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(RSS) Karim's Weblog

Random snippets and thoughts - hopefully mostly trauma related!

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(RSS) Trauma Research Blog

Selected new & juicy research papers, with editorial comment.

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PubMed ID: 21079092
Arch Surg. 2010 Nov;145(11):1048-53
Authors: Bowman SM, Bulger E, Sharar SR, Maham SA, Smith SD

Abstract:

BACKGROUND: Although nonoperative management is the standard of care for hemodynamically stable children with blunt splenic trauma, significant variation in practice exists. Little attention has been given to physician factors associated with management differences.

DESIGN: Nationally representative mail survey conducted in June 2008.

SETTING: United States.

PARTICIPANTS: Ten percent random sample of active, dues-paying fellows in the American College of Surgeons.

MAIN OUTCOME MEASURES: Knowledge, attitudes, and beliefs toward pediatric splenic injury management, including the role of clinical practice guidelines.

RESULTS: Almost all of the 375 responding surgeons (97.4%) agreed that surgical intervention is not immediately necessary for hemodynamically stable children. However, surgeons reported significant disagreement regarding whether blood should be administered before operative intervention for hemodynamically unstable children and whether explorative surgery is needed for stable patients with evidence of contrast extravasation on computed tomography. Only 18.7% of surgeons reported being very familiar with the clinical practice guidelines for the management of pediatric blunt splenic trauma from either the Eastern Association for the Surgery of Trauma or the American Pediatric Surgical Association. Surgeons who were very familiar with either guideline were significantly more likely to rate the guidelines as beneficial (90.0% vs 72.8%, P = .002).

CONCLUSIONS: General surgeons reported varying degrees of familiarity with and use of clinical practice guidelines for pediatric splenic injury management. Limited pediatric experience and lack of pediatric hospital resources may limit more widespread adoption of nonoperative management. Targeted educational interventions may help increase surgeon knowledge of guidelines and best practices.

Notes & Commentary:

I'm not normally a big fan of surveys of practice but it can be a useful exercise in highlighting deficiencies or discrepancies in care.  This is a case in point, where there are fundamental issues with the management of paediatric trauma.  Serious paediatric trauma is uncommon and most surgeons outside of paeditric trauma centres will see very few cases in their lifetime.  In a letter we wrote to the Annals of the Royal College of Surgeons of England we estimated that the average general surgeon in the UK would perform a paediatric splenectomy once every 25 years (and that as before the reduction of working hours!) (PMID: 12831498).

This study shows how low paediatric trauma is on the radar of general surgeons.  There is widespread understanding that the majority of paediatric splenic injuries can be managed non-operatively (over 90% in some series).  However this does not translate into ALL spleen injuries can be managed non-operatively.   Identifying the child with a spleen injury who is not responding to fluid resuscitation and making the decision to operate is extremely difficult when the condition is rare and the intervention even rarer - but these are the children whose lives can be saved by relatively simple immediate surgery.

Much has been written recently on the non-operative management of spleen injuries.  What needs to be focused on is operative management and specifically decision making in paediatric trauma.  

PubMed ID: 19204518
J Trauma. 2009 Feb;66(2):429-35
Authors: Fang JF, Shih LY, Wong YC, Lin BC, Hsu YP

Abstract:

BACKGROUND: Most arterial hemorrhage associated with pelvic fracture can be adequately controlled by a single transcatheter arterial embolization (TAE). However, there is a small group of patients who remain hemodynamically unstable after TAE, have no other identifiable source of bleeding, and who benefit from repeat TAE of the pelvis. METHODS: We conducted a retrospective study of patients with hemorrhage from pelvic fractures between January 2001 and June 2006. Clinical parameters and results were compared between patients requiring more than one pelvic TAE and those undergoing a single TAE. Risk factors for repeat TAE were identified by univariate and stepwise logistic regression analyses. RESULTS: During the study period, 174 of 964 patients with pelvic fracture received pelvic angiography for suspected arterial hemorrhage. One hundred forty TAEs were performed. Thirty-four (24.3%) patients underwent more than one angiography for suspected recurrent arterial hemorrhage, and 26 (18.6%) underwent repeat TAE. Repeat angiography was performed 3 to 58 hours (mean, 21 hours) after initial TAE. Patients with repeat TAE had significantly more blood transfusions, higher mortality rate, and longer intensive care unit stay. Independent predictors for repeat TAE included initial hemoglobin level lower than 7.5 g/dL (OR, 6.22), superselective arterial embolization in initial TAE (OR, 3.22), and more than 6 units of blood transfusion after initial TAE (OR, 3.22). CONCLUSION: Careful monitoring and prompt recognition of patients requiring repeat TAE is paramount. The arterial access sheath should remain in place for up to 72 hours after angiography. Initial hemoglobin level lower than 7.5 g/dL and more than 6 units of blood transfusion after initial angiography are predictors for repeat TAE. Superselective TAE is associated with a significantly higher risk of recurrent hemorrhage, and its use should be limited.

Notes & Commentary:

This paper and several others have discussed the incidence of subsequent haemorrhage following embolisation for pelvic haemorrhage.  While there is certainly the potential for rebleeding, certainly our rates are much lower than this (in fact I don't remember one in the last few years).  One possible explanation for this discrepancy is that we have had to re-learn how to read an angiogram for arterial distruption in the presence of haemorrhagic shock.  A contrast blush is rarely seen in these patients - blood pressure is low with permissive hypotension regimens and they are maximally vasoconstricted.  If vessels are not embolized because no blush is seen, when blood pressure is restored active haemorrhage will again ensue.  CT seems a lot better at picking up this contrast extravasation that angio - probably because of the delayed phase of the CT scan.  However of course CT is often bypassed in the exsanguinating patient.

Here's a patient with a left vertical shear fracture of the pelvis.  This is the initial left common iliac angiogram.  There's no blush or otherwise abnormal appearance.

supglutealangio3

However it's only when you look closely at the image that you can see that there is disruption in the superior gluteal artery territory.  On this close-up you can see severe 'pruning' of the vessels rather than the usual branching tree pattern.

supglutealangio3

Similarly if a patient is very haemodynamically unstable and has a unstable pelvic fracture, with no other obvious source for haemorrhage (abdomen, chest etc), we will gelfoam embolise both divisions of the internal iliac artery on that side (or sometimes bilaterally), even if no blush is seen.  We call this Damage Control Angioembolization, maybe others do too.

Today we've had a major overhaul of TRAUMA.ORG's services.  Most of these are back-end improvements to community features.  Users should now find it a lot easier to contribute images and cases, and institution to post fellowships and student elective opportunities. 

As part of our commitment to supporting and developing the global trauma community, this update of TRAUMA.ORG sees the addition of community blogs (including this one!).  The first one to role out is a trauma research blog.  New or interesting research will be highlighted here with a short editorial comment.  You're all welcome to discuss the article in the comments, and of course recommend articles yourselves.  Maybe it should be completely open for all to submit articles to?  We'll see how it develops! 

I thought we should have a momentous first post in the research blog.  So what is the most important trauma paper ever written?  There were a few candidates, but I finally settled on one that I think changed the way the world views trauma.  Which one did I choose?

PubMed ID: 6623052
Sci Am. 1983 Aug;249(2):28-35.
Authors: Trunkey DD

Abstract:

Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research.

Notes & Commentary:

Is this the most important trauma paper ever written?  This is Donald Trunkey's review of trauma epidemiology in the United States, publushed in Scientific American in 1983.  The core of the article relates in part to his paper with Baker published in 1980 describing the trimodal distribution of trauma deaths [PMID:7396078].

Why have I chosen it as the most important of all trauma papers?  This was the paper the first described trauma as a disease.  It brought together centuries of knowledge about wounds and their management into a paper that demonstrated that, if considered together, all these injuries can be described as a single disease entity, with its own epidemiology, pathophysiology, management and prognosis.  Once trauma was recognised as a disease, it would join cardiovascular disease and infectious diseases as some of the world's biggest killers.  Importantly - this is Scientific American - a popular science magazine with a huge audience.  This is the article that brought trauma to the masses.

So its my vote for all-time most important trauma paper, and a fitting start to our new research blog.  A global trauma journal club if you like.  What's your most important trauma paper of all time? Leave a comment below. 

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