As you know I am a surgeon in Portugal. Severe trauma patient is not the usual patient I treat, and I must confess I get anxious when dealing with one. Penetrating trauma is a rarity, but blunt trauma due to car or motorcycle crash is common. Fortunately, nowadays most accidents result in mild injuries. Facing an abdominal trauma an injury to major vessels pose a great pressure on the surgical team. You must act fast… “Winter is coming.”
Reading recent articles, I come to find one paper from 1996 entitled: “The ongoing challenge of retroperitoneal vascular injuries”. It was published by Dr. Raul Coimbra from San Diego, USA. It got my attention. Abdominal aortic injuries and inferior vena cava injuries found on 89 patients for a 10 years period were retrospectively analyzed. Who is the surgeon that won’t tremble with a case like this? Adrenalin rises-up and action is on. Tremble comes after. I bring this paper to you because I found some interesting data. Although we must not forget this is a 20 more years-old paper, I believe it is somehow actual and important.
Penetrating trauma is the main cause of aortic and IVC injuries.
Retroperitoneal vascular injuries are one of the most common causes of death following abdominal trauma. Some patients never reach the hospital and die at scene. Aortic injuries have a mortality rate up to 80%, and IVC injuries up to 60%. Imagine a patient with both aortic and IVC injuries. The authors analyzed 89 patients treated at the San Diego’s Level 1 Trauma Center with retroperitoneal vascular injuries diagnosed at surgery or autopsy. They collected data like Trauma Score (TS), Injury Severity Score (ISS), tamponade, associated injuries and location of injury according to Organ Injury Scale (OIS). Who were the patients? There were 39 patients with aortic injury, 65 patients with IVC injury, and 15 with both aortic and IVC injuries. What caused these lesions? Blunt trauma in 21% (19) and penetrating trauma in 79% (70). From these latter ones 30% (21) were due to stab wounds and 70% (49) from gunshots. I believe this is a completely different reality from Portugal, where the blunt trauma is the rule. Does having blunt trauma more than penetrating trauma a benefit? Mortality rates presented by Dr. R. Coimbra may answer. The overall mortality rate was 57% but excluding deaths on admission it decreased to 46%. Mortality rate for stab wounds was 14%, much lower than the 67% mortality rate for gunshot and lower than the 89% for blunt trauma. All with statistical significance. So, this means that retroperitoneal vascular injuries due to blunt abdominal trauma have a significantly higher mortality rate than penetrating trauma injuries. Is Portugal dealing with less trauma patients than the USA but dealing with the potentially severely ones? Not so fast… Patients with blunt trauma due to car/motorcycle accident probably have a higher rate of other associated lesions (thoracic and head trauma) which can rise the mortality rate.
Other interesting data are presented. As expected, non-survivors had more associated injuries than survivors, being 3 the number of lesions above which mortality is significantly affected. The mean ISS for aortic lesions was 37 and for IVC injuries was 35. Important to note is that only 1 out of 9 patients with injuries to both major vessels survived. Treatment methods also had different mortality rates. Suture was the most frequently used with a mortality rate of 33% and 31% for aortic and IVC injury respectively. End-to-end anastomosis for aortic injury had a mortality rate of 100%, the same as doing nothing for both aortic and IVC injuries. How about resuscitative thoracotomy? Is it worth the effort? Fifteen patients (5 aortic injuries, 6 combined injuries, 4 IVC injuries) had a resuscitative thoracotomy preformed. Only two (1 aortic injury, 1 combined injuries) patients survived (mortality of 87%). Of course, this is a technique used for critically ill patient on admission with severe hemorrhagic shock, reason why a high mortality rate would be expected. Even though, the authors state there is no evidence of its utility in reducing mortality.
Blunt trauma has the highest mortality rate.
I remember this is a paper from 1996, analyzing patients from a period between 1985 and 1995. However, some conclusions are made which I believe are still actual. The authors state that less time from admission to operation, aggressive resuscitation methods and having human and material resources ready for action, are all factors that can reduce mortality. In 1996 the authors were already resuscitating unstable patients with penetrating trauma in the operation room for the last 10 years, decreasing time to operation. Dr. Coimbra et al present three factors associated with higher risk of mortality. First, the presence of free bleeding into peritoneal cavity as opposite to retroperitoneal tamponade. The latter will promote a hematoma which decreases bleeding but also gives the surgeon more time to control the injury. Second, presence of shock at admission. Third, and I believe this is crucial, suprarenal located injury (OIS > 4) is associated with a 15 times higher risk of death. One important idea I took from the paper, is that is crucial to retrospectively analyze all difficult cases. The authors did that with all these cases and concluded that only one death could have eventually been prevented if treatment decision had taken a different path. We must not be afraid of doing so… Learning from errors is what make us stronger!
Free intraperitoneal bleeding and suprarenal location of injury are factors associated with high risk of mortality.
With advances in prehospital care, faster transport to hospital, hypotensive resuscitation and new surgical devices, I believe mortality rates of abdominal aortic and IVC injuries have not changed in the present day. Do you think differently? Despite the advances in intervention radiology and endovascular treatments, these options are frequently useless in severe vascular trauma. Surgery is mandatory. How can we train surgeons in Portugal (or other countries with low numbers of aortic/IVC vascular trauma) for these stressful situations? How can we say these situations are only for experienced surgeons if there is no sustained experience? In 2007 during the ATLS course, I assisted a conference by Dr. Ken Boffard from Johannesburg, South Africa. When questioning a room full of surgeons how many gunshots they have treated, only one had treated more than three during his entire career. Probably only with active learning from books and videos, and periodic hands-on courses with animal models, surgeons in Portugal (and other countries with low vascular trauma numbers) could gain some experience on how to approach these patients. Have never operated a patient with major vascular trauma cannot be an excuse for not doing what is necessary. Stress must be prevented with knowledge, with appropriate resources in the hospital and with an established coordination between surgeon-anesthesiologist-nurse-blood department, so that a severe trauma situation can be anticipated.
Surgeons cannot do with trauma, what Governments did with Covid-19! We must be prepared…
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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