Akiyoshi Hagiwara

The role of interventional radiology in the management of blunt renal injury : A practical protocol

OBJECTIVE The purpose of this study was to evaluate the efficacy of a protocol designed to minimize the need for surgery in the management of severe blunt renal injury. METHODS Forty-six of 752 trauma patients had evidence of renal injury on computed tomographic (CT) scan. Two patients required emergency laparotomy, and the remaining 44 patients were classified by CT scan grade using the American Association for the Surgery of Trauma classification system. Patients with CT scan grade 3 or over underwent renal angiography. RESULTS Twenty-one patients had a high-grade injury on CT scan (> or =3). Eight had angiographic evidence of extravasation from renal arterial branches and underwent transarterial embolization. One patient with a grade 5 injury had extravasation from a main renal vein and underwent immediate laparotomy. This was the only patient who required surgery for renal injury. CONCLUSION Surgery can be avoided in most cases of blunt renal injury. Hemodynamic instability and injury to main renal veins remain indications for surgical exploration.

Predictors of Death in Patients with Life-threatening Pelvic Hemorrhage after Successful Transcatheter Arterial Embolization

OBJECTIVE The purpose of this study was to determine predictors of death in patients with pelvic fracture whose pelvic arterial hemorrhage is controlled successfully by transcatheter arterial embolization (TAE). METHODS From January 1996 to December 2000, 61 patients with a pelvic fracture who had pelvic arterial hemorrhage were treated at our Level I trauma center according to a protocol that assigns a high priority to diagnostic and therapeutic angiography within the algorithm. Angiography is performed before laparotomy in patients with hemoperitoneum, who can be stabilized by fluid resuscitation, and otherwise afterward. External fixation was performed immediately after TAE in the angiography suite. Predictors of outcome were determined retrospectively by univariate and multivariate analysis using anatomic and physiologic parameters. RESULTS Forty-eight patients survived and 13 died. TAE successfully controlled pelvic arterial hemorrhage in all patients. Predictors of death included posterior pelvic arterial injury and an elevated Acute Physiology and Chronic Health Evaluation II score (odds ratio, 15.6 and 23.9, respectively). Need for fluid requirements to achieve hemodynamic stability were higher in nonsurvivors than in survivors. Outcome did not correlate with the type of fracture or the Injury Severity Score. CONCLUSION Application of angiography as a therapeutic intervention in patients with pelvic arterial bleeding may reduce the need for surgery, thereby avoiding or minimizing this additional trauma.

The efficacy and limitations of transarterial embolization for severe hepatic injury.

BACKGROUND The efficacy of transarterial embolization (TAE) for severe blunt hepatic injury has been reported. We performed a prospective study evaluating the efficacy and the limitation of TAE from January 1996 to December 2000. METHODS All patients with blunt abdominal injury who could be stabilized by fluid resuscitation underwent computed tomographic (CT) scan examinations. Patients with CT scan evidence of hepatic injury were classified into five grades according to CT scan findings on the basis of the injury scale of the American Association for the Surgery of Trauma (Mirvis classification). All patients with CT scan grade 3 to 5 injury underwent angiography. When angiography showed extravasation of contrast medium extending from hepatic arterial branches, TAE was performed. RESULTS Of 612 patients with blunt abdominal trauma, 51 had CT scan grade 3 to 5 injury. Thirty-seven of these patients had a CT scan grade 3 injury and 18 underwent TAE. One of 19 patients who did not undergo TAE developed a delayed hemorrhage on day 6 and required a laparotomy. All 13 patients with a CT scan grade 4 injury had angiographic findings of the extravasation. TAE was successful in 11 patients and unsuccessful in 2. Five patients with a CT scan grade 4 injury required laparotomy. One developed a delayed hemorrhage on day 4. The remaining four patients had a major venous injury (a right lobectomy was performed in two with inferior vena cava injury, and a gauze packing in two with hepatic venous injury). One patient with a CT scan grade 5 injury underwent immediate laparotomy after TAE. Laparotomy revealed inferior vena cava injury and a right lobectomy was performed. Only two patients who underwent a lobectomy died of an uncontrollable hemorrhage. All CT scans of patients with hepatic venous or inferior vena cava injury showed a large low-density area (> or = 10 cm) with involvement of these vessels. The volumes of fluid resuscitation needed from admission until TAE ranged from 2,109 to 2,638 mL/h. CONCLUSION It was considered that the combination of the presence of a CT scan grade 4 or 5 lesion and the fluid requirements of more than 2,000 mL/h to maintain normotension indicated the absolute necessity of surgery. We felt that these patients were not candidates for TAE, and should undergo immediate laparotomy.

Indications for Transcatheter Arterial Embolization in Persistent Hemothorax caused by Blunt Trauma

BACKGROUND To confirm the usefulness of contrast-enhanced computed tomography (CECT) and the efficacy of transcatheter arterial embolization (TAE) in patients, who undergo tube thoracostomy for hemothorax secondary to blunt chest trauma. MATERIALS CECT was performed at admission in patients, who suffered blunt chest trauma but did not require an emergent thoracotomy. Pulmonary injuries with intrapulmonary hematomas or traumatic pneumatoceles or both on computed tomography images were diagnosed as pulmonary lacerations (PL). The size of the pulmonary injuries with the PL was measured as percent volume (volume of the PL/volume of the lung). Rib fracture displacement was measured on computed tomography images and expressed as parallel and transverse displacement of the fractured ribs (PD and TD, respectively). Patients with an injury to a thoracic great vessel (e.g., aortic injury) were excluded. RESULTS CECT of the chest was performed on 154 of 976 consecutive patients with blunt torso trauma. Thirty-four patients have PL without a great vessel injury. Tube thoracostomy was performed at 38 sites in 29 patients. After the initial bloody drainage, the mean drainage during the first hour was 81.2 mL/h +/- 137 mL/h. The mean percent volume of the PL was 29.0% +/- 15.4%. The mean PD was 12.2 mm +/- 10.4 mm. The PD and the TD correlated with the hourly drainage (p = 0.001, p < 0.001, respectively). No correlation was found between the percent volume of PL and hourly drainage (p = 0.11). Of the 38 thoracostomy sites, 6 had a blood loss of > or =200 mL/h. Contrast extravasation on CECT was observed in five of these six sites, and angiography was performed. All five sites had contrast extravasation from an intercostal artery, and TAE was successfully performed. CONCLUSION Intercostal arterial bleeding should be suspected in patients with persistent hemothorax > or =200 mL/h and large displacement of a fractured rib. In such cases, CECT should be performed and TAE is indicated if contrast extravasation is observed.

Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan.

BACKGROUND To demonstrate the clinical characteristics of patients with cervical cord injury (CCI) without bony injury in Japan. METHODS Retrospective review of 127 patients with CCI without bony injury treated between January 2003 and October 2005 at 11 institutions. RESULTS Prevalence of CCI without bony injury was 32.2% among all CCIs and 0.81% among all blunt traumas. Mean age was 60.4 years (range, 19-90 years), with 104 patients (82%) > or = 46 years old (older group). The major mechanism of injury among younger patients (< 46 years) was traffic injuries (39%), whereas minor falls (44%) predominated in older patients. High-energy mechanisms of injury were significantly more common for younger patients (35% versus 15%, p = 0.041). Mean injury severity score, abbreviated injury score for the head and Glasgow coma scale on admission were 17.2 +/- 4.7, 0.6 +/- 0.9, and 14.2 +/- 2.1, respectively. Incomplete CCI occurred in 88.7%. On plain cervical spine radiography, spinal canal stenosis and spondylosis or ossification of the posterior longitudinal ligament were more frequent in older patients than in younger patients (43% vs. 13%, p = 0.008; 54% vs. 17%, p = 0.002, respectively). No abnormal findings were seen in 52% of younger patients. CONCLUSION CCI without bony injury occurred more frequently in this study population than previously reported. Degenerative changes and spinal canal stenosis represent important risk factors for developing CCI without bony injury and the present results suggest that this injury may occur in younger adults during high-energy injuries in the absence of pre-existing cervical spine disease.

Predictors of Vascular and Gastrointestinal Complications in Severe Acute Pancreatitis

Aim: To determine prognostic factors for arterial injury and gastrointestinal perforation in patients with severe acute pancreatitis (AP). Methods: A prospective cohort study was performed in 39 patients with AP whose Ranson scores were ≧3. The following parameters were assessed: Ranson score, APACHE II score, C-reactive protein (CRP) concentration on admission and on day 7, and contrast-enhanced computed tomography (CT) scans on admission (first CT) and between days 6 and 8 (second CT). The Balthazar CT severity index was calculated. Results: Six patients developed seven vascular and/or gastrointestinal complications (duodenal perforations in 3 and arterial pseudoaneurysm in 4). CRP on day 7 and the CT severity indices at the second CT were significantly higher in the complication group than in the noncomplication group. A stepwise logistic regression analysis demonstrated that CRP ≧15 mg/dl on day 7 and CT severity index ≧7 at the second CT were independent risk factors (p = 0.02 and 0.04, respectively). The odds ratio for CRP ≧15 mg/dl was 23.0 and 15.7 for a CT severity index of ≧7. Conclusion: A persistent elevation of the CRP concentration and a high CT severity index are independent risk factors for local complications associated with AP.

Hyperechoic appearance of hepatic parenchyma on ultrasound examination of patients with blunt hepatic injury

OBJECTIVE To study the significance of a geographic hyperechoic liver parenchyma pattern on ultrasound (US) examination of patients with blunt abdominal injury. DESIGN Prospective clinical study with double-blind evaluation of images and clinical data. METHODS AND MAIN RESULTS We performed US examinations in 831 consecutive patients admitted to our hospital for blunt abdominal trauma and identified 33 with a geographic hyperechoic pattern in the liver. We correlated the appearance with computed tomographic images and with clinical, angiographic, and scintigraphic data. All patients with a geographic hyperechoic pattern showed mild computed tomographic evidence of hepatic injury (Mirvis grade 2, 69%; Mirvis grade 3, 31%). Excluding patients who required urgent surgery for other reasons and patients in shock, patients with the geographic hyperechoic pattern were managed conservatively with no complications. CONCLUSION The geographic hyperechoic pattern of liver parenchyma on US examination of trauma patients is a mild injury that, of itself, does not require surgical therapy.

High D-dimer levels predict a poor outcome in patients with severe trauma, even with high fibrinogen levels on arrival : a multicenter retrospective study

ABSTRACT Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24 h were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190 mg/dL and 38 mg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38 mg/L)/high fibrinogen (>190 mg/dL), low D-dimer (<38 mg/L)/low fibrinogen (⩽190 mg/dL), high D-dimer (≥38 mg/L)/high fibrinogen (>190 mg/dL), and high D-dimer (≥38 mg/L)/low fibrinogen (⩽190 mg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Can Early Aggressive Administration of Fresh Frozen Plasma Improve Outcomes in Patients with Severe Blunt Trauma?—a Report by the Japanese Association for the Surgery of Trauma

Background: This study investigated the effect of a high ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) within the first 6 and 24 h after admission on mortality in patients with severe, blunt trauma. Methods: This retrospective observational study included 189 blunt trauma patients with an Injury Severity Score (ISS) ≥16 requiring RBC transfusions within the first 24 h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut-off values of the FFP/RBC ratio for outcome. The patients were then divided into two groups according to the cut-off value. Patient survival was compared between groups using propensity score matching (PSM). Results: The area under the ROC curve was 0.57, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.57) and specificity (0.67). All patients were then divided into two groups (FFP/RBC ratio ≥1 or <1) and analyzed using PSM and inverse probability of treatment weighting (IPTW). The unadjusted hazard ratio (HR) was 0.44, and the adjusted HR was 0.29. The HR was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio ≥1 within the first 6 h. Conclusions: Severe blunt trauma patients transfused with an FFP/RBC ratio ≥1 within the first 6 h had an HR of about 0.4. The transfusion of an FFP/RBC ratio ≥1 within the first 6 h was associated with the outcomes of blunt trauma patients with ISS ≥16 who need a transfusion within 24 h.

Development of Novel Criteria of the “lethal Triad” as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

Objectives: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. Design: Retrospective observational study. Settings: Fifteen acute critical care medical centers in Japan. Patients: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. Interventions: None. Measurements and Main Results: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and –3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. Conclusions: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.