Article 1
Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography. Delaplain PT, Tay-Lasso E, Biffl WL, et al. JAMA Surg. 2022;157(9):771–778.
The study collected data from trauma patients (age ≥18 years) presenting with abdominal seat belt signs who underwent abdominal and pelvic CT scans with contrast. Exclusions comprised pregnant women and patients operated on without abdominal CT. Enrollment occurred across nine trauma centers between August 2020 and October 2021, with discretion given to the treating teams for identifying abdominal seat belt sign. Data collection included patient demographics, injury severity, vital signs, laboratory results, abdominal examination details, FAST and CT scan findings, and details of abdominal operations and outcomes. The primary outcome aimed to identify enteric injuries during operative exploration, considering patients without operations as negative for enteric injury. Additionally, CT scan reviews were performed by the research team to ensure accuracy, with discrepancies confirmed by attending radiologists.
A positive CT scan was defined by the presence of abdominal wall soft tissue contusion (consistent with abdominal seat belt sign), free fluid in the abdomen, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilatation, pneumatosis, and pneumoperitoneum. Among the 754 patients with a seat belt sign, 69 patients (9.2%) were identified as having a hollow viscus injury, while 256 (34%) had a CT scan reported as negative. The most frequent CT finding among patients with hollow viscus injury was free fluid (60 out of 69 cases). In instances where the CT scan was deemed negative as per this study's definition, 255 out of 256 patients did not have a hollow viscus injury. There was only one patient who did not meet the criteria for a positive CT scan in this study but was found to have a hollow viscus injury. This patient was diagnosed with a pericolonic hematoma, initially thought not to arise from the mesentery, but found to be a mesenteric hematoma in the OR. This study suggests that discharging patients without clinically concerning symptoms and a negative CT scan without the presence of a soft tissue abdominal wall contusion on imaging is safe.
Article 2
Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review. Dumas RP, et al. Journal of Trauma and Acute Care Surgery. 2023 Jul 1;95(1):87-93.
As video recording and data technology have advanced over the past decade, video review has become an important tool in surgical education and individual surgeon performance improvement. Similarly, it is increasingly used in the trauma bay setting to review the trauma team’s performance and quality of patient care. This EAST Multicenter Trial published by Dumas et al. elegantly demonstrates how this tool is useful in measuring the quality of time to intervention by way of vascular access in hypotensive trauma patients.
19 centers participated in this prospective observational trial. Adult trauma patients greater than 16 years old, with hypotension (SBP <90) within the first 5 minutes of presentation to the ED were included in the study between May 2021 -May 2022. The primary outcomes were 1. vascular access success rates, defined as blood seen in IV tubing or successful flushing of catheter, compared between 3 groups, Peripheral IV (PIV), Central Venous Access (CVC) and Intra-osseous (IO) and 2. duration of successful and failed access attempts, defined as needle stick to success or procedure stop time respectively. The secondary outcome was timing to initiation of resuscitation.
Among 581 hypotensive trauma patients there were 1,397 vascular access attempts used in the analysis. The most frequent mechanism of injury was Gunshot wound (34.9%) followed by MVC (25.4%), with an overall median ISS score of 22. The overall mortality was 44.7%. The majority of access attempts were PIV (67%). The overall success rates among all modalities were 70%. IO had a significantly higher success rate at 93% compared to PIV 67% and CVC 59%. IO success rates remained high on the second, and significantly higher than the PIV and CVC on the third access attempts. A multivariable regression model for the outcome of success rate demonstrated that controlling for gender, initial SBP, and initial GCS, IO was 7.9 times more successful and CVC was 0.72 times as successful than PIV. Importantly, median duration of access attempts were 36s for IO, 44s for PIV, 171s for CVC, with IO and PIV both being significantly faster than CVC. In a subset analysis of patients arriving without vascular access obtained in the prehospital setting, IO continued to have a higher success rate than PIV. In this group, IO as a first access attempt reduced the time to resuscitation by 2 minutes compared with PIV.
The authors conclude that IO attempts are more successful than PIV and CVC, are as fast as PIV, and faster than CVC. With the goal of hemorrhage control as soon as possible in hypotensive patients, IO access leads to faster resuscitation compared to the other modalities and should be considered first line therapy in the appropriate setting. Importantly, this study provides evidence that central venous access should be avoided as initial access during resuscitation in hypotensive patients. Using video review in the trauma bay as a tool to measure these outcomes is novel and demonstrates the great potential this technology provides to improve the quality of care for our trauma patients.
