Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study.

PURPOSE: To review the management of patients >16 years with blunt splenic injury in a single, UK, major trauma centre and identify whether the following are associated with success or failure of non-operative management with selective use of arterial embolization (NOM ± AE): age, Injury Severity Score (ISS), head injury, haemodynamic instability, massive transfusion, radiological hard signs [contrast extravasation or pseudoaneurysm on the initial computed tomography (CT) scan], grade, and presence of intraparenchymal haematoma or splenic laceration. METHODS: Retrospective, cross-sectional study undertaken between April 2012 and October 2015. Paediatric patients, penetrating splenic trauma, and iatrogenic injuries were excluded. Follow-up was for at least 30 days. RESULTS: 154 patients were included. Median age was 38 years, 77.3% were male, and median ISS was 22. 14/87 (16.1%) patients re-bled following NOM in a median of 2.3 days (IQR 0.8-3.6 days). 8/28 (28.6%) patients re-bled following AE in a median of 2.0 days (IQR 1.3-3.7 days). Grade III-V injuries are a significant predictor of the failure of NOM ± AE (OR 15.6, 95% CI 3.1-78.9, p = 0.001). No grade I injuries and only 3.3% grade II injuries re-bled following NOM ± AE. Age ≥55 years, ISS, radiological hard signs, and haemodynamic instability are not significant predictors of the failure of NOM ± AE, but an intraparenchymal or subcapsular haematoma increases the likelihood of failure 11-fold (OR 10.9, 95% CI 2.2-55.1, p = 0.004). CONCLUSIONS: Higher grade injuries (III-V) and intraparenchymal or subcapsular haematomas are associated with a higher failure rate of NOM ± AE and should be managed more aggressively. Grade I and II injuries can be discharged after 24 h with appropriate advice.

Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre.

BACKGROUND: Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm. MAIN BODY: Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE. CONCLUSION: Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.

Changing prophylactic antibiotic protocol for reducing Clostridium difficile-associated diarrhoeal infections.

PURPOSE: To determine whether a change in prophylactic antibiotic protocol for orthopaedic surgeries may reduce the frequency of Clostridium difficile-associated diarrhoeal infections. METHODS: Records of 1331 patients who underwent trauma or elective surgeries involving implantation of metalwork were reviewed. 231 trauma and 394 elective patients who received intravenous cefuroxime-based antibiotic prophylaxis between August 2006 and January 2007 were compared with 216 trauma and 490 elective patients who received a single dose of gentamicin and flucloxacillin or teicoplanin for antibiotic prophylaxis between August 2007 and January 2008. Diarrhoeal faecal specimens of 148 (33%) trauma patients and 106 (12%) elective patients were examined. The outcome variables were the rates of C difficile infection and early deep wound infection. RESULTS: There were 32 cases of C difficile-associated diarrhoeal infection and 28 cases of early deep wound infection. The frequency of C difficile-associated diarrhoeal infection decreased after use of the new antibiotic protocol (from 4 to 1%, p = 0.004), particularly in the trauma patients (from 8 to 3%, p = 0.02); in the elective patients the difference was not significant (from 1 to 0.5%, p = 0.27). The change of antibiotic protocol did not significantly affect the incidence of deep wound infections in the trauma (p = 0.46) or elective (p = 0.90) patients. The rate of C difficile infection was 8-fold higher in the trauma than elective patients, both before and after the change of protocol. CONCLUSION: Changing antibiotic protocol is one way of reducing the incidence of C difficile-associated diarrhoeal infections in orthopaedic patients, without increasing the rate of deep wound infections.