General Surgery & Trauma

RCT: Early minimally invasive surgery may improve outcomes in selected patients with intracerebral hemorrhage – N Engl J Med

25 May, 2024 | 18:58h | UTC

Study Design and Population: This multicenter randomized clinical trial investigated the efficacy of early minimally invasive surgical removal of intracerebral hemorrhage compared to medical management alone. The trial enrolled 300 patients within 24 hours of symptom onset, who had either lobar or anterior basal ganglia hemorrhages, with hematoma volumes ranging from 30 to 80 ml. An adaptation rule was applied partway through the trial, resulting in the exclusive enrollment of patients with lobar hemorrhages after 175 patients were initially enrolled.

Main Findings: Patients in the surgery group achieved a significantly higher mean score on the utility-weighted modified Rankin scale at 180 days (0.458) compared to the control group (0.374), with a difference of 0.084 and a posterior probability of superiority of 0.981. Notably, the benefit of surgery was pronounced among patients with lobar hemorrhages (mean difference 0.127), whereas no benefit was observed in patients with anterior basal ganglia hemorrhages. Additionally, the surgery group experienced a lower 30-day mortality rate (9.3%) compared to the control group (18.0%).

Implications for Practice: The results suggest that early minimally invasive surgery for intracerebral hemorrhage, particularly for lobar hemorrhages, offers significant functional benefits over medical management alone. These findings support the selective use of this surgical approach in clinical settings, potentially leading to improved patient outcomes. Further studies could explore the differential impact of hemorrhage location on surgical outcomes to refine treatment guidelines.

Reference (link to abstract – $ for full-text):

Pradilla, G. et al. (2024). Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med, 390(14), 1277-1289. DOI: 10.1056/NEJMoa2308440.

Cluster Randomized Trial: Hyperangulated video laryngoscopy reduces intubation attempts in surgical patients – JAMA

11 May, 2024 | 13:39h | UTC

Study Design and Population: This cluster randomized multiple crossover clinical trial was conducted at a single U.S. academic hospital to compare the effectiveness of hyperangulated video laryngoscopy versus direct laryngoscopy in reducing the number of intubation attempts during surgery. The study involved 7,736 adult patients, aged 18 years or older, undergoing elective or emergent cardiac, thoracic, or vascular surgical procedures that required single-lumen endotracheal intubation for general anesthesia. The trial randomized two sets of 11 operating rooms on a weekly basis to use either video laryngoscopy or direct laryngoscopy for the initial intubation attempt from March 2021 to December 2022.

Main Findings: Hyperangulated video laryngoscopy significantly decreased the number of intubation attempts compared to direct laryngoscopy. Specifically, 1.7% of surgical procedures using video laryngoscopy required more than one intubation attempt versus 7.6% for direct laryngoscopy, with an estimated proportional odds ratio of 0.20 (95% CI, 0.14-0.28; P < .001). Furthermore, intubation failure was markedly lower with video laryngoscopy (0.27%) compared to direct laryngoscopy (4.0%). However, there was no significant difference in the rates of airway and dental injuries between the two methods.

Implications for Practice: The findings indicate that hyperangulated video laryngoscopy enhances initial intubation success and reduces the need for multiple intubation attempts in a variety of surgical settings. This suggests that video laryngoscopy could be considered a preferable technique for endotracheal intubation in the operating room, potentially improving patient outcomes and efficiency. Further research might explore the generalizability of these results to other medical centers and different patient populations.

Reference (link to abstract – $ for full-text):

Ruetzler, K. et al. (2024). Cluster Randomized Trial: Hyperangulated Video Laryngoscopy Reduces Intubation Attempts in Surgical Patients. JAMA, 331(15), 1279-1286. DOI: 10.1001/jama.2024.0762

Prospective Validation Study: High accuracy of PECARN rules in reducing unnecessary CT scans in pediatric blunt trauma – Lancet Child Adolesc Health

5 May, 2024 | 15:08h | UTC

Study Design and Population:

This multicenter prospective validation study tested the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules aimed at reducing unnecessary CT scans for children presenting with blunt abdominal or minor head trauma. Over a nearly five-year period, children and adolescents under 18 from six U.S. emergency departments in cities including Sacramento, Dallas, and Los Angeles were enrolled. Exclusion criteria included pregnancy, pre-existing neurological disorders, penetrating trauma, injuries older than 24 hours, prior CT or MRI scans, or suspicion of non-accidental trauma.

Main Findings:

A total of 7,542 children with blunt abdominal trauma and 19,999 with minor head trauma were enrolled. The intra-abdominal injury rule demonstrated a sensitivity and negative predictive value (NPV) of 100%, confirming its reliability in detecting injuries requiring acute intervention. For head traumas, the sensitivity varied slightly with age; 100% for children under 2 years and 98.8% for those aged 2 years and older, with an NPV of 100% in both groups. Only two cases in the older cohort were misclassified, neither requiring neurosurgery.

Implications for Practice:

The validation of PECARN rules with high sensitivity and NPV supports their use as a safe guideline to minimize unnecessary CT scans in pediatric trauma cases, thereby promoting efficient use of resources and reducing exposure to radiation in children. These results suggest that implementation of these rules should be considered in emergency pediatric care to improve outcomes and healthcare efficiency.

Reference (link to abstract – $ for full-text):

Holmes, J. F. et al. (2024). PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. The Lancet Child & Adolescent Health, May 2024, https://doi.org/10.1016/S2352-4642(24)00029-4.

Systematic Review: Comparing antibiotic treatment vs. appendectomy for the initial treatment of uncomplicated appendicitis – Cochrane Library

4 May, 2024 | 13:09h | UTC

Study Design and Population:

This Cochrane review analyzed 13 randomized controlled trials involving 3,358 participants to compare the efficacy of antibiotic treatment versus appendectomy in managing uncomplicated acute appendicitis. The included studies predominantly involved adult participants and utilized broad-spectrum antibiotics, with interventions ranging from open to predominantly laparoscopic appendectomy. Data collection spanned from hospital admission to up to seven years, with studies conducted across various global regions, including Asia, Europe, and North America.

Main Findings:

The primary outcomes revealed that antibiotic treatment might slightly increase the risk of unsuccessful treatment with 76 additional unsuccessful cases per 1,000 individuals compared to surgery, though these results did not reach clinical significance. Antibiotics reduced wound infections but possibly increased the average hospital stay by half a day. About 30.7% of participants treated with antibiotics required an appendectomy within one year. Secondary outcomes showed very uncertain evidence on antibiotics’ effect on intra-abdominal abscess or reoperation rates, and a slight increase in negative appendectomy rates was observed.

Implications for Practice:

The findings suggest that while antibiotics could serve as an initial treatment to avoid surgery in two-thirds of cases annually, a significant portion may still require surgical intervention. This information is crucial for clinicians in making informed treatment decisions, particularly considering patient preferences and the risk of surgery. Further research is needed to explore long-term outcomes and identify patient subgroups that may benefit most from either treatment.

Reference (link to abstract – $ for full-text):

Doleman B, Fonnes S, Lund JN, et al. (2024). Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database of Systematic Reviews, (April 29), CD015038.pub2. DOI: https://doi.org/10.1002/14651858.CD015038.pub2.

RCT: Serratus anterior plane block reduces pain and opioid use in rib fracture patients – JAMA Surgery

2 May, 2024 | 23:20h | UTC

Study Design and Population:
This study was a multicenter, open-label, pragmatic randomized clinical trial conducted across eight emergency departments in New South Wales, Australia. The trial included 210 patients aged 16 years or older who had clinically suspected or radiologically confirmed rib fractures. Patients intubated, transferred for urgent surgical intervention, or with major concomitant nonthoracic injuries were excluded.

Main Findings:
In the trial, patients were randomized to receive either a serratus anterior plane block (SAPB) along with standard rib fracture management or standard care alone. The primary outcome was a composite pain score measured 4 hours post-enrollment. The SAPB group showed a significant increase in patients achieving the desired pain score reduction (41% in SAPB group vs. 19.6% in control; RR 0.73, 95% CI 0.60-0.89, P = 0.001). Additionally, SAPB recipients had significantly lower opioid consumption at 24 hours compared to the control group.

Implications for Practice:

The trial’s results support the addition of a serratus anterior plane block (SAPB) to standard rib fracture management for providing effective early pain relief and reducing opioid use. However, it’s important to note that this study did not include a sham group, and patients were aware of whether they received the intervention. This lack of blinding could influence patient-reported outcomes due to placebo effects. Despite this limitation, the reduction in pain and opioid consumption suggests that SAPB is a beneficial component of care for patients with rib fractures.

Reference (link to abstract – $ for full-text):

Reference: Partyka, C. et al. (2024). Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management The SABRE Randomized Clinical Trial. JAMA Surg. Published online May 1, 2024. DOI: 10.1001/jamasurg.2024.0969

Original Guideline: The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline – Journal of Urology

Changes to breast structure and function across a woman’s lifespan: implications for managing and modeling female breast injuries

19 Jul, 2023 | 14:29h | UTC

Changes to breast structure and function across a woman’s lifespan: Implications for managing and modeling female breast injuries – Clinical Biomechanics

Commentary: Breast injuries are common for female athletes. Here’s why better awareness and reporting are needed – The Conversation

Cohort Study | Significant traumatic brain injury rates in e-scooter accidents in France

11 Jul, 2023 | 13:36h | UTC

Comparison of Injuries Associated With Electric Scooters, Motorbikes, and Bicycles in France, 2019-2022 – JAMA Network Open

AAP Policy Statement | Child pedestrian safety

10 Jul, 2023 | 13:44h | UTC

Child Pedestrian Safety – Pediatrics

Technical Report: Epidemiology and Prevention of Child Pedestrian Injury – Pediatrics

News Release: Speed, technology, road design are key factors in reducing pedestrian injuries – AAP News

Descending thoracic aortic emergencies: Past, present, and future

Thoracic aortic emergencies involving the aortic arch: An integrated cardiovascular surgical treatment approach

Ruptured abdominal aorto-iliac aneurysms: Diagnosis, treatment, abdominal compartment syndrome, and role of simulation-based training

Contemporary multimodal approach to diagnosis and treatment of vascular graft and endograft infections

Acute management of mesenteric emergencies: Tailoring the solution to the problem

Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results

Acute perioperative complications after arterial and venous femoral access in major vascular and cardiac procedures: Ischemic or hemorrhagic patterns and how to solve them

RCT | Dexmedetomidine administration shows promise in PTSD reduction for trauma surgery patients

23 Jun, 2023 | 13:30h | UTC

Effect of Dexmedetomidine on Posttraumatic Stress Disorder in Patients Undergoing Emergency Trauma Surgery: A Randomized Clinical Trial – JAMA Network Open

See also: Visual Abstract

Review | Nonsurgical management of major hemorrhage

22 Jun, 2023 | 15:16h | UTC

Nonsurgical management of major hemorrhage – Canadian Medical Association Journal

ERAS Guideline | Perioperative care for emergency laparotomy

22 Jun, 2023 | 15:14h | UTC

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations – World Journal of Surgery

Part 1: Preoperative: Diagnosis, Rapid Assessment and Optimization

Part 2: Emergency Laparotomy: Intra- and Postoperative Care

Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

Commentary: Dexamethasone Compared to Burr-Hole Drainage for Chronic Subdural Hematoma – HealthDay

RCT: Early minimally invasive surgery may improve outcomes in selected patients with intracerebral hemorrhage – N Engl J Med

Cluster Randomized Trial: Hyperangulated video laryngoscopy reduces intubation attempts in surgical patients – JAMA

Prospective Validation Study: High accuracy of PECARN rules in reducing unnecessary CT scans in pediatric blunt trauma – Lancet Child Adolesc Health

Systematic Review: Comparing antibiotic treatment vs. appendectomy for the initial treatment of uncomplicated appendicitis – Cochrane Library

RCT: Serratus anterior plane block reduces pain and opioid use in rib fracture patients – JAMA Surgery

Guideline | Closure of laparotomy in emergency settings

RCT | Restrictive vs. liberal red blood cell transfusion strategy for critically injured patients

Pictorial Review | Watch out for the early killers: imaging diagnosis of thoracic trauma

Review | Regional anesthesia in the emergency department outside the operating theatre

Position Paper | Management of complicated diaphragmatic hernia in the acute setting

BTS Clinical Statement on pleural procedures

Guideline | Source control in emergency general surgery

Guideline Synopsis | Diagnosis and management of priapism

Changes to breast structure and function across a woman’s lifespan: implications for managing and modeling female breast injuries

Cohort Study | Significant traumatic brain injury rates in e-scooter accidents in France

AAP Policy Statement | Child pedestrian safety

Position Statement | Prehospital hemorrhage control and treatment by clinicians

Position Paper | Assessing and managing frailty in emergency laparotomy

Special Series | Emergencies in vascular surgery

RCT | Dexmedetomidine administration shows promise in PTSD reduction for trauma surgery patients

Review | Nonsurgical management of major hemorrhage

ERAS Guideline | Perioperative care for emergency laparotomy

Editorial | How to become a good surgeon

Review | Traumatic hemorrhage and chain of survival

RCT | In chronic subdural hematoma, dexamethasone fails to match surgery for functional outcomes

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