Outcome predictors of patients who underwent limb amputation/s following trauma at a level I trauma center in North India.

PURPOSE: Limb amputation is one of the oldest medical operations, dating back over 2500 years to Hippocrates' time. In developing countries like India, most of the patients are young, and trauma is the primary cause of limb amputation. The objectives of this study were to investigate the factors that can predict the outcome of patients who underwent upper or lower limb amputations. MATERIALS AND METHODS: This was a retrospective analysis of the prospectively collected data of patients who underwent limb amputations from January 2015 to December 2019. RESULTS: From January 2015 to December 2019, 547 patients underwent limb amputations. Males predominated (86%). Road traffic injuries (RTI) were the most common (323, 59%) mechanism of injury. Hemorrhagic shock was present in 125 (22.9%) patients. Above-knee amputation was the most common (33%) amputation procedure performed. The correlation of hemodynamic status at presentation with the outcome was statistically significant (p-0.001). Outcome measures like delayed presentation, hemorrhagic shock, Injury severity scores (ISS), and the new injury severity scores (NISS) were statistically significant (p-0.001) when compared to the outcome. There were 47 (8.6%) mortalities during the study period. CONCLUSION: Factors that affected the outcome were delayed presentation, hemorrhagic shock, higher ISS, NISS, MESS scores, surgical-site infection, and associated injuries. Overall mortality during the study was 8.6%.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe.

INTRODUCTION: Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. METHODS: Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. RESULTS: The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. CONCLUSIONS: Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Validation of the adapted clavien dindo in trauma (ACDiT) scale to grade management related complications at a level I trauma center.

Objectives: Complications during trauma management are the main factor responsible for the overall increase in treatment cost. There are very few grading systems to measure the burden of complications in trauma patients. A prospective study was conducted using the Adapted Clavien Dindo in Trauma (ACDiT) scale, with the primary aim of validating it at our center. As a secondary aim, it was also wanted to measure the mortality burden among our admitted patients. Material and Methods: The study was conducted at a dedicated trauma center. All patients with acute injuries, who were admitted, were included. An initial treatment plan was made within 24 hours of admission. Any deviation from this was recorded and graded according to the ACDiT. The grading was correlated with hospital-free days and ICU-free days within 30 days. Results: A total of 505 patients were included in this study, with a mean age of 31 years. The most common mechanism of injury was road traffic injury, with a median ISS and NISS of 13 and 14, respectively. Two hundred and forty-eight out of 505 patients had some grade of complication as determined by the ACDiT scale. Hospital-free days (13.5 vs. 25; p <0.001) were significantly lower in patients with complications than those without complications, and so were ICU-free days (29 vs. 30; p <0.001). Significant differences were also observed when comparing mean hospital free and ICU free days across various ACDiT grades. Overall mortality of the population was 8.3 %, the majority of whom were hypotensive on arrival and required ICU care. Conclusion: We successfully validated the ACDiT scale at our center. We recommend using this scale to objectively measure in-hospital complications and improve trauma management quality. ACDiT scale should be one of the data points in any trauma database/registry.

Magnitude and outcomes of complex perineal injury - A retrospective analysis of five years' data from a Level 1 trauma centre.

Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.

Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study.

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty-six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer-generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In-hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train-associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.