Abdominal trauma: a disease in evolution

Frequency, causes and pattern of abdominal trauma: A 4-year descriptive analysis

BACKGROUND

The incidence of abdominal trauma is still underreported from the Arab Middle-East. We aimed to evaluate the incidence, causes, clinical presentation, and outcome of the abdominal trauma patients in a newly established trauma center.

MATERIALS AND METHODS

A retrospective analysis was conducted at the only level I trauma center in Qatar for the patients admitted with abdominal trauma (2008-2011). Patients demographics, mechanism of injury, pattern of organ injuries, associated extra-abdominal injuries, Injury Severity Score (ISS), Abbreviated Injury Scale, complications, length of Intensive Care Unit, and hospital stay, and mortality were reviewed.

RESULTS

A total of 6888 trauma patients were admitted to the hospital, of which 1036 (15%) had abdominal trauma. The mean age was 30.6 ± 13 years and the majority was males (93%). Road traffic accidents (61%) were the most frequent mechanism of injury followed by fall from height (25%) and fall of heavy object (7%). The mean ISS was 17.9 ± 10. Liver (36%), spleen (32%) and kidney (18%) were most common injured organs. The common associated extra-abdominal injuries included chest (35%), musculoskeletal (32%), and head injury (24%). Wound infection (3.8%), pneumonia (3%), and urinary tract infection (1.4%) were the frequently observed complications. The overall mortality was 8.3% and late mortality was observed in 2.3% cases mainly due to severe head injury and sepsis. The predictors of mortality were head injury, ISS, need for blood transfusion, and serum lactate.

CONCLUSION

Abdominal trauma is a frequent diagnosis in multiple trauma and the presence of extra-abdominal injuries and sepsis has a significant impact on the outcome.

Peritoneal Breach as an Indication for Exploratory Laparotomy in Penetrating Abdominal Stab Injury: Operative Findings in Haemodynamically Stable Patients

Introduction. Management of haemodynamically stable patients with penetrating abdominal injuries varies from nonoperative to operative management. The aim was to investigate whether peritoneal breach when used as an indication for exploratory laparotomy appropriately identified patients with intra-abdominal visceral injury. Methods. We conducted retrospective cohort study of all patients presenting with PAI at a major trauma centre from January 2007 to December 2011. We measured the incidence of peritoneal breach and correlated this with intra-abdominal visceral injury diagnosed at surgery. Results. 252 patients were identified with PAI. Of the included patients, 71 were managed nonoperatively and 118 operatively. The operative diagnoses included nonperitoneal-breaching injuries, intraperitoneal penetration without organ damage, or intraperitoneal injury with organ damage. The presenting trauma CT scan was reported as normal in 63%, 34%, and 2% of these groups, respectively. The total negative laparotomy/laparoscopy rate for all patients presented with PAI was 21%, almost half of whom had a normal CT scan. Conclusion. We found that peritoneal breach on its own does not necessarily always equate to intra-abdominal visceral injury. Observation with sequential examination for PAI patients with a normal CT scan may be more important than exclusion of peritoneal breach via laparoscopy.

Profile, outcome and predictors of mortality of abdomino-pelvic trauma patients in a tertiary intensive care unit in Saudi Arabia

INTRODUCTION

The Kingdom of Saudi Arabia (KSA) is one of countries with the world's highest number of deaths per 100,000 populations from road traffic accidents (RTAs). Numerous trauma victims sustain abdomino-pelvic injuries, which are associated with considerable morbidity and mortality. The purpose of this study was to describe profile, outcomes and predictors of mortality of patients with abdomino-pelvic trauma admitted to the intensive care unit (ICU) in a tertiary care trauma centre in Riyadh, KSA.

METHODS

This was a retrospective analysis of prospectively collected ICU database. All consecutive patients older than 14 years with abdomino-pelvic trauma from March 1999 to June 2013 were included. The followings were extracted: demographics, injury severity, mechanism and type of injury, associated injuries, use of vasopressors and mechanical ventilation, and worst laboratory results in the first 24h. The primary outcome was hospital mortality. We compared profile and outcomes between survivors and non-survivors and reported predictors of mortality.

RESULTS

Of the 11,374 trauma patients who were admitted to the hospital during the study period, 2120 (18.6%) patients had abdomino-pelvic injuries, out of which 702 (33.1%) patients were admitted to the ICU. The mean age was 30.7 (SD 14.4) years and the majority was male (89.5%). RTA was the most common cause of abdomino-pelvic trauma (70.4%). Pelvis (46.2%), liver (25.8%), and spleen (23.1%) were the most frequently injured organs; and chest (55.6%), head (41.9%), and lower extremities (27.5%) were the most commonly associated injuries. Mechanical ventilation was required in 89.6% with a mean duration of 9.1 (SD 9.2) days and emergency surgery was performed in 45.0% of the patients with prolonged ICU and hospital length of stay (10.8 [SD 10.8], 56.9 [SD 96.7] days; respectively). Of the 702 patients with abdomino-pelvic trauma, 115 (16.4%) patients did not survive. Associated head trauma and retroperitoneal haematoma, higher level of lactic acid on admission and ISS, and advanced age were potential risk factors for hospital mortality.

CONCLUSIONS

Abdomino-pelvic injuries are common in trauma patients, affecting mainly young male victims, and are associated with significant morbidity and mortality, and resource utilisation.

Compartmental anatomical classification of traumatic abdominal injuries from the academic point of view and its potential clinical implication

Background

The mechanism and outcome of traumatic abdominal injury (TAI) varies worldwide. Moreover, data comparing TAIs in each abdominal compartment are lacking. We aimed to assess from the academic point of view, TAI based on its anatomical compartments.

Patients & methods

We conducted a retrospective study for TAI patients between 2008 and 2011 in Qatar. Patients were categorized according to the involved anatomical compartment (C): intrathoracic (ITC), retroperitoneal (RPC), true abdomen (TAC), and pelvic abdomen (PAC) group. Chi Square test, One-Way ANOVA and multivariate regression analysis were appropriately performed.

Results

Of 6,888 patients admitted to the trauma unit, 1,036 (15%) had TAI that were grouped as ITC (65%), RPC (15%), TAC (13%), and PAC (7%). The mean age was lowest in ITC (29 ± 13) and highest in TAC (34 ± 11) group, (P = 0.001). Motor vehicle crash was the main mechanism of injury in all groups except for PAC, in which fall dominated. Vast majority of expatriates had PAC and TAC injuries. The main abdominal injuries included liver (35%; ITC), spleen (32%; ITC) and kidneys (18%; RPC). Extra-abdominal injuries involved the head in RPC and ITC, lung in ITC and RPC and extremities in PAC. Mean ISS was higher in RPC and ITC. Abdominal AIS was higher in TAC injuries. Overall hospital mortality was 10%: RPC (15%), TAC (11%), ITC (9.4%) and PAC (1.5%). Concurrent traumatic brain injury (OR 5.3; P = 0.001) and need for blood transfusion (OR 3.03; P = 0.003) were the main independent predictors of mortality.

Conclusion

In addition to its academic value, the anatomical approach of TAI would be a complementary tool for better understanding and prediction of the pattern and outcome of TAI. This would be possible if further research find accurate, early diagnostic tool for this anatomical classification.

Urotrauma: AUA guideline

PURPOSE

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries.

CONCLUSIONS

Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach

INTRODUCTION

Posterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury.

PRESENTATION OF CASE

A 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful.

DISCUSSION

Incisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries.

CONCLUSION

Thoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.

Evaluation of chest and abdominal injuries in trauma patients hospitalized in the surgery ward of poursina teaching hospital, guilan, iran

BACKGROUND

Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients.

OBJECTIVES

This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran.

PATIENTS AND METHODS

In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire.

RESULTS

In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%).

CONCLUSIONS

Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health.

Incidence, patterns, and factors predicting mortality of abdominal injuries in trauma patients

Background:

Abdominal trauma is a major public health problem for all nations and all socioeconomic strata.

Aim:

This study was designed to determine the incidence and patterns of abdominal injuries in trauma patients.

Materials and Methods:

We classified and identified the incidence and subtype of abdominal injuries and associated trauma, and identified variables related to morbidity and mortality.

Results:

Abdominal trauma was present in 248 of 300 cases; 172 patients with blunt abdominal trauma and 76 with penetrating. The most frequent type of abdominal trauma was blunt trauma; its most common cause was motor vehicle accident. Among patients with penetrating abdominal trauma, the most common cause was stabbing. Most abdominal trauma patients presented with other injuries, especially patients with blunt abdominal trauma. Mortality was higher among penetrating abdominal trauma patients.

Conclusions:

Type of abdominal trauma, associated injuries, and Revised Trauma Score are independent risk factors for mortality in abdominal trauma patients.

To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum managed by laparoscopy

BACKGROUND:

Laparoscopy is safe and effective in the management of blunt trauma abdomen (BTA) with haemoperitoneum, with all benefits of minimal access surgery.

AIMS:

To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum, managed by a new modality of treatment — laparoscopy.

MATERIALS AND METHODS:

Prospectively collected data on laparoscopy performed in patients with blunt abdominal injury, between the years 2004 to 2006, were analysed. Under general anaesthesia pneumoperitoneum was created. A 10 mm umbilical port, right-sided port in the anterior axillary line (5 mm / 10 mm), left-sided port in the anterior axillary line (5 mm / 10 mm) and an extra port were made according to the organ injury, and laparoscopy was performed and managed according to the organ injury.

RESULT:

Twenty-five patients had laparoscopy for blunt trauma abdomen with haemoperitoneum. Liver followed by the spleen were the most common sites of injuries. The overall failure rate was 4%. Post-operative stay and complications were much less. Laparoscopy reduced the number of negative laparotomies, with a limitation that it could not be performed in haemodynamically unstable patients.

CONCLUSION:

The liver and spleen are the most common organs involved in patients with blunt abdominal trauma with haemoperitoneum. Laparoscopy is safe and efficient in patients with blunt trauma abdomen with haemoperitoneum, with fast recovery and low hospital stay.

Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury

Introduction

Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center.

Methods

An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment.

Results

A total of 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%.

Conclusions

SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.

Literature review of the role of ultrasound, computed tomography, and transcatheter arterial embolization for the treatment of traumatic splenic injuries

Introduction

The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.

Diagnostics

Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.

Angiography and Embolization

The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.

Angiography and embolisation for solid abdominal organ injury in adults - a current perspective

Over the past twenty years there has been a shift towards non-operative management (NOM) for haemodynamically stable patients with abdominal trauma. Embolisation can achieve haemostasis and salvage organs without the morbidity of surgery, and the development and refinement of embolisation techniques has widened the indications for NOM in the management of solid organ injury. Advances in computed tomography (CT) technology allow faster scanning times with improved image quality. These improvements mean that whilst surgery is still usually recommended for patients with penetrating injuries, multiple bleeding sites or haemodynamic instability, the indications for NOM are expanding.

We present a current perspective on angiography and embolisation in adults with blunt and penetrating abdominal trauma with illustrative examples from our practice including technical advice.

Epidemiology of major trauma

First article of ‘Trauma Series’

Has the Pendulum Swung Too Far? The Impact of Missed Abdominal Injuries in the Era of Nonoperative Management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 ± 9 days postinjury. Intensive care unit length of stay (26 ± 24 vs 10 ± 6 days), hospital length of stay (40 ± 37 vs 11 ± 10 days), ventilator days (31 ± 29 vs 11 ± 10), and number of abdominal operative procedures (1.9 ± 1.5 vs 1 ± 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Emerging epidemic in Australia: abdominal stab wounds. Twenty-four months at a major trauma centre

BACKGROUND

The incidence of abdominal stab wounds treated at the Royal Melbourne Hospital, Parkville, Vic., Australia has noticeably increased over the 12 month period to March 2006, mirroring an increase in penetrating abdominal trauma throughout many Australian trauma centres. Management protocols for abdominal stab wounds are still contentious. The current study quantifies the increase in stab wounds at the Royal Melbourne Hospital over a 24 month period and analyses the management modalities used.

METHODS

A review of the Trauma Unit of the Royal Melbourne Hospital was performed for the period of 20 March 2004 until 20 March 2006. All anterior abdominal stab wounds were collated for the site of injury, investigations performed on admission, results of investigations, operations performed and findings at operation.

RESULTS

There were 4244 emergency trauma presentations over the 24 month period between 20 March 2004 and 20 March 2006. The second 12 month period showed a 21.5% increase in overall trauma admissions and a 91.3% increase in anterior abdominal stabbings. The percentage of stab wounds treated conservatively fell by 21.8%, with the percentage of laparotomies increasing by 14.2%. Almost 30% of all patients undergoing surgery had no visceral injury at operation. Twenty CT scans were performed preoperatively, with a sensitivity of 79% and specificity of 100%.

CONCLUSION

Abdominal stab wounds treated at Royal Melbourne Hospital have substantially increased over the past 12 months. Although management is still contentious, a management protocol for anterior abdominal stab wounds is proposed, outlining the role of CT scanning, conservative management, laparoscopy and laparotomy.

Laparoscopy versus laparotomy in management of abdominal trauma

BACKGROUND

A majority of abdominal injuries (AIs) are associated with shock, hence most of the patients are hemodynamically unstable, which limits the use of video-assisted laparoscopy (VAL) in their management. The purpose of this study is to demonstrate the possibility of using VAL in management of stable and unstable patients with abdominal trauma.

METHODS

In a period of six years 2,695 patients with AIs were evaluated. The subjects were evaluated retrospectively and divided into two groups. Group 1, consisting of 1,363 patients, had conventional routine investigations following which they underwent laparotomy for confirmatory diagnosis and definitive management. The second group, consisting of 1,332 patients, underwent diagnostic laparoscopy in addition to the conventional investigations in the first group; 411 patients of this group had therapeutic laparoscopy. Demographic information, incidence of organs injuries and operative findings, success rate of VAL and laparotomy repair, complications, associated injuries, and hospital mortality were evaluated.

RESULTS

The age of 62.6% of our patients was 20-50 years, while 10.6% and 14.5% were less than 19 and greater than 50 years, respectively. Associated injuries were head, chest, musculoskeletal, and vertebral column. Most of the victims presented with shock; 50.7%, 24.7%, and 15.9% of the patients were in mild, moderate, and severe shock respectively, and 8.7% of the subjects had stable hemodynamic status. In the first group 47.1% of the laparotomies were absolutely indicated and 24.4% were negative. Of the patients who had laparotomy, 26.0% would have been managed confidently by VAL. In the second group following VAL 42.5% of the patients did not require surgical intervention. VAL surgery was performed in 30.8% of patients. Conversion to laparotomy was performed in 26.7% of the patients.

CONCLUSIONS

The VAL technique can be confidently used as a main tool to expedite evaluation and treatment of patients with abdominal trauma in cases of both stable and unstable hemodynamic status.