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What’s New In Trauma?

Discover the latest advancements in trauma care, including the rise of non-operative management and the use of angioembolization as an adjunct. Learn about the efficacy and complications of these techniques for solid organ injuries, pelvic fractures, and more.

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What’s New In Trauma?

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

  2. 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

  3. Rise of Angioembolization • Endovascular techniques used in trauma 1990s • 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

  4. 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

  5. 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

  6. Angioembolization • Renal • Who? • No consensus • Stable patients • AAST Grade ≥ 4 • Extravasation of contrast or arterial injury • Peri-renal hematoma rim ≥ 3.5cm • Efficacy • Re-intervention rate 83% • AE failure rate 27%

  7. 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)

  8. Selective NOM of Low Velocity Penetrating Abdominal Injury

  9. History • Mandatory Exploratory Laparotomy: ‘standard of care’ until 1960s • 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

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

  11. 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

  12. Algorithm

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

  14. 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

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

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

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

  18. 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

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