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The coronavirus disease 2019 (COVID-19) pandemic has necessitated a redistribution of resources to meet hospitals’ service needs. This study investigated the impact of COVID-19 on a regional trauma center in South Korea.
We retrospectively reviewed cases of polytrauma at a single regional trauma center in South Korea between January 20 and September 30, 2020 (the COVID-19 period) and compared them to cases reported during the same time frame (January 20 to September 30) between 2016 and 2019 (the pre-COVID-19 period). The primary outcome was in-hospital mortality, and secondary outcomes included the number of daily admissions, hospital length of stay (LOS), and intensive care unit (ICU) LOS.
The mean number of daily admissions decreased by 15% during the COVID-19 period (4.0±2.0 vs. 4.7±2.2,
The observations at Regional Trauma Center, Pusan National University Hospital corroborate anecdotal reports that there has been a decline in the number of patients admitted to hospitals during the COVID-19 period. In addition, patients admitted during the COVID-19 pandemic had a significantly shorter hospital LOS than those admitted before the COVID-19 pandemic. These preliminary data warrant validation in larger, multi-center studies.
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Severe pelvic fractures are associated with genitourinary injuries, but the relationship between pelvic trauma and concomitant urethral injuries has yet to be elucidated. This study evaluated the incidence, mechanism, site, and extent of urethral injuries in male patients with pelvic fractures.
A retrospective cohort study was performed involving patients with urethral injuries accompanying pelvic fractures who visited Pusan National University Hospital from January 1, 2014 to December 31, 2019. Demographics, mechanisms of injury, clinical features of the urethral injuries, concomitant bladder injuries, methods of management, and the configuration of the pelvic fractures were analyzed.
The final study population included 24 patients. The overall incidence of urethral injury with pelvic fracture was 2.6%, with the most common mechanism of urethral injury being traffic accidents (62.5%). Complete urethral disruption (16/24, 66.7%) was more common than partial urethral injuries (8/24, 33.3%), and unstable pelvic fractures were the most common type of pelvic fracture observed (70.8%). There was no definitive relationship between the extent of urethral injury and pelvic ring stability.
The present study provides a 6-year retrospective review characterizing the incidence, mechanism, and clinical features of urethral injury-associated pelvic fractures. This study suggests that the possibility of urethral injury must be considered, especially in unstable pelvic fracture patients, and that treatment should be chosen based on the clinical findings.
The following recommendations are presented herein: All trauma patients admitted to the resuscitation room should be constantly (or periodically) monitored for parameters such as blood pressure, heart rate, respiratory rate, oxygen saturation, body temperature, electrocardiography, Glasgow Coma Scale, and pupil reflex (1C). Chest AP and pelvic AP should be performed as the standard initial trauma series for severe trauma patients (1B). In patients with severe hemodynamically unstable trauma, it is recommended to perform extended focused assessment with sonography for trauma (eFAST) as an initial examination (1B). In hemodynamically stable trauma patients, eFAST can be considered as the initial examination (2B). For the diagnosis of suspected head trauma patients, brain computed tomography (CT) should be performed as an initial examination (1B). Cervical spine CT should be performed as an initial imaging test for patients with suspected cervical spine injury (1C). It is not necessary to perform chest CT as an initial examination in all patients with suspected chest injury, but in cases of suspected vascular injury in patients with thoracic or high-energy damage due to the mechanism of injury, chest CT can be considered for patients in a hemodynamically stable condition (2B). CT of the abdomen is recommended for patients suspected of abdominal trauma with stable vital signs (1B). CT of the abdomen should be considered for suspected pelvic trauma patients with stable vital signs (2B). Whole-body CT can be considered in patients with suspicion of severe trauma with stable vital signs (2B). Magnetic resonance imaging can be considered in hemodynamically stable trauma patients with suspected spinal cord injuries (2B).
The following key questions and recommendations are presented herein: when is airway intubation initiated in severe trauma? Airway intubation must be initiated in severe trauma patients with a GCS of 8 or lower (1B). Should rapid sequence intubation (RSI) be performed in trauma patients? RSI should be performed in trauma patients to secure the airway unless it is determined that securing the airway will be problematic (1B). What should be used as an induction drug for airway intubation? Ketamine or etomidate can be used as a sedative induction drug when RSI is being performed in a trauma patient (2B). If cervical spine damage is suspected, how is cervical protection achieved during airway intubation? When intubating a patient with a cervical spine injury, the extraction collar can be temporarily removed while the neck is fixed and protected manually (1C). What alternative method should be used if securing the airway fails more than three times? If three or more attempts to intubate the airway fail, other methods should be considered to secure the airway (1B). Should trauma patients maintain normal ventilation after intubation? It is recommended that trauma patients who have undergone airway intubation maintain normal ventilation rather than hyperventilation or hypoventilation (1C). When should resuscitative thoracotomy be considered for trauma patients? Resuscitative thoracotomy is recommended for trauma patients with penetrating injuries undergoing cardiac arrest or shock in the emergency room (1B).
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Traumatic abdominal wall hernias (TAWHs) are uncommon and the incidence of this, which is rarely encountered in clinical practice, has been estimated at 1%. Furthermore, blunt transection of the entire abdominal wall musculature caused by seatbelt is a very rare complication. We report a case of adult with a complete disruption of the entire anterolateral abdominal wall muscle following the seatbelt injury. A 32-year-old male was wearing a seat belt in a high speed motor vehicle collision. Abdominal computed tomography (CT) scan revealed the complete disruption of bilateral abdominal wall musculatures including TAWH without visceral injury. However, injuries of small bowel and sigmoid colon were observed in the intra-operative field. The patient underwent the repair by primary closure of the defect with absorbable monofilament sutures. This case suggests that especially in TAWH patients, even if a CT scan is normal, clinicians should keep the possibility of bowel injury in mind, and choose a treatment based on the clinical findings.
Despite recent developments in the management of trauma patients in South Korea, a standardized system and guideline for trauma treatment are absent.
Five guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument.
Restrictive volume replacement must be used for patients experiencing shock from trauma until hemostasis is achieved (1B). The target systolic pressure for fluid resuscitation should be 80–90 mmHg in hypovolemic shock patients (1C). For patients with head trauma, the target pressure for fluid resuscitation should be 100–110 mmHg (2C). Isotonic crystalloid fluid is recommended for initially treating traumatic hypovolemic shock patients (1A). Hypothermia should be prevented in patients with severe trauma, and if hypothermia occurs, the body temperature should be increased without delay (1B). Acidemia must be corrected with an appropriate means of treatment for hypovolemic trauma patients (1B). When a large amount of transfusion is required for trauma patients in hypovolemic shock, a massive transfusion protocol (MTP) should be used (1B). The decision to implement MTP should be made based on hemodynamic status and initial responses to fluid resuscitation, not only the patient’s initial condition (1B). The ratio of plasma to red blood cell concentration should be at least 1:2 for trauma patients requiring massive transfusion (1B). When a trauma patient is in life-threatening hypovolemic shock, vasopressors can be administered in addition to fluids and blood products (1B). Early administration of tranexamic acid is recommended in trauma patients who are actively bleeding or at high risk of hemorrhage (1B). For hypovolemic patients with coagulopathy non-responsive to primary therapy, the use of fibrinogen concentrate, cryoprecipitate, or recombinant factor VIIa can be considered (2C).
This research presents Korea's first clinical practice guideline for patients with traumatic shock. This guideline will be revised with updated research every 5 years.
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Hemorrhagic shock is the leading cause of death in trauma patients worldwide. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique used to improve the hemodynamic stability of patients with traumatic shock and to temporarily control arterial hemorrhage. However, further research is required to determine whether REBOA with cardiopulmonary resuscitation (CPR) in near-arrest or arrest trauma patients can help resuscitation. We analyzed trauma patients who underwent REBOA according to their CPR status and evaluated the effects of REBOA in arrest situations.
This study was a retrospective single-regional trauma center study conducted at a tertiary medical institution from February 2017 to November 2019. We evaluated the mortality of severely injured patients who underwent REBOA and analyzed the factors that influenced the outcome. Patients were divided into CPR and non-CPR groups.
We reviewed 1,596 trauma patients with shock, of whom 23 patients underwent REBOA (1.4%). Two patients were excluded due to failure and a repeated attempt of REBOA. The Glasgow Coma Scale score was lower in the CPR group than in the non-CPR group (
Our study suggests that if REBOA is deemed necessary in a timely manner, it is better to perform REBOA before an arrest occurs. Therefore, appropriate protocols, including pre-hospital REBOA, should be constructed to demonstrate the effectiveness of REBOA in reducing mortality in arrest or impending arrest patients.
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