a necessary strategy to optimize the care of injured patients locally and nationally.

404

ORIGINAL RESEARCH

José G Parreira, Sandro Rizoli, Joao Rezende-Neto

The Other Side of the Coin: Using Rotational Thromboelastometry to Stop or Avoid Blood Transfusions in Trauma Patients

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:7] [Pages No:35 - 41]

Keywords: Blood transfusion, Coagulopathy, Diagnostics, Hemorrhage, Injury, Massive transfusion, Rotational thromboelastometry, Shock, Trauma, Viscoelastic

   DOI: 10.5005/jp-journals-10030-1413  |  Open Access |  How to cite  | 

Abstract

Aim: To assess rotational thromboelastometry (ROTEM) as a tool to stop or avoid unnecessary transfusions in trauma patients. Materials and methods: Retrospective analysis in a period of 12 months, including all adult patients with a ROTEM assay upon arrival. In an initial analysis, patients were assigned to one of the two groups—“normal (NL) ROTEM” or “abnormal ROTEM.” The “NL ROTEM” group had all ROTEM parameters within the normal range. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) were calculated, which was repeated in subgroups of patients with ISS ≥ 16 and with systolic blood pressure (SBP) ≤90 mm Hg. In a second analysis, prediction models for the transfusion of each blood product were created by multivariate logistic regression, including all ROTEM parameters and the SBP on hospital admission. The prediction models were analyzed by the area under the receiver operating characteristics curve (AUROC). Results: A total of 793 patients fulfilled the inclusion criteria (80.2% blunt trauma and 73.5% male). NL ROTEM was observed in 604 (76.2%) patients. The NL ROTEM NPV for transfusion of any blood product (BBP), plasma (PLS), platelets (PLT), and >9 units of red blood cells (>9 RBC) were, respectively, 94.7, 98.3, 98.8, and 99.7%. Regarding patients with ISS ≥ 16, the NL ROTEM NPV for BBP, PLS, PLT, and >9 RBC were, respectively, 83.8, 92.5, 96.3, and 98.8%. In the subgroup of patients admitted with SBP ≤ 90 mm Hg, NL ROTEM predicted 93.3% of cases in which massive transfusion did not happen. Considering all patients, the AUC observed for the prediction model of >9 RBC was 0.982. Conclusion: Patients with an NL ROTEM assay at admission had a lower need for blood transfusions in the first 24 hours after trauma, even in subgroups sustaining severe injuries and hemodynamic instability. Clinical significance: The NL ROTEM seems to be a useful tool to avoid transfusions in trauma patients.

456

ORIGINAL RESEARCH

Nicolas Solano Arboleda, Alexei Rojas Diaz, Alvaro J Zuñiga, Angela Merchan-Galvis

Shock Index, Lactate, and Base Deficit as Bleeding Predictors in Trauma Patients from a Complex Emergency Department: A Prospective Cohort Study

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:5] [Pages No:42 - 46]

Keywords: Base deficit, Blood gas analysis, Emergencies, Hemorrhage, Lactic acid, Shock, Shock index, Wounds and injuries

   DOI: 10.5005/jp-journals-10030-1416  |  Open Access |  How to cite  | 

Abstract

Background: Hemorrhagic shock (HS) is the leading preventable cause of death in trauma patients. Shock index (SI), lactate, and base deficit (BD) are suggested to be rapid markers for triage tools; this study aimed to assess whether these tools can identify bleeding and predict specific outcomes in trauma patients. Methods: A prospective cohort of trauma patients from a complex Emergency Department were analyzed between October 2019 and March 2020. Sociodemographic and clinical data, prehospital care, vital signs, arterial blood gases on admission, and 30-day follow-ups were collected. Evidence of significant bleeding was defined as physical or imaging findings of significant bleeding that led to blood transfusions, hemostatic surgery, and death due to hypovolemic shock. Results: Out of the 111 patients aged 35 ± 16.2 years (97% male), 72% had nonpenetrating trauma, and 63% had high-energy trauma, with a mean injury severity score (ISS) of 15.8 ± 14.1, and revised trauma score (RTS) 7.3 ± 1.3. The cut-off points for bleeding were determined by the following—SI > 0.9 with an area under the curve (AUC) of 0.64 [95% confidence interval (CI) 0.541–0.743]; lactate levels >2 with an AUC of 0.77 [95% CI 0.695–0.864], and a BD <−6 with an AUC of 0.74 [95% CI 0.657–0.839]. The sensitivity was 32.4, 76.5, and 64.7%, and the specificity was 93, 62.8, and 79.1%, respectively. Conclusion: Base deficit (BD) and lactate are good triage tools for identifying HS in trauma patients.

913

ORIGINAL RESEARCH

Sachin Doshi, Khushali Shrenik Parikh, Christine Nguyen, David Gomez, Joao B Rezende-Neto

Using the Delphi Method to Establish a Novel and Universal System for Classifying Indications behind Delayed Abdominal Closure

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:9] [Pages No:47 - 55]

Keywords: Abdomen, Abdominal injury, Abdominal trauma, Blunt abdominal trauma, Damage control, Damage control surgery, Emergency general surgery, Emergency surgery, Open abdomen, Open abdominal

   DOI: 10.5005/jp-journals-10030-1402  |  Open Access |  How to cite  | 

Abstract

Introduction: Delayed fascial closure is a common lifesaving feature of damage control laparotomy but may result in serious complications. Accordingly, it should only be applied when required; however, a paucity of guidelines and framework for research makes knowing when this is challenging. This study aims to evaluate a classification system that facilitates the categorization of clinical reasoning behind delayed fascial closure. Methods: A literature search on open abdomens in trauma or acute care surgery over 5 years (n = 185) were simplified into 11 unique scenarios. The Delphi method was employed to capture expert opinions from 202 clinical experts internationally. Participants classified each scenario into one or more of three categories—anatomic, physiologic, and/or logistic reason to leave the abdomen open. This is based on a classification system previously proposed by our group. Three rounds of the survey were distributed, with supplemental information provided between rounds, as per the Delphi process. Results: In the first round, 600 international surgeons and intensivists were approached with 168 responses. In round 2, 24 of 55 traumatologists responded, and in round 3, 10 of 30 trauma surgeons responded. At the end of round 3, a strong consensus for appropriate classification (≥95%) was achieved for scenarios 1 and 2, consensus approval (≥75–94%) for scenarios 3, 6, and 10, and majority approval (≥50–74%) for the remaining scenarios. Conclusion: This study demonstrates the universality of a classification system for delayed fascial closure in damage control surgery. The previous absence of such a system has been a barrier in the effective study of delayed abdominal closure, given that indications can be widely disparate for the same procedure. Laying this foundation will allow trauma researchers to better understand delayed abdominal closure and ensure its optimized application or lack thereof.

327

ORIGINAL RESEARCH

Salah Mansor, Ahmad Zarour, Salahaldeen Dawdi, Idress Suliman, Abdulhameed Ali, Hatim Aljumaili, Mohamed Said Ghali

Surgical Management of Secondary Peritonitis: An Experience of 212 Cases in 5 Years

[Year:2023] [Month:January-April] [Volume:12] [Number:1] [Pages:5] [Pages No:56 - 60]

Keywords: Emergency, Perforation, Peritonitis, Sepsis

   DOI: 10.5005/jp-journals-10030-1407  |  Open Access |  How to cite  | 

Abstract

Aim: Secondary peritonitis is a common serious surgical condition that has a significant rate of morbidity and mortality. Postoperative abdominal abscesses are considered a common complication. The purpose of this study is to analyze how the type of peritonitis, whether general or localized, can influence the formation of postoperative abdominal abscesses and the use of surgical drains to minimize the development of this complication. Materials and methods: A retrospective study was conducted on patients who presented with secondary peritonitis and had surgical treatment over a 5-year period in the acute care surgery section, Hamad Medical Corporation, Doha, Qatar. Patients’ age, gender, indications for surgery, intraoperative findings, surgical procedure, antibiotic used, postoperative complications, postoperative intervention, surgical reexploration, and hospital stays were among the data collected. Results: A total of 212 patients were admitted with secondary peritonitis during the study period. Around 112 (52.8%) patients with localized and 100 (47%) with generalized peritonitis. The average age was 37. Perforated appendicitis was the cause of secondary peritonitis in 150 (70.8%) patients, perforated peptic ulcers in 45 (21.2%), perforated colon in nine (4.3%), perforated small bowel in five (2.4%), perforated gallbladder in two (0.9%), and perforated gastric ulcer in one patient (0.5%). A postoperative abdominal abscess was diagnosed in 25% of the patients with generalized peritonitis and 22.3% of those with localized peritonitis. Surgical drains were placed in 152 (71.6%) patients, and 38 (25%) of them developed a postoperative abdominal abscess. Conclusion: Postoperative abdominal abscess is common in patients operated on for secondary peritonitis, and whether the peritonitis was localized or diffused, or a drain was placed at the initial surgery had no measurable significance on the postoperative abdominal abscess formation.

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