Incidence and Predictive Factors of Massive Hemothorax Due to Thoracic Vertebral Fractures.

Introduction: Massive hemothorax due to thoracic vertebral fractures (MHTVF) is a potentially lethal condition; however, its epidemiological and clinical data have been rarely described. Thus, in this study, we aimed to evaluate the incidence, predictive factors, and clinical features of MHTVF. Methods: This retrospective cohort study enrolled 202 consecutive patients (136 male and 66 female patients) with thoracic vertebral fractures treated at our institute between January 2009 and December 2019. Their mean age was 60.7 (range, 17-90) years. Unstable fractures accounted for 57.4% (n=116) of the total fractures. The patients were then divided into MHTVF and non-MHTVF groups. We assessed the following MHTVF-associated factors: sex, age, history of medical conditions, anticoagulation/antiplatelet drug use, injury severity score, anatomical distribution of levels of the vertebral fractures, fracture type, and presence or absence of diffuse idiopathic skeletal hyperostosis (DISH) fracture. Results: In total, eight patients (six men and two women) with a mean age of 68.9 years (range, 22-85 years) were determined to exhibit MHTVF. The incidence of MHTVF in patients with unstable thoracic spinal fractures was 6.9%, whereas none of those with stable spinal fractures exhibited MHTVF. Factors like type B (p=0.049) and DISH (p=0.017) fractures were noted to be significantly associated with the MHTVF. Three patients experienced shock upon arrival, whereas two exhibited delayed shock. Chest tube insertion and/or emergency thoracotomy was performed. The survival rate was 100.0%. Conclusions: MHTVF is not rare. Because type B and DISH fractures are identified as predictive factors of MHTVF, it must be carefully treated to avoid preventable death even after hospitalization in patients with these thoracic fractures.

Prediction of early acute kidney injury after trauma using prehospital systolic blood pressure and lactate levels: A prospective validation study.

BACKGROUND: Acute kidney injury (AKI) after trauma is a major complication independently associated with a prolonged hospital stay and increased mortality. We previously reported that the prehospital systolic blood pressure (SBP) and early hospital arterial lactate level, along with specific cut-off values, show good performance in the early prediction of AKI using AUC-ROC [1]. The purpose of this study was to prospectively validate whether or not these parameters are predictive of newly occurring AKI after trauma. METHODS: This was a prospective review of trauma patients who were admitted to a single trauma center from January to December 2019. Patients who were <16 years old, who had burns, and who had chronic kidney disease were excluded. AKI was defined according to the Risk, Injury, Failure, Loss of the kidney function, and End-stage kidney disease (RIFLE) classification based on serum creatinine alone. Patients with a low prehospital SBP (≤126 mmHg) and high lactate levels (≥2.5 mmol/L) were defined as the high-risk group, and other patients were defined as the low-risk group. RESULTS: A total of 489 trauma patients were admitted to our center, of whom 403 were eligible for the study. The high-risk group consisted of 38 patients, and the low-risk group consisted of 365 patients. The incidence of severe AKI in Stage Injury and Failure was significantly higher in the high-risk group (5 patients, 13.2%) than in the low-risk group (7 patients, 1.9%), with an odds ratio of 7.75 and 95% confidence interval of 2.33-25.77. CONCLUSIONS: These predictors showed good performance in the early prediction of severe AKI after trauma. Early prediction of the high-risk groups for severe AKI after trauma prompting early treatment may help improve the prognosis of trauma patients.

Prehospital Blood Pressure and Lactate are Early Predictors of Acute Kidney Injury After Trauma.

BACKGROUND: The purpose of this study is to report the prevalence of acute kidney injury (AKI) after trauma in our center, describe the risk factors associated with AKI, and determine whether these risk factors help avoid AKI. MATERIALS AND METHODS: We retrospectively analyzed the data which were prospectively collected from a single center trauma registry from January 2017 to December 2018. Patients who were <16 years of age, patients with burns, and patients with chronic kidney disease were excluded from the present study. AKI was defined according to the risk, injury, failure, loss of the kidney function, and end-stage kidney disease (RIFLE) classification from serum creatinine alone. A logistic regression analysis was performed to identify prehospital and early hospital risk factors for AKI. RESULTS: There were 806 trauma patients recorded in the database. One hundred thirty cases were excluded based on the abovementioned exclusion criteria. Six hundred seventy-six patients were included in the analysis. The prevalence of AKI in the overall population was 14.5% including 10.5% of patients with stage R, 3.0% of patients with stage I and 1.0% with stage F. The incidence of AKI increased to 36.3%, 12.1% and 3.3% in the subgroup of patients with hemorrhagic shock. The multivariate analysis revealed that the minimum prehospital systolic blood pressure and arterial lactate level were independent predictors of AKI. The model showed good discrimination with an area under the receiver operating characteristic curve (AUC-ROC) of 0.867 and 0.852 in the prediction of AKI stage I or F. The cutoff values were ≤126 mmHg and ≥2.5 mmol/L, respectively. CONCLUSION: These parameters showed good performance in the early prediction of AKI after trauma. They are associated with the early onset of AKI after trauma and may be an early predictor of the effects of treatment to prevent AKI.

Usefulness of Repeat Angiography to Establish Spontaneous Coronary Artery Dissection in Small Vessels.

Background: Spontaneous coronary artery dissection (SCAD) is a rare disease that is often misdiagnosed, except in typical cases. Although intracoronary imaging and multislice coronary computed tomography angiography (CCTA) are useful in establishing dissection, they may not be feasible in all instances, especially in small vessels. Methods and Results: We describe a series of 7 patients with acute coronary syndrome secondary to small vessel SCAD that was detected only upon repeat coronary angiography (CAG). This cohort had a mean (±SD) age of 50±6 years, was predominantly female (n=6; 86%), and had few coronary risk factors. Three patients (43%) had dissection of the distal segment of the right coronary artery, 3 (43%) had distal left circumflex artery dissection, and 1 patient (14%) had a diagonal branch dissection. None of the patients required percutaneous coronary intervention, and received conservative therapy only, because the infarct area was sufficiently small. No definitive diagnosis of SCAD could be established in any of the patients at first admission because CAG alone or CCTA did not reveal the presence of a flap or intraluminal hemorrhage. However, in such patients without a definitive diagnosis, repeat CAG in the chronic stage showed enlargement of vessels, suggesting the healing of an SCAD. Conclusions: Repeat CAG may be useful for suggesting the occurrence of SCAD.

Outcomes of abdominal trauma patients with hemorrhagic shock requiring emergency laparotomy: efficacy of intra-aortic balloon occlusion.

Aim: The aims of this study were to investigate outcomes of abdominal trauma in patients with hemorrhagic shock requiring emergency laparotomy and clarify the beneficial effects of intra-aortic balloon occlusion (IABO) for intra-abdominal hemorrhage in patients with critically uncontrollable hemorrhagic shock (CUHS). Methods: We reviewed 44 hemorrhagic shock patients who underwent emergency laparotomy for intra-abdominal hemorrhage over a 6-year period. Of these patients, we examined data for 19 subjects who underwent IABO during initial resuscitation to control massive intra-abdominal bleeding leading to CUHS. Results: The average Injury Severity Score and probability of survival (Ps) of the 44 patients were 27.6 ± 15.4 and 0.735 ± 0.304, respectively, and the overall survival rate was 77.3%. The differences in the Glasgow Coma Scale, lactate level, prothrombin time - international normalized ratio, and Ps between the two groups (21 responders and 23 non-responders) were statistically significant (P < 0.05). Intra-aortic balloon occlusion was attempted in 19 of 23 patients (82.6%) with CUHS, and there were no statistically significant differences in presenting Glasgow Coma Scale, body temperature, lactate, prothrombin time - international normalized ratio, or Revised Trauma Score between the survivors (n = 12) and non-survivors (n = 7). The only significant differences between these two groups were observed in Injury Severity Score (P = 0.047) and Ps (P = 0.007). In all patients, the balloons were successfully placed in 8.1 ± 3.3 min in the thoracic aorta, and a significant increase in systolic blood pressure was observed immediately after IABO. Conclusion: The IABO procedure can be life-saving in the management of patients with CUHS arising from intra-abdominal hemorrhage, permitting transport to surgery.

Comparison of hemostatic durability between N-butyl cyanoacrylate and gelatin sponge particles in transcatheter arterial embolization for acute arterial hemorrhage in a coagulopathic condition in a swine model.

This study was designed to compare the efficacy of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) or gelatin sponge particles (GSP) for acute arterial bleeding in a coagulopathic condition using a swine model. Four healthy swine were divided into two coagulopathic conditions: mild and severe. Five hemorrhages were created in each swine (10 hemorrhages per coagulopathy). Mild coagulopathy was achieved by bloodletting 10% of the total circulatory whole blood and preserving activated clotting time (ACT) less than 200 s (ACT < 200 s state); severe coagulopathy was achieved by bloodletting 30% and preserving ACT > 400 s (ACT > 400-second state). For each state, of ACT < 200 s or ACT > 400 s, TAE was conducted with GSP or NBCA to control five hemorrhages arising from artificially created renal and splenic injuries. Angiography immediately after TAE with GSP or NBCA showed complete occlusion in both coagulopathic conditions. In the ACT < 200-second state, follow-up angiography at 5-30 min after TAE with GSP or NBCA showed no evidence of recurrent hemorrhage. In the ACT > 400-second state, follow-up angiography showed recurrent hemorrhage in four (80%) of the five hemorrhages embolized with GSP and in one (20%) of the five hemorrhages embolized with NBCA. Microscopically, red thrombi were observed densely surrounding GSP in mild coagulopathy but were scarce in severe coagulopathy. In a condition with severe coagulopathy, TAE with NBCA was more effective in durability to cease active arterial bleeding than with GSP.

Evaluation of transcatheter arterial embolization with gelatin sponge particles, microcoils, and n-butyl cyanoacrylate for acute arterial bleeding in a coagulopathic condition.

PURPOSE: To evaluate the outcome of transcatheter arterial embolization with gelatin sponge particles, microcoils, and N-butyl cyanoacrylate (NBCA) for acute arterial hemorrhage in the setting of coagulopathy. MATERIALS AND METHODS: Coagulopathy is defined by a platelet count less than 5 x 10(4)/microL and/or International Normalized Ratio (INR) greater than 1.5. Forty-six patients (31 male patients; mean age, 62 years) with acute arterial hemorrhage in a coagulopathic condition were treated by transcatheter arterial embolization with gelatin sponge particle, microcoils, and NBCA. RESULTS: Because of failure of hemostasis or recurrent hemorrhage, 10 patients who underwent gelatin sponge particle embolization also received transcatheter arterial embolization with microcoils or NBCA embolization and two patients who underwent microcoil embolization also received transcatheter arterial embolization with NBCA. The gelatin sponge particle group consisted of 27 hemorrhagic arteries in 25 patients, the microcoil group had 20 in 20 patients, and the NBCA group had 16 in 13 patients. The mean platelet count and mean INR value were 5.8 x 10(4)/microL +/- 3.5 and 1.81 +/- 0.50, respectively. The primary hemostatic rate, recurrent hemorrhage rate, and mean treatment time for the gelatin sponge particle, microcoil, and NBCA groups were 67%, 23%, and 25 minutes +/- 10; 80%, 0%, and 37 min +/- 19; and 100%, 0%, and 9 min +/- 4, respectively. Primary and secondary hemostasis were achieved in 50 (80%) and 60 (95%) of the 63 hemorrhagic arteries, respectively. Three hemorrhagic arteries in which transcatheter arterial embolization failed were treated with surgical repair. CONCLUSIONS: Although transcatheter arterial embolization with microcoils took a greater amount of time, transcatheter arterial embolization with NBCA or microcoils was more effective and feasible than that with gelatin sponge particle in terms of hemostasis and prevention of recurrent hemorrhage in a coagulopathic condition.

[Surgical stabilization of multiple rib fracture and flail chest].

The experience of 14 cases with surgical stabilization of multiple rib fracture and flail chest was reported. They were 11 men and 3 women of 31 to 87 years of age. Paradoxical chest movement was noted in 10 patients. Thirteen of 14 patients successfully weaned from the ventilator less than 7 days after surgery. Of 14, 4 cases were treated with internal fixation and the others were with acetabular reconstruction plates with or without rib stapler. No case of death was experienced. Ten patients who were performed fixation with acetabular reconstruction plate weaned from the ventilator earlier than cases treated by internal fixation, suggesting the superiority of the acetabular reconstruction plate. Improvement of rib stapler and the development of a titanium plate of specific use for rib is expected in the future.