Selection of patients with severe pelvic fracture for early angiography remains controversial

<p>Abstract</p> <p>Background</p> <p>Patients with severe pelvic fractures represent about 3% of all skeletal fractures. Hemodynamic compromise in unstable pelvic fractures is associated with arterial hemorrhage in less than 20% of patients. Angiography is an important tool in the management of severe pelvic injury, but indications and timing for its performance remain controversial.</p> <p>Methods</p> <p>Patients with major pelvic fractures [Pelvic Abbreviated Injury Score (AIS) ≥ 3] admitted to two high volume Trauma Centers from January 2000 to June 2005 were identified and divided into two groups: Group I patients did not undergo angiography, Group II patients underwent angiography with/without embolization. Demographics, hemodynamic status on admission, concomitant injuries, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), pelvic AIS, blood requirement before and after angiography, arterial blood gases and mortality were evaluated. Patients with an additional reason for hemodynamic instability were excluded.</p> <p>Results</p> <p>Charts of 106 patients were retrospectively reviewed. Twenty nine patients (27.4%) underwent angiography. Bleeding vessel embolization was performed in 20 (18.9%) patients. Patients who underwent angiography had a significantly higher pelvic AIS and a lower Base Excess level on admission. A blood transfusion rate of greater than 0.5 unit/hour was found to be a reliable indicator for early angiography.</p> <p>Conclusion</p> <p>A high pelvic AIS, amount of blood transfusions and decreased BE level should be considered as an indicators for early angiography in patients with severe pelvic injury.</p

Updates in the management of severe coagulopathy in trauma patients

Coagulopathy is the major cause of bleeding-related mortality in patients who survive the operating room. Its association with hypothermia and metabolic acidosis is common and constitutes a vicious cycle. Usually, post-traumatic coagulopathy is an early event and may be present during surgery. The pathogenesis of severe post-traumatic coagulopathy is complex and multifactorial. Virtually every aspect of the normal coagulation cascade is affected in the cold, acidotic, exsanguinating trauma patient. In the last decade many surgeons have emphasized the role of prevention or early treatment of this vicious cycle. Damage control surgery with planned re-operations has demonstrated superiority over the traditional approach in cases where the patients' condition is deteriorating. Early control of surgical bleeding and significant contamination, together with vigorous correction of hypothermia and continuous resuscitation, has improved the survival of these patients. Recently, a new adjunct to the treatment of coagulopathy in trauma patients has been reported and is undergoing controlled animal trials. Recombinant activated factor VII (rFVIIa) was originally developed as a pro-hemostatic agent for the treatment of bleeding episodes in hemophilia patients. rFVIIa has been successfully used in moribund trauma patients in whom standard procedures had failed to correct bleeding. Preliminary preclinical and clinical studies are under way

Frequency of intra-abdominal organ injury is higher in patients with concomitant stab wounds to other anatomical areas

Abstract Background Management of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas. Methods We performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury. Results The study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1–1.6, p < 0.001). These patients also had a higher rate of injury to the solid organs than patients with an isolated abdominal stab wound. Conclusions Patients with multi-regional stab wounds have an increased risk of intra-abdominal injury. Worldwide accepted “clinical follow up” protocol may not be appropriate in management of patients with multi-regional stab wounds