Journal of Trauma and Injury

Volume 37(3); September 2024

Review Article

Renal embolization for trauma: a narrative review: Peter Lee, Simon Roh; J Trauma Inj. 2024;37(3):171-181. Published online September 24, 2024; DOI: https://doi.org/10.20408/jti.2024.0021

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Abstract PDF: Renal injuries commonly occur in association with blunt trauma, especially in the setting of motor vehicle accidents. Contrast-enhanced computed tomography is considered the gold-standard imaging modality to assess patients for renal injuries in the setting of blunt and penetrating trauma, and to help classify injuries based on the American Association for the Surgery of Trauma injury scoring scale. The management of renal trauma has evolved in the past several decades, with a notable shift towards a more conservative, nonoperative approach. Advancements in imaging and interventional radiological techniques have enabled diagnostic angiography with angiographic catheter-directed embolization to become a viable option, making it possible to avoid surgical interventions that pose an increased risk of nephrectomy. This review describes the current management of renal trauma, with an emphasis on renal artery embolization techniques.; Summary

Original Articles

Experience of vascular injuries at a military hospital in Korea: Doohun Kim, Soyun Nam, Yoon Hyun Lee, Hojun Lee, Hyun Chul Kim; J Trauma Inj. 2024;37(3):182-191. Published online May 19, 2023; DOI: https://doi.org/10.20408/jti.2022.0041

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Abstract PDF: Purpose
Vascular injuries require immediate surgical treatment with standard vascular techniques. We aimed to identify pitfalls in vascular surgery for trauma team optimization and to suggest recommendations for trauma and vascular surgeons. Methods: We reviewed 28 victims and analyzed the patterns of injuries, methods of repair, and outcomes. Results: Ten patients had torso injuries, among whom three thoracic aorta injuries were repaired with thoracic endovascular aortic repair, one left hepatic artery pseudoaneurysm with embolization, and two inferior vena cava with venorrhaphy, three iliac arteries with patch angioplasty or embolization, and three common femoral arteries with bypass surgery or arterioplasty. Four patients had upper extremity injuries, among whom one brachial artery and vein was repaired with bypass surgery after temporary intravascular shunt perfusion, two radial arteries were repaired with anastomoses, and one ulnar artery was repaired with ligation. One radial artery under tension was occluded. Fourteen patients had lower extremity injuries, among whom one superficial femoral artery and vein was repaired with bypass and concomitant ligation of the deep femoral artery and vein, three superficial femoral arteries were repaired with bypass (two concomitant femoral veins with bypass or anastomosis), one deep femoral artery with embolization, two popliteal arteries with bypass or anastomosis, four infrapopliteal transected arteries, one arteriovenous fistula with ligation, and one pseudoaneurysm with bypass. However, one superficial femoral artery and all femoral veins were occluded. One leg replantation failed. Conclusions: There are potential complications of vascular access during resuscitative endovascular balloon occlusion of the aorta procedures. Vascular repair should be performed without tension or spasm. Preservation of the harvested vein in papaverine solution and blood while using a temporary intravascular shunt is a method of eliminating spasms.; Summary

Traumatic peripheral nerve injuries in young Korean soldiers: a recent 10-year retrospective study: Chul Jung, Jae-hyun Yun, Eun Jin Kim, Jaechan Park, Jiwoon Yeom, Kyoung-Eun Kim; J Trauma Inj. 2024;37(3):192-200. Published online August 8, 2024; DOI: https://doi.org/10.20408/jti.2024.0001

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Abstract PDF: Purpose
Traumatic peripheral nerve injury (PNI), which occurs in up to 3% of trauma patients, is a devastating condition that often leads to permanent disability. However, knowledge of traumatic PNI is limited. We describe epidemiology and clinical characteristics of traumatic PNI in Korea and identify the predictors of traumatic complete PNI. Methods: A list of enlisted soldier patients who were discharged from military service due to PNI over a 10-year period (2012–2021) was obtained, and their medical records were reviewed. Patients were classified according to the causative events (traumatic vs. nontraumatic) and injury severity (complete vs. incomplete). Of traumatic PNIs, we compared the clinical variables between the incomplete and complete PNI groups and identified predictors of complete PNI. Results: Of the 119 young male patients who were discharged from military service due to PNI, 85 (71.4%) were injured by a traumatic event; among them, 22 (25.9%) were assessed as having a complete injury. The most common PNI mechanism (n=49, 57.6%), was adjacent fractures or dislocations. Several injury-related characteristics were significantly associated with complete PNI: laceration or gunshot wound, PNI involving the median nerve, PNI involving multiple individual nerves (multiple PNI), and concomitant muscular or vascular injuries. After adjusting for other possible predictors, multiple PNI was identified as a significant predictor of a complete PNI (odds ratio, 3.583; P=0.017). Conclusions: In this study, we analyzed the characteristics of enlisted Korean soldiers discharged due to traumatic PNI and found that the most common injury mechanism was adjacent fracture or dislocation (57.6%). Patients with multiple PNI had a significantly increased risk of complete injury. The results of this study contribute to a better understanding of traumatic PNI, which directly leads to a decline in functioning in patients with trauma.; Summary

Predicting 30-day mortality in severely injured elderly patients with trauma in Korea using machine learning algorithms: a retrospective study: Jonghee Han, Su Young Yoon, Junepill Seok, Jin Young Lee, Jin Suk Lee, Jin Bong Ye, Younghoon Sul, Se Heon Kim, Hong Rye Kim; J Trauma Inj. 2024;37(3):201-208. Published online August 8, 2024; DOI: https://doi.org/10.20408/jti.2024.0024

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Abstract PDF: Purpose
The number of elderly patients with trauma is increasing; therefore, precise models are necessary to estimate the mortality risk of elderly patients with trauma for informed clinical decision-making. This study aimed to develop machine learning based predictive models that predict 30-day mortality in severely injured elderly patients with trauma and to compare the predictive performance of various machine learning models. Methods: This study targeted patients aged ≥65 years with an Injury Severity Score of ≥15 who visited the regional trauma center at Chungbuk National University Hospital between 2016 and 2022. Four machine learning models—logistic regression, decision tree, random forest, and eXtreme Gradient Boosting (XGBoost)—were developed to predict 30-day mortality. The models’ performance was compared using metrics such as area under the receiver operating characteristic curve (AUC), accuracy, precision, recall, specificity, F1 score, as well as Shapley Additive Explanations (SHAP) values and learning curves. Results: The performance evaluation of the machine learning models for predicting mortality in severely injured elderly patients with trauma showed AUC values for logistic regression, decision tree, random forest, and XGBoost of 0.938, 0.863, 0.919, and 0.934, respectively. Among the four models, XGBoost demonstrated superior accuracy, precision, recall, specificity, and F1 score of 0.91, 0.72, 0.86, 0.92, and 0.78, respectively. Analysis of important features of XGBoost using SHAP revealed associations such as a high Glasgow Coma Scale negatively impacting mortality probability, while higher counts of transfused red blood cells were positively correlated with mortality probability. The learning curves indicated increased generalization and robustness as training examples increased. Conclusions: We showed that machine learning models, especially XGBoost, can be used to predict 30-day mortality in severely injured elderly patients with trauma. Prognostic tools utilizing these models are helpful for physicians to evaluate the risk of mortality in elderly patients with severe trauma.; Summary

Evaluating chemical venous thromboembolism prophylaxis in trauma patients at a single Australian center: Natalie Quarmby, Minh Tu Vo, Sean Weng Chan; J Trauma Inj. 2024;37(3):209-213. Published online September 24, 2024; DOI: https://doi.org/10.20408/jti.2024.0020

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Abstract PDF: Purpose
Trauma patients are at an elevated risk of developing venous thromboembolism (VTE), with the subsequent mortality in patients requiring intensive care unit admission ranging from 25% to 38%. There remains significant variability in clinical practice related to VTE prophylaxis in trauma patients due to the frequent presence of contraindications impacting the timing and consistency of application. This study aimed to assess the effectiveness of the current practice of chemical VTE prophylaxis in trauma patients at a single Australian center. Methods: A prospective review was conducted on patients admitted to the ACT Trauma Service (Canberra, Australia) from July to November 2022. The included patients were 18 years or older, without a direct contraindication to anticoagulation, who received chemical VTE prophylaxis with low-molecular-weight heparin (enoxaparin) for at least three doses and underwent subsequent testing of anti-factor Xa (aFXa) levels. Results: During the study period, 187 patients were admitted, of whom 63 were included in the study. Of these, 47 patients achieved therapeutic levels of anticoagulation as determined by their aFXa levels, while 16 were subtherapeutic. The only statistically significant difference between the two groups was in weight, with patients in the subtherapeutic group weighing an average of 91.9 kg compared to 79.1 kg in the therapeutic group (P<0.05). Conclusions: A fixed-dose enoxaparin regimen was utilized, with limited individualization based on patient factors, such as injuries, comorbidities, and other biological factors. Sixteen patients (25%) had subtherapeutic VTE prophylaxis, as measured by aFXa levels. Higher weight was significantly correlated with inadequate VTE prophylaxis dosing. While age, sex, and smoking status might play important roles in clinical decision-making, weight-based dosing of low-molecular-weight heparin may be more effective in achieving adequate VTE prophylaxis.; Summary

The causes and numbers of hospital admissions and deaths during the Korean War: Kun Hwang, Hun Kim, Chan Yong Park; J Trauma Inj. 2024;37(3):214-219. Published online September 30, 2024; DOI: https://doi.org/10.20408/jti.2023.0067

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PDF: Summary

Case Reports

Life-threatening nasotracheal tube obstruction by a blood clot: a case report: Dajeong Lee, Chan Yong Park, Sang Wha Kim; J Trauma Inj. 2024;37(3):220-223. Published online September 3, 2024; DOI: https://doi.org/10.20408/jti.2023.0084

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Abstract PDF: The nasotracheal tube (NTT) is frequently used in oral and maxillofacial surgery and is generally considered a safe means of protecting the airway while ensuring an adequate surgical field. The most common complication associated with NTT is epistaxis, and only a few cases of foreign body obstruction have been reported. In this case report, the authors aimed to highlight the potential for NTT obstruction following surgery. A 24-year-old female patient, who underwent mandibuloplasty and rhinoplasty at a local clinic, was referred to our hospital patient due to dyspnea and edema on her right mandibular angle. Even with NTT, patient continued to experience mild dyspnea and tachypnea, so a T-piece was applied. However, tachycardia accompanied by a sudden worsening of dyspnea was observed, and bag-valve-mask ventilation was initiated promptly. But oxygen saturation remained unimproved, so an emergency cricothyroidotomy was performed. After 4 hours, the patient’s condition stabilized. Upon examination, the previously inserted NTT was identified, and a blood clot approximately 10 cm long at the NTT tip was discovered, causing lumen obstruction. The obstructions of NTT can lead to serious or life-threatening consequences if left unobserved or ignored. Therefore, when a patient with an NTT complains of dyspnea, clinicians should promptly investigate the possibility of partial NTT obstruction to ensure the airway’s security.; Summary

Use of helicopter emergency medical services with a physician on board in severe pediatric trauma in Korea: a case report: Yoonsuk Lee, Gunwoo Kim, Pil Young Jung; J Trauma Inj. 2024;37(3):224-227. Published online June 14, 2024; DOI: https://doi.org/10.20408/jti.2023.0080

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Abstract PDF: In Korea, helicopter emergency medical services (HEMS) with a physician on board were introduced in September 2011, funded by both central and regional governments. HEMS was integrated into the Korean emergency medical system to address the need for EMS in remote rural areas. The present report describes 16-month-old twins who fell from the fifth floor of an apartment building, located approximately 100 km from the nearest level I trauma center. Utilizing HEMS along with initial emergency management by an emergency physician, the patients were transported to the level I trauma center within the critical “golden hour.” The children had sustained multiorgan injuries. Without intervention at the scene by an emergency physician, a fatal outcome was anticipated for both children. With the use of HEMS, one patient died, but the other survived with a good prognosis. The use of HEMS flights with an emergency physician on board may improve outcomes for pediatric patients with severe trauma in medically underserved rural areas.; Summary

Spontaneous intracranial hypotension in young and middle-aged patients with chronic subdual hematoma in Korea: three case reports: Ae Ryoung Lee, Yun Suk Choi; J Trauma Inj. 2024;37(3):228-232. Published online August 8, 2024; DOI: https://doi.org/10.20408/jti.2024.0008

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Abstract PDF: This case series highlights chronic subdural hematoma in previously healthy young and middle-aged patients, where symptoms persisted despite initial surgical intervention. Subsequent diagnosis revealed spontaneous intracranial hypotension through computed tomography myelography. All patients experienced symptom relief after undergoing epidural blood patch. In conclusion, spontaneous intracranial hypotension should be considered in chronic subdural hematoma cases without trauma or underlying disease, with epidural blood patch recommended before surgical intervention if spontaneous intracranial hypotension is suspected.; Summary

Penetrating cardiac injury resulting in a bullet embolus: a case report: Sammy Shihadeh, Anwar Khan, Kristen Walker, Ali Al-Rawi, Alfredo Cordova; J Trauma Inj. 2024;37(3):233-237. Published online September 3, 2024; DOI: https://doi.org/10.20408/jti.2024.0018

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Abstract PDF: Bullet embolism is a potential complication of a gunshot wound, especially with a low-velocity missile. This is because the trajectory of the low-velocity bullet can be significantly slowed as it passes through tissue. An unusual form of travel can occur in which the bullet enters the vasculature but does not have enough kinetic energy to create a through-and-through wound, leading it to remain inside the vasculature. Once inside the vasculature, the bullet could migrate to different parts of the body, potentially causing complications such as ischemia, becoming a source of thromboembolism, or functioning as a nidus for infection. The management of a bullet embolism varies from case to case, as each patient with this issue has a unique body habitus that can result in infinite possibilities of the trajectory and destination of the bullet embolus. Additional damage to surrounding vasculature or tissue can occur, as well as embolization of the bullet to critical areas of the body. Here we present the case of a 72-year-old man who had a self-inflicted gunshot wound to the chest with a low-velocity bullet, which penetrated the right atrium of the heart. It traveled into the venous vasculature through the right atrium, into the inferior vena cava, and eventually settled in the right internal iliac vein. He refused further intervention and management after initial workup and resuscitation.; Summary

Minimally invasive techniques as adjuncts in low- versus high-lying retained rectal foreign bodies of autoerotic nature in young men: a tailored management algorithm with two contrasting case reports from India: Shubham Kumar Gupta, Vivek Kumar Katiyar, Sumit Sharma, Shashi Prakash Mishra, Satyanam Kumar Bhartiya; J Trauma Inj. 2024;37(3):238-242. Published online September 30, 2024; DOI: https://doi.org/10.20408/jti.2024.0003

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Abstract PDF: Retained rectal foreign bodies (RFBs) of an autoerotic nature represent an emerging and rare surgical emergency, posing a sensitive challenge for surgeons. RFBs exhibit a wide range of presentations and require varied management approaches, with the choice of treatment modality differing from case to case. Recently, minimally invasive techniques have been employed for the retrieval of RFBs. In 2021, the World Society of Emergency Surgery and the American Association for the Surgery of Trauma released guidelines on anorectal emergencies, highlighting the usefulness of these techniques as adjunctive tools for both diagnosis and ruling out associated complications. In this report, we describe two noteworthy cases of men who presented to the trauma emergency department with foreign bodies lodged in their rectums. We also highlight the potential role of minimally invasive techniques within a “step-up” approach for the management of retained RFBs.; Summary

Delayed diagnosis of proximal ureter injury after a blunt abdominal trauma in Korea: a case report: Soon Ki Min, Byungchul Yu, Gil Jae Lee, Min A Lee, Yang Bin Jeon, Youngeun Park, Kang Kook Choi, Hyuk Jun Yang; J Trauma Inj. 2024;37(3):243-246. Published online September 3, 2024; DOI: https://doi.org/10.20408/jti.2024.0016

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Abstract PDF: Traumatic ureteral injuries account for fewer than 1% of traumatic urologic injuries, and those caused by blunt trauma are even rarer than those caused by penetrating trauma. The symptoms associated with ureteral injury may be subtle, with or without hematuria, making it difficult to diagnose. We report the case of a 31-year-old man with a delayed diagnosis of proximal ureter injury after abdominal blunt trauma sustained in a motorcycle traffic accident. The patient underwent emergency laparotomy on admission for liver injury, mesenteric injury, and resultant hemoperitoneum. On postoperative day 6, he underwent angioembolization for suspected remnant intra-abdominal bleeding. Persistent symptoms of flank pain and leukocytosis led to follow-up imaging studies that revealed proximal ureter injury, and the patient underwent unilateral nephrectomy. This case stresses the importance of clinical suspicion for genitourinary injuries in the presence of abdominal trauma.; Summary

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