Objectives:The aim of this study was to assess 24-month functional outcomes of patients randomly assigned to prehospital tranexamic acid (TXA) compared with those assigned to placebo. Methods:The PATCH-Trauma trial assessed administration of TXA by prehospital clinicians and demonstrated greater survival at 28 days from injury among patients allocated to receive TXA, but no difference in favorable functional outcomes at 6 months.This was a subgroup analysis of patients enrolled in the PATCH-Trauma trial. The primary outcome measure was the 8-point Glasgow Outcome Scale-Extended (GOS-E) at 24 months after injury, dichotomized to favorable functional outcomes (GOS-E 5-8) and dead or unfavorable functional outcomes (GOS-E 1-4). We also assessed mortality at 24 hours, 28 days, 6 months, and 24 months after injury. Results:There were 584 patients eligible for inclusion, and 516 patients had data on 24-month outcomes available. Baseline characteristics were comparable. At 24 months, a favorable outcome was reported in 167 (64.0%; 95% CI: 57.8-69.8) patients in the TXA group and 149 (58.4%; 95% CI: 52.1-64.5) in the placebo group (P = .20). There was no difference in the change in GOS-E profile from 6 to 24 months (coeff -0.06; 95% CI: -0.30 to 0.19; P = .64). There was no difference in mortality at any timepoint. Conclusion:Prehospital treatment and ongoing hospital infusion of TXA did not result in improved survival or statistically significant functional outcomes at 24 months compared to placebo. Consideration of longer-term outcomes after trauma is recommended for evidence to practice decisions.

OBJECTIVE:Hypocalcaemia is a common electrolyte disturbance in major trauma patients, particularly those with haemorrhagic shock. Trauma patients are often intubated as part of their care, which can result in post-induction hypotension. We aimed to estimate the effect of hypocalcaemia on post-induction hypotension. METHODS:We conducted a retrospective observational study of trauma patients ≥ 18 years old intubated in a tertiary Australian Emergency Department between 1st January 2020 and 30th September 2024. Epidemiological and clinical management data were extracted to estimate the effect of hypocalcaemia on outcomes. RESULTS:Of 478 eligible patients, 151 had available haemodynamic and calcium measurements. Post-induction hypotension occurred in 38/47 (81%) of hypocalcaemic and 69/104 (66%) of non-hypocalcaemic patients. Hypocalcaemia was associated with higher odds of post-induction hypotension (adjusted odds ratio [aOR] 2.15, 95% confidence interval [CI] 0.84-5.51), with considerable uncertainty in this estimate. Hypocalcaemic patients were more likely to receive red blood cells within 15-min post-induction (OR 2.13, 95% CI 1.12-4.04). Minimal differences were observed in cardiac arrest 15-min post-induction (OR 0.65, 95% CI 0.07-5.73) or mortality at discharge (OR 1.00, 95% CI 0.51-1.97). CONCLUSIONS:Hypocalcaemia may be associated with higher odds of post-induction hypotension in trauma patients; however, our findings require corroboration across a larger multi-centre prospective observational study. If corroborated, a randomised controlled trial is warranted to establish the utility of calcium replacement for the prevention of post-induction hypotension.

BACKGROUND:Pelvic fractures, although relatively uncommon, are associated with high economic burden, morbidity, and mortality. Mortality is largely driven by severe associated injuries and high-energy mechanisms. While predictors of mortality are well established, their local applicability for the study institution has not been updated using site-specific data since an earlier regional study (2001-2008). As trauma management protocols have evolved, this study utilizes prediction model development and internal validation-adhering to the TRIPOD guidelines-to update the prognostic value of these established predictors within our institutional context by using site-specific data. METHODS:Data from July 2010 - December 2022 were sourced from a Level I adult Major Trauma Centre's registry. The cohort included patients > =15 years old with Injury Severity Score (ISS)> 12 and pelvic fractures. In-hospital mortality was the outcome of interest. Model development utilized backward elimination for predictor selection into a multivariable logistic regression model, with internal validation via bootstrap methods. Model performance was assessed using the Brier scaled score, and discrimination (c-statistic), and calibration (calibration plot). RESULTS:Out of 1564 included patients, 118 were non-survivors (mortality rate 7.5%). The optimism-adjusted prediction model identified ISS≥ 50 (OR 7.4), age≥ 65 (OR 6.1), and severe head injury (OR 3.6) as strong predictors of mortality. Additional predictors with ORs between 2-3 included ISS 25-49, shock on admission, direct transport from the scene of injury, and severe comorbidity. The model demonstrated good to excellent discrimination with an optimism-adjusted c-statistic of 0.88. CONCLUSIONS:This study developed and internally validated a prediction model for in-hospital mortality in major trauma patients with high-energy pelvic fractures using recent, single-center data, identifying key predictors. Notably, the severity of the pelvic fracture itself was not an independent predictor, indicating that pelvic injuries act primarily as markers of overall systemic injury severity. While optimism-adjusted odds from internal validation were attenuated, the findings remain comparable to the broader literature. External validation is recommended to assess the model's transportability and broader applicability.

BACKGROUND:The clinical associations of patient deterioration necessitating a Medical Emergency Team (MET) response have been studied in several types of hospital patient cohorts. However, there is limited information on MET events in the Australasian trauma population. METHODS:A retrospective patient cohort study was conducted through merger of the Royal Melbourne Hospital trauma and MET registries between July 1st, 2018, and December 31st, 2022. Data included patient demographics, MET events, selected trauma characteristics, and hospital survival. These data were summarised using standard descriptive statistics and univariable tables, along with a multivariable logistic regression model using hospital mortality as the dependent variable. Ethics approval was obtained (QA2022121) as per the institutional policy. RESULTS:There were 20 815 trauma admissions involving 20 111 individual patients. Overall, MET events occurred in 6% of admissions and were more common within major trauma patients. Overall, hospital mortality occurred in 2% of admissions, distributed as 7.1% major and 0.3% nonmajor trauma. Mortality for patients attended by at least one MET response was 5.9% overall but 9.0% in cases of major trauma. Within a multivariable logistic model accounting for clustered observations within individuals, MET events considered together were strongly associated with hospital mortality (odds ratio [OR]: 3.7 [95% confidence interval {CI}: 2.6-5.3]), as were advanced patient age (OR ≥ 24) and the presence of major trauma (OR: 11 [95% CI: 7.8-17]). MET events triggered by a systolic blood pressure <90 mmHg showed the strongest independent association with subsequent in-hospital mortality (OR: 7.5 [95% CI: 4.2-13]), whereas those triggered by heart rates >130 bpm showed the least association (OR: 1.4 [95% CI: 0.61-3.1]). CONCLUSION:MET events occurred in 6% of adult trauma centre patients, more commonly in the presence of major trauma. While patient age and trauma severity were each strong independent predictors of hospital mortality, there was substantial heterogeneity in the clinical implications of MET events according to the type of underlying physiological disturbance.

BackgroundOlder adults make up 33% of all trauma admissions in Australia despite comprising 17% of the population with rates rising faster for older age groups compared to any other age group. A high proportion of older adults admitted to hospital following trauma are frail and have increased rates of hospital acquired complications, resulting in poorer outcomes as well as increased resource utilisation and cost to the healthcare system. Length of Stay (LOS) is an important outcome for hospitals, contributing to resource utilisation and patient flow. This study aimed to determine factors associated with the primary outcome of LOS in older persons admitted with trauma at a major trauma centre as targets for improvement.MethodsEthics approval was obtained to collect data on all adult trauma admissions >= 1 day in patients aged 65 years and over. Patients were included in the Trauma in older persons (TOPS) database if they otherwise met criteria for the pre-existing trauma registry maintained by the hospital's trauma service. Admissions between January 2022 and January 2023 were included. Univariable negative binomial regression identified variables associated with LOS with p-values <= 0.1 which were then included in a multivariable regression model. Significance was taken as p-value <= 0.05.Results1250 admissions >= 1 day and alive at discharge were included in the primary analysis. The median LOS was 7 (4-13) days. In the multivariable model, delirium (Incidence Rate Ratio (IRR) = 1.41, 95%CI = 1.25-1.59), inpatient fall (IRR = 1.46, 95%CI = 1.15-1.86), pneumonia (IRR = 1.28, 95%CI = 1.08-1.53), thromboembolism (IRR = 1.43, 95%CI = 1.05-1.96), blood transfusion (IRR = 1.34, 95%CI = 1.17-1.53) and unplanned intensive care admission (IRR = 1.52, 95%CI = 1.08-2.14) were all associated with increased LOS. Low fall mechanism was high risk for longer LOS (IRR = 1.26, 95%CI = 1.11-1.43).ConclusionsAfter controlling for available factors, inpatient complications and patients admitted following low falls were identified as high risk for increased LOS and may represent areas for targeted quality improvement for older adults admitted following trauma.

Rural Australians have a higher age adjusted rate of both hospitalisation and death from injury, and this rate increases with increasing remoteness. However, it is uncertain if this is due to an increased incidence of injury or less access to treatment. The aim of this study is to examine the association of remoteness and in-hospital mortality in Major Trauma patients admitted to the Royal Melbourne Hospital. This study was a retrospective cohort study of all persons aged 15 + years diagnosed with ‘major trauma’, (defined as Injury Severity Score, ISS > 12) from a Motor Vehicle Collision admitted to the Royal Melbourne Hospital from 2010 to 2021. The exposure of interest was remoteness as measured by the Accessibility/Remoteness Index of Australia (ARIA), the outcome of interest was in-hospital mortality. Logistic regression models were constructed looking at the odds of death by increasing remoteness adjusting for age, ISS, and comorbidity. Missing data were imputed using chained equations. A sensitivity analysis was performed for ARIA+ category, and a quantitative bias analysis performed for potential selection bias. All analyses were performed using Stata v17. Ethical approval was obtained from the Melbourne Health Human Research Ethics Committee (HREC2022_044). Eligibility was met for 2324 cases, of whom 53.3

To describe the demographics, injury patterns and outcomes of pregnant trauma patients following resuscitative hysterotomy performed in the emergency department. A retrospective case series reviewing resuscitative hysterotomies performed in pregnant trauma patients in the emergency department from 1 January 1999, until 30 June 2024. Three cases of resuscitative hysterotomy were identified. The mean maternal age was 33 years, with a mean gestational age of 33.3 weeks. Maternal survival was 33%, whereas neonatal survival was 67%. All three procedures were performed by obstetricians. Considering the rarity of resuscitative hysterotomy following trauma, multicentre data collection, perhaps even nationwide, could further characterise this procedure.

BACKGROUND:E-scooter associated injury patterns are well described, but less is known about the riders. This study describes the epidemiological characteristics of injured riders with the aim of providing information for preventative strategies. METHODS:A retrospective review of prospectively collected data on admissions (2021) and all hospital presentations (2022-2023) to the Royal Melbourne Hospital, due to injury in a rider of an e-scooter. Data collected were demographics (age, gender, postcode), drug and alcohol usage, helmet usage, circumstances of injury (how, where and when), reported speed, and insurance status. Data was analysed with multiple cross tabulations using two-sided Fischer's exact test. RESULTS:Over the 3 years 562 cases were identified, with a median age 29 years (IQR 23-40), 383 (68.5%) were male. Alcohol (29.5%) and drug (10.9%) usage were prevalent. The majority (70.4%) "fell off" without collision, 274 were admitted, and 9.6% were major trauma. Alcohol usage was more likely seen in men (P = 0.006), in major trauma (P = 0.02) but showed no association with age. Speed over 20 km/h was seen in 38.5% when recorded and associated with drug usage and major trauma status but not alcohol. Medicare ineligibility patients (12.1%) were younger, more likely to be female (P = 0.012) and less likely to use drugs (P = 0.001) and alcohol (P < 0.001). CONCLUSION:This hospital level data of injured e-scooter riders has shown high prevalence of alcohol and drug usage and speeding, all of which were associated with more severe injury, and are hence prime targets for injury prevention.

BACKGROUND:The occurrence and sequelae of acute myocardial infarction (AMI) in major trauma patients is underexplored across both trauma and cardiology specialties. Coronary reperfusion greatly reduces the risk of significant morbidity and mortality in AMI. However, in patients presenting with significant injuries, concurrent AMI presents a competing management priority given the increase in risk of bleeding with standard anticoagulation and antiplatelet therapy, which may be contraindicated. This study aimed to evaluate the epidemiology and clinical outcomes associated with AMI in a contemporary major trauma cohort. METHODS:This study used data from the Victorian State Trauma Registry (VSTR). All adult patients with major trauma from 1 January 2013 to 31 December 2022 were included. Patients that died prior to hospital arrival were excluded. AMI was identified by ICD-10-AM diagnosis codes recorded against the first hospital admission. Clinical outcomes included in-hospital mortality, length of stay, and discharge destination. RESULTS:28,928 patients were identified over the 10-year study period. AMI occurred in 401 patients (1.4 %). AMI patients were older, had more comorbidities and were more frequently on anticoagulation or antiplatelet therapy. Low impact fall was the most common trauma mechanism in AMI patients. Patients with AMI experienced longer hospital stays (12 [7-20] versus 7 [4-12] days, p < 0.001) and higher rates of in-hospital mortality (adjusted RR 1.45, 95 % CI 1.25-1.65). CONCLUSION:AMI in the setting of major trauma occurs in an older, more comorbid, and vulnerable group of patients. AMI is associated with an increased risk of in-hospital mortality and prolonged hospital stay in the setting of major trauma, underscoring the importance of identifying and treating major trauma associated AMI in a timely and effective manner.

Background Acute colonic pseudo-obstruction (ACPO) is a common and potentially serious complication of surgical and trauma care. A possible contributor to ACPO development is impaired mobility. Major trauma patients, particularly those with spinal trauma, are at risk of prolonged mobility restrictions. The aim of this study was to assess the association between impaired mobility and the development of ACPO in major trauma patients undergoing acute thoraco-lumbar spinal fixation. Methods A retrospective cohort study involving major trauma patients admitted to a tertiary trauma facility was performed. The Hospital Trauma Registry was utilised to identify consecutive major trauma patients having urgent thoraco-lumbar spinal fixation. ACPO was defined as dilation of the transverse colon >6 cm or caecum >9 cm without mechanical cause. Immobility was defined by proxy as surgeon-prescribed mobility restrictions. Analysis was performed using multivariable logistic regression. Results ACPO occurred in 34 of 454 patients studied (7.5%). Colonoscopic decompression was required twice. Neostigmine or surgical resection were not required. There was no ACPO-related mortality. On multivariable regression, adjusted for confounding variables, post-operative mobility restrictions were associated with a three-fold increase in odds of ACPO (odds ratio 3.1; 95% confidence interval 1.1–8.9, P = 0.04). Conclusion ACPO was a common, although low-morbidity complication in this cohort. Surgically prescribed mobility restrictions were associated with higher odds of ACPO in major trauma patients having thoraco-lumbar spinal fixation. Attention should be given to early mobilisation, where possible, in these patients.

PURPOSE:Acute diverticulitis is a common presentation to hospital emergency departments (ED) and a significant burden on healthcare resources worldwide. Multiple studies have shown that outpatient management of uncomplicated diverticulitis is safe, yet many patients are still treated in the hospital. We instituted a protocol for the outpatient treatment at our institution, focusing on safety and healthcare costs. METHODOLOGY:From February 2021, the new outpatient management of uncomplicated left-sided diverticulitis protocol was implemented; all patients that presented through the ED with a computed tomography diagnosis of uncomplicated left-sided diverticulitis were managed as an outpatient with oral antibiotics unless they met exclusion criteria (insulin-dependent diabetes, immunosuppression, active malignancy, pregnancy, or inflammatory bowel disease). This was compared to a historical comparison immediately prior. The primary outcome of interest was length of stay (LOS) in hours. RESULTS:There were 106 patients in each group. The LOS in the outpatient group was 29.7 h less than in the inpatient group (95% CI 21.9-37.5; p < 0.001). Patients with co-morbidities stayed significantly longer, with ASA 3 and 4 more than 17 h (53 h vs. 35 h, p < 0.001), and a high CCI (score ≥ 5) more than 32 h (67 h vs. 35 h, p < 0.001). The odds of readmission were not significantly different between the outpatient and inpatient cohorts (OR 1.49, 95% CI 0.54-4.07, p = 0.438). CONCLUSION:Outpatient management for uncomplicated left-sided diverticulitis results in a significant reduction of LOS and does not result in an increase in readmissions.

IntroductionAlcohol is commonly detected in patients presenting to hospital after major trauma and is a key preventable risk factor for injury. While it has been suggested that alcohol intoxication at the time of injury results in worse acute patient outcomes, there is currently limited knowledge on the impact of alcohol on health outcomes following hospital discharge. The aim of this study was to examine the relationship between acute pre-injury alcohol exposure and the self-reported health outcomes of survivors of major trauma 12-months post-injury.MethodsData from the Victorian State Trauma Registry (January 1, 2018 to December 31, 2020) were used to identify major trauma patients who: (1) were aged ≥18 years; (2) survived to 12-months post-injury; and (3) had blood alcohol data available in the registry. Logistic regression analyses were used to examine differences in self-reported health status (EQ-5D) and return to work at 12-months post-injury by blood alcohol concentration (BAC) at the time of presentation to hospital. Analyses were adjusted for potential confounders including a range of demographic, hospital and injury characteristics.ResultsA total of 2957 patients met inclusion criteria, of which 857 (29.0 %) had a BAC >0 and 690 (23.3 %) had a BAC ≥0.05 g/100 mL. After adjusting for potential confounders, having any alcohol detected (i.e., BAC >0) was associated with lower odds of reporting problems on the EQ-5D mobility (aOR = 0.72, 95 %CI = 0.53 to 0.99) and usual activities dimensions (aOR = 0.79, 95 %CI = 0.63 to 0.99). Having a BAC ≥0.05 g/100 mL was only associated with lower adjusted odds of reporting problems on the usual activities dimension (aOR = 0.69, 95 %CI = 0.55 to 0.88) of the EQ-5D. Alcohol detection was not associated with the self-care, pain/discomfort or anxiety/depression dimensions of the EQ-5D, or with return to work in adjusted analyses.ConclusionAcute pre-injury alcohol exposure was not associated with increased reporting of problems on the EQ-5D or with return to work at 12-months post-injury. Further research is needed to understand why patients with alcohol detections were sometimes associated with paradoxically better 12-month post-injury outcomes relative to patients without alcohol detections.

PURPOSE:Interhospital transfer of critically injured patients to a major trauma service reduces preventable death in major trauma. Yet some of those transferred die without intervention. These 'futile' interhospital trauma transfers (IHTs), and other potentially avoidable IHTs place enormous stress on families of trauma victims, can delay care, and incur great cost to public health resources. This study sought to characterise these IHTs using current state guidelines for interhospital transfer. METHODS:A retrospective cohort study was conducted using our institution's trauma registry from January 2016-December 2020. All adult patients transferred to our major trauma service were analysed. Futile IHTs were defined as death or transfer to hospice care without surgical, endoscopic, or radiological intervention, and without ICU admission, within 72 h of admission. Potentially avoidable IHTs were defined as all patients discharged alive without intervention or ICU care, and secondary over-triage patients are a subset of these patients who were discharged within 72 h of admission. Patient demographics, injuries, and treatments were categorised from electronic records and analysed. RESULTS:Of 2,837 IHTs, seven (0.2 %) met criteria for futility. The majority were female, median age of 80 (IQR 85-75) and had a median Injury Severity Score (ISS) of 16 (IQR 25.5-11.5). By contrast, 1391 patients (49 %) were classified as potentially avoidable and 513 (18 %) were considered secondary over-triage. The majority were male, median age of 43 (IQR 62-28), and had a median ISS of 9 (IQR 13-4). Of these potentially avoidable IHTs, 984 (70.7 %) were discharged directly home. CONCLUSION:Futile IHTs were infrequent, however over half of all trauma patients transferred from other hospitals were discharged without tertiary-level intervention. Trauma services should consider developing systems such as telehealth to support regional general and orthopaedic surgeons to co-manage lower risk trauma, particularly minor head and minor spinal trauma patients. This could be an integral part of safely reducing potentially avoidable IHTs and their associated costs while maintaining a low rate of preventable mortality in trauma.

BACKGROUND: Hospitalized patients are well described as having a high prevalence of constipation. While the risks associated with constipation in trauma patients are well known, the prevalence rate is not. OBJECTIVE: This study aims to measure the prevalence of constipation and associated risk factors in trauma patients. METHODS: This study is a single-center analytic cross-sectional study on constipation in hospitalized trauma patients aged 18–65 years, admitted from January 2021 to July 2021 to the trauma service at The Royal Melbourne Hospital, a Level I major trauma and teaching hospital servicing the state of Victoria, Australia. Exclusion criteria include patients with traumatic brain injury, blunt or penetrating abdominal or spinal injuries, pregnancy, and gastrointestinal comorbidities. RESULTS: A total of N = 99 patients were studied, of which n = 78 (78.8%) were male with a median (interquartile range) age of 46 years (33–58). The overall prevalence of constipation was 76%. The univariate analysis demonstrated higher constipation rates in males and patients with multisystem injuries. However, in the multivariate analysis, mode of toileting and mobility were not associated with constipation after adjusting for confounding factors. CONCLUSION: This study demonstrated a high prevalence of constipation in all trauma patients. There is a strong association between the development of constipation in patients with multisystem injuries when compared to those with single system.

BACKGROUND:Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. METHODS:A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. RESULTS:Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. DISCUSSION:This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.

PURPOSE:Penetrating neck injuries (PNIs), defined as deep to the platysma, can result in significant morbidity and mortality. Management has evolved from a zone-based approach to a 'no zone' algorithm, resulting in reduced non-therapeutic neck exploration rates. The aim of this study was to examine PNIs and its management trends in an Australian tertiary trauma centre, to determine if a 'no zone' approach could be safely implemented in this population, as has been demonstrated internationally. METHODOLOGY:This was a retrospective observational study at a level 1 adult Australian tertiary trauma centre using prospectively collated data from January 2008 to December 2018. Observed data included age, gender, mechanism of injury, computed tomography angiography (CT-A) use and operative intervention. Patients were examined based on zone of injury and presenting signs - 'hard', 'soft' or 'asymptomatic'. Major outcomes were CT-A usage, positive CT-A correlation with therapeutic neck explorations and negative neck exploration rates. RESULTS:This study identified 238 PNI patients, with 204 selected for review. Most injuries occurred in zone 2 (71.6%), with soft signs accounting for 53.4% of cases. Over 10 years, CT-A utilization increased from 55% to 94.1%, with positive CT-As being more likely to yield therapeutic neck explorations. There was a general decreased trend in operative intervention but without a clear reduction in non-therapeutic neck explorations. CONCLUSION:Our data suggests similarities with results from around the world, demonstrating that the 'no zone' approach should be considered when managing PNIs, but with clinician discretion in individual cases.

Introduction: Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW. Methodology: Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure. Results: Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury. Conclusion: This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/ hospital experience, patient factors, and resource availability.

-BACKGROUND: Acute colonic pseudo-obstruction (ACPO) is a potentially highly morbid surgical complica-tion. The incidence of ACPO following spinal trauma is -nknown, but is likely higher than after elective spinal fusion. The purpose of this study was to establish the incidence of ACPO in patients with major trauma under -going spinal fusion for unstable thoracic and lumbar frac-ture, and secondly, to characterize the nature of ACPO in this group, including treatment and complications.-METHODS: A metropolitan hospital prospective trauma database was utilized to identify all patients from November 2015 to December 2021 meeting major trauma criteria and undergoing thoracic or lumbar spinal fusion for fracture. Individual records were then evaluated for occurrence of ACPO. ACPO was defined as radiologic ev-idence of colonic dilation without mechanical obstruction in symptomatic patients undergoing dedicated abdominal imaging.-RESULTS: After exclusions, 456 patients with major trauma undergoing thoracic or lumbar spinal fusion were identified. ACPO occurred in 34-an incidence rate of 7.5%. There was no evidence of difference in terms of the spinal fracture type, level, surgical approach, or number of seg-ments fused. There were no perforations; only 2 patients required colonoscopic decompression and none required surgical resection.-CONCLUSIONS: ACPO occurred at a high frequency in this group of patients, although it required relatively simple treatment. High vigilance for ACPO should be maintained in trauma patients requiring thoracic or lumbar fixation, with a view to early intervention. The etiology driving the high rates of ACPO in this cohort is not understood and would benefit from further investigation.

Introduction Blunt diaphragm injury (BDI) is an uncommon, potentially fatal consequence of blunt torso injury. While associations between BDI and other factors such as mechanism of injury or other injuries have been described elsewhere, little recent research has been done in Australia into BDI. The aims of this study were to determine the incidence rate of BDI in our centre, identify how it was diagnosed, determine rates of missed injury and identify predictive factors for BDI. The hypothesis was that patients with BDI would significantly differ to those without BDI. Methods All major trauma patients with blunt torso injuries at our Level 1 major trauma service from 2010 to 2018 were included. Data for patient demographics, other injuries, diagnosis and treatment of BDI were extracted. Patients with BDI were compared with patients without BDI in order to identify differences that could be used to predict BDI in future patients. Results Of 5190 patients with a blunt torso injury, 51 (0.98%) had a BDI at a mean age of 53 ± 19.6 years, and median Injury Severity Score (ISS) of 27(IQR 21–38.5) compared with 5139 patients with a mean age of 48.2 ± 20.7 years and median ISS of 21.9(IQR 14–26) who did not have a BDI. The diagnosis of BDI was made at CT ( n = 35), surgery ( n = 14) or autopsy ( n = 2). Blunt diaphragm injury was missed on index imaging for 11 of 43 patients (25.6%). On multivariate analysis, each point increase in ISS (OR 1.03, p = 0.02); rib fractures (OR 4.65, p = 0.004); splenic injury (OR 2.60, p = 0.004); and liver injury (OR 2.78, p = 0.003) were independently associated with BDI. Conclusion Injury Severity Score, rib fractures and solid abdominal organ injury increase the likelihood of BDI. In patients with these injuries, BDI should be considered even in the presence of normal CT findings.