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

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

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 Define anigoembolization – the use of endovascular techniques to embolize bleeding blood vessels (foam or coils)

Angioembolization Spleen Who? Efficacy “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 Stable patients – deemed haemodynamically stable, some major trauma centres have expanded indications to those who transiently respond High grade injury – reduces failure rate down to 7% (from angio paper), G4 33% fail NOM G5 75% fail NOM

Angioembolization Hepatic Injuries Who? Efficacy 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 NOM success rate of > 90% (Green et al 2016 paper) systematic review Issue is with selection – Grade (50% therapeutic), Contrast blush (60% therapeutic) – Misselbeck paper – single large series

Angioembolization Renal Who? Efficacy 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% Renal is not as well studied as splenic injury – no consensus but these features are associated with likely need for AE AAST American association for the surgery of trauma 10% of all intraabdominal injuries High failure rate is to do with missed arterial injuries missed on CT – in spleen these injuries are often fixed with proximal embolization (hypothesis) – proximal embolization not possible with kidneys as no rich collateral exists

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) Initial reluctance to go to the angio suite now more mainstream treatment for the haemodynamically stable patient with bleeding Radiologists are often reluctant to take patients without a CT

Selective NOM of Low Velocity Penetrating Abdominal Injury Elaborate on the difference between the two – the more severe one is actually the easy one in terms of decisions The one on the right is stable and not particularly tender ? What to do?

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

Selection Clinical Imaging Interventional (diagnostic +/- therapeutic) Assessable Generalised peritonism, evisceration, and instability  exploration Imaging USS CT Interventional (diagnostic +/- therapeutic) Local Wound Exploration Laparoscopy Key is in the selection – How do you pick those who will benefit from an intervention USS: operator dependent, sensitivity 84% and specificity 99% CT: 94% sensitivity for bowel injury and 96% for mesenteric injury Laparoscopy: Historically thought to be inaccurate in trauma setting, but now it has changed – poor initial experience 18% sensitivity (studies in the 90s) for GI injury, systematic review recent: missed injury 3% and 3% laparoscopy related complication. Added advantage of being more accurate than CT for diaphragmatic injuries (CT only accurate in 25%)

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 Alfred study 2015 Kevric et al 2015 – those that complied 0% non therapeutic laparotomy vs 33% in those that did not

Algorithm Alfred Hospital Protocol

Thoracoabdominal wounds Risk for diaphragmatic injuries Low threshold for laparoscopy CT is not very good at excluding diaphragm injury CT sensitivity is 25%

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 10% of all trauma patients and 20% of all thoracic trauma Rib fractures increase mortality and morbidity -> single fracture 6% mortality and 8 or more 34% mortality!, increased morbidity (LRTI, tracheostomy, ARDS, prolonged ICU admissions etc) 65 year and older  almost double OR for mortality compared to younger patients

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 interest in selected cases 1975 study Paris et al – sparked interest and the evidence has increased 10 fold in the last decade Increased understanding of biomechanics of respiration with regards to ribs and better devices have lead to the increased in interest Despite the interest, consensus to the indications, technique and timing is still elusive

Role of Fixation Who? De Moya et al, 2017 3 randomised clinical trials – others are retrospective, common findings are see next page

Role of Rib Fixation Benefit Pneumonia reduction Reduction of ICU stay Reduced tracheostomy rates Earlier return to work 3 RCTs one had chose 5 ribs or more and ventilated for 5 days at least and the others looked at all comers - benefit was strongest in the former Weakness are different timing to OT, and different fixation devices Infection rates 2%

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