Blunt small bowel perforation (SBP): An Eastern Association for the Surgery of Trauma multicenter update 15 years later. Fakhry SM, Allawi A, Ferguson PL, Michetti CP, Newcomb AB, Liu C, Brownstein MR and the EAST small bowel perforation (SBP) Multi-Center Study Group. J Trauma Acute Care Surg. 2019 Apr;86(4):642-650.
Small bowel perforation (SBP) as a complication of blunt torso trauma is a rare event. Yet, even with the latest advances in CT scan technology, diagnosing SBP remains challenging due to the variability in diagnostic sensitivity and a small but persistent false-negative rate that is still associated with CT imaging. Fifteen years ago, as CT imaging became common in the management of blunt trauma patients, an EAST multicenter study demonstrated that an initial CT scan had a false-negative rate of 13% and increased mortality was associated with delays in diagnosis of more than 24 hours. Fakhry and colleagues sought to determine if, over the last 15 years, there had been an improvement in diagnostic efficiency, time to surgery, and morbidity and mortality for patients with SBP.
This multicenter retrospective study involved 39 centers (29 were Level I trauma centers) that contributed information about admitted patients from October 2013 to September 2015. Included cases were adults (age 18 and older) with blunt trauma who had no duodenal injury and non-abdominal Abbreviated Injury Scores (AIS) < 3. Each center contributed both cases of isolated SBP (which required CT imaging 6 hours from admission) along with potential controls; cases of SBP diagnosed without a CT scan were excluded from analysis. Ultimately, 72 cases of SBP were compared with 131 control patients. CT findings of free fluid had the highest sensitivity, specificity, and accuracy (83.33%, 91.6%, and 88.67%, respectively) for SBP, followed by free air (43.06%, 100%, and 79.8%) and bowel wall thickening (37.5%, 99.24%, and 77.34%). Initial CT scans were normal in 3 cases (4.2%) of SBP. Mean time to surgery was 8.43 hours, and 78% of cases went to surgery within 8 hours. Five of the 72 patients with SBP underwent a second CT scan prior to surgery, and all survived. Mortality occurred in one patient (1.4%) who was 71 years old with an ISS of 8, normal initial physiology and WBC, and who had an initial CT that demonstrated free fluid and underwent surgery 16.9 hours after admission.
The key takeaways from this report are that SBP following blunt trauma remains a rare diagnosis, a false-negative rate is still associated with initial CT imaging but has improved over the last 15 years (from 13% to 4.2%), and mortality can occur with traumatic SBP though this has also improved over the last 15 years (from 6% to 1.3%). It is important to emphasize that the absence of free air on a CT scan does not rule out the diagnosis of SBP. Moreover, when patients have findings of free fluid, bowel wall thickening, or mesenteric stranding either in isolation or in some combination, the possibility of a traumatic SBP should be strongly considered and further investigated.
1] Watts DD, Fakhry SM. EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis of 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma. 2003; 54(2): 289-294.
The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study. Duchesne J, Costantini TW, Khan M, Taub E, Rhee P, Morse B, Namias N, Schwarz A, Graves J, Kim DY, Howell E, Sperry J, Anto V, Winfield RD, Schreiber M, Behrens B, Martinez B, Raza S, Seamon M, Tatum D. J Trauma Acute Surg. 2019 Jul;87(1):117-124.
Patients with severe pelvic fractures from blunt trauma who are hemodynamically unstable and in extremis at the time of presentation have a significant risk for mortality. To rescue these patients, a multimodality approach is often necessary. A previous report demonstrated that the methods of achieving control of hemorrhagic shock in severe pelvic fractures are highly variable among trauma centers. The purpose of this study was to examine the effect of the various adjunctive interventions for hemorrhage control as well as the type of resuscitation used on time to bleeding control and final outcome in patients with severe pelvic fractures.
The study was a multi-center retrospective review of adult trauma patients with severe pelvic fractures admitted to 12 trauma centers (11 of which were Level I trauma centers) from January 2011 through December 2016. Inclusion criteria included age of 18 years or older and the presence of a physiologic shock state (sBP ≤ 90, HR > 120 BPM, base deficit > 5). Exclusion criteria included pregnancy, penetrating trauma mechanism, lack of pelvic imaging, and isolated hip fracture. The primary outcomes were the frequency of each pelvic hemorrhage intervention used (i.e. binder, pre-peritoneal packing, external fixator, resuscitative endovascular occlusion of the aorta (REBOA), angioembolization, etc.) and mortality. The secondary outcomes included the frequency of combinations of the adjunctive hemorrhage interventions that were used, and 24-hour transfusion requirements.
Two hundred and seventy-nine patients were enrolled in the study and were predominantly young men (median age of 40, 62% male) who were severely injured (median ISS = 38). The majority of patients presented with other injuries (75% had extremity injuries, 64% had thoracic injuries, and 49% had head injuries). The overall mortality rate was 32%. The most common intervention was the use of a pelvic binder, followed by no intervention at all. Only 7 patients underwent REBOA as an initial intervention, which was available at only two centers. Patients who underwent pre-peritoneal packing or REBOA received the largest quantities of blood products and had the highest mortality rates (54% and 86%, respectively), but also had the fastest times to definitive bleeding control. The ratio of packed red blood cells to fresh frozen plasma transfused was not significantly different among the various interventions and ranged from 1.1:1 to 1.3:1. Two hundred and one patients received operative or endovascular interventions for definitive management of their injuries, and there was no significant difference in median time to OR or IR. Also, there was no difference in the amount of pRBC transfusions among patients who required OR or IR interventions despite the combinations of hemorrhage control interventions they received.
The use of a combination of initial adjunctive interventions (as compared to interventions in isolation) seemed to influence the definitive management for hemorrhage control. Notably, the majority of patients who underwent a combination of a pelvic binder placement and one more additional intervention underwent angioembolization for definitive hemorrhage control, as did patients who underwent pre-peritoneal packing or REBOA with an additional adjunctive intervention. Also, patients who underwent REBOA were significantly more likely to be comatose on admission which may have contributed to their mortality. Of thirteen patients who underwent REBOA (alone or in combination), nine died; of these nine mortalities, all had an admission GCS score of 3. Furthermore, multivariable logistic regression determined that age, initial GCS scores of 3 to 8, and number of transfused units of pRBCs in the first 24 hours were significant predictors of death, whereas use of pelvic binders was significantly associated with reduced mortality risk.
There are several takeaway points from this study. First, there is a lack of a consensus approach to managing severe pelvic trauma even among a cohort of Level I trauma centers. Second, the use of a pelvic binder for fracture reduction is an important step in controlling pelvic hemorrhage. Third, though REBOA can be a useful adjunct for refractory hemorrhagic shock management in severe pelvic fractures, it was only used in 5% of all cases in this study. It is the opinion of the authors that REBOA should be strongly considered for preemptive control of refractory hemorrhagic shock rather than as a rescue intervention. Finally, a standardized approach is needed to maximize outcomes and transfusion requirements in patients with hemorrhagic shock from severe pelvic trauma.
 Costantini TW, Coimbra R, Holcomb JB, et al. AAST Pelvic Fracture Study Group. Current management of hemorrhage from severe pelvic fractures: results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg. 2016; 80: 717-23.
Acute Kidney Injury After Burn: A Cohort Study From the Parkland Burn Intensive Care Unit. Clark AT, Li Xilong, Kulangara, R, et al. Journal of Burn Care & Research. 2019 Jan 1; 40(1):72-78.
Acute kidney injury is commonly encountered after burn injury, but the significance on survival is less clear. This article does a good job of trying to categorize the intersection between %TBSA burn, severity of kidney injury and mortality. The authors conducted a single center retrospective cohort study limited only to those burn patients admitted to the burn intensive care unit (BICU) at Parkland burn center in Dallas, TX. ICU admissions between January 2008 and December 2015 were included. 1,040 patients met all inclusion and exclusion criteria. The authors hypothesized that AKI is frequently encountered in the burn ICU and is independently associated with mortality. AKI was defined and categorized by the KDIGO criteria – which is based on serum creatinine. Patients were then stratified into three categories by burn size (<10%, 10-40%, >40%). Of the 1040 patients, 601 (58%) developed some level of AKI. Most had stage 1 AKI (60%). 19.8% with stage 2 and 10.5% with stage 3 AKI. 58 patients (9.7%) required RRT. Not surprisingly hospital mortality was significantly higher for those who developed any AKI (20.3% vs. 3.9%; P<.001). The most interesting finding was that any degree of AKI is independently associated with hospital mortality in the small burn (<10%) group. Additionally, only severe – stage III AKI with RRT – was associated with mortality in the medium group. Importantly, AKI did not have a significant impact on mortality in the >40% TBSA group.
The findings clearly demonstrate that AKI is very common after burn injury, but is infrequently severe. The authors show that mortality after severe burns is determined primarily by %TBSA, inhalation injury and comorbid factors. Their data seem to argue that AKI in severe burns may simply be a marker of injury severity. Importantly, the group of burns <10% admitted to the ICU were significantly older and had higher incidence of comorbidities. The increased mortality with AKI in this group may reflect frailty in this cohort.
Early application of continuous high-volume haemofiltration can reduce sepsis and improve the prognosis of patients with severe burns. You B, Zhang YL, Luo GX, Dang YM. Critical Care. 2018 Jul 6; 22(1):173.
The role and timing of early venovenous hemofiltration (CVVH) after severe burn injury remains controversial. In most burn centers, CVVH is used when significant oliguria is present during the acute resuscitation. In this article, the authors evaluate the very early use of high volume hemofiltration (HVHF) based solely on burn admission criteria consistent with severe injury. A prospective cohort of patients were randomized to standard therapy OR standard therapy + 3 continuous days of HVHF. Inclusion criteria were age 18 to 65, %TBSA burn >50% AND >30% full thickness injury. Exclusions were for patients who presented more than 3 days post injury, had significant comorbid pre-existing organ dysfunction or presented with a multiple organ failure with a SOFA score ≥ 3. Standard therapy was appropriately aggressive with a typical crystalloid followed by colloid fluid resuscitation as well as early excision and grafting within 3-7 days. The primary endpoints were incidence of sepsis and 90-day mortality. Sepsis was defined by the ABA Sepsis criteria. Laboratory data, plasma cytokine levels, and immune cell cytometry were collected on days 1,3,5,7,14,21 and 28. The authors found that the incidence of sepsis, septic shock and duration of vasopressor treatment were significantly decreased in the HVHF group. The subgroup with %TBSA >80 showed a significant decrease in mortality at 90 days. There was no difference in mortality with %TBSA 50-79. Interestingly, the blood levels of inflammatory cytokines as well as calcitonin were found to be significantly reduced in the treatment group.
The authors applied this therapy to an appropriately severe injured cohort of burn patients. It appears that early – essentially prophylactic - use of CVVH and HVHF may have a role in very severe burn injuries over 80% TBSA. According to their findings, there seems to be less benefit with smaller TBSA burns. Interestingly, the ICU length of stay was not different between the two cohorts, suggesting that minimal benefit was derived from the overall lower serum inflammatory markers and duration of vasopressor treatment in the treatment group. This is a very interesting and well done study that convincingly shows a benefit for hemofiltration upon admission in very severe burns.