2018 Lunevicius_Buttock wound_Klaipeda LT
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This document discusses the importance of grading systems for buttock wounds from penetrating injuries. It presents a case study of a 25-year-old male who was stabbed in the buttock and suffered recurrent bleeding requiring multiple hospital readmissions and blood transfusions before undergoing surgery. The key learning point is that patients with recurrent bleeding after high-risk penetrating gluteal injuries should receive further imaging like angiography to allow for early endovascular intervention like angioembolization to reduce the need for surgery.
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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
- 5. Re-review of CT-scan images: right obturator artery pseudoaneurysm21/10/2020 5
- 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 21/10/2020 7
- 8. Abbreviated Injury Scale: severity ranking 1. Minor 2. Moderate 3. Serious 4. Severe 5. Critical 6. Maximal 21/10/2020 8
- 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 21/10/2020 11
- 12. References 1. Clark S,Westley S, CouplandA, Hamady M, DaviesAH. Buttock wounds: beware what lies beneath. BMJ Case Rep 2017 Oct 24 2. Abbreviated Injury Scale 2005© Update 2008. Editors: GennarelliTA, Wodzin E. 2008.Association for the Advancement of Automotive Medicine, Barrington, IL, USA. 3. Lunevicius R, Lewis D,Ward RG, ChangA, Samalavicius NE, Schulte KM. Penetrating injury to the buttock: an update.Tech Coloproctol 2014;18:981-92. 4. Lunevicius R, Schulte KM.Analytical review of 664 cases of penetrating buttock trauma.World J Emerg Surg 2011; 6:33. 21/10/2020 12
Editor's Notes
- 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.