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2018 Lunevicius_Buttock wound_Klaipeda LT
1. Buttock wound:
the importance of grading system
Lunevicius R, Samalavicius NE
Aintree University Hospital NHS FoundationTrust, Liverpool, England
Department of Surgery, Klaipėda University Hospital, Lithuania
International Colorectal Forum, Klaipėda, Lithuania
4th May 2018
21/10/2020 1
2. Disclosures
None
Raimundas Lunevicius, FRCS (Engl.)
Consultant Surgeon,Aintree University Hospital NHS FoundationTrust, Liverpool
Directorate Lead for Mortality, Morbidity and Audit
Honorary Senior Clinical Lecturer, University of Liverpool, England
21/10/2020 2
3. The authors aimed to reinforce the importance of early angioembolization
Manuscript Major revision (s) Published in BMJ
Commentary Not published in BMJ Reason: unknown
Review via PUBLONS
BMJ Case Rep 2017 Oct 221/10/2020 3
4. Story
• 25-year-old male
• Bleeding stabbed w..
• MajorTrauma Centre
• ABP 74/43, HR 119
• In stage 2-3 shock
• A pressure dressing
• Pelvic binder
• 3L fluids + 1 Unit of RBC
• Trauma CT-scan: no blush
• Removal of p-binder
• Profuse bleeding
• Closure of the wound
• Discharge / next day
• 7 readmissions / 1 month
• Surgery under GA
• The estimated blood loss 5L
21/10/2020 4
6. Learning point
‘Patients presenting with recurrent bleeding after
high-risk penetrating gluteal injury warrant further
imaging in the form of a digital subtraction
angiogram.This will allow for endovascular
intervention such as angioembolisation that may
obviate the need for, or reduce the risk of, surgical
intervention’
21/10/2020 6
7. More questions than learning points
• Criteria for MTT activation
• MH Resuscitation protocols
• CT-scan: within 30 min
• Interpretation of CT-images
• Trauma MDT meetings
• Discharge criteria
• Injury diagnosis: in
terms of AIS
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8. Abbreviated Injury Scale: severity ranking
1. Minor
2. Moderate
3. Serious
4. Severe
5. Critical
6. Maximal
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9. Penetrating injury to the buttock
Grade 1: superficial, minor
Grade 2: with tissue loss >
25cm2
Grade 3 (serious):
-with blood loss >20% by
volume (shock stage 2 >)
21/10/2020 9
10. Story
• 25-year-old male
• Bleeding stabbed w..
• MajorTrauma Centre
• ABP 74/43, HR 119
• In stage 2-3 shock
• A pressure dressing
• Pelvic binder
• 3L fluids + 1 Unit of RBC
• Trauma CT-scan: no blush
• Removal of p-binder
• Profuse bleeding
• Closure of the wound
• Discharge / next day
• 7 readmissions / 1 month
• Surgery under GA
• The estimated blood loss 5L
21/10/2020 10
11. The take-home message
• Circulatory physiology
(not anatomical
integrity of tissues)
• Is the criterion for gr. 3
injury to the buttock
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A year ago I received an email from the Editor in Chief of the BMJ Case Reports. She asked me to review a manuscript entitled as ….
I have accepted this offer. It was clear that the authors aimed to reinforce the importance of early angioembolization managing patients with deep wounds of the buttock. However, the review process was complicated, it took a long time because of a simple reason – the title of the section: REMINDER OF IMPORTANT CLINICAL LESSON. Happily, the authors have highlighted all of them but one. That is why I would like to speak out about one more lesson - correct application of AIS (Abbreviated Injury Scale) grading for injuries to the buttock.
Major Trauma Team activation criteria (as a hypovolemic shock) – i.e., physiological criteria, anatomical criteria, injury mechanism, special considerations (human factors).
Resuscitation Protocols: 3L of crystalloids infused in a Major Trauma centre of London, and just one unit of RBC.
The interval between the admission time point and CT-scan
The application of a pelvic binder for injuries of soft tissues of the buttock: does that mean severe damage to a buttock vessel?
Interpretation of CT-images. Grade of radiologist, surgeon, etc.
What is the medico-legal perspective for this case?
And WHAT WAS INJURY DIAGNOSIS IN TERMS OF AIS?
The AIS is an anatomically based, consensus-derived system conceived more than four decades ago to describe the severity of injuries throughout the body. The severity codes 1 – 6 are not arbitrary; they are based on current clinical substantiation of the relative severity of these injuries not only in terms of threat to life but also on the longstanding AIS principles of determining overall tissue damage.
The severity of injury to the soft tissues of the buttock ranking is unique. First two ranks of damage to the buttock are based on tissue loss criterion – less or more than 25cm2.
The criterion for grade 3 is different.
When I have asked the authors of the case report to discuss the importance of AIS grading, the answer was quite surprising: ‘let’s say injury grade 2 or 3, would that matter on management strategy?’.
My comment: indeed, yes, that would matter because the AIS 2005 describes clearly: penetrating injury to the soft tissues of the buttock has to be ranked as grade 3 if a wound to the buttock is associated with significant blood loss, >20% by volume (the equivalent of shock stage 2). That would guide a doctor towards CT-angiography and Interventional Radiology on the day of admission.
Back to the story: the patient was in stage 3 hypovolemic shock secondary to bleeding buttock wound.