, Chiyoung Cha 
, Adel Elkbuli, Sarah E. Johnson, David L. McClure, Antonio Pepe 
, Chan Yong Park 
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, Arun Kumar M, Kshitij Jyoti, A Saravana Santhosh, Vitesh Popli 
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, Kyu-Hyouck Kyoung, Sungjeep Kim, Min Ae Keum, Seongho Choi, Kyounghak Choi, Jihoon Kim 
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, Jae Hun Kim, Sun Hyun Kim 
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, Im-kyung Kim, Jae Gil Lee 
, Young Sun Yoo, Seong Pyo Mun 
, Kiyoung Sung, Jinbeom Cho Citations
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, Ki Hoon Kim 
, Giljae Lee, Jungnam Lee, Byungchul Yu Citations
Adrenal gland injuries in trauma are rare and usually misdiagnosed or undere-stimated in an emergency setting because they are asymptomatic and associated with severe abdominal injuries. This paper reviews the clinical characteristics of adrenal injuries.
A retrospective analysis of trauma patients who visited the authors’ emergency center was performed from March, 2010 to December, 2017. The patient demographic data, injury mechanism & associated injuries, injury severity score, hospital stay, and mortality were retrieved and analyzed.
Adrenal gland injuries were found in 52 patients: 73.1% (n=38) were males and the mean age was 43.6 years. Of the patients, 84.6% (n=44) had ISS =15. Right adrenal gland injuries occurred in 82.7% (n=43). The mechanism of injury was falls in 30.8% (n=16), motor vehicle accidents in 25.0% (n=13), and pedestrian accidents in 23.1% (n=12). Associated injures were liver injury (58.5%), rib fracture (52.8%), kidney injury (24.5%), pelvic bone fracture (20.8%), spine fracture (28.3%), and spleen injury (13.2%). The mean hospital stay was 34.2 days, and the intensive care unit stay was 9 days. The mortality rate was 3.8% (n=2).
Adrenal gland injuries are common in males and frequent in the right side. Falls are the leading cause of injury. Most injuries have an associated injury at the abdominal or thoracic region. Adrenal injury is accompanied by high injury severity but showed a good prognosis.
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Mangled injury is defined as severe injury, including three or more tissues such as bones, nerves, vessels, muscles, and tendons in the upper or lower extremities. The choice of treatment results in different cosmetic and functional outcomes for mangled injury. In this study, we estimated patients’ quality of life after treatment with the future intention of having patients make proper decisions at the time of injury.
Twenty patients were treated at Asan Medical Center from January, 2009 to November, 2011, and 11 patients were included who agreed with the questionnaire. We used 36-item short form health survey (SF-36) for estimating quality of life after treatments.
Subjective satisfaction of cosmetic and functional aspects was higher in the reconstruction group than in the amputation group. However, in the estimation of specified satisfaction using SF-36, the amputation group was more satisfied than the reconstruction group.
Among the many treatment considerations at the time of injury, expected cosmetic and functional outcomes were important parts determining the decision. In our study, the amputation group showed a better satisfaction level. This result could help patients make more appropriate decisions in the case of mangled injury.
The concept of acute care surgery (ACS) incorporates trauma, surgical critical care, and emergency general surgery. It was designed in the early 2000s by the United States as a solution to the looming crisis of trauma care and non-trauma emergency surgery. Reduced surgical opportunities for trauma surgeons resulted in a decreased interest in trauma surgery. Surgical sub-specialization further accelerated an indifference towards trauma and emergency general surgery. Started in 2008, the trauma center project in Korea is still in its infancy. Although the need for ACS was presented since the inception of the trauma center project, there was a lack of implementation at trauma centers due to government regulations. However, ACS has been initiated at several non-trauma center hospitals and is mainly operated by surgical intensivists. Studies demonstrate that adding emergency surgery to a trauma service does not compromise the care of the injured patients, despite an increase in trauma volume. Positive impacts of ACS are reported by numerous researches. We believe that the development and advancement of trauma centers will necessitate a discussion for the implementation of the ACS model at trauma centers in Korea.
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The traditional drug for anticoagulation in those with a high risk of thrombosis is a vitamin K antagonist, such as warfarin. On the other hand, this drug has several limitations and hemorrhagic complications. Recently, novel or non-vitamin K-dependent antagonist oral anticoagulants (NOACs) have been developed to solve these problems. This paper presents a case of adaptation of NOAC for a warfarin anticoagulated patient with traumatic ongoing hemorrhages with a discussion of the clinical implications of NOAC.
Takotsubo syndrome, also known as stress-induced cardiomyopathy, is a transient cardiac syndrome that mimics acutecoronary syndrome. This condition should be suspected if the patient presents with chest pain after intense emotional stress, accompanied by an abnormal electrocardiogram, elevated levels of myocardial enzymes, and left ventricular apical akinesia on echocardiography. Coronary angiography should be performed for prompt differentiation from ischemic heart disease. A 77-year-old female presented with traumatic multiple fractures of the left sixth and seventh ribs resulting from a violent strike. Clinical findings of physical examination, laboratory tests, electrocardiogram, and coronary angiography provided the diagnosis of Takotsubo syndrome. We performed conservative management including pain control, and the patient was uneventfully discharged seven days after admission.
The aim of this study is to evaluate treatment outcomes and mortality risks associated with hemodynamic instability caused by severe pelvic fracture in a regional trauma center.
The medical charts of 44 patients with hemodynamic instability due to pelvic fractures who were admitted to a regional trauma center from January 2014 to May 2017 were analyzed retrospectively.
The mean age was 61.8 years, and the mean injury severity score was 39.1. Twenty-six patients (59.1%) were transferred from other hospitals, and the median time from injury to emergency room arrival was 115.5 minutes. Preperitoneal pelvic packing, pelvic angiography, and external pelvic fixation were performed in 38 patients (86.4%) for hemostasis. The mortality rate was 52.3%, and 15 patients (34.1%) died from hemorrhage. Logistic regression analysis showed that initial low systolic blood pressure and packed red blood cell (PRBC) requirement were independent risk factors associated with mortality. PRBC requirement for four hours and application of emergent hemostatic procedures were independent factors associated with hemorrhage-induced mortality.
Emergency procedures for hemostasis should be performed immediately for patients with hemodynamic instability due to pelvic fracture, and they should be transferred to a regional trauma center as soon as possible.
, Hyun Min Cho, Kwang Hee Yeo, June Pill Seok, Chan Kyu Lee We report a rare case of a 47-year-old male with posttraumatic phlegmasia cerulea dolens caused by a ruptured right external iliac vein and treated with an endovascular venous stent graft. The patient was the victim of motor vehicle accident, and suffered direct injuries to the head and abdomen. The patient had a cyanotic and swollen right lower leg. Abdominal and lower extremity computed tomography angiography revealed a large retroperitoneal hematoma caused by a ruptured right external iliac vein, and grade I liver injury. The right external iliac vein rupture was successfully treated with a venous stent graft, followed by inferior vena cava filtering, because a venous thrombus was identified below the stent graft. He initially was hemodynamically unstable but recovered following treatment. The patient was comatose when presenting at the emergency department. He was discharged, fully recovered, on hospital day 18.
An ischemia-reperfusion injury of the intestine due to blunt trauma is very rare. Low blood flow can result in an incarceration and an ischemia-reperfusion injury of the small intestine. A 63-year-old woman fell, producing a splenic rupture. Despite the successful angio-embolization of the splenic rupture, the patient continued to suffer from hypotension. During laparotomy to identify the bowel injury, no intestinal perforation was found. However, we found a hemorrhagic infarction of the small intestine with congestion of the submucosal blood vessels. The part of bowel with the hemorrhagic infarction was resected and reconstructed with a jejuno-colic anastomosis. After surgery, she recovered from the trauma and was discharged without complications. We present this ischemia-reperfusion injury of the intestine due to blunt trauma. Meticulous examination and computed tomography scan is mandatory for diagnosis and assessment of treatment outcome.
A peripherally inserted central catheter (PICC) provides effective, reliable intravenous access in patients who require long term therapy such as intravenous antibiotics, total parenteral nutrition, transfusion or inotropic agents. This retrospective study evaluated the usefulness of PICC in trauma patients by examining patient characteristics and common complications, including PICC related bloodstream infection.
We reviewed the trauma patients who underwent PICC at Pusan National University Hospital Trauma Center from January 2016 to February 2017.
From January 2016 to February 2017, 32 patients underwent PICC. Total catheter insertion days were 875 days, and the average catheter indwelling time was 27.3±25.02 days. The most common indication for PICC was total parenteral nutrition (n=20, 62.5%), while the remainder was to ensure a long-term fluid administration route (n=12, 37.5%). Catheter related complications included infection (n=3, 9.4%; 3.42 per 1,000 catheter-days), catheter tip malposition (n=2, 6.3%), catheter dislodgement (n=1, 3.1%), insertion site leakage (n=1, 3.1%) and arm swelling (n=1, 3.1%). No statistically significant differences were found between those who developed bloodstream infection and those who did not.
If the PICC is performed by correcting adjustable factors that increase the risk of infection, effective and reliable intravenous access can be maintained in patients who require long-term therapy without bleeding, pneumothorax, or other complications of central venous catheter insertion.
, Im-kyung Kim, Seo Hee Choi, Changro Lee, Man Ki Ju Patients with multiple traumas often experience multiple fractures that are missed or overlooked, despite the use of imaging, careful history taking, and physical examinations. This study aimed to evaluate the usefulness of whole body bone scan (WBBS) for detecting missed bone injuries in patients with multiple traumas.
We evaluated 30 patients with multiple traumas who underwent WBBS at single tertiary referral center between March 2008 and February 2016. We assessed the association of patient demographics with WBBS uptake as a binomial outcome variable.
There were no significant differences in patient demographics by WBBS. The mean injury severity score did not differ by WBBS (18.1 in the WBBS-negative group vs. 18.4 in the WBBS-positive group), and duration from admission to the evaluation of the WBBS was similar (5.4 days in both groups). The most common uptake site in the WBBS was the ribs (n=7), followed by the tibia (n=3), skull (n=2), ankle (n=1), and sternum (n=1). None of the missed injuries required further treatment, such as manual reduction or surgery.
WBBS was useful for detecting missed bone injuries in patients with multiple trauma.
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Splenic injury management has shifted to non-surgical treatment to preserve the spleen because of the postoperative risks of overwhelming post-splenectomy infection. In this study, we analyzed risk factors of therapeutic options for splenic injury, using medical records of Chonnam National University Hospital.
We reviewed the medical records of 110 consecutive patients with traumatic splenic injuries admitted from January 2009 to December 2013. Demographic characteristics and therapeutic options such as conservative treatment, angiographic embolization and emergency operation and clinical parameters were analyzed in this study.
Thirty-four patients were treated surgically and seventy-six were managed with non- surgical treatment. Multivariate logistic regression identified age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.009∼1.072; p=0.01), hematocrit (OR, 0.878; 95% CI, 0.806∼0.957; p=0.003), contrast extravasation (OR, 7.644; 95% CI, 2.248∼25.986; p=0.001), spleen grade (OR, 2.08; 95% CI, 1.128∼ 3.836; p=0.019) as significant risk factors of emergent splenectomy.
Age, hematocrit, contrast extravasation, spleen grade were significant risk factors for emergent splenectomy.
In a narrow sense, the trauma team is intra-hospital organization that perform the initial assessment and resuscitation for the victims. Cooperation with the administrative and governance body of the hospital is essential for the function as a trauma center. The hospital could be as a core of the trauma care system with this support. Essential to this core position is a hospital trauma program that regulates and supports the trauma team activities. This trauma program consists of the hospital governance, administration, the trauma team and leader, trauma program manager, the registrar and the multidisciplinary committee of the performance improvement program. The essential elements of the trauma team include a trauma surgeon, an emergency physician, emergency department nurses, a laboratory and radiology technician, an anesthesiologist and a scribe. The team leader should be a trauma surgeon and coordinate the multidisciplinary professions in the team during the entire trauma care process. Clear criteria for the trauma team activation should be defined in advance. The composition of the team and the activation criteria may vary with the hospital capacity, the severity of injury, and the level of activation. The tiered criteria are based on clinical information from the field: physiologic and anatomic conditions and mechanism of injury and are recommended. The multidisciplinary committee for the performance improvement should monitor and assess trauma program outcomes. These activities will lead to trauma care improvements.
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