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Traumatic ureteral injuries account for fewer than 1% of traumatic urologic injuries, and those caused by blunt trauma are even rarer than those caused by penetrating trauma. The symptoms associated with ureteral injury may be subtle, with or without hematuria, making it difficult to diagnose. We report the case of a 31-year-old man with a delayed diagnosis of proximal ureter injury after abdominal blunt trauma sustained in a motorcycle traffic accident. The patient underwent emergency laparotomy on admission for liver injury, mesenteric injury, and resultant hemoperitoneum. On postoperative day 6, he underwent angioembolization for suspected remnant intra-abdominal bleeding. Persistent symptoms of flank pain and leukocytosis led to follow-up imaging studies that revealed proximal ureter injury, and the patient underwent unilateral nephrectomy. This case stresses the importance of clinical suspicion for genitourinary injuries in the presence of abdominal trauma.

Abstract High-energy impacts, like vehicle crashes or falls, can lead to pelvic ring injuries. Rapid diagnosis and treatment are crucial due to the risks of severe bleeding and organ damage. Pelvic radiography promptly assesses fracture extent and location, but struggles to diagnose bleeding. The AO/OTA classification system grades pelvic instability, but its complexity limits its use in emergency settings. This study develops and evaluates a deep learning algorithm to classify pelvic fractures on radiographs per the AO/OTA system. Pelvic radiographs of 773 patients with pelvic fractures and 167 patients without pelvic fractures were retrospectively analyzed at a single center. Pelvic fractures were classified into types A, B, and C using medical records categorized by an orthopedic surgeon according to the AO/OTA classification system. Accuracy, Dice Similarity Coefficient (DSC), and F1 score were measured to evaluate the diagnostic performance of the deep learning algorithms. The segmentation model showed high performance with 0.98 accuracy and 0.96–0.97 DSC. The AO/OTA classification model demonstrated effective performance with a 0.47–0.80 F1 score and 0.69–0.88 accuracy. Additionally, the classification model had a macro average of 0.77–0.94. Performance evaluation of the models showed relatively favorable results, which can aid in early classification of pelvic fractures.

Purpose Patients with penetrating injuries are at a high risk of mortality, and many of them require emergency surgery. Proper triage and transfer of the patient to the emergency department (ED), where immediate definitive treatment is available, is key to improving survival. This study aimed to evaluate the epidemiology and outcomes of patients with penetrating torso injuries in Incheon Metropolitan City. Methods Data from trauma patients between 2014 and 2018 (5 years) were extracted from the National Emergency Department Information System. In this study, patients with penetrating injuries to the torso (chest and abdomen) were selected, while those with superficial injuries were excluded. Results Of 66,285 patients with penetrating trauma, 752 with injuries to the torso were enrolled in this study. In the study population, 345 patients (45.9%) were admitted to the ward or intensive care unit (ICU), 20 (2.7%) were transferred to other hospitals, and 10 (1.3%) died in the ED. Among the admitted patients, 173 (50.1%) underwent nonoperative management and 172 (49.9%) underwent operative management. There were no deaths in the nonoperative management group, but 10 patients (5.8%) died after operative management. The transferred patients showed a significantly longer time from injury to ED arrival, percentage of ICU admissions, and mortality. There were also significant differences in the percentage of operative management, ICU admissions, ED stay time, and mortality between hospitals. Conclusions Proper triage guidelines need to be implemented so that patients with torso penetrating trauma in Incheon can be transferred directly to the regional trauma center for definitive treatment.

Depending on the degree of fracture, pelvic fracture can be accompanied by vascular damage, and in severe cases, it may progress to hemorrhagic shock. Pelvic radiography can quickly diagnose pelvic fractures, and the Association for Osteosynthesis Foundation and Orthopedic Trauma Association (AO/OTA) classification system is useful for evaluating pelvic fracture instability. This study aimed to develop a radiomics-based machine-learning algorithm to quickly diagnose fractures on pelvic X-ray and classify their instability. data used were pelvic anteroposterior radiographs of 990 adults over 18 years of age diagnosed with pelvic fractures, and 200 normal subjects. A total of 93 features were extracted based on radiomics:18 first-order, 24 GLCM, 16 GLRLM, 16 GLSZM, 5 NGTDM, and 14 GLDM features. To improve the performance of machine learning, the feature selection methods RFE, SFS, LASSO, and Ridge were used, and the machine learning models used LR, SVM, RF, XGB, MLP, KNN, and LGBM. Performance measurement was evaluated by area under the curve (AUC) by analyzing the receiver operating characteristic curve. The machine learning model was trained based on the selected features using four feature-selection methods. When the RFE feature selection method was used, the average AUC was higher than that of the other methods. Among them, the combination with the machine learning model SVM showed the best performance, with an average AUC of 0.75±0.06. By obtaining a feature-importance graph for the combination of RFE and SVM, it is possible to identify features with high importance. The AO/OTA classification of normal pelvic rings and pelvic fractures on pelvic AP radiographs using a radiomics-based machine learning model showed the highest AUC when using the SVM classification combination. Further research on the radiomic features of each part of the pelvic bone constituting the pelvic ring is needed.

Abstract Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092–3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB.

Purpose Trauma is the top cause of death in people under 45 years of age. Deaths from severe trauma can have a negative economic impact due to the loss of people belonging to socio-economically active age groups. Therefore, efforts to reduce the mortality rate of trauma patients are essential. The purpose of this study was to investigate preventable mortality in trauma patients and to identify factors and healthcare-related challenges affecting mortality. Ultimately, these findings will help to improve the quality of trauma care. Methods We analyzed the deaths of 411 severe trauma patients who presented to Gachon University Gil Hospital regional trauma center in South Korea from January 2015 to December 2017, using an expert panel review. Results The preventable death rate of trauma patients treated at the Gachon University Gil Hospital regional trauma center was 8.0%. Of these, definitely preventable deaths comprised 0.5% and potentially preventable deaths 7.5%. The leading cause of death in trauma patients was traumatic brain injury. Treatment errors most commonly occurred in the intensive care unit (ICU). The most frequent management error was delayed treatment of bleeding. Conclusions Most errors in the treatment of trauma patients occurred in early stages of the treatment process and in the ICU. By identifying the main causes of preventable death and errors during the course of treatment, our research will help to reduce the preventable death rate. Appropriate trauma care systems and ongoing education are also needed to reduce preventable deaths from trauma.

Purpose Traumatic pancreatic injuries are rare, but their diagnosis and management are challenging. The aim of this study was to evaluate and report our experiences with the management of pancreatic injuries. Methods We identified all adult patients (age >15) with pancreatic injuries from our trauma registry over a 7-year period. Data related to patients’ demographics, diagnoses, operative information, complications, and hospital course were abstracted from the registry and medical records. Results A total of 45 patients were evaluated. Most patients had blunt trauma (89%) and 21 patients (47%) had pancreatic injuries of grade 3 or higher. Twenty-eight patients (62%) underwent laparotomy and 17 (38%) received nonoperative management (NOM). The overall in-hospital mortality rate was 24% (n=11), and only one patient died after NOM (due to a severe traumatic brain injury). Twenty-two patients (79%) underwent emergency laparotomy and six (21%) underwent delayed laparotomy. A drainage procedure was performed in 12 patients (43%), and pancreatectomy was performed in 16 patients (57%) (distal pancreatectomy [DP], n=8; DP with spleen preservation, n=5; pancreaticoduodenectomy, n=2; total pancreatectomy, n=1). Fourteen (31%) pancreas-specific complications occurred, and all complications were successfully managed without surgery. Solid organ injuries (n=14) were the most common type of associated abdominal injury (Abbreviated Injury Scale ≥3). Conclusions For traumatic pancreatic injuries, an appropriate treatment method should be considered after evaluation of the accompanying injury and the patient’s hemodynamic status. NOM can be performed without mortality in appropriately selected cases.

There are many reasons for solitary kidney. Congenital causes include renal agenesis and dysplasia. Acquired causes include nephrectomy performed for reasons including traumatic kidney injury, disease (e.g., renal cell carcinoma), and donation for kidney transplantation. According to the European Association of Urology, the World Society of Emergency Surgery, and the American Association for the Surgery of Trauma guidelines, it is important to preserve the remaining renal function as much as possible when a solitary kidney patient has suffered a traumatic kidney injury. The authors present a case of kidney preservation in a solitary kidney patient with a traumatic grade IV renal injury through non-operative management involving superselective renal artery angioembolization.

In certain circumstances, invasive procedures such as creation of a surgical airway, insertion of a chest drain, intraosseous puncture, or amputation in the field are necessary. These invasive procedures can save lives. However, emergency medical service teams cannot perform such procedures according to the law in Korea. The upper arm of a 29-year-old male patient was stuck in a huge machine and the emergency medical service team could not rescue the patient. A doctor-car team was dispatched to the scene and the team performed the filed amputation to extricate the patient. He was brought to the trauma center immediately and underwent formal above-elbow amputation. Here we describe a case of field amputation to rescue a patient through a “doctor car” system, along with a literature review.

Purpose Nutritional therapy in the intensive care unit is an essential factor for patient progress. The purpose of this study was to compare resting energy expenditure (REE) calculated by prediction equations (PEs) to the REE measured by indirect calorimetry (IC) in trauma patients. Methods Patients admitted to the trauma intensive care unit who received mechanical ventilation between January and December 2015 were enrolled. REE was measured by IC (CCM Express, MGC Diagnostics) and calculated by the following PEs: Harris-Benedict, Fleisch, Robertson and Reid, Ireton-Jones, and the maximum value (25 kcal/kg/ day) of the European Society for Clinical Nutrition and Metabolism (ESPEN). All patients were ventilated at a fraction of inspired oxygen (FiO2) below 60%. Results Of the 31 patients included in this study, 24 (77.4%) were men and seven (22.6%) were women. The mean age of the patients was 49.7±13.2 years, their mean weight was 68.1±9.6 kg, and their mean Injury Severity Score was 26.1±11.3. The mean respiratory quotient on IC was 0.93±0.19, and their mean FiO2 was 38.72%±6.97%. The mean REE measured by IC was 2,146±444.36 kcal/day, and the mean REE values calculated by the PEs were 1,509.39±205.34 kcal/day by the Harris and Benedict equation, 1,509.39±154.33 kcal/day by the Fleisch equation, and 1,443.39±159.61 kcal/day by the Robertson and Reid equation. The Ireton-Jones equation yielded a higher value (2,278.90±202.35 kcal/ day), which was not significantly different from the value measured using IC (p=0.53). The ESPEN maximum value (1,704.03±449.36 kcal/day) was lower, but this difference was likewise not significant (p=0.127). Conclusions The REE measured by IC was somewhat higher than that calculated using PEs. Further studies are needed to determine the proper nutritional support for trauma patients.

The following recommendations are presented herein: All trauma patients admitted to the resuscitation room should be constantly (or periodically) monitored for parameters such as blood pressure, heart rate, respiratory rate, oxygen saturation, body temperature, electrocardiography, Glasgow Coma Scale, and pupil reflex (1C). Chest AP and pelvic AP should be performed as the standard initial trauma series for severe trauma patients (1B). In patients with severe hemodynamically unstable trauma, it is recommended to perform extended focused assessment with sonography for trauma (eFAST) as an initial examination (1B). In hemodynamically stable trauma patients, eFAST can be considered as the initial examination (2B). For the diagnosis of suspected head trauma patients, brain computed tomography (CT) should be performed as an initial examination (1B). Cervical spine CT should be performed as an initial imaging test for patients with suspected cervical spine injury (1C). It is not necessary to perform chest CT as an initial examination in all patients with suspected chest injury, but in cases of suspected vascular injury in patients with thoracic or high-energy damage due to the mechanism of injury, chest CT can be considered for patients in a hemodynamically stable condition (2B). CT of the abdomen is recommended for patients suspected of abdominal trauma with stable vital signs (1B). CT of the abdomen should be considered for suspected pelvic trauma patients with stable vital signs (2B). Whole-body CT can be considered in patients with suspicion of severe trauma with stable vital signs (2B). Magnetic resonance imaging can be considered in hemodynamically stable trauma patients with suspected spinal cord injuries (2B).

Purpose This retrospective multicenter study analyzed trauma patients who underwent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the Republic of Korea. Methods This study was conducted from February 2017 to May 2018 at three regional trauma centers in the Republic of Korea. The patients were divided into two groups (cardiopulmonary resuscitation [CPR] and No-CPR) for comparative analysis based on two criteria (complication and mortality) for logistic regression analysis (LRA). Results There were significant differences between the CPR and No-CPR groups in mortality (p=0.003) and treatment administered (p=0.016). By LRA for complications, total occlusion has significantly lesser risk than intermittent or partial occlusion in both univariate (odds ratio [OR] 0.06, 95% confidence interval [CI] 0.00-0.36, p=0.01) and multivariate (OR 0.05, 95% CI 0.00-0.38, p=0.01) analyses. The Rescue had a higher risk than the Coda or Reliant in univariate analysis (OR 4.91, 95% CI 1.14-34.25, p=0.05); however, it was not statistically significant in multivariate analysis (OR 6.98, 95% CI 1.03-74.52, p=0.07). By LRA for mortality, the CPR group was the only variable that had a significantly higher risk of mortality than the No-CPR group in both univariate (OR 17.59, 95% CI 3.05-335.25, p=0.01), and multivariate (OR 24.92, 95% CI 3.77-520.51, p=0.01) analyses. Conclusions This study was conducted in the early stages of REBOA implementation in the Republic of Korea and showed conflicting results from studies conducted by multiple institutions. Therefore, additional research with more accumulated data is needed.

The following key questions and recommendations are presented herein: when is airway intubation initiated in severe trauma? Airway intubation must be initiated in severe trauma patients with a GCS of 8 or lower (1B). Should rapid sequence intubation (RSI) be performed in trauma patients? RSI should be performed in trauma patients to secure the airway unless it is determined that securing the airway will be problematic (1B). What should be used as an induction drug for airway intubation? Ketamine or etomidate can be used as a sedative induction drug when RSI is being performed in a trauma patient (2B). If cervical spine damage is suspected, how is cervical protection achieved during airway intubation? When intubating a patient with a cervical spine injury, the extraction collar can be temporarily removed while the neck is fixed and protected manually (1C). What alternative method should be used if securing the airway fails more than three times? If three or more attempts to intubate the airway fail, other methods should be considered to secure the airway (1B). Should trauma patients maintain normal ventilation after intubation? It is recommended that trauma patients who have undergone airway intubation maintain normal ventilation rather than hyperventilation or hypoventilation (1C). When should resuscitative thoracotomy be considered for trauma patients? Resuscitative thoracotomy is recommended for trauma patients with penetrating injuries undergoing cardiac arrest or shock in the emergency room (1B).

Purpose There is increasing evidence in the literature regarding resuscitative endovascular balloon occlusion of the aorta (REBOA) globally, but few cases have been reported in Korea. We aimed to describe our experience of successful Zone III REBOA and to discuss its algorithm, techniques, and related complications. Methods We reviewed consecutive cases who survived from hypovolemic shock after Zone III REBOA placement for 4 years. We reviewed patients’ baseline characteristics, physiological status, procedural data, and outcomes. Results REBOA was performed in 44 patients during the study period, including 10 patients (22.7%) who underwent Zone III REBOA, of whom seven (70%) survived. Only one patient was injured by a penetrating mechanism and survived after cardiopulmonary resuscitation. All patients underwent interventions to stop bleeding immediately after REBOA placement. Conclusions This case series suggests that Zone III REBOA is a safe and feasible procedure that could be applied to traumatic shock patients with normal FAST findings who receive a chest X-ray examination at the initial resuscitation.

The Coronavirus disease 2019 (COVID-19) has rapidly spread across the world and caused a pandemic. It can be transmitted by an infected person or an asymptomatic carrier and is a highly contagious disease. Prevention and early identification of COVID-19 are important to minimize the transmission of COVID-19. Chest computed tomography (CT) has a high sensitivity for detecting COVID-19, but relatively low specificity. Therefore, chest CT may be difficult to distinguish COVID-19 findings from those of other infectious (notably viral types of pneumonia) or noninfectious disease. Pulmonary contusion has also a lot of similarities on chest CT with COVID-19 pneumonia. We present trauma patients with pulmonary contusion whose CT scans showed findings similar to those of COVID-19, and we report our experience in the management of trauma patients during the COVID-19 pandemic.

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.

Purpose Accurate and appropriate prehospital field triage is essential for a trauma system. The Korean trauma system (established in 2014) uses the trauma field triage algorithm of the United States Centers for Disease Control and Prevention (CDC). This study evaluated the suitability of the CDC field triage criteria for major trauma cases (injury severity score >15) in Korea. Methods This retrospective cohort study evaluated trauma patients who presented at the authors’ regional trauma center from January 1 to May 7, 2017. The undertriage and overtriage rates of each CDC field triage step were calculated. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was evaluated for each step. Results Among the 1,009 enrolled patients, 168 (16.7%) had major trauma. The undertriage/overtriage rates of each step (steps I, II, III, and IV) of CDC field triage were 9.2%/47.4%, 6.3%/50.8%, 4.5%/59.4%, and 5.3%/78.9%, respectively. The AUC values of each CDC triage step were 0.722, 0.783, 0.791, and 0.615, respectively. The AUC values of the separate components of each step (physiologic criteria, anatomic criteria, mechanism-of-injury criteria, and special considerations) were 0.722, 0.648, 0.647, and 0.456, respectively. Conclusions The CDC field triage system is acceptable, but not ideal, for Korean trauma care. If we follow the protocol, it would be preferable to omit step IV. The Korean Triage and Acuity Scale may be a good indicator for in-hospital triage. However, a new triage protocol that is simple to estimate on-scene while having good performance should be developed.

Purpose Immediate post-laparotomy hypotension (PLH) is a precipitous drop in blood pressure caused by a sudden release of abdominal tamponade after laparotomy in cases of severe hemoperitoneum. The effect of laparotomy on blood pressure in patients with significant hemoperitoneum is unknown. Methods In total, 163 patients underwent laparotomy for trauma from January 1, 2013 to December 31, 2015. Exclusion criteria included the following: negative laparotomy, only a hollow viscous injury, and hemoperitoneum

Background The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). Methods We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. Results The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. Conclusions In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

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