Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis

BACKGROUND

Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT.

METHODS

A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project.

RESULTS

In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model.

CONCLUSIONS

ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Aortic Transection after Blunt Abdominal Trauma in a Child

Abdominal aortic injury secondary to blunt abdominal aortic trauma (BAAI) is rare in children but frequently occurs in association with other injuries, including bowel injury and vertebral fracture. We present a case of a 14-year-old boy who sustained a partial transection of the infrarenal aorta with a lumbar chance fracture and small bowel injury after a motor vehicle accident. Repair was performed with bowel resection followed by Dacron graft interposition. We reviewed the literature on BAAI in children with a focus on the method of repair of these injuries.

[A focal abdominal swelling after an accident with a 'space scooter']

A 7-year-old boy presents at the Emergency Department with an abdominal swelling after an accident with a space scooter. He was diagnosed with a traumatic anterior abdominal wall hernia, for which he underwent surgical correction.

The use of computed tomography imaging for abdominal seatbelt sign: A single-center, prospective evaluation

INTRODUCTION

Guidelines surrounding abdominal seat belt sign (SBS) were made prior to the use of modern computed tomography (CT) imaging. We sought to prospectively determine whether a negative CT scan is associated with the absence of hollow viscus injury (HVI), and we hypothesized that trauma patients with an abdominal SBS without CT imaging findings would not have a hollow viscus injury (HVI).

METHODS

A prospective cohort of patients with SBS was compiled over one year. Subjects were divided into those with and without HVI. Covariate distributions were summarized by group. Bivariate tests and logistic regression were used to investigate associations between covariates and HVI.

RESULTS

Of 220 patients with SBS, the incidence of HVI was 7% (n = 15). Radiographic findings were strongly associated with HVI and no patients with a negative CT scan had HVI. Free fluid was seen in 80% (12) of patients with HVI, whereas it was found in only 11% (23) without injury. A composite variable for negative CT scan was found to be associated with the absence of HVI: (Fisher's exact 1-tailed p, doubled = 0.014).

CONCLUSION

In this study, the incidence of HVI with SBS is lower than previously reported, and no patients with negative CT imaging required an operation for HVI-suggesting there is a population of patients with SBS who could be discharged from the emergency room. A prospective multicenter study is needed to confirm these findings.

Pediatric Liver Injury: Physical Examination, Fast and Serum Transaminases Can Serve as a Guide

BACKGROUND

The aim of our study was to determine if the combination of physical examination (PE), serum transaminases along with Focused Assessment with Sonography in Trauma (FAST) would effectively rule out major hepatic injuries (HIs) after blunt abdominal trauma (BAT) in hemodynamically stable pediatric patients.

METHODS

We conducted a 9-year retrospective study of pediatric patients (<18 y) with BAT. We collected data on liver enzymes (aspartate transaminase [AST] and alanine transaminase [ALT]), FAST, and PE findings. Definitive diagnosis and staging of HI were based on abdominal CT scanning. The sensitivity and specificity of ALT/AST, FAST, and PE were then calculated individually and in combination.

RESULTS

We identified a total of 423 pediatric patients with BAT. Mean age was 11 y, median abdominal Abbreviated Injury Scale was 3 [2-4], and mean ED-SBP was 132 mm Hg. One hundred ninety-eight patients had HI of which 107 were major HI, defined by the American Association for the Surgery of Trauma as ≥grade III. Using ROC curve analysis, optimum ALT and AST thresholds were determined to be 90 U/L and 120 U/L, respectively. The sensitivity of FAST was 50% while that of PE was 40%. Combining PE with AST/ALT and FAST had an overall sensitivity of 97%, a specificity of 95%, a positive predictive value of 87%, and a negative predictive value of 98%.

CONCLUSIONS

In hemodynamically stable pediatric blunt abdominal trauma patients, CT scanning can be avoided using a combination of readily available tests thus avoiding unnecessary radiation exposure. However, pediatric patients with positive PE, FAST, and elevated AST/ALT may eventually require CT scan to further evaluate liver injuries.

[Traumatic pancreatic lesions]

In this review, the recommendations for treating pancreatic traumas are summarised. A pancreatic trauma is rare but serious. Initially, the symptoms can be subtle and may easily be overlooked by concurrent injuries such as internal bleeding. Delayed detection of pancreatic lesions is associated with increased mortality and morbidity. There is a tendency towards a more conservative approach in the treatment of pancreatic lesions, including injuries involving the pancreatic duct. In the haemodynamically instable patient damage control surgery is preferred, with closed suction drainage of the pancreas and later definitive surgery. We propose contact to a hepato-pancreato-biliary facility in case of any suspicion of a pancreatic injury.

[Severe intra-abdominal injuries following the LUCAS chest compression system being applied for cardiopulmonary resuscitation]

In this case report two patients, having severe intra-abdominal injuries after cardiopulmonary resuscitation (CPR) with the LUCAS system, are presented. They both underwent surgical intervention. Severe intra-abdominal injuries following manual CPR are rare, but little is known about the incidence of these injuries associated with mechanical CPR. We have reviewed the literature on clinical outcome and adverse events after out-of-hospital cardiac arrest with LUCAS CPR and manual CPR, and our conclusion is, that more research is needed to establish the safety of mechanical chest compression systems.

[Liver Injury after a Collapse Caused by Acute Myocardial Infarction, Resuscitation and Acute Myocardial Revascularisation]

The presented case report describes primarily an unrecognized liver injury after the resuscitation with cardiac massage due to myocardial infarction. After myocardial revascularization, the hemodynamic instability and anaemia in the patient persisted. The performed CT scan confirmed a liver injury, namely the rupture of liver parenchyma with hemoperitoneum, which had to be treated surgically. It represents a complication of cardiac massage that occurs, though less frequently. Key words: resuscitation, liver trauma.

Seat-Belt Syndrome as managed in Babcock University Teaching Hospital. A Case Report and Literature Review

BACKGROUND

This paper is a case report of a 54 year old woman that presented in our casualty with just "seat belt sign" following a road traffic injury. At laparotomy, she was found to have sustained disastrous internal/visceral injuries with torrential intraperitoneal haemorrhage from the surface of the liver caused by the seat belt. Frantic attempts at haemostasis were proving difficult and time wasting. The lacerated liver surface was then generously packed with absorbent abdominal mops which were left in-situ for 48hrs. A second-look operation 48 hrs later revealed satisfactory haemostasis of the bleeding surface of the left lobe of the liver OBJECTIVE: This paper is to highlight the wisdom in using "Damage Control" techniques to save a patient's life in an unsuspecting torrential bleed during laparotomy - especially in seatbelt injuries.

DESCRIPTION

"Damage Control" implies doing the minimum, in the quickest time possible, to keep patient alive and coming back when patient is stable to deal with the pathology.

RESULT

After 48hrs, a re-laparotomy was performed on the patient and it was found that complete haemostasis had been achieved. The packs were removed and abdomen closed in a single layer. The patient remained well till discharge after two weeks of hospitalisation and has remained well on follow up.

CONCLUSION

Seatbelts, although protective, can lead to complex injury patterns. Early detection and prompt management of the injuries is key to survival.

Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers

PURPOSE

This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers.

METHODS

We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries.

RESULTS

Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001).

CONCLUSION

Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

II.

Traumatic bicycle handlebar hernia in children: a systematic review

This is a systematic review of existing literature on the diagnostic modalities and treatment of traumatic abdominal wall hernia caused by bicycle handlebar injury in children. 
METHODS: A systematic literature search was conducted covering incidents involving children below 17 years of age. Data were extracted regarding gender, age, diagnostic modality, timing of surgery, location of hernia, associated injuries, management and recurrence of hernia.
 RESULTS: A total of 62 cases of handlebar hernia were included in the systematic review. CT scan was the most frequently used final diagnostic modality (52%) followed by 
ultrasonography (13%), explorative laparotomy (5%) and diagnostic laparoscopy (5%). Coexisting intraabdominal injuries were present in 57% of all hernias located in the upper abdomen. Open surgical repair was the preferred treatment of choice (85%). Laparoscopic suturing was performed in one study. Six cases of handlebar hernia were treated conservatively. No cases of recurrence of hernia were reported in any of the cases. 
CONCLUSIONS: Traumatic abdominal wall hernia can be visualized by ultrasonography, but CT scan is often used as the final diagnostic modality because of the risk of associated intra-abdominal injuries. Open surgical repair in layers or laparoscopic suturing during diagnostic laparoscopy may be appropriate in managing traumatic abdominal wall hernias in children. Non-surgical management has been described, but available data do not support a general recommendation for a non-surgical approach.

Current treatment procedures for civilian gunshot wounds

INTRODUCTION

This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment.

METHOD

We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 1871). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established.

RESULTS

Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve. Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal.

CONCLUSION

Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious. Key words: gunshot wound - civilian settings surgical treatment.

3D-printed “fistula stent” designed for management of enterocutaneous fistula: An advanced strategy

Enterocutaneous fistulas (ECFs) are great challenges during the open abdomen. The loss of digestive juice, water-electrolyte imbalance and malnutrition are intractable issues during management of ECF. Techniques such as “fistula patch” and vacuum-assisted closure therapy have been applied to prevent contamination of open abdominal wounds by intestinal fistula drainage. However, failures are encountered due to high-output fistula and anatomical complexity. Here, we report 3D-printed patient-personalized fistula stent for ECF treatment based on 3D reconstruction of the fistula image. Subsequent follow-up demonstrated that this stent was well-implanted and effective to reduce the volume of enteric fistula effluent.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Early laparotomy and timely reconstruction for patients with abdominal electrical injury: Five Case Reports and Literature Review

INTRODUCTION

High-tension electricity can cause devastating injuries that may result in abdominal wall loss, visceral damage, and sometimes major threat to life. The visceral organ may be exposed after debridement and require flap cover, but the tensile strength of abdominal wall may be lack even if flap transplanted.

METHODS

From April 2007 through May 2015, 5 patients with severe abdominal electrical injury were treated at our hospital. Exploratory laparotomy was performed based on their clinical manifestations and debridement findings of abdominal wall at early stage, and decision regarding technique for reconstruction of abdominal wall was based on an assessment of the location and extent of the defect. Medical records were reviewed for these data.

RESULTS

Clinical evaluation and debridement findings of the abdomen revealed 4 patients with suspicious visceral damage. Laparotomy was performed in 4 cases, and revealed obvious lesion in 3 cases, including segmental necrosis of small intestine, partial necrosis of diaphragm, left liver and gastric wall, and greater omentum. Five patients underwent abdominal wall reconstruction using island retrograde latissimus dorsi myocutaneous flap or free/island composite anterolateral thigh myocutaneous flap. All flaps survived, abdominal bulging occurred in 3 cases after follow-up of 12 to 36 months.

CONCLUSIONS

The clinical manifestations and wound features of abdomen collectively suggest a possible requirement of laparotomy for severe abdominal electrical burns. Retrograde latissimus dorsi myocutaneous flap or composite anterolateral thigh myocutaneous flap is an effective option for reconstruction of abdominal wall loss, the long-term complication of abdominal bulging, however, remains a significant clinical challenge.

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial

IMPORTANCE

The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown.

OBJECTIVE

To determine if the FAST examination during initial evaluation of injured children improves clinical care.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center.

INTERVENTIONS

Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges.

RESULTS

Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291).

CONCLUSIONS AND RELEVANCE

Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01540318.

An unusual case of multiple self-inflicted punctures to the precordium

Sewing needles, albeit a rare case of penetrating cardiac injury, are potentially life-threatening. We report a case of successful intra-cardiac needle removal from a 32 year old who inserted multiple needles into the chest and abdomen.

The Hidden Story of Innovation: Charity Hospital, Angola Prison, and the Challenging of Surgical Dogma

The late 1960s was a period of significant upheaval of social, cultural, and scientific norms. The generally accepted notion of mandatory laparotomy for all penetrating abdominal injuries was among those norms being called into question across the country and many advocated expectant management of selected patients presenting with this type of injury. Leaders of the surgical community published opinions on either side of the argument. The house staff at Charity Hospital during this period was among the busiest in the nation in treating these injuries, many of them inmates of the Louisiana State Penitentiary who used self-inflicted stab wounds to the abdomen as a means of temporary respite from the inhumane conditions in the prison. Inspired, in part, by the overabundance of negative laparotomies among this group, F. Carter Nance went on to systematically challenge the standard of care. This effort constitutes one of the major forces for change of the surgical dogma of mandatory laparotomy for all abdominal stab wounds. It is the first major study to show conclusively that delayed laparotomy for perforated viscous was not significantly detrimental and posed less of a risk than unnecessary laparotomy. The circumstances surrounding this initiative constitute a powerful and heretofore unknown chapter in the history of surgical innovation.

Acute traumatic renal arteriocalyceal fistula: selective angioembolisation for haemodynamic instability

Abdominal angiography with selective arteriography and subsequent embolisation is an accepted management modality in the treatment of selected solid organ injuries following blunt abdominal trauma. This management practice is well established in the haemodynamically stable patient; however, this remains more controversial in haemodynamically compromised patients, though warrants consideration in both cases due to the associated benefits of non-operative management. This case report describes the successful non-operative management of a severe renal injury in a young polytraumatised patient following a high-speed motor vehicle crash. In addition, the rare CT diagnosis and management of an acute traumatic arteriocalcyeal fistula is discussed with a focus on the importance of renal parenchymal preservation.