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Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates. It is photochromogenic, with colonies turning yellow to orange on exposure to light.[3] Ziehl-Neelsen stain will show acid-fast bacilli, but yield can be difficult as the number of mycobacteria in clinical specimens is low.[[2], [6]] It is important to culture biopsies to allow for differentiation from other non-tuberculous mycobacterial infections ( I Mycobacterium avium-intracellulare, Mycobacterium abscessus, Mycobacterium fortuitum, Mycobacterium chelonae i ) which can also present as chronic non-healing wounds.[7] There is no standard treatment for I M. marinum i infection. Keywords: Mycobacterium; Skin diseases, infectious; Wounds, penetrating EN Mycobacterium Skin diseases, infectious Wounds, penetrating 250 252 3 09/20/23 20230915 NES 230915 Clinical record A 32-year-old woman presented with a painless but cosmetically bothersome chronic indolent lesion on her left knee. [Extracted from the article]

Background: Rectal trauma carries significant morbidity, particularly if there is a delay in diagnosis. Digital rectal examination has a relatively low sensitivity. Proctoscopy and sigmoidoscopy are available but can be limited in situations with increased fecal burden or uncooperative patients. We suggest more sensitive bedside techniques are necessary to diagnose low rectal injury, and here present a case report to demonstrate proof of concept using hydrogen peroxide to directly visualize an injury., Methods: Digital rectal examination was performed in a patient after multiple gunshot wounds and was negative for gross blood. Suspicion for low rectal injury remained high, and hydrogen peroxide was used to evaluate bullet trajectory. Approximately 25 mL of 3% hydrogen peroxide was instilled into the bullet tract., Results: Hydrogen peroxide evaluation of the bullet tract was performed in less than 1 min with minimal supplies and preparation. It revealed an extraperitoneal injury where the rectal examination had been falsely negative., Conclusion: Hydrogen peroxide may be used to evaluate a suspected penetrating injury of the rectum. Considering the potential of this modality to diagnose injuries in a timely and reliable manner, additional investigation may be warranted., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Prolonged casualty care (PCC), previously known as prolonged field care, is a system to provide patient care for extended periods of time when evacuation or mission requirements surpass available capabilities. Current guidelines recommend a 7- to 10-day course of ertapenem or moxifloxacin, with vancomycin if methicillin-resistant Staphylococcus aureus is suspected, for all penetrating trauma in PCC. Data from civilian and military trauma have demonstrated benefit for antibiotic prophylaxis in multiple types of penetrating trauma, but the recommended regimens and durations differ from those used in PCC, with the PCC guidelines generally recommending broader coverage. We present a review of the available civilian and military literature on antibiotic prophylaxis in penetrating trauma to discuss whether a strategy of broader coverage is necessary in the PCC setting, with the goal of optimizing patient outcomes and antibiotic stewardship, while remaining cognizant of the challenges of moving medical material to and through combat zones. Empiric extended gram-negative coverage is unlikely to be necessary for thoracic, maxillofacial, extremity, and central nervous system trauma in most medical settings. However, providing the narrowest appropriate antimicrobial coverage is challenging in PCC because of limited resources, most notably, delay to surgical debridement. Antibiotic prophylaxis regimen must be determined on a case-by-case basis based on individual patient factors while still considering antibiotic stewardship. Narrower regimens, which focus on matching up the site of infection to the antibiotic chosen, may be appropriate based on available resources and expertise of treating providers. When resources permit in PCC, the narrower cefazolin-based regimens (with the addition of metronidazole for esophageal or abdominal involvement, or gross contamination of central nervous system trauma) likely provide adequate coverage. Levofloxacin is appropriate for ocular trauma. Ideally, cefazolin and metronidazole should be carried by medics in addition to first-line antibiotics (moxifloxacin and ertapenem, Literature Synthesis and Expert Opinion; Level V)., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients., Methods: An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization., Results: A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge., Conclusion: Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements., Methods: We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30 mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72 h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution., Results: Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37 h ± 14.21 vs 59.05 h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24 h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48 h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72 h, peak sodium (Na) concentration (146.2 mEq/L ± 2.94 vs 142.8 mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1 mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days., Conclusions: HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm., Level of Evidence: Level III., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Introduction: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population., Methods: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes., Results: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012)., Conclusions: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts., Methods: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality., Results: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052)., Conclusions: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Hemorrhaging trauma patients may be disproportionately affected by choice of induction agent during rapid sequence intubation (RSI). Etomidate, ketamine, and propofol are safe in the trauma population-at-large but have not been assessed in patients with ongoing hemorrhage. We hypothesize that in hemorrhaging patients with penetrating injury, propofol deleteriously affects peri-induction hypotension compared to etomidate and ketamine., Methods: Retrospective cohort study. Primary outcome was the effect of induction agent on peri-induction systolic blood pressure. Secondary outcomes were the incidence of peri-induction vasopressor use and quantity of peri-induction blood transfusion requirements. Linear multivariate regression modeling assessed the effect of induction agent on the variables of interest., Results: 169 patients were included, 146 received propofol and 23 received etomidate or ketamine. Univariate analysis revealed no difference in peri-induction systolic blood pressure (P = .53), peri-induction vasopressor administration (P = .62), or transfusion requirements within the first hour after induction (PRBC P = .24, FFP P = .19, PLT P = .29). Choice of RSI agent did not independently predict peri-induction systolic blood pressure or blood product administration. Rather, only presenting shock index independently predicted peri-induction hypotension., Conclusions: This is the first study to directly assess the peri-induction effects of anesthetic induction agent choice in penetrating trauma patients undergoing emergent hemorrhage control surgery. Propofol does not appear to worsen peri-induction hypotension regardless of dose. Patient physiology is most predictive of peri-induction hypotension., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Penetrating cardiac injury (PCI) is a rare injury with high morbidity and mortality. Aim: To analyze the evolution of clinical and anatomical characteristics, severity, morbidity and mortality of patients operated on by PCI. Materials and Methods: Analytical study of patients surgically treated for PCI at the “Guillermo Grant Benavente” Regional Clinical Hospital, Concepción, Chile. Two periods were analyzed: January-1990 to December-2004 and January-2005 to December-2019. Sex, age, associated injuries, trauma agent and mechanism, pathophysiological behavior, anatomic location of the injury, classifications of cardiac trauma: Attar, Saadia and OIS-AAST, TSI (trauma severity indices): ISS, RTS-T and TRISS, morbidity and mortality were compared according to periods. Statistical analysis was performed with SPSS25®, the chi-square, Fisher exact and Mann-Whitney tests were used. A p value < 0.05 was considered significant. Results: Total 235 PCI, 112 in the first period and 123 in the second. Stab as mechanism in 96 (85.7%) and 104 (84.6%) according to periods. An increase in associated extra thoracic injuries, cardiorespiratory arrest, and injury to the left location were observed in the second period. The cardiac trauma classifications and the TSI ISS, RTS-T and TRISS showed greater severity and probability of death in the second period patients. Mortality did not show differences: 14 (12.5%) and 14 (11.4%) according to periods, p = 0.792. Discussion: In our series, patients treated with PCI have evolved towards a more severity profile in both, physiological and anatomical parameters. Mortality has been stable over time. [ABSTRACT FROM AUTHOR]

Introduction Laryngeal trauma can be an immediately life-threatening entity. Failure to recognize such injuries and delay in securing the airway may have fatal results. Early diagnosis and accurate evaluation with proper treatment is vital. Materials and Methods Fifteen patients with laryngotracheal injuries were analyzed prospectively. The outcome was assessed both in terms of voice and airway, on short term and long term basis. Result Commonest cause of injury was suicidal followed by road traffic accidents and strangulation. The main presenting symptoms and signs were stridor, hoarseness, haemoptysis and odynophagia. Five patients suffered penetrating trauma and ten patient sustained blunt trauma. Sites of laryngeal injury included; hyoid bone fracture, mixed soft tissue and cartilaginous injuries, thyrohyoid membrane and cricothyroid membrane injuries. Eleven patients presented within 24 hours of the injury. Outcome (airway and voice) was good in ten patients whereas it was poor in three patients. Poor results were seen in patients who had delayed surgical intervention. Conclusion Early surgical intervention is recommended for traumatic laryngeal injuries to ensure a good outcome; which further depends upon patient’s condition, injury and treatment-specific factors.

The Russian invasion of Ukraine in 2022 caused a significant spike in the number of deaths from blast injury. The impossibility of evacuating the bodies of dead servicemen or civilians from the battlefield for a long time leads to the fact that forensic experts often have to deal with the examination of bodies in a state of decomposed changes. At the same time, the material and technical support of forensic medical institutions in different parts of Ukraine is heterogeneous: most experts do not have access to laboratory or instrumental research methods and can only rely on macroscopic research data. This article provides an overview of the cases of expert examination of cases of explosive trauma of decomposed bodies using macroscopic, microscopic, chemical and instrumental research, which indicates the high efficiency of their use for the purpose of solving expert questions of various nature. At the same time, the identified morphological characteristics of the damage are not purely specific and indicate the action of a blunt solid object with a limited contact surface, which had high kinetic energy and significant penetrating capacity., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Most cases of traumatic injury during pregnancy involve blunt trauma, with penetrating trauma being uncommonly rare. In glass shard injuries, fragments often penetrate deeply, and multiple injuries may occur simultaneously; attention must be paid to the possibility of organ injury from the residual fragments. However, no case of this occurring during pregnancy has been reported yet., Case Presentation: We present the case of a 34-year-old pregnant Cameroonian woman who retained intraabdominal glass shards following a penetrating injury at 13 weeks gestation and not diagnosed until 22 weeks gestation. Notably, this patient continued the pregnancy without complications and gave birth via cesarean section at 36 weeks gestation., Conclusion: In pregnant women sustaining a penetrating glass trauma during pregnancy, careful attention should be paid to the fragments; in that case, computed tomography is a useful modality for accurately visualizing any remaining fragments in the body. Essentially, the foreign bodies in glass shard injuries during pregnancy should be removed immediately, but conservative management for term delivery is an important choice for patients at risk for preterm delivery., (© 2024. The Author(s).)

Background: Gunshot wounds (GSW) to the heart are lethal, and most patients die before they arrive to the hospital. Survival decreases with number of cardiac chambers involved. We report a case of a 17-year-old male who survived a GSW injury involving two cardiac chambers with acute severe tricuspid regurgitation (TR) who subsequently developed cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO) support., Case Presentation: A 17-year-old male sustained a single gunshot wound to the left chest, resulting in pericardial tamponade and right hemothorax. Emergency sternotomy revealed injury to the right ventricle and inferior cavoatrial junction with the adjacent pericardium contributing to a right hemothorax. The cardiac injuries were repaired primarily. Tricuspid regurgitation was confirmed immediately postoperatively. Five days after presentation, the patient developed cardiogenic shock secondary to TR requiring emergent stabilization with ECMO. He subsequently underwent successful tricuspid valve replacement., Conclusions: This is the first report to our knowledge of successful ECMO support of severe TR due to gunshot injury to the heart., (© 2024. The Author(s).)

Introduction: Over and under-triage represent a misallocation of resources that can affect patient outcomes. The purpose of this study is to evaluate over and under-triage rates in relation to risk factors and associated outcomes of trauma patients nationwide., Methods: A retrospective cohort study using the Trauma Quality Improvement Program from 2017 to 2020. Multivariable regression models were used to assess predictors of over-triage (activation when unnecessary) and under-triage (limited activation when full activation was necessary)., Results: 22.2 % (32,782) of the study population were over-triaged and 20.3 % (29,996) were under-triaged. Most over-triaged patients were Black, with Medicaid, or had a penetrating injury, whereas most under-triaged patients were White, with private/commercial insurance, or had a blunt injury. With covariates adjusted for, Pacific Islander (p = 0.024) and American Indian patients (p = 0.015) were associated with higher odds of over-triage, and Hispanic patients had higher odds of under-triage (p<0.001). Patients with Medicare (p<0.001) had higher odds of over-triage, and patients with private/commercial insurance (p<0.001) had higher odds of under-triage compared to Medicaid patients. Patients in level II (p<0.001) and level III (p<0.001) trauma hospitals were associated with higher odds of over-triage., Conclusion: Pacific Islander and American Indian patients, Medicare, and level II and III trauma centers are at increased risk of over-triage rates, while Hispanic and privately insured trauma patients had a higher risk for under-triage. Future studies should further investigate factors contributing to poor outcomes linked to under-triage practices and methods to improve consistency and standardization of triage tools across various levels of trauma centers., Competing Interests: Declaration of Competing Interest Authors declare no competing Interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: An emergency department thoracotomy (EDT) is performed in critically injured patients after a recent or in an imminent cardiac arrest following trauma. Emergent thoracotomy (ET) or operation room thoracotomy is reserved for more stable patients. However, the number of these interventions performed in an European settings is limited. Thus, we initiated the current study to investigate outcomes and risk factors for mortality of patients required EDT or ET at the largest trauma center in Estonia., Methods: All patients admitted after trauma to the North Estonia Medical Centre between 1/1/2017 and 31/12/2021 subjected to EDT or ET were included. Primary outcome was 30-day mortality., Results: Overall, 39 patients were included. EDT and ET were performed in 16 and 23 patients, respectively. Median age was 45 (33-53) years and 89.7% were males. The crude 30-day mortality was 56.4% being 87.5% and 34.8% in the EDT and ET group, respectively. None of the patients with pre-hospital CPR requirement, severe head injury (AIS head ≥ 3) or severe abdominal injury (AIS abdomen ≥ 3) survived. All the patients in the survival group had signs of life in the emergency department. The rate of stab wounds was significantly higher in the survival group (p = 0.007). Patients with CGS < 9 had significantly lower possibility for survival (p < 0.001)., Conclusions: EDT and ET outcomes in Estonian trauma system are comparable to similar advanced trauma systems in Europe. Patients with GCS > 8, signs of life in the ED and with isolated penetrating chest injury had the most favorable outcomes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Context: Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury., Methods: The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged., Conclusion: Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility., Methods: The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest., Results: We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR., Conclusion: Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency., (© 2024. The Author(s).)

Objective: This study aims to assess the change in cervical spine (C-spine) immobilization frequency in trauma patients over time. We hypothesize that the frequency of unnecessary C-spine immobilization has decreased., Methods: A retrospective chart review of adult trauma patients transported to our American College of Surgeons-verified Level I trauma center from January 1, 2014, to December 31, 2021, was performed. Emergency medical services documentation was manually reviewed to record prehospital physiology and the application of a prehospital cervical collar (c-collar). C-spine injuries were defined as cervical vertebral fractures and/or spinal cord injuries. Univariate and year-by-year trend analyses were used to assess changes in C-spine injury and immobilization frequency., Results: Among 2906 patients meeting inclusion criteria, 12% sustained C-spine injuries, while 88% did not. Patients with C-spine injuries were more likely to experience blunt trauma (95% vs. 68%, p < 0.001), were older (46 years vs. 41 years, p < 0.001), and had higher Injury Severity Scores (31 vs. 18, p < 0.001). They also exhibited lower initial systolic blood pressures (108 mm Hg vs. 119 mm Hg, p < 0.001), lower heart rates (92 beats/min vs. 97 beats/min, p < 0.05), and lower Glasgow Coma Scale scores (9 vs. 11, p < 0.001). In blunt trauma, c-collars were applied to 83% of patients with C-spine injuries and 75% without; for penetrating trauma, c-collars were applied to 50% of patients with C-spine injuries and only 8% without. Among penetrating trauma patients with C-spine injury, all patients either arrived quadriplegic or did not require emergent neurosurgical intervention. The proportion of patients receiving a c-collar decreased in both blunt and penetrating traumas from 2014 to 2021 (blunt-82% in 2014 to 68% in 2021; penetrating-24% in 2014 to 6% in 2021)., Conclusions: Unnecessary C-spine stabilization has decreased from 2014 to 2021. However, c-collars are still being applied to patients who do not need them, both in blunt and in penetrating trauma cases, while not being applied to patients who would benefit from them., (© 2023 Society for Academic Emergency Medicine.)

Background: A novel method for trapping voles is the use of pistol-like explosive tools loaded with bolt-action ammunition. When triggered the vole is killed by the very high gas pressure created. Accidental releases can result in facial and/or eye injuries. The aim of this work was to describe the injury pattern in the patient and to experimentally verify whether there is a risk of penetrating eye injuries., Methods: Two emergency patients presented to our eye clinic with eye injuries after unintentional triggering of the explosive trap. Based on the new pattern of injury noted, experiments were performed on enucleated porcine eyes to determine the possible severity. For this purpose, a vole trap was clamped in a holder and loaded with a Cal. 9 × 17 mm cartridge in each case. In front of the muzzle opening, 3 pig eyes each were fixed on Styrofoam at a distance of 20, 40, 60 and 80 cm. The foreign body indentations in the cornea were visualized and measured by spectral domain optical coherence tomography (SD-OCT). The pig eyes were then dissected and searched for foreign bodies using microscopy. The SD-OCT images of an injured patient were also included for human comparison., Results: On patient examination, in addition to the usual fine gunshot marks on the face and conjunctiva/eye area, wax-like, larger and heavier particles of approximately 0.1-0.2 mm in size were found, which originated from the cartridge end cap. Removal of these foreign bodies, some of which were injected more deeply into the cornea, conjunctiva, and tenon, is much more difficult and extensive than in usual blast trauma. There was no evidence of intraocular foreign bodies in either patient. Likewise, no intraocular foreign bodies could be detected experimentally in any pig eyeball (n = 12). Remnants of the wax-like cartridge end were found deeply penetrating into the corneal stroma. The maximum penetration depth measured against the total corneal thickness was 46% at 20 cm device distance and decreased with greater distance to the vole trap (penetration depth at 40 cm at 37%, at 60 cm at 28% and at 80 cm at 19%). For comparisons on the human eye, a penetration depth of 54% was measured at a distance of about 40 cm. In pig eyes the number of foreign bodies per cm 2 decreased with increasing distance from the vole trap (mean: n = 174 foreign bodies, FB, at 20 cm distance, n = 46 FB at 40 cm, n = 23 FB at 60 cm, and n = 9 FB at 80 cm). The largest penetrating foreign bodies measured a mean of 383 ± 43 μm with a maximum of 451 μm., Conclusion: New vole traps with gas-powered mechanisms result in larger deeply penetrating wax-like foreign bodies in the cornea, conjunctiva, and tenon of the eye, which are difficult to remove and only surgically possible. Despite the significant explosion during triggering, there was no evidence of penetrating ocular injury from the foreign bodies either in the patient or experimentally in the pig eyes. Safety goggles should be worn when handling the traps to avoid penetration of foreign bodies into the eye., (© 2023. The Author(s).)

Background: Trauma team activation (TTA) allows the provision of specialized and timely care to improve outcomes for severely injured patients. Limited information is available on the current state of TTA in Canadian trauma centres (TC). Study objectives were to describe TTA processes, data and reports, along with the challenges and successes from a national perspective., Methods: A mixed-methods, cross-sectional survey was undertaken with Canadian trauma leadership, utilizing a total population sampling strategy. The questionnaire, containing 108-items, was administered online between February-April 2022, utilizing a modified Dillman technique. Descriptive statistics and thematic analyses were performed., Results: Trauma leaders from 9 out of 10 provinces responded for a response rate of 68% (32/47). Two-thirds (67%) of respondents worked in adult TC; 63% in a level I center. A higher proportion of pediatric TC had a two-tiered TT response (60% pediatric; 35% adult). The most common criteria were neurologic compromise (100% one-level TTA) and hypotension (pediatric: 100% one-level, 100% tier 1; adult: 92% one-level, 86% tier 1). All one-level TTA included penetrating trauma criteria. One-third of respondents reported using TTA subgroup criteria for pediatric, pregnant, and/or geriatric patients. There was variability with disciplines responding to TTA, with largest, most comprehensive teams for tier 1. Two-thirds of TC review activation compliance (under/overtriage), while 55% focus on non-compliance and reasons for missed TTA. The most frequent challenges related to TTA practices were reliable data collection (60%) while successes included were the establishment of TTA guidelines to improve team compliance (33%) and RN initiated TTA., Conclusions: Some TTA practices were similar among Canadian TC, while others showed variability. Findings provide opportunities for improvement, including a two-tier system, geriatric-specific criteria, and RN initiated TTA, and could help establish national standards and best practices. Compliance with standards has the potential to improve Canadian TTA practices and patient outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this manuscript., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Penetrating chest trauma is an avoidable cause of death in traumatic patients. In initial management of these patients, evaluation of airway, respiratory status and circulation are prioritized. Patients with unstable conditions and life-threatening injuries require immediate intervention, but patients with stable vital signs should be investigated with further imaging. In the presence of a foreign body in the chest in a patient with stable conditions, removal should be performed in the operating room after complete imaging assessments including computed tomography (CT) scan without contrast agent, echocardiography and CT angiography. This article introduces a patient with penetrating chest trauma and stable vital signs with the presence of a foreign body and discuss about the importance of managing such patients.

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