Jonghwan Moon

Suprahepatic inferior vena cava (SHIVC) injuries from blunt trauma are exceptionally rare and nearly uniformly fatal, with reported mortality rates ranging from 70% to 90%. Traditional approaches require cardiopulmonary bypass or extensive thoracotomy, often unavailable in emergency trauma settings. We report successful management of SHIVC injury utilizing the transdiaphragmatic pericardial window (TDPW) technique. An 18-year-old man presented with hemorrhagic shock after a high-speed motorcycle collision. Emergency laparotomy revealed grade V splenic and renal injuries and an SHIVC laceration at the hepatic vein junction. Through an extended midline incision, a 10-cm diaphragmatic incision provided direct pericardial access, enabling SHIVC visualization and repair without sternotomy. Despite requiring staged operations and a 31-day course of continuous renal replacement therapy, the patient achieved complete recovery with preserved renal function. This case demonstrates that TDPW, although previously described for other indications, can be successfully adapted for life-threatening SHIVC injuries when conventional resources are unavailable.

Background/Objectives: Blunt suprahepatic inferior vena cava (SHIVC) injury is a rare and highly lethal condition associated with severe thoracoabdominal trauma. This study describes the clinical characteristics and outcomes of SHIVC injuries treated at a single institution. Methods: We retrospectively reviewed patients with blunt SHIVC injury treated between January 2014 and September 2023. Demographics, injury characteristics, management strategies, and outcomes were analyzed descriptively. The primary outcome was in-hospital mortality. Given the small sample size, statistical analyses were exploratory. Results: Ten patients were identified (mean age: 47 ± 17 years; mortality: 40%; ISS: 43 ± 19). On admission, 50% presented with systolic blood pressure < 90 mmHg and a mean Glasgow Coma Scale score of 7 ± 5. Non-survivors had lower systolic blood pressure (70 ± 12 vs. 115 ± 34 mmHg, p = 0.05), lower GCS scores (3 ± 0 vs. 9 ± 5, p = 0.02), and worse base excess (−20.1 ± 5.8 vs. −7.8 ± 7.1) than survivors. Surgical intervention was performed in 9 patients, while 1 was managed nonoperatively. Common associated injuries included right atrial injury (70%), liver injury (50%), and diaphragm injury (30%). Four patients received intraoperative circulatory support; two treated with cardiopulmonary bypass survived, whereas those treated with extracorporeal membrane oxygenation died. No definitive conclusions can be drawn regarding treatment effectiveness due to the limited sample size. Conclusions: Outcomes appear strongly influenced by initial physiological status and injury severity. This study is descriptive and hypothesis-generating; further multicenter studies remain warranted to define optimal management strategies.

Background: Left ventricular (LV) thrombosis after blunt trauma is uncommon and is most often attributed to traumatic coronary artery injury; however, it can also arise from severe myocardial contusions. Here, we report a case of LV thrombosis due to severe myocardial contusion without coronary artery injury. Case Presentation: A 36-year-old man struck by industrial fan fragments presented with hemorrhagic shock. Focused Assessment with Sonography for Trauma revealed cardiac tamponade. An emergent sternotomy was performed under cardiopulmonary bypass via the femoral vessels, which exposed severe contusion-associated hemorrhage with epicardial–myocardial dissection at the LV apex. On postoperative day (POD) 5, transthoracic echocardiography showed apical akinesia with mural thrombi; prophylactic anticoagulation was escalated and later transitioned to warfarin. Coronary computed tomography on POD 21 and invasive angiography at 6 months revealed negative findings. The thrombi resolved within 3 months; however, apical akinesia persisted. After discontinuing anticoagulation, a transient ischemic event occurring at 9 months prompted direct oral anticoagulant therapy. Apical akinesia persisted for over 7 years without recurrent thrombosis. Conclusions: This case underscores the importance of vigilance for intracardiac thrombosis in severe contusions, as well as the value of stepwise imaging (contrast echocardiography) and cautious, individualized discontinuation of anticoagulation when regional dysfunction persists.

Subclavian artery injury is a rare complication of clavicular fracture. This condition most often results from penetrating trauma but may also occur after blunt injury, when bone fragments cause rupture, pseudoaneurysm, dissection, or arterial thrombosis. Subclavian artery injury associated with clavicular fracture occurs in less than 1% of cases and may lead to life-threatening hemorrhage or limb ischemia. We report a case of subclavian artery injury secondary to a clavicular fracture that was successfully managed with endovascular intervention. A 48-year-old man presented to the emergency department after a downhill bicycle crash with a right midshaft clavicle fracture and was scheduled for open reduction and internal fixation (ORIF) 11 days later. Intraoperatively, rupture of a subclavian artery pseudoaneurysm caused massive hemorrhage. Surgical dissection was complicated by severe perivascular inflammation and a high risk of iatrogenic subclavian vein injury. Immediate conversion to an endovascular approach allowed successful hemostasis through femoral artery access and covered stent deployment, after which ORIF was completed. The patient recovered without neurovascular complications and was discharged on postoperative day 5. At 12 weeks, he achieved full shoulder range of motion, and 2-year follow-up angiography showed no stent-related complications. This case underscores the effectiveness of emergent endovascular intervention for ruptured traumatic subclavian pseudoaneurysm when inflammation and risk of iatrogenic injury preclude safe open dissection. A hybrid or rescue endovascular strategy should be considered for similar complex trauma cases.

Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is often used as a life-saving therapy for lung injuries; however, it presents challenges, including bleeding risks and potential reductions in ECMO flow. This case report details the intricate management of a 16-year-old boy who suffered severe thoracoabdominal trauma following a nine-floor fall. The patient sustained severe lung injury and damage to multiple solid organs, including liver lacerations, and was placed on VV-ECMO. When initiating ECMO, it is crucial to carefully consider anticoagulation to avoid potential bleeding complications. Therefore, despite the usual risks associated with ECMO, such as bleeding and reduced flow rates, anticoagulation was withheld due to the risk of hemorrhage from the liver injury. While on ECMO support, the patient experienced a sudden decrease in flow and blood pressure, suggesting an increase in intra-abdominal pressure. An immediate decompressive laparotomy revealed a significant hemoperitoneum, primarily caused by oozing from the liver laceration. The prompt recognition of abdominal distension and the timely decision to proceed with surgery without further imaging were key to the successful treatment. Postoperatively, the patient showed good recovery, with gradual weaning from ECMO, extubation, and eventual discharge. In conclusion, this case highlights the importance of ongoing monitoring for patients with complex trauma who are on ECMO. External factors, including elevated intra-abdominal pressure, can impair ECMO performance. Meticulous management and a multidisciplinary approach are essential in these intricate cases, which involve the nonsurgical treatment of solid organ damage accompanied by severe lung injury.

Delayed amputation after failed limb salvage can lead to negative clinical and functional outcomes due to complications, including re-amputation. This study aimed to compare clinical outcomes and identify risk factors according to the timing of amputation. A retrospective review of lower-extremity injuries managed between January 2016 and December 2022 at a level 1 trauma center was conducted. Outcomes were compared between early amputation (within 48 h) and delayed amputation (beyond 48 h) groups. The primary outcome was the risk of a more proximal amputation level according to the timing of amputation. Secondary outcomes included trauma-related complications and clinical outcomes. Trauma-related complications were more common in the delayed amputation group, with no significant differences in 30-day mortality. Delayed amputation and deep surgical infection at the stump site were associated with higher odds of a more proximal amputation level than initially predicted. The overall hospital stay was significantly longer in the delayed amputation group. While there is no established standard for deciding between limb salvage and amputation strategies, delayed amputation could be a risk factor for shorter limb stumps owing to re-amputation, and patients may experience more trauma-related complications and prolonged hospitalization.

Kwon J, et al. J Korean Med Sci. 2025 Jun;40:e196. https://doi.org/10.3346/jkms.2025.40.e196

Kang BH, et al. J Korean Med Sci. 2025 May;40:e165. https://doi.org/10.3346/jkms.2025.40.e165

We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics—abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016–2017) and after (after-FD, 2019–2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan–Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality.

Inferior vena cava (IVC) injuries can have fatal outcomes and are associated with high mortality rates. Patients with IVC injuries require multiple procedures, including prehospital care, surgical techniques, and postoperative care. We present the case of a 67-year-old woman who stabbed herself in the abdomen with a knife, resulting in an infrarenal IVC injury. We shortened the transfer time by transporting the patient using a helicopter and decided to perform direct-to-operating room resuscitation by a trauma physician in the helicopter. The patient underwent laparotomy with IVC ligation for damage control during the first operation. The second- and third-look operations, including previous suture removal, IVC reconstruction, and IVC thrombectomy, were performed by a trauma surgeon specializing in cardiovascular diseases. The patient was discharged without major complications on the 19th postoperative day with rivaroxaban as an anticoagulant medication. Computed tomography angiography at the outpatient clinic showed that thrombi in the IVC and both iliac veins had been completely removed. Patients with IVC injuries can be effectively treated using a trauma system that includes fast transportation by helicopter, damage control for rapid hemostasis, and expert treatment of IVC injuries.