Abdulaziz AlSharydah

Introduction:

Trauma and motor vehicle collisions (MVCs) are the two most significant causes of mortality and morbidity worldwide.1 In 2004, deaths from MVCs were globally ranked second after deaths from ischemic heart diseases. According to World Health Organization (WHO), in 2018, there were 28.8 fatalities from MVCs per 100,000 population in Saudi Arabia, which exceeded the fatality rates in the USA, UK, and Australia. The continuous assessment and triaging of the various injuries according to the severity of the damage and based on the extent of vital organ involvement enables proper medical care, and efficient management of trauma patients can be achieved by the implementation of a standardized workflow algorithm by the multidisciplinary trauma team.

Diagnostic radiology (DR) and interventional radiology (IR) play a major role in the diagnosis and management of patients injured in MVCs. Since their revolutionary introduction in the 1970s, endovascular techniques have contributed to important developments in medical equipment, damage-control strategies, and procedures, and IR has become an integral part of the medical care provided by the trauma team. The Society of Interventional Radiology recommended that endovascular interventions (EI) in trauma require the availability of an IR-ready team within 60 minutes of the decision to proceed with angiography.

The American Association for the Surgery of Trauma–World Society of Emergency Surgery (AAST-WSES) guideline preferentially recommends non-operative management (NOM) for hemodynamically stable patients without lesions that require surgical interventions, such as hollow viscus injuries or isolated grades 1 to 3 AAST vascular or viscus injuries without active extravasations detectable on imaging. Diagnostic and IR teams should recognize the spectrum of traumatic injuries and learn to manage mass casualty incidents using radiological equipment. Imaging examinations, including ultrasound (US), radiography (XR), Technetium-labeled RBC scintigraphy (Tc-99m RBC scan), and computed tomography (CT), are prioritized modalities for improving triaging accuracy.

Alternatively, conventional catheter angiography can be used for defining vascular injuries and problem-solving in therapeutic scenarios.

This study was conducted with a primary aim to bridge a gap in the literature with regard to the determination of patient characteristics of victims of trauma in whom IR was used, and secondary objective to identify demographic and clinical factors, including acuity levels, coagulopathies, blood transfusions, and length of hospital stays, that may be of interest in endovascular therapies.

Material(s) and Method(s): Data collection

Data were retrospectively obtained through multistage collection using the keyword “trauma” in the International Classification of Diseases 10th Edition (ICD-10) coding system, as well as the codes S20–S39, related to injuries to the thorax, abdomen, lower back, lumbar spine, and pelvis, to identify the relevant patient charts from the electronic medical record archival system at King Fahad Hospital of the University (KFHU). Next, the hospital’s radiology department’s database was reviewed using the PACS system to screen the data collected over the past 10 years (from December 2010 to December 2020), including pertinent radiography, sonography, digital subtracted angiography, and computed tomography imaging studies. The list thus obtained was perused to identify cases that met the inclusion criteria of this study, and1000 adult and pediatric trauma, from both sexes, were confirmed and retrospectively enrolled. An extensive chart review of each case was performed using both digital and paper-based data to collect the study-related variables over an 8-month period.

Setting

The study was conducted at KFHU, a tertiary-care, 650-bed, university teaching hospital located in the Eastern Province of Saudi Arabia. The academic hospital in the Eastern Province of Saudi Arabia is accredited by the Joint Commission International (JCI) and The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). According to the 2018 annual report, the hospital received approximately 270,000 annual outpatient (OPD 21,767 and emergency room [ER] 247,331) visits. The radiology department was operational since 1981, and the IR division, comprising four modern angiography suites operated by seven trained interventional radiologists, was established in 2010. In 2017, approximately 800 patients benefited from the IR unit, compared to 700 patients in 2016.

Result(s):

Assessment of demographics

Among 790 participants, the majority were adolescents (age, mean±SD [range] 20±13 [11–21] years), and Saudi Arabians (n=693 [81%]; Table 1) including 501 (63.42%) males and 289 (36.58%) females.

Assessment of injury type

Based on their injures, participants were categorized as motor vehicle collision (MVC) victims (n=630 [79,75%]) or non-MVC victims (n=160 [20,25%]). Iatrogenic injuries (97/160 [60,62%]) represented the majority of non-MVC patients, followed by patients with stab wounds (63/160, [39,37%]). In the diagnostic modalities, liver injuries were the most frequent acute solid-organ injuries (n=158 [20%]), with hemoperitoneum (n=317 [40.8%]) representing the most commonly associated finding

Assessment of circulation stability

In the study cohort, 242 (30.63%) participants were “hemodynamically unstable”15 on ER arrival. Hypotension (n=550 [69.62%]) was the most contributory vital sign in patients with altered stability. (“(un)stability” was defined based on available objective criteria (blood pressure, cardiac output, rate of vasopressor, or inotrope)).

Assessment of laboratory results

No significant age-related differences in the laboratory test results of the trauma victims were observed (Table 2); less than half of the patients (n=340 [43.03%]; P=0.07) had coagulopathies and, among them, 119 (35%) were on routine anticoagulants (P=0.09), and only 173 (22%) were corrected (i.e., discontinuation of anticoagulant and administration of antidote) before the EI. Creatinine levels and premedication for possible allergic reactions were documented suboptimally before the EI (n=526 [66.6%] and n=71 [8.9%], respectively). Baseline hemoglobin and hematocrit levels were obtained in all patients.

Assessment of fluid volume and resuscitation

Crystalloid intravenous fluids (normal saline or Ringer’s lactate) were administered for initial volume correction of the participants (n=660 [83.54%]; P=0.005, one-sample t-test). Aggregated data on fresh-frozen plasma and platelets concentrate were collected (n=196 [24.8%]; P=0.1, one-sample t-test). Paired t-test comparisons showed significantly higher mean pre-intervention than post-intervention packed red blood cell transfusions (4.2 units vs. 0.7 units; P<0.0005).

Assessment of diagnostic imaging

The majority of plain radiographs (n=767 [97.14%]) and CT scans (n=513 [64.93%], [85% with intravenous contrast) were interpreted by a non-interventional radiologist (n=765 [96.8%]). The Focused Assessment with Sonography for Trauma (FAST) scans (n=774 [97.97%]) were performed and interpreted by non-radiologists. Tc-99m RBC scans were not performed at our institution. CT was the most advantageous diagnostic modality for identifying hemorrhage (P=0.007, one-way ANOVA) and was superior to sonography and fluoroscopy

Assessment of outcomes

No immediate procedural mortality occurred in the interventional suites; post-interventional in-hospital mortality was 4.05%. The mean length of the hospital stay was 18 days.

Conclusion(s):

The role of IR in the management of acutely injured polytrauma patients is gaining magnitude. However, not all patients are equally suited for EI; thus, the early recognition and considerations of operative versus EI are essential for optimizing patient outcomes. A multidisciplinary decision on the best treatment should be made on a case-by-case basis. Many patients are hemodynamically unsuitable for endovascular embolization and management should be optimized to achieve higher operative success rates. Therapeutic embolization by endovascular routes is the next benchmark in the NOM and considerably decreases the morbidity and duration of hospital stay. The interventionalists were primarily radiologists who advocated their contribution as trauma team members, and reported trauma cases with vascular injuries with concise preoperative planning. Therefore, it is imperative to develop internal operational guidelines, standardized workups, and management protocols based on the available resources.