Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have bee... more Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have been reported to date. Case presentation: The authors report a case of gangliocytic paraganglioma verified by post-op pathology after pancreaticoduodenectomy for a tumor in the ampulla of Vater. The 56-year-old male patient concerned visited our emergency room with melena that started one week prior to hospitalization. The patient was diagnosed to have a tumor in the ampulla of Vater with bleeding on its surface. However post-op, he was diagnosed as having gangliocytic paraganglioma by immunohistochemistry. Conclusion: This tumor has precise clinical implications, and if continuous follow up is conducted after careful diagnosis and surgical treatment, invasive major operations, such as, radical pancreaticoduodenectomy can be avoided.
Background Open pelvic fractures are associated with pelvic-perineal soft tissue injuries and pel... more Background Open pelvic fractures are associated with pelvic-perineal soft tissue injuries and pelvic infections as late complications. The study aimed to analyse and compare the clinical results and medical costs of the conventional and modi ed instillation negative-pressure wound therapy (cNPWT and m-iNPWT, respectively). Methods This retrospective study compared the outcomes of cNPWT and m-iNPWT for soft tissue management in patients with open pelvic fractures. We analysed the Injury Severity Score (ISS), hospital stay, medical costs, number of NPWT, time required to reach de nite wound coverage, and occurrence of complications. Results Seventeen patients with open pelvic fractures were treated with NPWT. The median ISS (interquartile range) for m-iNPWT and cNPWT were 40 (26-48) and 43 (35-43), respectively. The numbers of NPWT changes were 6 (3-8) for m-iNPWT and 21 (20-32) for cNPWT. The time to wound coverage for patients who underwent m-iNPWT and cNPWT was 30 and 49 days, respectively. The overall medical costs of m-iNPWT and cNPWT were 80076 and 248395 USD. The hospital and intensive care unit (ICU) stay was 53 (41-70) and 12 (5-26) days for m-iNPWT and 167 (107-284) and 43 (23-151) days for cNPWT. One patient receiving cNPWT died of pelvic sepsis during ICU treatment. Conclusions Our study ndings indicate that m-iNPWT would be a feasible method for complex pelvic soft tissue infection in open pelvic fractures to reduce complication rates, hospital stay, and medical costs.
Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have bee... more Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have been reported to date. The authors report a case of gangliocytic paraganglioma verified by post-op pathology after pancreaticoduodenectomy for a tumor in the ampulla of Vater. The 56-year-old male patient concerned visited our emergency room with melena that started one week prior to hospitalization. The patient was diagnosed to have a tumor in the ampulla of Vater with bleeding on its surface. However post-op, he was diagnosed as having gangliocytic paraganglioma by immunohistochemistry. This tumor has precise clinical implications, and if continuous follow up is conducted after careful diagnosis and surgical treatment, invasive major operations, such as, radical pancreaticoduodenectomy can be avoided.
Non-operative management has been preferred in blunt spleen injury. Moreover children are more su... more Non-operative management has been preferred in blunt spleen injury. Moreover children are more susceptible to post-splenectomy infection, spleen should be preserved if possible. However, splenectomy is inevitable to patients with severe splenic injury. Therefore splenic autotransplantation could be the last chance for preserving splenic function in these patients although efficacy has not proven. Here we reported four cases of children who were underwent splenic autotransplantation successfully after blunt trauma.
Purpose: Despite recent developments in the management of trauma patients in South Korea, a stand... more Purpose: Despite recent developments in the management of trauma patients in South Korea, a standardized system and guideline for trauma treatment are absent. methods: Five guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. results: Restrictive volume replacement must be used for patients experiencing shock from trauma until hemostasis is achieved (1B). The target systolic pressure for fluid resuscitation should be 80-90 mmHg in hypovolemic shock patients (1C). For patients with head trauma, the target pressure for fluid resuscitation should be 100-110 mmHg (2C). Isotonic crystalloid fluid is recommended for initially treating traumatic hypovolemic shock patients (1A). Hypothermia should be prevented in patients with severe trauma, and if hypothermia occurs, the body temperature should be increased without delay (1B). Acidemia must be corrected with an appropriate means of treatment for hypovolemic trauma patients (1B). When a large amount of transfusion is required for trauma patients in hypovolemic shock, a massive transfusion protocol (MTP) should be used (1B). The decision to implement MTP should be made based on hemodynamic status and initial responses to fluid resuscitation, not only the patient's initial condition (1B). The ratio of plasma to red blood cell concentration should be at least 1:2 for trauma patients requiring massive transfusion (1B). When a trauma patient is in life-threatening hypovolemic shock, vasopressors can be administered in addition to fluids and blood products (1B). Early administration of tranexamic acid is recommended in trauma patients who are actively bleeding or at high risk of hemorrhage (1B). For hypovolemic patients with coagulopathy non-responsive to primary therapy, the use of fibrinogen concentrate, cryoprecipitate, or recombinant factor VIIa can be considered (2C). Conclusions: This research presents Korea's first clinical practice guideline for patients with traumatic shock. This guideline will be revised with updated research every 5 years.
Background Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been ... more Background Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been performed in Korea. In this study, we review our experience of RT after a regional trauma center was constructed. Methods This is a retrospective study of RT conducted at a single Korean trauma center from May 2014 to March 2018. The primary outcome was survival, and the secondary outcome was return of spontaneous circulation (ROSC). The clinical characteristics of the patients were compared between the ROSC and non-ROSC groups. Survivors were also reviewed. Results A total of 62 patients were reviewed, and 60 patients had experienced blunt injury. Thirty-nine patients had ROSC. The ROSC group had short cardiopulmonary resuscitation (CPR) time (6 [2-10] min vs 11 [8-12] min, p \ 0.001), the presence of sign of life at the trauma bay [32 (86.5%) vs 7 (28.0%), p \ 0.001], and a low Injury Severity Score [26 (25-39) vs 37 (30-75), p = 0.038] compared to the non-ROSC group. On multivariate analysis, only the presence of sign of life was significantly associated with ROSC [11.297 (1.496-85.309) OR (95% CI), p = 0.019]. The 24-h survival rate was 8.1%, and the successful discharge rate was 4.8%. Conclusion The outcome of RT in a Korean trauma center was favorable. ROSC after RT was strongly associated with the presence of sign of life, and RT may be performed in the presence of sign of life regardless of prehospital CPR time.
A new blood bank system was established in our trauma bay, which allowed immediate utilization of... more A new blood bank system was established in our trauma bay, which allowed immediate utilization of uncross-matched type O packed red blood cells (UORBCs). We investigated the efficacy of UORBC compared to that of the ABO type-specific packed red blood cells (ABO RBCs) from before the bank was installed. From March 2016 to February 2017, data from trauma patients who received UORBCs in the trauma bay were compared with those of trauma patients who received ABO RBCs from January 2013 to December 2015. Propensity matching was used to overcome retrospective bias. The primary outcome was 24-hour mortality, while the secondary outcomes were in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Data from 252 patients were reviewed and UORBCs were administered to 64 patients. The time to transfusion from emergency room admission was shorter in the UORBC group (11 [7-16] minutes vs. 44 [29-72] minutes, P < 0.001). After propensity matching, 47 patients were included in each group. The 24-hour mortality (4 [8.5%] vs. 9 [13.8%], P = 0.135), in-hospital mortality (14 [29.8%] vs. 18 [38.3%], P = 0.384), and ICU LOS (9 [4-19] days vs. 5 [0-19] days, P = 0.155) did not differ significantly between groups. The utilization of UORBCs resulted in a faster transfusion but did not significantly improve the clinical outcomes in traumatic shock patients in this study. However, the tendency for lower mortality in the UORBC group suggested the need for a large study.
Background Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RS... more Background Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favoured when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on rst-pass success and mortality in patients with trauma after RSI-facilitated emergency intubation. Methods We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma centre between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. Results In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a
Purpose: Recently, social interest in an organized trauma system for the treatment of patients ha... more Purpose: Recently, social interest in an organized trauma system for the treatment of patients has been increasing in government and academia and the establishment of trauma center is being considered across the country. However, establishing such a system has not been easy in Korea, because enormous experiences and resources are necessary. The objectives of this study were (1) to estimate a trauma patient’s demands during the course of treatment and (2) to provide appropriate direction for trauma centers to be established in Korea. Methods: The records of 207 patients who were admitted to the Department of Trauma Surgery in Ajou University Medical Center due to trauma were retrospectively reviewed for a 1 year period from March 2010 to February 2011. Patients were reviewed for general characteristics, number of hospital days, numbers and kinds of surgeries, numbers and kinds of consultations, ISS (Injury Severity Score) and number of patients with ISS more than 15. Results: All 207 patients were enrolled. The average number of hospital days was 36.7 days. The ICU stay was 15.9 days, and the general ward stay was 20.8 days. Admitted patients occupied 9.02 beds in ICU and 11.80 beds in the general ward per day. The average number of surgeries per patient was 1.4, and surgery at the Department of Trauma Surgery was most common. Number of consultations per patient was 14.23, and consultations with orthopedic surgeons were most common. The average ISS was 18.6. The number of patients with ISS more than 15 was 141 (61.8%) and the average number of patients treated per trauma surgeon as a major trauma patient was 94.3. The number of mortalities was 20, and the mortality rate was 9.7%. Conclusion: To reduce mortality and to provide proper treatment of patients with major trauma, hospitals need some number of beds, especially in the ICU, to treat patients and to prepare them for emergent surgery. An appropriate number of trauma surgeons and various specialists for consultation are also needed. (J Korean Soc Traumatol 2011;24:37-44)
Fat embolism refers to the presence of fat droplets within the peripheral and lung microcirculati... more Fat embolism refers to the presence of fat droplets within the peripheral and lung microcirculation with or without clinical sequelae. However, early diagnosis of fat embolism is very difficult because the embolism usually does not show at the computed tomography as a large fat complex within vessels. Forty-eight-year-old male with pedestrian traffic accident ransferred from a local hospital by helicopter to the regional trauma center by two flight surgeons on board. At the rendezvous point, he had suffered with dyspnea without any airway obstruction sign with 90% of oxygen saturation from pulse oximetry with giving 15 L of oxygen by a reserve bag mask. The patient was intubated at the rendezvous point. The secondary survey of the patient revealed multiple pelvic bone fracture with sacrum fracture, right femur shaft fracture and right tibia head fracture. Abdominal computed tomography was performed in 191 minutes after the injury and fat embolism with Hounsfield unit of-86 in his right common iliac vein was identified. Here is a very rare case that mass of fat embolism was shown within common iliac vein detected in computed tomography. Early detection of the fat embolus and early stabilization of the fractures are essential to the prevention of sequelae such as cerebral fat embolism.
The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high... more The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population. Methods The subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU). Results The ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group. Conclusion The re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.
Several reports indicate that early plasma transfusion may promote survival and reduce the incide... more Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. Tis retrospective study examined the efect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fxed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. Te MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no signifcant between-group diference in the plasma : RBC ratio at 24 h of hospitalization. Te MTP group had a lower 24 h mortality rate than the control group. Tere was no signifcant diference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to afect 24-hour mortality; however, 30day mortality did not change.
Insufficient nutritional support of critically ill patients is closely associated with poor outco... more Insufficient nutritional support of critically ill patients is closely associated with poor outcomes such as increased complications and mortality [1,2]. Patients admitted to the intensive care unit (ICU) often have medical problems such as ABSTRACT Purpose: To investigate the status of protein supply by comparing the recommended amount with the delivered amount of protein in patients in the trauma and surgical intensive care units (ICU). Feedback on the protein supply status was presented to each hospital, and we evaluated whether the protein supply had increased to an appropriate level. Methods: In this retrospective observational multicenter study, nutritional information on patients in the trauma and surgical ICUs who had received nutritional support intervention was collected on the 1st Wednesday of each month at two-month intervals from August 2020 to June 2021, from nine domestic hospitals in Korea. Every two months, the nutritional status of each hospital was shared with all hospitals, and each nutritional support team received feedback on protein supply status. Results: There were 246 patients from nine hospitals included in this study, and data over the study period from six protein days, were analyzed. The mean ratios of delivered calories to calculated required calories were 74.
Background: Trauma mortality review is the first step in assessing the quality of the trauma trea... more Background: Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. Methods: From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. Results: Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. Conclusion: The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.
Background: This study examined the impact of the performance improvement and patient safety (PIP... more Background: This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. Methods: The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. Results: Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). Conclusion: Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.
Background This study evaluated the effectiveness and clinical outcomes of the implementation of ... more Background This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system. Methods We included patients (1) aged [15 years, (2) with an Injury Severity Score [15, (3) who received C10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for C24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups. Results Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the freshfrozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre-to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p \ 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors. Conclusions Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.
European Journal of Trauma and Emergency Surgery, Feb 14, 2022
To evaluate changes in the management and outcome of severe liver injury after trauma center impl... more To evaluate changes in the management and outcome of severe liver injury after trauma center implementation. Trauma patients with severe liver injury (organ injury scale score ≥ 4) treated between January 2011 and December 2020 were retrospectively reviewed. A trauma center was built in 2016 at our institution, and patients were dichotomized into two groups: before trauma center (BTC) and after trauma center (ATC) group. Treatment methods and outcomes were compared between the groups with 1:1 propensity score matching. We included 50 patients in the BTC group and 104 patients in the ATC group. Patients in the ATC group had frequent utilization of angiography (16% vs 47.1%, p < 0.001), faster transfusion [84 (37–152) min vs 17 (10–79) min, p < 0.001], and less fluid administration within 24 h [8.3 (5.7–13.7) L vs 5.7 (3.1–10.1) L, p = 0.002]. However, mortality rate was not significantly different between the groups (26.0% vs 20.2%, p = 0.416). 1:1 propensity score matching was performed using the variables of age, injury severity score, systolic blood pressure, Glasgow Coma Scale, and initial base excess level. After matching, the mortality rate (26.0% vs 10.0%, p = 0.037) and ventilator application (74.0% vs 54.0%, p = 0.037) significantly improved. Severe liver injury management improved after trauma center implementation.
Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have bee... more Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have been reported to date. Case presentation: The authors report a case of gangliocytic paraganglioma verified by post-op pathology after pancreaticoduodenectomy for a tumor in the ampulla of Vater. The 56-year-old male patient concerned visited our emergency room with melena that started one week prior to hospitalization. The patient was diagnosed to have a tumor in the ampulla of Vater with bleeding on its surface. However post-op, he was diagnosed as having gangliocytic paraganglioma by immunohistochemistry. Conclusion: This tumor has precise clinical implications, and if continuous follow up is conducted after careful diagnosis and surgical treatment, invasive major operations, such as, radical pancreaticoduodenectomy can be avoided.
Background Open pelvic fractures are associated with pelvic-perineal soft tissue injuries and pel... more Background Open pelvic fractures are associated with pelvic-perineal soft tissue injuries and pelvic infections as late complications. The study aimed to analyse and compare the clinical results and medical costs of the conventional and modi ed instillation negative-pressure wound therapy (cNPWT and m-iNPWT, respectively). Methods This retrospective study compared the outcomes of cNPWT and m-iNPWT for soft tissue management in patients with open pelvic fractures. We analysed the Injury Severity Score (ISS), hospital stay, medical costs, number of NPWT, time required to reach de nite wound coverage, and occurrence of complications. Results Seventeen patients with open pelvic fractures were treated with NPWT. The median ISS (interquartile range) for m-iNPWT and cNPWT were 40 (26-48) and 43 (35-43), respectively. The numbers of NPWT changes were 6 (3-8) for m-iNPWT and 21 (20-32) for cNPWT. The time to wound coverage for patients who underwent m-iNPWT and cNPWT was 30 and 49 days, respectively. The overall medical costs of m-iNPWT and cNPWT were 80076 and 248395 USD. The hospital and intensive care unit (ICU) stay was 53 (41-70) and 12 (5-26) days for m-iNPWT and 167 (107-284) and 43 (23-151) days for cNPWT. One patient receiving cNPWT died of pelvic sepsis during ICU treatment. Conclusions Our study ndings indicate that m-iNPWT would be a feasible method for complex pelvic soft tissue infection in open pelvic fractures to reduce complication rates, hospital stay, and medical costs.
Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have bee... more Background: Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have been reported to date. The authors report a case of gangliocytic paraganglioma verified by post-op pathology after pancreaticoduodenectomy for a tumor in the ampulla of Vater. The 56-year-old male patient concerned visited our emergency room with melena that started one week prior to hospitalization. The patient was diagnosed to have a tumor in the ampulla of Vater with bleeding on its surface. However post-op, he was diagnosed as having gangliocytic paraganglioma by immunohistochemistry. This tumor has precise clinical implications, and if continuous follow up is conducted after careful diagnosis and surgical treatment, invasive major operations, such as, radical pancreaticoduodenectomy can be avoided.
Non-operative management has been preferred in blunt spleen injury. Moreover children are more su... more Non-operative management has been preferred in blunt spleen injury. Moreover children are more susceptible to post-splenectomy infection, spleen should be preserved if possible. However, splenectomy is inevitable to patients with severe splenic injury. Therefore splenic autotransplantation could be the last chance for preserving splenic function in these patients although efficacy has not proven. Here we reported four cases of children who were underwent splenic autotransplantation successfully after blunt trauma.
Purpose: Despite recent developments in the management of trauma patients in South Korea, a stand... more Purpose: Despite recent developments in the management of trauma patients in South Korea, a standardized system and guideline for trauma treatment are absent. methods: Five guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. results: Restrictive volume replacement must be used for patients experiencing shock from trauma until hemostasis is achieved (1B). The target systolic pressure for fluid resuscitation should be 80-90 mmHg in hypovolemic shock patients (1C). For patients with head trauma, the target pressure for fluid resuscitation should be 100-110 mmHg (2C). Isotonic crystalloid fluid is recommended for initially treating traumatic hypovolemic shock patients (1A). Hypothermia should be prevented in patients with severe trauma, and if hypothermia occurs, the body temperature should be increased without delay (1B). Acidemia must be corrected with an appropriate means of treatment for hypovolemic trauma patients (1B). When a large amount of transfusion is required for trauma patients in hypovolemic shock, a massive transfusion protocol (MTP) should be used (1B). The decision to implement MTP should be made based on hemodynamic status and initial responses to fluid resuscitation, not only the patient's initial condition (1B). The ratio of plasma to red blood cell concentration should be at least 1:2 for trauma patients requiring massive transfusion (1B). When a trauma patient is in life-threatening hypovolemic shock, vasopressors can be administered in addition to fluids and blood products (1B). Early administration of tranexamic acid is recommended in trauma patients who are actively bleeding or at high risk of hemorrhage (1B). For hypovolemic patients with coagulopathy non-responsive to primary therapy, the use of fibrinogen concentrate, cryoprecipitate, or recombinant factor VIIa can be considered (2C). Conclusions: This research presents Korea's first clinical practice guideline for patients with traumatic shock. This guideline will be revised with updated research every 5 years.
Background Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been ... more Background Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been performed in Korea. In this study, we review our experience of RT after a regional trauma center was constructed. Methods This is a retrospective study of RT conducted at a single Korean trauma center from May 2014 to March 2018. The primary outcome was survival, and the secondary outcome was return of spontaneous circulation (ROSC). The clinical characteristics of the patients were compared between the ROSC and non-ROSC groups. Survivors were also reviewed. Results A total of 62 patients were reviewed, and 60 patients had experienced blunt injury. Thirty-nine patients had ROSC. The ROSC group had short cardiopulmonary resuscitation (CPR) time (6 [2-10] min vs 11 [8-12] min, p \ 0.001), the presence of sign of life at the trauma bay [32 (86.5%) vs 7 (28.0%), p \ 0.001], and a low Injury Severity Score [26 (25-39) vs 37 (30-75), p = 0.038] compared to the non-ROSC group. On multivariate analysis, only the presence of sign of life was significantly associated with ROSC [11.297 (1.496-85.309) OR (95% CI), p = 0.019]. The 24-h survival rate was 8.1%, and the successful discharge rate was 4.8%. Conclusion The outcome of RT in a Korean trauma center was favorable. ROSC after RT was strongly associated with the presence of sign of life, and RT may be performed in the presence of sign of life regardless of prehospital CPR time.
A new blood bank system was established in our trauma bay, which allowed immediate utilization of... more A new blood bank system was established in our trauma bay, which allowed immediate utilization of uncross-matched type O packed red blood cells (UORBCs). We investigated the efficacy of UORBC compared to that of the ABO type-specific packed red blood cells (ABO RBCs) from before the bank was installed. From March 2016 to February 2017, data from trauma patients who received UORBCs in the trauma bay were compared with those of trauma patients who received ABO RBCs from January 2013 to December 2015. Propensity matching was used to overcome retrospective bias. The primary outcome was 24-hour mortality, while the secondary outcomes were in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Data from 252 patients were reviewed and UORBCs were administered to 64 patients. The time to transfusion from emergency room admission was shorter in the UORBC group (11 [7-16] minutes vs. 44 [29-72] minutes, P < 0.001). After propensity matching, 47 patients were included in each group. The 24-hour mortality (4 [8.5%] vs. 9 [13.8%], P = 0.135), in-hospital mortality (14 [29.8%] vs. 18 [38.3%], P = 0.384), and ICU LOS (9 [4-19] days vs. 5 [0-19] days, P = 0.155) did not differ significantly between groups. The utilization of UORBCs resulted in a faster transfusion but did not significantly improve the clinical outcomes in traumatic shock patients in this study. However, the tendency for lower mortality in the UORBC group suggested the need for a large study.
Background Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RS... more Background Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favoured when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on rst-pass success and mortality in patients with trauma after RSI-facilitated emergency intubation. Methods We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma centre between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. Results In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a
Purpose: Recently, social interest in an organized trauma system for the treatment of patients ha... more Purpose: Recently, social interest in an organized trauma system for the treatment of patients has been increasing in government and academia and the establishment of trauma center is being considered across the country. However, establishing such a system has not been easy in Korea, because enormous experiences and resources are necessary. The objectives of this study were (1) to estimate a trauma patient’s demands during the course of treatment and (2) to provide appropriate direction for trauma centers to be established in Korea. Methods: The records of 207 patients who were admitted to the Department of Trauma Surgery in Ajou University Medical Center due to trauma were retrospectively reviewed for a 1 year period from March 2010 to February 2011. Patients were reviewed for general characteristics, number of hospital days, numbers and kinds of surgeries, numbers and kinds of consultations, ISS (Injury Severity Score) and number of patients with ISS more than 15. Results: All 207 patients were enrolled. The average number of hospital days was 36.7 days. The ICU stay was 15.9 days, and the general ward stay was 20.8 days. Admitted patients occupied 9.02 beds in ICU and 11.80 beds in the general ward per day. The average number of surgeries per patient was 1.4, and surgery at the Department of Trauma Surgery was most common. Number of consultations per patient was 14.23, and consultations with orthopedic surgeons were most common. The average ISS was 18.6. The number of patients with ISS more than 15 was 141 (61.8%) and the average number of patients treated per trauma surgeon as a major trauma patient was 94.3. The number of mortalities was 20, and the mortality rate was 9.7%. Conclusion: To reduce mortality and to provide proper treatment of patients with major trauma, hospitals need some number of beds, especially in the ICU, to treat patients and to prepare them for emergent surgery. An appropriate number of trauma surgeons and various specialists for consultation are also needed. (J Korean Soc Traumatol 2011;24:37-44)
Fat embolism refers to the presence of fat droplets within the peripheral and lung microcirculati... more Fat embolism refers to the presence of fat droplets within the peripheral and lung microcirculation with or without clinical sequelae. However, early diagnosis of fat embolism is very difficult because the embolism usually does not show at the computed tomography as a large fat complex within vessels. Forty-eight-year-old male with pedestrian traffic accident ransferred from a local hospital by helicopter to the regional trauma center by two flight surgeons on board. At the rendezvous point, he had suffered with dyspnea without any airway obstruction sign with 90% of oxygen saturation from pulse oximetry with giving 15 L of oxygen by a reserve bag mask. The patient was intubated at the rendezvous point. The secondary survey of the patient revealed multiple pelvic bone fracture with sacrum fracture, right femur shaft fracture and right tibia head fracture. Abdominal computed tomography was performed in 191 minutes after the injury and fat embolism with Hounsfield unit of-86 in his right common iliac vein was identified. Here is a very rare case that mass of fat embolism was shown within common iliac vein detected in computed tomography. Early detection of the fat embolus and early stabilization of the fractures are essential to the prevention of sequelae such as cerebral fat embolism.
The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high... more The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population. Methods The subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU). Results The ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group. Conclusion The re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.
Several reports indicate that early plasma transfusion may promote survival and reduce the incide... more Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. Tis retrospective study examined the efect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fxed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. Te MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no signifcant between-group diference in the plasma : RBC ratio at 24 h of hospitalization. Te MTP group had a lower 24 h mortality rate than the control group. Tere was no signifcant diference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to afect 24-hour mortality; however, 30day mortality did not change.
Insufficient nutritional support of critically ill patients is closely associated with poor outco... more Insufficient nutritional support of critically ill patients is closely associated with poor outcomes such as increased complications and mortality [1,2]. Patients admitted to the intensive care unit (ICU) often have medical problems such as ABSTRACT Purpose: To investigate the status of protein supply by comparing the recommended amount with the delivered amount of protein in patients in the trauma and surgical intensive care units (ICU). Feedback on the protein supply status was presented to each hospital, and we evaluated whether the protein supply had increased to an appropriate level. Methods: In this retrospective observational multicenter study, nutritional information on patients in the trauma and surgical ICUs who had received nutritional support intervention was collected on the 1st Wednesday of each month at two-month intervals from August 2020 to June 2021, from nine domestic hospitals in Korea. Every two months, the nutritional status of each hospital was shared with all hospitals, and each nutritional support team received feedback on protein supply status. Results: There were 246 patients from nine hospitals included in this study, and data over the study period from six protein days, were analyzed. The mean ratios of delivered calories to calculated required calories were 74.
Background: Trauma mortality review is the first step in assessing the quality of the trauma trea... more Background: Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. Methods: From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. Results: Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. Conclusion: The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.
Background: This study examined the impact of the performance improvement and patient safety (PIP... more Background: This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. Methods: The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. Results: Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). Conclusion: Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.
Background This study evaluated the effectiveness and clinical outcomes of the implementation of ... more Background This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system. Methods We included patients (1) aged [15 years, (2) with an Injury Severity Score [15, (3) who received C10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for C24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups. Results Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the freshfrozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre-to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p \ 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors. Conclusions Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.
European Journal of Trauma and Emergency Surgery, Feb 14, 2022
To evaluate changes in the management and outcome of severe liver injury after trauma center impl... more To evaluate changes in the management and outcome of severe liver injury after trauma center implementation. Trauma patients with severe liver injury (organ injury scale score ≥ 4) treated between January 2011 and December 2020 were retrospectively reviewed. A trauma center was built in 2016 at our institution, and patients were dichotomized into two groups: before trauma center (BTC) and after trauma center (ATC) group. Treatment methods and outcomes were compared between the groups with 1:1 propensity score matching. We included 50 patients in the BTC group and 104 patients in the ATC group. Patients in the ATC group had frequent utilization of angiography (16% vs 47.1%, p < 0.001), faster transfusion [84 (37–152) min vs 17 (10–79) min, p < 0.001], and less fluid administration within 24 h [8.3 (5.7–13.7) L vs 5.7 (3.1–10.1) L, p = 0.002]. However, mortality rate was not significantly different between the groups (26.0% vs 20.2%, p = 0.416). 1:1 propensity score matching was performed using the variables of age, injury severity score, systolic blood pressure, Glasgow Coma Scale, and initial base excess level. After matching, the mortality rate (26.0% vs 10.0%, p = 0.037) and ventilator application (74.0% vs 54.0%, p = 0.037) significantly improved. Severe liver injury management improved after trauma center implementation.
Uploads
Papers by Tio Ra