Early Outcomes of Pelvic Trauma Patients - Complications, ICU Stay and Treatment Concepts in Two ATLS Compliant Trauma Centers: Germany and Qatar.

PURPOSE OF THE STUDY Pelvic trauma causes severe threats especially to polytraumatized patients. Not only it is in itself a possible cause for significant bleeding, but it also indicates a high risk for intra-abdominal injuries. The initial treatment of patients with pelvic trauma follows the ATLS principles of priority-oriented treatment. To examine the value of this highly standardized concept and to evaluate the effect of different patient collectives on early outcome parameters, two large collectives from Germany and Qatar were analyzed regarding injury parameters and early outcomes. MATERIAL AND METHODS Patients were recruited in Hamad General Hospital, Doha, Qatar (HGH) and BG Trauma Center Ludwigshafen, Germany (BG). All patients that were treated with a pelvic fracture between 2013 and 2016 were included in this retrospective analysis. Demographic parameters were collected as well as type of injury and the frequency of complication parameters as pneumonia, acute kidney failure, ARDS, sepsis and amount of blood transfusion. 1436 patients with pelvic fracture (645 from BG and 791 from HGH) were recruited. The mean age was 57.4 years in the BG and 33.6 years in the HGH group (p<0.000). The mean ISS was 17.81 in the BG and 15.88 in the HGH group (p=0.009). The mean pelvic AIS was 2.65 in the BG and 2.25 in the HGH group (p<0.000). RESULTS The mean frequency of complications was 9.3% in the BG and 9.9% in the HGH group (p=0.128). The mean frequency of ARDS was significantly higher in the BG group than in the HGH group (5.6% vs. 1.8%, p<0.000). The mean frequency of blood transfusion was significantly lower in the BG group than in the HGH group (28.8% vs. 39.2%, p<0.000). CONCLUSIONS Despite significant differences in the two collectives, this analysis shows comparable results regarding early outcome parameters in patients with pelvic injuries. In total, pelvic injuries are accompanied by a relatively high complication risk and need to be evaluated and treated according to priority-based algorithms. Key words: ATLS®, pelvic injury, complications, polytrauma.

Trauma research in Qatar: a literature review and discussion of progress after establishment of a trauma research centre.

A structured research programme is one of the main pillars of a trauma care system. Despite the high rate of injury-related mortalities, especially road traffic accidents, in Qatar, little consideration has been given to research in trauma. This review aimed to analyse research publications on the subject of trauma published from Qatar and to discuss the progress of clinical research in Qatar and the Gulf Cooperation Council countries with special emphasis on trauma research. A literature search using PubMed and Google Scholar search engines located 757 English-language articles within the fields of internal medicine, surgery and trauma originating from Qatar between the years 1993 and 2013. A steep increase in the number of trauma publications since 2010 could be linked to the setting up of a trauma research centre in Qatar in 2011. We believe that establishing a research unit has made a major impact on research productivity, which ultimately benefits health care.

Epidemiology, causes and prevention of car rollover crashes with ejection.

Rollover crashes (ROCs) are responsible for almost a third of all highway vehicle occupant fatalities. Although ROCs are common and serious mechanism of injury, ROCs are under-reported. To analyze the causes, mechanism, impact and prevention of ROCs, we reviewed the literature between 1984 and 2013. By utilizing the search engines PubMed, MEDLINE and EMBASE by using key words "ROCs" "Ejection" and "vehicle" the initial search yielded 241 abstracts, of which 58 articles were relevant. Most of the articles were either retrospective or experimental studies funded by automobile companies. All vehicles are susceptible to rollovers to certain extents. Despite continuing innovation in vehicles' safety, human factor is pivotal in prevention of ROCs. Distracted driving, speeding and drinking escalate the chances of rollover crashes. Wearing a seatbelt greatly improves the chances of surviving a ROC.

Where cancer genomics should go next: a clinician's perspective.

Large-scale, genomic studies of specific tumors such as The Cancer Genome Atlas have provided a better understanding of the alterations of pathways involved in the development of solid tumors including glioblastoma, breast cancer, ovarian and endometrial cancers, colon cancer and lung squamous cell carcinoma. This tremendous effort of the scientific community has confirmed the view that cancer actually represents a wide variety of diseases originating from different organs. These studies showed that TP53 and PI3KCA are the two most mutated genes in all types of cancers and that 30-70% of all solid tumors harbor potentially 'actionable' mutations that can be exploited for patient stratification or treatment optimization. Translation of this huge oncogenomic data set to clinical application in personalized medicine programs is now the main challenge for the future. The gap between our basic knowledge and clinical application is still wide. Closing the gap will require translational personalized trials, which may initiate a radical change in our routine clinical practice in oncology.

Occult hemopneumothorax following chest trauma does not need a chest tube.

BACKGROUND: The increasing use of thoracic computed tomography (CT) in trauma patients has led to the recognition of intrapleural blood and air that are not initially evident on admission plain chest X-ray, defining the presence of occult hemopneumothorax. The clinical significance of occult hemopneumothorax, specifically the role of the tube thoracostomy, is not clearly defined. OBJECTIVE: To identify those patients with occult hemopneumothorax who can be safely managed without chest tube insertion. DESIGN: Prospective observational study. METHODS: During the recent 24 month period ending July 2010, comprehensive data on trauma patients with occult hemopneumothorax were recorded to determine whether tube thoracostomy was needed and, if not, to define the consequences of nondrainage. Pneumothorax and hemothorax were quantified by computed tomography (CT) measurement. Data included demographics, injury mechanism and severity, chest injuries, need for mechanical ventilation, indications for tube thoracostomy, hospital length of stay, complications and outcome. RESULTS: There were 73 patients with hemopenumothorax identified on CT scan in our trauma registry. Tube thoracostomy was successfully avoided in 60 patients (83 %). Indications for chest tube placement in 13 (17 %) of patients included X-ray evidence of hemothorax progression (10), respiratory compromise with oxygen desaturation (2). Mechanical ventilation was required in 19 patients, five of them required chest tube insertion, and six developed ventilator associated pneumonia, while there were no cases of empyema. There was one death due to severe head injury. CONCLUSIONS: Occult hemopneumothorax can be successfully managed without tube thoracostomy in most cases. Patients with a high ISS score, need for mechanical ventilation, and CT-detected blood collection measuring >1.5 cm increased the likelihood of need for tube thoracostomy. The size of the pneumothorax did not appear to be significant in determining the need for tube thoracostomy.

Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications.

BACKGROUND: Enteral nutrition (EN) is a widely used, standard-of-care technique for nutrition support in critically ill and trauma patients. OBJECTIVE: To review the current techniques of gastrointestinal tract access for EN. METHODS: For this traditional narrative review, we accessed English-language articles and abstracts published from January 1988 through October 2012, using three research engines (MEDLINE, Scopus, and EMBASE) and the following key terms: "enteral nutrition," "critically ill," and "gut access." We excluded outdated abstracts. RESULTS: For our nearly 25-year search period, 44 articles matched all three terms. The most common gut access techniques included nasoenteric tube placement (nasogastric, nasoduodenal, or nasojejunal), as well as a percutaneous endoscopic gastrostomy (PEG). Other open or laparoscopic techniques, such as a jejunostomy or a gastrojejunostomy, were also used. Early EN continues to be preferred whenever feasible. In addition, evidence is mounting that EN during the early phase of critical illness or trauma trophic feeding has an outcome comparable to that of full-strength formulas. Most patients tolerate EN through the stomach, so postpyloric tube feeding is not needed initially. CONCLUSION: In critically ill and trauma patients, early EN through the stomach should be instituted whenever feasible. Other approaches can be used according to patient needs, available expertise, and institutional guidelines. More research is needed in order to ensure the safe use of surgical tubes in the open abdomen.

Age and traumatic chest injury: a 3-year observational study.

BACKGROUND: A quarter of trauma-related deaths are attributable to traumatic chest injury (TCI). OBJECTIVE: To outline the pattern and outcome of TCI in a rapidly developing country among different age groups. METHODS: We conducted a retrospective observational study for patients who sustained TCI and admitted between January 2008 and December 2010 to the Level I trauma center at Hamad General Hospital in Qatar. Patients were classified and analyzed in four age groups (group 1 ≤18, group 2 between 19-44, group 3 45-59, and group 4 >60 years). Multivariate regression analysis was performed for predictors of mortality. RESULTS: Of 5,118 cases admitted to the Section of Trauma Surgery, 1,355 (26.5 %) had TCI (12, 67, 16, and 5 % in groups 1-4, respectively), which was due to blunt trauma in 96 % of cases. The overall mean age was 33 ± 15 years and males comprised 94 % of cases. Children (≤18 years of age) had more traffic-related injury, intubation, high Injury Severity Score (ISS) (19 ± 12), and associated head and liver injuries in comparison to the other groups. The overall mortality rate was 13 % (24, 11, 12, and 16 % in groups 1-4, respectively). The death rate was higher in pedestrians, followed by motor vehicle crashes (MVCs) and fall-related injuries (24 vs. 13 vs. 7 %, respectively, p = 0.001). The highest mortality occurred within the first day (n = 115, 65 %). In comparison to old age, children were more likely to die early (on the first day) and the adult group died mostly within the first week of hospitalization. Independent predictors for mortality included associated head injury [odds ratio (OR) 2.3, 95 % confidence interval (CI) 1.48-3.62), ISS (OR 1.11, 95 % CI 1.09-1.13), and age (OR 0.37, 95 % CI 0.22-0.62). CONCLUSION: TCI is an alarming problem in Qatar, with a bimodal mortality curve. The highest mortality peak occurred in children, followed by old age. However, young males are the most exposed population. Regulatory efforts and strict enforcement of traffic laws would likely reduce morbidity and mortality.

Percutaneous dilatational tracheostomies in a newly established trauma center: a report from Qatar.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) is a routine surgical procedure for critically ill patients who require prolonged ventilatory support. METHODS: We conducted a retrospective cohort study of all PDTs performed at the adult Trauma Intensive Care Unit (TICU) of Hamad Medical Corporation in Doha, Qatar, from January 2009 through September 2012. For all adult patients, we analyzed the demographic characteristics, mean ventilator time before the procedure, injury severity score (ISS), complications, and outcomes. RESULTS: Of the 1,442 trauma patients admitted to the adult TICU during our study period, 124 (8.5 %) underwent PDT using the Ciaglia Blue Rhino technique. The vast majority were male (94.3 %). The mean age was 35 ± 15.6 years; mean ventilator time before the procedure, 12 ± 3 days; and mean ISS, 24.2 ± 9.3. More than half of patients had head injury (56 %), followed by chest and abdomen (26 %) and cervical spine injuries (18 %). Early complications included difficult tube placement (0.8 %), hypoxemia (0.8 %), minor bleeding (1.6 %), and hypotension (0.8 %), but the vast majority (93 %) of patients had no complications. The procedure-related mortality rate was 0 %. CONCLUSION: PDT is safe and can be performed with minimal complications even in a newly established trauma center.

Clinical outcomes of multiple rib fractures: does age matter?

PURPOSE: To evaluate the clinical outcomes of multiple rib fracture due to blunt trauma in young patients, a 3-year retrospective study was conducted. Patients with ≥3 rib fractures were divided into two groups (group I: <45 years old and group II: ≥45 years old). Mortality, hospital stay, ventilatory support, chest tubes insertion and associated injuries were studied. RESULTS: Of the 902 patients admitted with blunt chest trauma, 240 (27 %) met the inclusion criteria and 72.5 % patients were <45 years old. The most common causes of injury were motor vehicle crash (59 %) and fall (29 %). The Injury Severity Score (ISS) was higher in group I (16 ± 9 vs. 13 ± 6; p = 0.04). Hospital mortality was higher in group II (6 vs. 2 %; p = 0.18). Pneumothorax, haemothorax and ventilatory support were comparable. Patients in group II were more likely to undergo chest tubes insertion (26 vs. 14 %; p = 0.04), while group I had a significantly higher incidence of associated abdominal injuries (25 vs. 12 %; p = 0.03). CONCLUSION: Old age presenting with rib fractures is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture.

Trichosporon fungal arteritis causing rupture of vascular anastamosis after commercial kidney transplantation: a case report and review of literature.

This is a case report of a ruptured vascular anastomosis resulting from fungal arteritis in a commercial renal transplantation. The diagnosis was made quite early posttransplantation (at the 18th posttransplant day); this was proved by histopathologic examination and culture of the vessel wall,which showed Trichosporon fungal infection. The patient underwent operation for control of the bleeding and removal of the graft and of the diseased iliac vascular segment. On reviewing the literature, we found 17 reports of fungal arteritis in solid-organ transplant recipients; our case was the first one to report Trichosporon species as the causative agent. Infection could result from surgical or graft contamination or from preexistent infection in the patient. There is a consensus that the standard of care should include removal of the graft and the diseased iliac vascular segment with an appropriate vascular graft, because simple suturing of the disrupted infected anastomosis generally ends with disastrous recurrent rupture. A high index of suspicion is required to ensure both early diagnosis and appropriate treatment to prevent tragic loss of recipient life.