Journal of Trauma and Injury

Volume 37(2); June 2024

Review Article

Predictors of massive transfusion protocols activation in patients with trauma in Korea: a systematic review: Dongmin Seo, Inhae Heo, Juhong Park, Junsik Kwon, Hye-min Sohn, Kyoungwon Jung; J Trauma Inj. 2024;37(2):97-105. Published online June 14, 2024; DOI: https://doi.org/10.20408/jti.2024.0015

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Purpose
Massive transfusion protocols (MTPs) implementation improves clinical outcomes of the patient’s resuscitation with hemorrhagic trauma. Various predictive scoring system have been used and studied worldwide to improve clinical decision. However, such research has not yet been studied in Korea. This systematic review aimed to assess the predictors of MTPs activation in patients with trauma in Korea.
Methods
The PubMed, Embase, Cochrane Library, Research Information Sharing Service databases, KoreaMed, and KMbase were searched from November 2022. All studies conducted in Korea that utilized predictors of MTPs activation in adult patients with trauma were included.
Results
Ten articles were eligible for analysis, and the predictors were assessed. Clinical assessments such as systolic and diastolic blood pressure, shock index (SI), prehospital modified SI, modified early warning system (MEWS) and reverse SI multiplied by the Glasgow Coma Scale (rSIG) were used. Laboratory values such as lactate level, fibrinogen degradation product/fibrinogen ratio, and rotational thromboelastometry (ROTEM) were used. Imaging examinations such as pelvic bleeding score were used as predictors of MTPs activation.
Conclusions
Our systematic review identified predictors of MTPs activation in patients with trauma in Korea; predictions were performed using tools that requires clinical assessments, laboratory values or imaging examinations only. Among them, ROTEM, rSIG, MEWS, SI, and lactate level showed good effects for predictions of MTPs activation. The application of predictors for MTP’s activation should be individualized based on hospital resource and skill set, also should be performed as a clinical decision supporting tools.

Summary

Citations

Citations to this article as recorded by

A Case Study on Simulation Training for Operational Improvements in the Massive Transfusion Protocol
Sooin Choi, Jongbin Wee, Haeri Jung, Young Soon Cho
The Korean Journal of Blood Transfusion.2024; 35(2): 113. CrossRef

Original Articles

The characteristics and clinical outcomes of trauma patients transferred by a physician-staffed helicopter emergency medical service in Korea: a retrospective study: Myung Jin Jang, Woo Sung Choi, Jung Nam Lee, Won Bin Park; J Trauma Inj. 2024;37(2):106-113. Published online February 23, 2024; DOI: https://doi.org/10.20408/jti.2023.0074

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Abstract PDF: Purpose
Helicopter transport with medical teams has been proven to be effective, with improvements in patient survival rates. This study compared and analyzed the clinical characteristics and treatment outcomes of trauma patients transported by doctor helicopters according to whether patients were transferred after a clinical evaluation or without a clinical evaluation.
Methods
This study retrospectively reviewed data from the Korean Trauma Data Bank of trauma patients who arrived at a regional trauma center through doctor helicopters from January 1, 2014, to December 31, 2022. The patients were divided into two groups: doctor helicopter transport before evaluation (DHTBE) and doctor helicopter transport after evaluation (DHTAE). These groups were compared.
Results
The study population included 351 cases. At the time of arrival at the trauma center, the systolic blood pressure was significantly lower in the DHTAE group than in the DHTBE group (P=0.018). The Injury Severity Score was significantly higher in the DHTAE group (P<0.001), and the accident to trauma center arrival time was significantly shorter in the DHTBE group (P<0.001). Mortality did not show a statistically significant between-group difference (P=0.094). Surgical cases in the DHTAE group had a longer time from the accident scene to trauma center arrival (P=0.002). The time from the accident to the operation room or from the accident to angioembolization showed no statistically significant differences.
Conclusions
DHTAE was associated with significantly longer transport times to the trauma center, as well as nonstatistically significant trends for delays in receiving surgery and procedures, as well as higher mortality. If severe trauma is suspected, air transport to a trauma center should be requested immediately after a simple screening test (e.g., mechanism of injury, Glasgow Coma Scale, or Focused Assessment with Sonography in Trauma), which may help reduce the time to definitive treatment.; Summary

Validation of chest trauma scoring systems in polytrauma: a retrospective study with 1,038 patients in Korea: Hongrye Kim, Mou Seop Lee, Su Young Yoon, Jonghee Han, Jin Young Lee, Junepill Seok; J Trauma Inj. 2024;37(2):114-123. Published online May 9, 2024; DOI: https://doi.org/10.20408/jti.2023.0087

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Abstract PDF Supplementary Material: Purpose
Appropriate scoring systems can help classify and treat polytrauma patients. This study aimed to validate chest trauma scoring systems in polytrauma patients.
Methods
Data from 1,038 polytrauma patients were analyzed. The primary outcomes were one or more complications: pneumonia, chest complications requiring surgery, and mortality. The Thoracic Trauma Severity Score (TTSS), Chest Trauma Score, Rib Fracture Score, and RibScore were compared using receiver operating characteristic (ROC) analysis in patients with or without head trauma.
Results
In total, 1,038 patients were divided into two groups: those with complications (822 patients, 79.2%) and those with no complications (216 patients, 20.8%). Sex and body mass index did not significantly differ between the groups. However, age was higher in the complications group (64.1±17.5 years vs. 54.9±17.6 years, P<0.001). The proportion of head trauma patients was higher (58.3% vs. 24.6%, P<0.001) and the Glasgow Coma Scale score was worse (median [interquartile range], 12 [6.5–15] vs. 15 [14–15]; P<0.001) in the complications group. The number of rib fractures, the degree of rib fracture displacement, and the severity of pulmonary contusions were also higher in the complications group. In the area under the ROC curve analysis, the TTSS showed the highest predictive value for the entire group (0.731), head trauma group (0.715), and no head trauma group (0.730), while RibScore had the poorest performance (0.643, 0.622, and 0.622, respectively)
Conclusions
Early injury severity detection and grading are crucial for patients with blunt chest trauma. The chest trauma scoring systems introduced to date, including the TTSS, are not acceptable for clinical use, especially in polytrauma patients with traumatic brain injury. Therefore, further revisions and analyses of chest trauma scoring systems are recommended.; Summary

A predictive nomogram-based model for lower extremity compartment syndrome after trauma in the United States: a retrospective case-control study: Blake Callahan, Darwin Ang, Huazhi Liu; J Trauma Inj. 2024;37(2):124-131. Published online May 22, 2024; DOI: https://doi.org/10.20408/jti.2023.0077

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Abstract PDF Supplementary Material: Purpose
The aim of this study was to utilize the American College of Surgeons Trauma Quality Improvement Program (TQIP) database to identify risk factors associated with developing acute compartment syndrome (ACS) following lower extremity fractures. Specifically, a nomogram of variables was constructed in order to propose a risk calculator for ACS following lower extremity trauma.
Methods
A large retrospective case-control study was conducted using the TQIP database to identify risk factors associated with developing ACS following lower extremity fractures. Multivariable regression was used to identify significant risk factors and subsequently, these variables were implemented in a nomogram to develop a predictive model for developing ACS.
Results
Novel risk factors identified include venous thromboembolism prophylaxis type particularly unfractionated heparin (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.33–3.05; P<0.001), blood product transfusions (blood per unit: OR 1.13 [95% CI, 1.09–1.18], P<0.001; platelets per unit: OR 1.16 [95% CI, 1.09–1.24], P<0.001; cryoprecipitate per unit: OR 1.13 [95% CI, 1.04–1.22], P=0.003).
Conclusions
This study provides evidence to believe that heparin use and blood product transfusions may be additional risk factors to evaluate when considering methods of risk stratification of lower extremity ACS. We propose a risk calculator using previously elucidated risk factors, as well as the risk factors demonstrated in this study. Our nomogram-based risk calculator is a tool that will aid in screening for high-risk patients for ACS and help in clinical decision-making.; Summary

Implementation of structured trauma training for first-year surgical residents in Ethiopia: a novel pilot program in a low income country: Segni Kejela, Meklit Solomon Gebremariam; J Trauma Inj. 2024;37(2):132-139. Published online June 12, 2024; DOI: https://doi.org/10.20408/jti.2024.0010

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Abstract PDF: Purpose
Curricula for surgical residents should include training in trauma care; however, such training is absent in many low income countries. At the largest surgical training institution in Ethiopia, a trauma training program was developed, integrated into the existing surgical curriculum, and implemented. This study was conducted to evaluate the trainees’ response to the new program.
Methods
Over a 5-month period, 35 first-year surgical residents participated in weekly trauma care training sessions. The program included journal clubs, practical sessions, didactic sessions, and case-based discussions. Six months after the conclusion of the training, changes in knowledge, attitude, and practices were evaluated through a self-report survey.
Results
For knowledge-based items, the survey data revealed reported improvements in 83.8% to 96.8% of students. Furthermore, 90.3% to 93.5% of participants indicated improvements in practice, while 96.7% exhibited a change in attitude. Respondents reported that attending didactic courses improved their presentation skills and facilitated the acquisition of knowledge. They suggested the inclusion of additional practical sessions.
Conclusions
Training structures that are simple to implement are crucial for residency programs with limited resources. Such programs can be developed using existing academic staff and can aid residents in delivering improved care to trauma patients.; Summary

Clinical predictors of therapeutic laparotomy in anterior abdominal stab injuries: a multicenter study from low-income institutions in Ethiopia: Segni Kejela, Abel Hedato, Yeabsera Mekonnen Duguma, Meklit Solomon Gebremariam; J Trauma Inj. 2024;37(2):140-146. Published online June 19, 2024; DOI: https://doi.org/10.20408/jti.2024.0009

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Abstract PDF: Purpose
Despite the high incidence of abdominal stab injuries, the rate of nontherapeutic laparotomies and the predictors of therapeutic laparotomies have rarely been studied in low-income settings.
Methods
This multicenter retrospective study involved three of the largest academic medical centers in central Ethiopia. All patients who sustained an anterior abdominal stab injury and underwent exploratory laparotomy, regardless of the intraoperative findings, were included over the 3-year course of the study.
Results
Of the 117 patients who underwent exploratory laparotomy, 35 patients (29.9%) underwent nontherapeutic laparotomies. Three factors predicted therapeutic laparotomy: hollow viscus evisceration (adjusted odds ratio [AOR], 5.77; 95% confidence interval [CI], 1.16–28.64; P=0.032), localized and generalized peritonitis (AOR, 4.77; 95% CI, 1.90–11.93; P=0.001), and white blood cell count ≥11,500/mm3 (AOR, 2.77; 95% CI, 1.002–7.650; P=0.049). The overall positive predictive value of the therapeutic predictors was 80.2%, while the negative predictive value of all predictor-negative patients was 58.1%. The predictors would have prevented 51.4% of the nontherapeutic laparotomies.
Conclusions
Close to one-third of the patients had a nontherapeutic laparotomy. The clinical predictors of therapeutic laparotomy were shown to have a high positive predictive value despite a lower negative predictive value. Further prospective studies that involve all patients who sustain anterior abdominal stab injuries are needed to potentially improve on the negative predictive value of the predictors suggested by our study.; Summary

Case Reports

An unstable patient with a large sucking chest wound managed with gauze packing for preventing tension and bleeding control before surgery in Korea: a case report: Chang-Sin Lee, Min-Jeong Cho, Tae-Wook Noh, Nak-Jun Choi, Jun-Min Cho; J Trauma Inj. 2024;37(2):147-150. Published online February 23, 2024; DOI: https://doi.org/10.20408/jti.2023.0066

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Abstract PDF: This case report describes the management of a 51-year-old female patient who arrived at the emergency room with a stab wound to the upper right chest. Immediate medical interventions were undertaken, including blood transfusions and endotracheal intubation. To prevent tension and control bleeding, gauze packing was applied directly through the large open wound. Further surgical exploration identified a laceration in the lung, necessitating a right upper lobe resection. Postoperatively, the patient’s vital signs stabilized, and she was subsequently discharged without complications. This case highlights the decision-making process in selecting between an emergency department thoracotomy and an operating room thoracotomy for patients with penetrating chest trauma. It also illustrates the role of gauze packing in managing tension and hemorrhage. In summary, gauze packing can be an effective interim measure for stabilizing patients with traumatic injuries, unstable vital signs, and large open chest wounds, particularly when a chest tube is already in place, to prevent tension and facilitate bleeding control prior to surgical intervention.; Summary

A step-by-step intraoperative strategy during one-stage reconstruction of an acute electrical burn injury in the neck for superior surgical outcome in India: a case report: Mainak Mallik, Sanjay Kumar Giri, M. Vishnu Swaroop Reddy, Kallol Kumar Das Poddar; J Trauma Inj. 2024;37(2):151-157. Published online May 17, 2024; DOI: https://doi.org/10.20408/jti.2023.0075

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Abstract PDF: Electrical burn injuries can cause more damage than clinical evaluations initially suggest. The energy waves penetrate from the surface to the deepest layers of tissue, causing extensive harm at every level. The neck is a critical area, both functionally and aesthetically. We present a case involving a young male patient with a severe fourth-degree electrical burn on the neck, who underwent a single-stage debridement and reconstructive surgery. The pectoralis major myocutaneous flap is a versatile option for various head and neck reconstructions. However, if the donor site cannot be closed primarily and requires split-thickness skin grafting, it can result in unsightly scars and deformities. For large flap paddles, it is ideal to reconstruct the secondary defect with locoregional flaps. In this case, we successfully reconstructed the donor site's secondary defect using a contralateral internal mammary artery perforator flap, without resorting to any skin grafts. The early postoperative results demonstrated satisfactory cosmesis, patient satisfaction, and functional outcomes.; Summary

Traumatic arterial thoracic outlet syndrome after multiple rib fractures not including the first rib in Korea: a case report: Seock Yeol Lee; J Trauma Inj. 2024;37(2):158-160. Published online June 5, 2024; DOI: https://doi.org/10.20408/jti.2023.0081

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Abstract PDF: Arterial thoracic outlet syndrome (TOS) resulting from thoracic trauma is an exceedingly rare condition, typically caused by a fracture of the first rib or clavicle. In this report, the author presents a case of traumatic arterial TOS precipitated by multiple left rib fractures, notably excluding the first rib, following a fall from a 2-m high stepladder. The patient was treated successfully with first rib resection via a transaxillary approach, and the postoperative course was uneventful. The literature includes no known reports of traumatic arterial TOS in patients with multiple fractures that spare the first rib, making this the first documented case of its kind. In this instance, the patient sustained fractures to the fourth and fifth ribs. The TOS was likely not a direct result of the multiple rib fractures, which were located some distance from the thoracic outlet. Rather, it is hypothesized that the trauma from these fractures caused a soft tissue injury within the thoracic outlet, which ultimately led to the development of TOS.; Summary

Relevance of the Watson-Jones anterolateral approach in the management of Pipkin type II fracture-dislocation: a case report and literature review: Nazim Sifi, Ryad Bouguenna; J Trauma Inj. 2024;37(2):161-165. Published online June 17, 2024; DOI: https://doi.org/10.20408/jti.2024.0004

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Abstract PDF

Femoral head fractures with associated hip dislocations substantially impact the functional prognosis of the hip joint and present a surgical challenge. The surgeon must select a safe approach that enables osteosynthesis of the fracture while also preserving the vascularization of the femoral head. The optimal surgical approach for these injuries remains a topic of debate. A 44-year-old woman was involved in a road traffic accident, which resulted in a posterior iliac dislocation of the hip associated with a Pipkin type II fracture of the femoral head. Given the size of the detached fragment and the risk of incarceration preventing reduction, we opted against attempting external orthopedic reduction maneuvers. Instead, we chose to perform open reduction and internal fixation using the Watson-Jones anterolateral approach. This involved navigating between the retracted tensor fascia lata muscle, positioned medially, and the gluteus medius and minimus muscles, situated laterally. During radiological and clinical follow-up visits extending to postoperative month 15, the patient showed no signs of avascular necrosis of the femoral head, progression toward coxarthrosis, or heterotopic ossification. The Watson-Jones anterolateral approach is a straightforward intermuscular and internervous surgical procedure. This method provides excellent exposure of the femoral head, preserves its primary vascularization, allows for anterior dislocation, and facilitates the anatomical reduction and fixation of the fracture.

Summary

Citations

Citations to this article as recorded by

Pipkin fractures: fracture type-specific management
Axel Gänsslen, Richard A. Lindtner, Dietmar Krappinger, Jochen Franke
Archives of Orthopaedic and Trauma Surgery.2024;[Epub] CrossRef

Experiencing cardiac arrest during surgical exploration in hemodynamically stable patients with multiple stab wounds, including lower extremity in Korea: a case report: Jung Rae Cho, Dae Sung Ma; J Trauma Inj. 2024;37(2):166-169. Published online June 14, 2024; DOI: https://doi.org/10.20408/jti.2024.0025

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Abstract PDF: Stab wounds, particularly those affecting multiple body regions, present considerable challenges in trauma care. This report describes a case of sustained self-inflicted stab injuries to the abdomen and thighs of a 23-year-old male patient. Although the patient’s vital signs were stable and bleeding was minimal from thigh wounds without overt signs of vascular injury, the patient experienced a sudden, profound hemorrhage from the right thigh, leading to cardiac arrest. Successful resuscitation was followed by surgical repair of a right superficial femoral arterial injury accompanying a resuscitative endovascular balloon of the aorta. Subsequent lower extremity computed tomography angiography revealed no additional vascular abnormalities. The patient was discharged in stable condition on the 12th postoperative day. This case underscores the unpredictability of stab wound trajectories and the potential for hidden vascular injuries, even in the absence of immediate life-threatening signs. It also emphasizes the critical role of advanced imaging modalities, such as computed tomography angiography, in identifying concealed injuries, and the importance of strategic intraoperative techniques, including resuscitative endovascular balloon occlusion of the aorta, in achieving favorable patient outcomes.; Summary

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