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

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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

8. 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?

9. 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

10. 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%)

11. 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

12. Algorithm
Alfred Hospital Protocol

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

14. 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

15. 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

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

17. 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%

18. 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