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Alcohol and drugs misuse represents an important social problem. There is no agreement about influence of ethanol and drugs on trauma severity and clinical course. The aim of this study was to investigate the impact of alcohol and drugs abuse on road related trauma managed to our Level I Trauma Center. Data of 1067 car or motorcycle drivers consecutively admitted in a 5 years period were retrospectively analyzed. The sample was divided into two groups: patients with alcohol and/or drugs misuse and patients without detectable plasmatic levels or not screened because no clinical suspicion of these substance. Demographic data, mechanism of trauma, severity of injury, daily and season time of trauma distribution, alcohol and drugs levels and outcomes were retrieved. Alcohol or drugs misuse were detected in 242 patients. Heavy alcohols levels were the 62.3%. Among drugs cannabis was the most detected substance. These patients were significantly younger than the overall study population (p = 0.011), with a higher ISS (p = 0.012) a lower RTS (p = 0.047), a lower GCS (p = 0.005) and an higher head injuries severity (p = 0.030). Regarding time distribution, Saturday was the day with the highest percentage of trauma associated with substance misuse (21%). Alcohol/drugs misuse plays a very important role in the epidemiology of road related trauma. Despite the higher severity of trauma scores and the higher incidence of severe head injuries in patients with alcohol or drugs consumption, there were no effects of this substances on mortality of injured patients involved in road crashes.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the Covid-19 pandemic (C-19), different trends for Pediatric Trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of C-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SA).Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyzes. Results: 684 PT were accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (pConclusions: NTC is the adult level I referral trauma center for the Milan urban area, with pediatric commitment. During C-19, every traumatic emergency was centralized to NCT. In 2020 we observed an increasing trend of SA and VRT among PTs. The psychological impact of the C-19 restriction could explain this evidence. The long-term effects of C-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SA and VRT should be implemented, especially during socio-demographic storms like the last pandemic.

Purpose: To identify preoperative predictive factors for technically challenging laparoscopic appendectomy (LA) and the need for external help to laparoscopically complete the procedure. Methods: We analysed data from a two-year data lock on the Resident-1 multicentre registry. The operator classified each procedure following a five-grade Likert scale to define technical difficulty. We performed univariate analysis comparing Grade 1–3 versus 4–5 procedures and then built a logistic regression model to identify independent predictors of Grade 4–5 procedures defined as needing external help to complete a LA. Results: 561 patients were recruited from 2019 to 2021, and 485 patients were included in the final analysis due to missing data. A BMI > 30 kg/m2, preoperative CT scan, and the AIR score were independent preoperative predictors of complex LA with the need for external help to be completed. Patients undergoing such procedures were more affected by CA, had longer operative times, and had the worst postoperative outcomes. Conclusion: The preoperative identification of technically demanding LA could be helpful in optimising the preoperative planning, maximise surgeons’ preparedness, and include expert surgeons in the procedure earlier. Creating a scoring system for the technical difficulty of LA is desirable.

Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL.Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL.561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL.This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the COVID-19 pandemic (COVID-19), different trends for pediatric trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of COVID-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SAs). Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyses. Results: There were 684 cases of PT accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (p < 0.001), 66.2% male, mean age 9.88 (±5.17). We observed a higher number of traffic-related, fall-related injuries and an increasing trend for VRT and SAs, peaking in 2020. We report an increasing trend over time for head trauma (p = 0.002). The Injury Severity Score did not significantly change. During COVID-19 we recorded a higher number of self-presenting patients with low priority codes. Conclusions: NTC is the adult level I referral trauma center for the Milan urban area with pediatric commitment. During COVID-19, every traumatic emergency was centralized to NCT. In 2020, we observed an increasing trend in SAs and VRT among PT patients. The psychological impact of the COVID-19 restriction could explain this evidence. The long-term effects of COVID-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SAs and VRT should be implemented, especially during socio-demographic storms such as the last pandemic.

Fournier’s gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.

Noncompressible torso injuries (NCTIs) represent a trauma-related condition with high lethality. This study&rsquo, s aim was to identify potential prediction factors of mortality in this group of trauma patients at a Level 1 trauma center in Italy. Materials and Methods: A total of 777 patients who had sustained a noncompressible torso injury (NCTI) and were admitted to the Niguarda Trauma Center in Milan from 2010 to 2019 were included. Of these, 166 patients with a systolic blood pressure (SBP) &lt, 90 mmHg were considered to have a noncompressible torso hemorrhage (NCTH). Demographic data, mechanism of trauma, pre-hospital and in-hospital clinical conditions, diagnostic/therapeutic procedures, and survival outcome were retrospectively recorded. Results: Among the 777 patients, 69% were male and 90.2% sustained a blunt trauma with a median age of 43 years. The comparison between survivors and non-survivors pointed out a significantly lower pre-hospital Glasgow coma scale (GCS) and SBP (p &lt, 0.001) in the latter group. The multivariate backward regression model identified age, pre-hospital GCS and injury severity score (ISS) (p &lt, 0.001), pre-hospital SBP (p = 0.03), emergency department SBP (p = 0.039), performance of torso contrast enhanced computed tomography (CeCT) (p = 0.029), and base excess (BE) (p = 0.008) as independent predictors of mortality. Conclusions: Torso trauma patients who were hemodynamically unstable in both pre- and in-hospital phases with impaired GCS and BE had a greater risk of death. The detection of independent predictors of mortality allows for the timely identification of a subgroup of patients whose chances of survival are reduced.

BackgroundMotorcyclists are often victims of road traffic incidents. Though elderly patients seem to have worse survival outcomes and sustain more severe injuries than younger patients, concordance in the literature for this does not exist. The aim of the study is to evaluate the impact of age and injury severity on the mortality of patients undergoing motorcycle trauma. MethodsData of 1725 patients consecutively admitted to our Trauma Center were selected from 2002 to 2016 and retrospectively analyzed. The sample was divided into three age groups: ≤ 17 years, 18-54 years and ≥ 55 years. Mortality rates were analyzed for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Differences in survival among age groups were evaluated with Log-Rank test and multivariate logistic regression models were created to identify independent predictors of mortality.ResultsA lower survival rate was detected in patients older than 55 years (83,6% vs 94,7%; p = 0.049) and in those sustaining critical injuries (ISS ≥ 25, 61% vs 83% p = 0.021). Age (p =0,027; OR: 1,03), ISS (p p p p p p =0,014; OR: 1,26) injuries as independent risk factors related to mortality as well. Compared to the theoretical probability of survival, patients of all age groups showed a survival advantage when managed at a level I Trauma Center.ConclusionsWe detected anatomical injury distributions and mortality rates among three age groups. Patients aging more than 55 years had an increased risk of death, with a prevalence of severe chest injuries, while younger patients sustained more severe head trauma. Age represented an independent predictor of death. Management of these patients at a Level I Trauma Center may lead to improved outcomes.

Background In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. Methods The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. Results The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. Conclusion Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. Level of evidence Systematic review of predominantly level II studies, level II.

Background A wide variety of hemostats are available as adjunctive measures to improve hemostasis during surgical procedures if residual bleeding persists despite correct application of conventional methods for hemorrhage control. Some are considered active agents, since they contain fibrinogen and thrombin and actively participate at the end of the coagulation cascade to form a fibrin clot, whereas others to be effective require an intact coagulation system. The aim of this study is to provide an evidence-based approach to correctly select the available agents to help physicians to use the most appropriate hemostat according to the clinical setting, surgical problem and patient’s coagulation status. Methods The literature from 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] protocol. Sixty-six articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development and Evaluation] system, and a national meeting was held. Results Fibrin adhesives, in liquid form (fibrin glues) or with stiff collagen fleece (fibrin patch) are effective in the presence of spontaneous or drug-induced coagulation disorders. Mechanical hemostats should be preferred in patients who have an intact coagulation system. Sealants are effective, irrespective of patient’s coagulation status, to improve control of residual oozing. Hemostatic dressings represent a valuable option in case of external hemorrhage at junctional sites or when tourniquets are impractical or ineffective. Conclusions Local hemostatic agents are dissimilar products with different indications. A knowledge of the properties of each single agent should be in the armamentarium of acute care surgeons in order to select the appropriate product in different clinical conditions.