Vascular injuries after minor blunt upper extremity trauma: pitfalls in the recognition and diagnosis of potential "near miss" injuries

<p>Abstract</p> <p>Background</p> <p>Low energy trauma to the upper extremity is rarely associated with a significant vascular injury. Due to the low incidence, a high level of suspicion combined with appropriate diagnostic algorithms are mandatory for early recognition and timely management of these potentially detrimental injuries.</p> <p>Methods</p> <p>Review of the pertinent literature, supported by the presentation of two representative "near miss" case examples.</p> <p>Results</p> <p>A major diagnostic pitfall is represented by the insidious presentation of significant upper extremity arterial injuries with intact pulses and normal capillary refill distal to the injury site, due to collateral perfusion. Thus, severe vascular injuries may easily be missed or neglected at the upper extremity, leading to a long-term adverse outcome with the potential need for a surgical amputation.</p> <p>Conclusion</p> <p>The present review article provides an outline of the diagnostic challenges related to these rare vascular injuries and emphasizes the necessity for a high level of suspicion, even in the absence of a significant penetrating or high-velocity trauma mechanism.</p

The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon\u27s point of view.

Background: The number of bariatric procedures is increasing worldwide. No consensus or guidelines about the emergency management of long-term complications following bariatric surgery are currently available. The aim of this study is to investigate by a web survey how an emergency surgeon approaches this unique group of patients in an emergency medical scenario and to report their personal experience. Method: An international web survey was sent to 197 emergency surgeons with the aim to collect data about emergency surgeons\u27 experience in the management of patients admitted in the emergency department for acute abdominal pain after bariatric surgery. The survey was conceived as a questionnaire composed by 26 (multiple choice and open) questions and approved by a steering committee. Results: One hundred seventeen international emergency surgeons decided to join the project and answered to the web survey with a response rate of 59.39%. Conclusions: The aim of this WSES web survey was to highlight the current management of patients previously submitted to bariatric surgical procedures by ES.Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinal opacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon.In case of inconclusive clinical and radiological findings, when symptoms fail to improve, surgical exploration for bariatric patients presenting acute abdominal pain, by laparoscopy if expertise is available, is mandatory in the first 12-24 h, to have good outcomes and decrease morbidity rate

Blunt trauma induced splenic blushes are not created equal

<p>Abstract</p> <p>Background</p> <p>Currently, evidence of contrast extravasation on computed tomography (CT) scan is regarded as an indication for intervention in splenic injuries. In our experience, patients transferred from other institutions for angioembolization have often resolved the blush upon repeat imaging at our hospital. We <it>hypothesized </it>that not all splenic blushes require intervention.</p> <p>Methods</p> <p>During a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan.</p> <p>Results</p> <p>During the study period, 241 patients were referred for splenic injuries, of whom 16 had a contrast blush on initial CT imaging (88% men, mean age 35 ± 5, mean ISS 26 ± 3). Eight (50%) patients were managed without angioembolization or operation. Comparing patients with and without intervention, there was a significant difference in admission heart rate (106 ± 9 <it>vs </it>83 ± 6) and decline in hematocrit following transfer (5.3 ± 2.0 <it>vs </it>1.0 ± 0.3), but not in injury grade (3.9 ± 0.2 <it>vs </it>3.5 ± 0.3), systolic blood pressure (125 ± 10 <it>vs </it>115 ± 6), or age (38.5 ± 8.2 <it>vs </it>30.9 ± 4.7). Of the 8 observed patients, 3 underwent repeat imaging immediately upon arrival with resolution of the blush. In the intervention group, 4 patients had ongoing extravasation on repeat imaging, 2 patients underwent empiric embolization, and 2 patients underwent splenectomy for physiologic indications.</p> <p>Conclusions</p> <p>For blunt splenic trauma, evidence of contrast extravasation on initial CT imaging is not an absolute indication for intervention. A period of observation with repeat imaging could avoid costly, invasive interventions and their associated sequelae.</p

WSES classification and guidelines for liver trauma

The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines

Sexual Dimorphism in Hematocrit Response Following Red Blood Cell Transfusion of Critically Ill Surgical Patients

The change in hematocrit (ΔHct) following packed red blood cell (pRBCs) transfusion is a clinically relevant measurement of transfusion efficacy that is influenced by post-transfusion hemolysis. Sexual dimorphism has been observed in critical illness and may be related to gender-specific differences in immune response. We investigated the relationship between both donor and recipient gender and ΔHct in an analysis of all pRBCs transfusions in our surgical intensive care unit (2006–2009). The relationship between both donor and recipient gender and ΔHct (% points) was assessed using both univariate and multivariable analysis. A total of 575 units of pRBCs were given to 342 patients; 289 (49.9%) donors were male. By univariate analysis, ΔHct was significantly greater for female as compared to male recipients (3.81% versus 2.82%, resp., P < 0.01). No association was observed between donor gender and ΔHct, which was 3.02% following receipt of female blood versus 3.23% following receipt of male blood (P = 0.21). By multivariable analysis, recipient gender remained associated significantly with ΔHct (P < 0.01). In conclusion, recipient gender is independently associated with ΔHct following pRBCs transfusion. This association does not appear related to either demographic or anthropomorphic factors, raising the possibility of gender-related differences in recipient immune response to transfusion

Diagnosis and Management of Esophageal Injuries: A Western Trauma Association Critical Decisions Algorithm

ABSTRACT: This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols. The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries

Establishing position papers by the WSES

A position paper (PP) should establish a unified voice in areas where controversy occurs based upon multiple practices and/or therapeutic choices. Typically, a position paper should elucidate the knowledge gap, followed by an evidence-based review of options, leading to an "endorsed position." A position paper should represent more than the opinion or consensus of the authors but should present current opinions and practices supported by the World Society of Emergency Surgery (WSES). Accordingly, position papers should require the approval of an expert group of WSES and in parallel be presented at an annual meeting prior to submission for publication. It is important that a unified approach for drafting of position papers be established and endorsed by WSES in order to establish credibility and prevent misunderstandings during a smooth transition to publication. The purpose of this article is to suggest a uniform process for the development of WSES guidelines.Peer reviewe

The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon's point of view

Background: The number of bariatric procedures is increasing worldwide. No consensus or guidelines about theemergency management of long-term complications following bariatric surgery are currently available. The aim ofthis study is to investigate by a web survey how an emergency surgeon approaches this unique group of patientsin an emergency medical scenario and to report their personal experience. Method: An international web survey was sent to 197 emergency surgeons with the aim to collect data aboutemergency surgeons\u2019experience in the management of patients admitted in the emergency department for acuteabdominal pain after bariatric surgery. The survey was conceived as a questionnaire composed by 26 (multiplechoice and open) questions and approved by a steering committee. Results: One hundred seventeen international emergency surgeons decided to join the project and answered tothe web survey with a response rate of 59.39%. Conclusions: The aim of this WSES web survey was to highlight the current management of patients previouslysubmitted to bariatric surgical procedures by ES.Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinalopacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon.In case of inconclusive clinical and radiological findings, when symptoms fail to improve, surgical exploration forbariatric patients presenting acute abdominal pain, by laparoscopy if expertise is available, is mandatory in the first12\u201324 h, to have good outcomes and decrease morbidity rate

The role of teamwork and non-technical skills for improving emergency surgical outcomes: an international perspective

The assurance of patient safety in emergency general surgery remains challenging due to the patients' high-risk underlying conditions and the wide variability in emergency surgical care provided around the globe. The authors of this article convened as an expert panel on patient safety in surgery at the 8(th) International Conference of the World Society of Emergency Surgery (WSES) in Edinburgh, Scotland, on September 7-10, 2021. This review article represents the proceedings from the expert panel discussions at the WSES congress and was designed to provide an international perspective on optimizing teamwork and non-technical skills in emergency general surgery

IROA: the International Register of Open Abdomen.

Actually the most common indications for Open Abdomen (OA) are trauma, abdominal sepsis, severe acute pancreatitis and more in general all those situations in which an intra-abdominal hypertension condition is present, in order to prevent the development of an abdominal compartment syndrome. The mortality and morbidity rate in patients undergone to OA procedures is still high. At present many studies have been published about the OA management and the progresses in survival rate of critically ill trauma and septic surgical patients. However several issues are still unclear and need more extensive studies. The definitions of indications, applications and methods to close the OA are still matter of debate. To overcome this lack of high level of evidence data about the OA indications, management, definitive closure and follow-up, the World Society of Emergency Surgery (WSES) promoted the International Register of Open Abdomen (IROA). The register will be held on a web platform (Clinical Registers®) through a dedicated web site: www.clinicalregisters.org. This will allow to all surgeons and physicians to participate from all around the world only by having a computer and a web connection. The IROA protocol has been approved by the coordinating center Ethical Committee (Papa Giovanni XXIII hospital, Bergamo, Italy). IROA has also been registered to ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT02382770)