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Background: Haemorrhage remains the leading cause of preventable mortality following trauma, often aggravated by the acidosis, hypothermia and coagulopathy-the lethal triad of trauma. However, the impact of trauma-induced hypocalcemia on the haemorrhage remains unclear. It is intuitive to consider perturbations of ionised calcium early during trauma resuscitation in acutely injured patients given its pathophysiological significance for an improved outcome. Thus, we conducted a prospective study to analyse the role of ionized calcium ion levels during trauma resuscitation and its association with the need for blood transfusion(s) requirement and mortality. Methods: A prospective study was conducted on acutely injured patients with haemorrhage getting admitted to a Level 1 trauma center in India between September 2020 and June 2022. Ionised calcium was measured on arrival, after 6 h, and on day two of the injury to assess the prevalence. The amount of blood transfusion received by the patient was noted along with other demographic and in-hospital details. The association of hypocalcemia with blood transfusion and mortality was also evaluated. Results: Of the 1961 patients screened for eligibility, 200 patients were recruited and analysed. 72.5% of patients were hypocalcaemic on emergency department (ED) admission. Ionized hypocalcaemia was significantly associated with the need for blood transfusion(s) (p-value < 0.01). A significant association was also noted between ionized hypocalcaemia and mortality (p-value: 0.0085). On the univariate and multivariable analysis, ionized hypocalcaemia was a significant predictor of mortality. Conclusions: Ionized hypocalcaemia is widely prevalent among acutely injured. Trauma-induced hypocalcaemia at admission is associated with increased need for blood transfusions and increased mortality. [ABSTRACT FROM AUTHOR]

Background: Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD. Methods: This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma. Results: Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay. Conclusion: The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema. Level of evidence: Therapeutic Study, Level II Trial registration: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403. [ABSTRACT FROM AUTHOR]

The aim of this study is to compare outcomes of patients with and without use of systemic post-operative anti-coagulation (SPAC) having undergone end to end medium-sized arterial repair following trauma. A prospective, single-blinded, pilot randomized control trial was conducted at a level 1 trauma center from April 2019 through August 2020. Patients between 14 and 65 years having medium size vessel injury and undergoing end to end arterial repair were included. Patients were randomized into two groups—SPAC and no SPAC. Primary outcome measure was vessel patency measured clinically and/or by Doppler at 48 h and at the time of discharge. Secondary outcome measures included post-operative bleeding, re-exploration, ongoing blood product transfusion, limb salvage, duration of ICU stay, and hospital stay. A total of 32 patients were randomized. There was no difference in vessel patency at 48 h. (93.7% vs. 93.7%, p value 0.572) or at discharge (93.7% vs. 87.5%, p value 0.654). Incidence of post-operative hemorrhage (5 patients vs. 0, p value 0.030), need for additional vascular procedures (37.5% vs. 18.75, p value 0.030), need for further post-operative transfusions (50% vs. 12.5%, p value 0.040), and additional operative procedures (30 vs. 18, p value 0.024) were more in the SPAC group. There was no difference in limb salvage rates (93.7% vs. 87.5%, p value 0.513), rates of fasciotomy (68% vs. 56.3%, p value 0.412), hospital stay (mean 20.12 vs. 16.28 days, p value 0.663), and ICU stay (mean 0.81 vs. 2.7 days, p value 0.358). SPAC does not seem to improve post-operative vessel patency following end to end arterial repair of injured medium-sized vessels. An increase in adverse events following use of SPAC was noted. An adequately powered randomized trial is needed to conclusively bridge the lacunae on the use of anticoagulation in these groups of patients. Trial Registry: ctri.nic.in/clinical trials/login.php, number REF/2019/04/018649 dated 18/04/2019 [ABSTRACT FROM AUTHOR]

Blunt traumatic aortic injury is a rare life-threatening injury. Last few decades had witnessed a paradigm shift in the management of blunt traumatic aortic injury. This study was conducted to review the clinical spectrum of thoracic aortic injuries, the different management strategies and their associated outcomes at a level 1 trauma centre. Case series analysis of all the patients admitted with blunt thoracic aortic injuries between January 2010 and December 2020 was done. The primary endpoints were in-hospital mortality and early morbidity between the different grades of aortic injury. The overall incidence of blunt thoracic aortic injury was 0.9% (n = 55). The median age of the cohort was 30 years (IQR, 23–40 years). The predominant mode of injury was road traffic injury involving the vulnerable road users (42.3%). One-third of the patients were hemodynamically unstable on arrival with odds of mortality of 4.5 (Odds ratio 16, 95%CI 2.91–87.7). Grade III aortic injury was predominant (63.5%). Of all, 31 (59.6%) patients underwent endovascular stenting, 19 (36.5%) had NOM and 2 (3.9%) had surgical repair. In-hospital mortality was 21.1%; however, aortic injury–specific mortality was 1.92%. Mortality was highest in operative followed by NOM and endovascular stenting cohorts with 50%, 26.3% and 16.1% respectively. Endovascular stent repair is the preferred mode of treatment in hemodynamically stable patients with blunt thoracic aortic injuries with reduced risk of complications. The final outcome in patients with blunt thoracic aortic injury correlates with the hemodynamic status on arrival, severity of the concomitant injuries and the grade of the aortic injury. [ABSTRACT FROM AUTHOR]

Purpose: To study the role of prolonged prophylactic antibiotic therapy (PAT) in the prevention of Inter-costal drain (ICD) related infectious complications in patients with Blunt Trauma Chest (BTC). Methods: Patients of age 15 years and above with BTC requiring ICD were included. Patients with penetrating chest injuries, associated injuries/illnesses requiring antibiotic administration, need for mechanical ventilation, known pulmonary disease or immuno-compromised status and need for open thoracotomy were excluded. 120 patients were randomized equally to two groups; no prolonged PAT group (Group A) and prolonged PAT group (group B). Both group patients received one shot of injectable antibiotic prior to ICD insertion. Primary outcome measure was comparison of ICD related infectious complications (pneumonia, empyema and SSI) and secondary outcome measures included the duration of ICD, Length of Hospital stay (LOS) and in-hospital mortality in both the groups. Results: Infectious complications (pneumonia, empyema and SSI) were seen in only one patient in antibiotic group, and none in no antibiotic group (p value = 0.500). Other complications such as post ICD pain scores, respiratory failure requiring ventilatory support, retained hemothorax or recurrent pneumothorax, did not show any statistical difference between both groups. Also, no significant difference was seen in both the groups in terms of mean duration of ICD (p value = 0.600) and LOS (p value = 0.259).m Conclusion: Overall prevalence of ICD related infectious complications are low in BTC patients. Definitive role of prolonged prophylactic antibiotics in reducing infectious complications and other associated co morbidities in BTC patients with ICDs could not be established. Trial registry details: Clinical Trial Registry, India (Trial registered at ctri.nic.in/clinical trials/login.php, number REF/2019/021704 dated 18/10/2019). [ABSTRACT FROM AUTHOR]

Since the description of bilateral ligation of internal iliac arteries (BLIIA) and preperitoneal pelvic packing (PPP) for hemorrhage control in pelvic injury patients, multiple reports have been published advocating its use with acceptable outcomes. We analyzed our experience with this technique in a setting where the facility of hybrid operating room for simultaneous angioembolization is not available. We analyzed data of sixty-six patients who presented in a state of unresponsive shock with pelvic fracture between January 2014 and September 2019. After initial resuscitation, they all underwent BLIIA with PPP as part of damage control surgery. Out of 66 patients, 55 were male. The mean age was 36.12 years. All patients sustained blunt trauma, with road traffic injuries being the most common mechanism involving 65% of the patients followed by fall from height. The mean systolic blood pressure at the time of surgery was 77 ± 34.46 mm Hg. Median packed red blood cell transfusion in the first 24 h was 8.5 units with IQR of 6–12. The hemorrhage-related mortality was 48%. BLIIA with PPP may be considered as a viable treatment option in hemodynamically unstable patients with pelvic injuries in resource constraint facilities. [ABSTRACT FROM AUTHOR]

It is advised that we should never hesitate in leaving the abdomen open when required. However, once the patient is stabilised, we should close it as soon as possible. But the factors which would hamper delayed primary fascial closure (DPFC) are not well studied. A retrospective 5-year analysis of patients with open abdomen (OA) after trauma laparotomy who survived was conducted. Patients were divided into 2 groups: those in which DPFC was possible and those in whom it was not. Out of the 58 patients that were recruited, DPFC could not be performed in 48 patients. Quantum of fluid resuscitation at 48 h was not associated with an inability to perform DPFC. Early definitive control of bleeding and damage control resuscitation are associated with the ability to perform DPFC in OA patients. Presence of blood stream infections (BSIs), ventilator-associated pneumonia (VAP), and intra-abdominal sepsis (IAS) precluded DPFC. [ABSTRACT FROM AUTHOR]

Open abdomen or laparostomy as a method of damage control in emergency surgery especially with perforated viscus has been used mainly to prevent abdominal compartment syndrome, burst abdomen and delayed ventral hernia. The authors aimed to study the associated morbidity of open abdomen with clinical and resuscitative parameters. A historical cohort of patients with open abdomen after emergency laparotomy at Trauma Centre AIIMS, New Delhi, from January 2013 to December 2017 was included in this analysis. Patients operated elsewhere came to this hospital for further care; patients with AIS (abbreviated injury score) > 3 in other body regions and patients who died within 48 h were excluded. These patients were studied for their requirement of more than usual post-operative care in the form of requirement of resuscitative measures and other vital clinical parameters. A comparative analysis of patients with and without intra-abdominal complications (enteric fistula and intra-abdominal sepsis) was performed. Of the 113 subjects studied from historical case records, 52 had intra-abdominal sepsis and 10 had entero-cutaneous fistulae. These patients in comparison with those who did not undergo laparotomy during the same period did not require extra efforts for resuscitation, ICU care, increased hospital stay, chest infection and other clinical and biochemical morbid parameters. Immediate post-operative period in this cohort of patients with open abdomen was not associated with extra effort to resuscitate or burden on clinical work. Early definitive closure of abdomen is recommended once patients are stabilised to avoid laparostomy-related complications. [ABSTRACT FROM AUTHOR]

We analyzed one feasible timeline of critical surgery within the first hour of admission as a possible intervention, which could be applied in existing trauma systems in Low and middle-income countries (LMIC), and may improve trauma care outcomes. Retrospective analysis of a prospectively maintained data registry under project named TITCO (Towards Improved Trauma Care Outcome) was done at a level one trauma center in India from October 2013 to September 2015. All admitted patients who underwent critical surgery within the first hour of admission were analyzed. These patients were divided in two groups depending upon primary presentation or referred from other facility. Statistical analysis was done between these two groups to compare outcome. Sixty-one (57.6%) patients were directly admitted, whereas forty-five (42.4%) were transferred from other hospitals. The median time from injury to presentation for primary patients was 50 min with interquartile range (IQR) of 40. In referred patient median time gap between the injury to our center (not referring center) was 230 min with IQR of 350. This difference was statistically significant. Both the groups were comparable in terms of injury severity measured by ISS. Major outcome indicators in the form of median ICU and total stay, as well as mortality, were not significantly different. We propose that critical surgery within the first hour of presentation might be a useful hospital-based key performance indicator even in the existing trauma systems in LMIC to improve the outcome of injured patients. [ABSTRACT FROM AUTHOR]

Objective: We present our experience of pediatric injuries over 5 years from a level I trauma centre. Methods: De-identified data from a prospectively maintained database of pediatric patients was analyzed for demography and injury-related parameters, and management provided. Results: There were 906 patients (698 male, median age 12 years). Predominant cause was road traffic injuries. The median injury severity score was 9. Abdomen and thorax were the commonest regions affected. There were 44 deaths. Sepsis and hemorrhage were the commonest causes of mortality. Conclusions: The magnitude of pediatric injuries is significant, and maintenance of dedicated trauma registries is the need of the hour. [ABSTRACT FROM AUTHOR]

Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20-25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity. [ABSTRACT FROM AUTHOR]

Pancreatic injury is an uncommon and frequently missed injury in abdominal trauma patients. However, missed pancreatic injury is associated with significant morbidity and mortality. This study was conducted to know the burden of pancreatic injury and its outcome in our setup. A retrospective analysis of 53 patients with pancreatic injury from January 2008 through March 2012 at the Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi. Pancreatic injuries were present in 1.18 % of all trauma admissions. Blunt trauma to the abdomen ( n = 49, 92.45 %) due to road traffic injury ( n = 38, 71.70 %) was the most common mechanism of injury. Isolated pancreatic injury was present in eight (15.09 %) patients. Grade III pancreatic injury ( n = 25, 47 %) was the most common. Of these patients, 18.86 % were managed nonoperatively and 81.13 % were managed operatively. Among the operatively managed patients ( n = 43), 74.4 % were operated due to pancreatic injury and 25.5 % were operated due to associated injuries. Distal pancreatectomy with or without spleen preservation ( n = 25) was the most common operative procedure done. Three out of five patients of Whipple operation for pancreatic injury died. Pancreatic injury was associated with complications in 43.40 % and death in 20 % ( n = 11). Pancreatic injury is rare, but delay in diagnosis of pancreatic injury has been associated with higher morbidity and mortality. Low-grade pancreatic injury with intact main pancreatic duct (MPD) could be successfully managed nonoperatively, whereas in high-grade pancreatic injury, an operative intervention is invariably necessary. Distal pancreatectomy with spleen preservation is a desirable goal whenever possible for distal transaction of the pancreas. Whipple resection should be reserved only for hemodynamically stable patients with complex pancreaticoduodenal injury and is associated with high mortality. [ABSTRACT FROM AUTHOR]

Non-operative management has become a norm in patients with liver trauma and operative management is guided by hemodynamic status. Introduction of haemodynamic status. Introduction of contrast enhanced computed tomography (CECT) abdomen has made NOM possible by helping in exclusion of other injuries and identification of vascular injuries. Haemodynamic instability is now considered as an only absolute indication for operative intervention in liver injuries. However, liver trauma is associated with a large number of complications in the form of perihepatic abscess, hepatic necrosis, bile leak, etc. Patient's undergoing operative intervention for liver trauma are more at risk for these complications. As such regular dynamic assessment is required for early identification and management of these complications. We present a case of a complex liver injury in a 27-year-old male who underwent operative intervention for liver trauma and had a varied number of liver trauma associated complications, with enterohepatic fistula as one of the rarest associated complications. [ABSTRACT FROM AUTHOR]

The objectives of this study are (1) to evaluate prevalence of traumatic diaphragmatic injury (TDI), (2) identify the predictors of mortality, and (3) study the accuracy of investigations in survivors of TDI. Retrospective analysis of prospectively maintained database of TDI from January 2007 to December 2011. Emergency department (ED) records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the SPSS ver.15 software. TDI was identified in 75 individuals. Thirty-two of 75 (42.6 %) cases were brought dead to the hospital, and 43/75 (57.3 %) were survivors presented to emergency department, diagnosed to have TDI intraoperatively. Seven of 43 (16.3 %) died postoperatively. Mortality in TDI was significantly related to age ( p = 0.001), injury severity ( p < 0.001), site of TDI ( p = 0.002), and associated injuries ( p = 0.021, odds ratio of 9). Death increased with increase in the number of organ injured ( p < 0.001, odds ratio of 12). Multi-detector computer tomography (MDCT) detected TDI in 23/26 (88.5 %) cases preoperatively. Laparotomy ( p < 0.001, odds ratio of 22) and thoracotomy ( p = 0.021, with odds ratio of 9) were associated with survival benefit when compared to minimal invasive surgery in injured cases. The prevalence of TDI was 2.67 %, TDI's mark severity of injury. Mortality increases with increasing number of organ injured. Right-sided or bilateral injury of diaphragm is associated with increased mortality. [ABSTRACT FROM AUTHOR]

The objective of our study was to evaluate the role of splenic artery embolization (SAE) in the management of traumatic splenic injuries. From September 2008 to September 2010, a total of 67 patients underwent nonoperative management (NOM) for blunt splenic injuries. Twenty-two patients were excluded from the study because of associated significant other organ injuries. Twenty-five patients underwent SAE followed by NOM (group A) and 20 patients underwent standard NOM (group B). Improvement in clinical and laboratory parameters during hospital stay were compared between two groups using Chi-square test and Mann-Whitney test. SAE was always technically feasible. The mean length of the total hospital stay was lower in the group A patients (5.4 vs. 6.6 day, [ P = 0.050]). There was significant increase in hemoglobin and hematocrit levels and systolic blood pressure (SBP) in group A patients after SAE, whereas in group B patients there was decrease in hemoglobin and hematocrit levels and only slight increase in SBP (pre- and early posttreatment relative change in hemoglobin [ P = 0.002], hematocrit [ P = 0.001], and SBP [ P = 0.017]). Secondary splenectomy rate was lower in group A (4 % [1/25] vs. 15 % [3/20] [ P = 0.309]). No procedure-related complications were encountered during the hospital stay and follow-up. Minor complications of pleural effusion, fever, pain, and insignificant splenic infarct noted in 9 (36 %) patients. SAE is a technically feasible, safe, and effective method in the management of splenic injuries. Use of SAE as an adjunct to NOM of splenic injuries results improvement in hemoglobin, hematocrit levels, and SBP. SAE also reduces secondary splenectomy rate and hospital stay. [ABSTRACT FROM AUTHOR]

Chylothorax is known for its rarity, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional, and immunologic disorders, can result from chylothorax. Management of chylothorax is challenging. It can either be managed nonoperatively or surgically. Surgical treatment is required in cases of persistent or high output fistulae. We report here in three cases of blunt trauma chest following road traffic crash associated with chylothorax. All of them were successfully managed nonoperatively with inter costal tube drainage and supportive treatment sans need of any operative intervention. [ABSTRACT FROM AUTHOR]