Whats New In Trauma Damien Ah Yen Trauma

What’s New In Trauma? Damien Ah Yen Trauma and General Surgeon Waikato Hospital

What’s New? • Little progress in Operative Management • Progress Non Operative Management (NOM) • Sometimes LESS surgery is MORE • Angioembolization • Selective NOM of penetrating abdominal injury • With some exceptions… • Rib Fixation

Rise of Angioembolization • Endovascular techniques used in trauma 1990 s • Adjunct of Non-Operative Management (NOM) • From paediatric NOM experience • Principles • Gel foam vs Coils • Selective vs Non-selective • What types of injuries? • Solid Organ Injuries • Spleen • Liver • Kidneys • Pelvic fractures with vascular injury

Angioembolization • Spleen • Who? • “Stable patients” Transiently responsive? • • AAST Grade ≥ 4 Contrast Blush Arterial Injury Hemoperitoneum • Efficacy • Improves success of NOM up to 97% in the high grade injuries • Major complications – 9% re-bleed or major infarction requiring splenectomy

Angioembolization • Hepatic Injuries • Who? • Stable patients • No consensus • Contrast blush • High grade injury (AAST ≥ 4) • Unstable patient: Operative adjunct • Hepatic arterial bleed • Efficacy • 93% effective in haemorrhage control • Complications (11%) • Liver and gallbladder necrosis (majority) • Bile leak • Liver failure

Angioembolization • Renal • Who? • No consensus • Stable patients • AAST Grade ≥ 4 • Extravasation of contrast or arterial injury • Peri-renal hematoma rim ≥ 3. 5 cm • Efficacy • Re-intervention rate 83% • AE failure rate 27%

Angioembolization • Pelvic haemorrhage associated with an unstable pelvic fracture • Mortality up to 33% - polytrauma with pelvic ring fractures • Who? • Haemodynamically unstable • CT confirmed bleed • Contrast blush? • Efficacy • One series report 0% mortality in AE group vs 20% in the non-AE • Morbidity associated with delay to AE • ARDS, transfusion requirement, MOF • Complications • Access site (up to 9%) • Nephropathy (24%) • Claudication, skin necrosis, erectile dysfunction (rare)

Selective NOM of Low Velocity Penetrating Abdominal Injury

History • Mandatory Exploratory Laparotomy: ‘standard of care’ until 1960 s • Up to 45% are non-therapeutic • 20% complications • Selective Non-Operative Management • There is a role of selective approach • Diagnostic accuracy of various modalities is variable • Other factors add to the complexity • Resource constraints • Local expertise and team infrastructure • Volume

Selection • Clinical • Assessable • Generalised peritonism, evisceration, and instability exploration • Imaging • USS • CT • Interventional (diagnostic +/- therapeutic) • Local Wound Exploration • Laparoscopy

Algorithms • Several algorithms • All reduce non-therapeutic laparotomies • Combination of modalities mentioned before • Principles • Selection of those at ‘low risk’ • Assessable • No peritonism, no evisceration, haemodynamically stable and normal CT • Active observation (serial exams, blood tests, regular observations) of those for NOM • Access to OT with experienced operators

Algorithm

Thoracoabdominal wounds • Risk for diaphragmatic injuries • Low threshold for laparoscopy • CT is not very good at excluding diaphragm injury

Role of Rib Fixation • Rib fractures are common • Rib fractures increased morbidity and mortality • Risk worsened by age and other co-morbidities • Multiple aspects of “bundled care” • • Identification of ‘at risk patients’ Multimodal analgesia Pulmonary Hygiene OPERATIVE INTERVENTION

Role of Rib Fixation • Been around a while – dates back 1950 s • Different fixation devices • Generally in and out of favour • 1970 s benefit in the flail chest • Currently there is increasing interest in selected cases

Role of Fixation • Who? • De Moya et al, 2017

Role of Rib Fixation • Benefit • • Pneumonia reduction Reduction of ICU stay Reduced tracheostomy rates Earlier return to work

Summary • Angioembolization is an adjunct to NOM of solid organ injuries and it is the standard of care for haemorrhage associated with pelvic fractures • Consider NOM for stab wounds to the abdomen in the absence of peritoneal signs and haemodynamic instability • • Select those who are suitable for this approach CT is useful in stratifying risk Laparoscopy is safe in experienced hands to explore the abdomen Low threshold for a laparotomy • Chest injury management is multi-modal and multidisciplinary • Identify the ‘high risk’ • Provide adequate analgesia • Look out for those who may benefit from rib fixation