Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience

Abdominal trauma in primary blast injury

BACKGROUND

Blast injury is uncommon, and remains poorly understood by most clinicians outside regions of active warfare. Primary blast injury (PBI) results from the interaction of the blast wave with the body, and typically affects gas-containing organs such as the ear, lungs and gastrointestinal tract. This review investigates the mechanisms and injuries sustained to the abdomen following blast exposure.

METHODS

MEDLINE was searched using the keywords 'primary blast injury', 'abdominal blast' and 'abdominal blast injury' to identify English language reports of abdominal PBI. Clinical reports providing sufficient data were used to calculate the incidence of abdominal PBI in hospitalized survivors of air blast, and in open- and enclosed-space detonations.

RESULTS

Sixty-one articles were identified that primarily reported clinical or experimental abdominal PBI. Nine clinical reports provided sufficient data to calculate an incidence of abdominal PBI; 31 (3·0 per cent) of 1040 hospitalized survivors of air blast suffered abdominal PBI, the incidence ranging from 1·3 to 33 per cent. The incidence for open- and enclosed-space detonations was 5·6 and 6·7 per cent respectively. The terminal ileum and caecum were the most commonly affected organs. Surgical management of abdominal PBI is similar to that of abdominal trauma of other causes.

CONCLUSION

Abdominal PBI is uncommon but has the potential for significant mortality and morbidity, which may present many days after blast exposure. It is commoner after blast in enclosed spaces and under water.

Intestinal-FABP and liver-FABP: Novel markers for severe abdominal injury

OBJECTIVES

Fatty acid-binding proteins (FABPs) have relatively high tissue concentrations and low plasma concentrations and are released into the circulation following organ injury. We explored the utility of intestinal-(I)-FABP and liver-(L)-FABP for the diagnosis of abdominal injury in patients with multiple trauma.

METHODS

This prospective study included 102 trauma patients and 30 healthy volunteers. Plasma I-FABP and L-FABP levels were measured in the emergency department (ED) by enzyme-linked immunosorbent assay (ELISA). Forty-one patients suffered from serious or severe abdominal trauma (Abbreviated Injury Score [AIS] code "ai" for abdominal injury, AISai > or = 3) and nine were moderately abdominally injured (AISai < 3). Fifty-two had no abdominal injury.

RESULTS

Median I-FABP and L-FABP levels in the AISai > or = 3 group (516 pg/mL and 135 ng/mL, respectively) were significantly higher compared to the AISai < 3 group (154 pg/mL and 13 ng/mL, respectively) or those without abdominal injury (207 pg/mL and 21 ng/mL, respectively) or normal controls (108 pg/mL and 13 ng/mL, respectively). The cutoff to distinguish the ai > or = 3 is 359 pg/mL for I-FABP and 54 ng/mL for L-FABP, with 93% specificity and 75% sensitivity for I-FABP and 93% and 82% for L-FABP, respectively.

CONCLUSIONS

High I-FABP and L-FABP levels correlate with relevant severity of abdominal tissue damage in patients with multiple trauma. I-FABP and L-FABP could be useful as markers for the early detection of significant abdominal injury in acute multiple trauma and identify patients who require rapid intervention.

Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma

INTRODUCTION

Computed tomographic (CT) scans have become invaluable in the management of patients with blunt abdominal trauma. No clear consensus exists on its role in hollow viscus injuries (HVI) and mesenteric injuries (MI). The aim of this study was to correlate operative findings of HVI and MI to findings on pre-operative CT.

METHODS

All patients treated for blunt abdominal trauma at Tan Tock Seng Hospital from January 2003 to January 2008 were reviewed. CT scans were only performed if the patients were haemodynamically stable and indicated. All scans were performed with intravenous contrast using a 4-slice CT scanner from 2003 to December 2004 and a 64-slice CT scanner from January 2005 onwards. All cases with documented HVI/MI that underwent both CT scans and exploratory laparotomy were analysed.

RESULTS

Thirty-one patients formed the study group, with median age of 40 (range, 22-65) years and a significant male (83.9%) predominance. Vehicular-related incidents accounted for 67.7% of the injuries and the median Injury Severity Score (ISS) was 13 (4-50). The 2 commonest findings on CT scans were extra-luminal gas (35.5%) and free fluid without significant solid organ injuries (93.5%). During exploratory laparotomy, perforation of hollow viscus (51.6%) occurred more frequently than suspected from the initial CT findings of extra-luminal gas. Other notable findings included haemoperitoneum (64.5%), and mesenteric tears (67.7%). None of our patients with HVI and MI had a normal pre-operative CT scan.

CONCLUSION

Our study suggests that patients with surgically confirmed HVI and MI found at laparotomy were very likely to have an abnormal pre-operative CT scan. Unexplained free fluid was a very common finding in blunt HVI/MI and is one major indication to consider exploratory laparotomy.

Nonoperative management of blunt abdominal trauma: have we gone too far?

BACKGROUND

The paradigm shift in the management of blunt abdominal trauma has been to become less invasive with both diagnostic tools and management. Avoidance of a laparotomy with its short-term and long-term risks is of obvious benefit to the patient.

METHOD

Review of the pertinent literature.

RESULTS

Most blunt hepatic and splenic injuries are managed nonoperatively. Management of blunt splenic injury with observation and organ preservation will avoid the lifelong risk of overwhelming postsplenectomy infection. However, what are the risks? Does nonoperative management simply delay laparotomy? The answer is no. The pendulum has swung too far toward observation. Most patients with blunt hepatic injury, irrespective of the grade, are hemodynamically stable and can be observed. On the other hand, high-grade injury (IV and V) often necessitates operation or management of complications by interventional radiology or gastroenterology procedures. When hepatic injury necessitates laparotomy because of hemodynamic instability, the operation is technically challenging, with a significant risk of death. As shown by large studies, the risk of failure of nonoperative management of blunt splenic injury includes preventable deaths. Factors in such deaths include inappropriate clinical decision-making, false-negative diagnostic studies, and initial misreading of computed tomography scans.

CONCLUSION

Safe nonoperative management requires adherence to cardinal surgical principles, examination and re-examination of the patient, and fastidious clinical judgment.

Prognostic significance of lower extremity long bone fractures after automobile versus pedestrian injuries

BACKGROUND

Fractures of the tibia and femur are common after automobile versus pedestrian (AVP) injuries. This study evaluates the effect of age on the type of fracture and the incidence and type of associated injuries.

METHODS

All patients involved in an AVP crash from January 1, 1995, through June 30, 2006, were included in the study. Variables obtained from our trauma registry included age, gender, Injury Severity Score, Abbreviated Injury Scale, intra-abdominal and spine injuries, and mortality. Patients were divided into three age groups for analysis: younger than 15 years, 15 years to 55 years, and older than 55 years. The incidence and type of associated injuries were assessed according to the presence or absence of fractures of the tibia only, femur only, or combined femur and tibia fractures.

RESULTS

A total of 6,652 patients had AVP crashes and 1,936 (29%) had tibia or femur fractures (tibia, 20%; femur, 7%; tibia/femur, 3%). The incidence of tibia fractures increased with age ranging from 13% in those younger than 15 years to 25% in those older than 55 (p < 0.001). Combined tibia and femur fractures were also more common in adults and isolated femur fractures were more common in children. Hollow viscus injury was 1.8% in those with lower extremity fractures and 0.9% in those without (p = 0.0013). Mortality was 10% in those with fractures and 6% in those without (p < 0.0001) and was 20% in those with tibia and femur fractures.

CONCLUSIONS

Age affects the incidence and type of lower extremity fractures after AVP injuries. The presence of lower extremity fracture is associated with a higher incidence of chest, spine, and intra-abdominal injuries. It is advisable that all patients with lower extremity fractures after AVP injuries be evaluated by a surgeon familiar with these injury patterns.

Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient

BACKGROUND

Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to determine whether delay in treatment had an adverse affect on patient outcome.

METHODS

A multi-institutional retrospective chart review using the American Pediatric Surgical Association Committee on Trauma was initiated after Institutional Review Board approval was obtained at each of the 18 institutions. All children younger than 15 years diagnosed with a BII were identified, and only those with BII noted during surgery or autopsy from January 2002 through December 2007 were included. The data form was designed and approved before chart review, and all data were combined into one database.

RESULTS

Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to determine the interval between injury and operation. These were divided into 4 groups (<6, 6-12, 12-24, and >24 hours) based on time from injury to intervention. Early and late complications, as well as hospital days, were compared in each group. There were 3 deaths from an abdominal source in the less-than-6-hour group and 2 in the 6-to-12-hour group. Injury Severity Score was significantly greater in the less-than-6-hour intervention group. There was no correlation between time to surgery and complication rate, nor was there a significant increase in hospital days.

CONCLUSIONS

These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric BII. Appropriate observation and serial examination rather than repeated computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

The utility of seat belt signs to predict intra-abdominal injury following motor vehicle crashes

OBJECTIVE

Safety belts are the most important safety system in motor vehicles and should always be worn to prevent serious injury. The purpose of this study, using Crash Injury Research Engineering Network (CIREN) data, was to assess occupant and crash factors associated with minor contusions and abrasions caused by the safety belt (commonly referred to as seat belt signs) and their association with serious intra-abdominal trauma.

METHODS

CIREN data were used to determine which factors are associated with seat belt signs. Occupant variables (age, gender, body mass index, proper safety belt use, driver v. passenger status) and crash variables (crash type, crash severity, and airbag deployment) were compared for occupants with seat belt sign who had serious (AIS 3 or greater) intra-abdominal injury and those who did not have intra-abdominal injuries. Adjusted odds ratios were used to quantify the independent association between predictive factors for serious intra-abdominal injury for occupants with seat belt signs.

RESULTS

Of 1539 occupants included in this study, 419 had a positive seat belt signs. Of those 419 occupants, 100 had serious intra-abdominal injury and 319 did not. Being in the passenger seat position increased the odds, whereas front airbag deployment and frontal impact were associated with decreased odds of serious intra-abdominal injury for occupants with seat belt signs. However, multivariate analysis showed only that being a passenger increased the odds (OR = 2.64) of having serious intra-abdominal injury for occupants with seat belt signs when other factors, including crash severity and type of impact, were controlled for in the analysis.

CONCLUSIONS

Seat belt signs remain an important physical finding in patients with intra-abdominal injury following motor vehicle crashes. Front seat passengers presenting with seat belt signs were more than twice as likely to sustain intra-abdominal injury; thus, emergency physicians and trauma surgeons should be aware of passenger position when evaluating a seat belt sign.

Management of blunt bowel and mesenteric injuries: Experience at the Alfred hospital

BACKGROUND

The incidence of blunt bowel and mesenteric injury (BBMI) has increased recently in blunt abdominal trauma, possibly due to an increasing number of high-speed motor accidents and the use of seat belts.

OBJECTIVE

Our aim was to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with BBMI. This was achieved by reviewing our experience as a major Victorian trauma service in the management of bowel and mesenteric injuries and comparing this to the experiences reported in the literature.

METHODS

A retrospective study reviewing 278 consecutive patients who presented to the Alfred trauma center with blunt bowel and mesenteric injuries over a 6-year period.

RESULTS

The patient cohort comprised 278 patients with BBMI (66% were male, 34% were female), of whom 80% underwent a laparotomy, 17% were treated conservatively and 3% were diagnosed post-mortem. In terms of time from admission to laparotomy, 67% were treated within 0-4 h, 9% within 4-8 h, 3% within 8-12 h, 10% within 12-24 h, 4% within 24-48 h and 7% at >48 h. A focused abdominal sonography for trauma (FAST) was performed in 86 patients, of whom 51% had a positive FAST, 44% had a negative FAST and 4% had an equivocal FAST. Overall, 13% of the patient cohort did not have a FAST. Computerized tomography (CT) scans were undertaken preoperatively in 68% of the patients, revealing free gas (22% of patients), bowel-wall thickening (31%), fat and mesenteric stranding or hematoma (38%) and free fluid with no solid organ injury (43%).

CONCLUSION

The timing of surgical intervention in cases of BBMI is mostly determined by the clinical examination and the results of the helical CT scan findings. The FAST lacks sensitivity and specificity for identifying bowel and mesenteric trauma. A delayed diagnosis of > 48 h has a significantly higher bowelrelated morbidity but not mortality.

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.

Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial

BACKGROUND

The optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates.

METHODS

A multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively.

RESULTS

Three hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention.

CONCLUSIONS

Shock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.

[Gastrointestinal and mesenteric injuries in the trauma patient: incidence, diagnosis delay and prognosis]

BACKGROUND

Gastrointestinal and mesenteric injuries (GIMI) are uncommon in trauma patients, and their diagnosis are often delayed. Our aims were to determine the reliability of CT scan in our centre, and to assess the clinical significance of a delayed diagnosis.

MATERIALS AND METHOD

Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of Gregorio Marañón University General Hospital, between 1993 and 2006.

RESULTS

We found 105 (16.6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1495 severe trauma cases included. A total of 46% had blunt injuries. The mean injury severity score (ISS) and new ISS (NISS) were 20 and 25, respectively. There were 9 (8.5%) deaths, 4 of which were unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 there were signs suggestive of a GIMI. In another 43 (41%) patients an urgent laparotomy was indicated because of positive clinical findings or instability. Surgery was delayed for more than 8 hours in 21 (20%) patients, the most common reason being a false negative result in the CT scan.

CONCLUSIONS

The overall incidence of GIMI was high in our centre (31% due to penetration and 10.7% blunt trauma). Several factors, such as the initial lack of symptoms, a low diagnostic sensitivity of the CT scan (34% false negatives), and the non-surgical management of solid organ injuries, have contributed to a delayed diagnosis and treatment in one out of each five patients in our series, but this has not led to a significant increase in septic complications in this group.

Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma

STUDY OBJECTIVE

We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma.

METHODS

We prospectively enrolled adult patients (>or=18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients.

RESULTS

In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval [CI] 8.1% to 10.1%) with intra-abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra-abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%).

CONCLUSION

These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning.

Blunt abdominal trauma with small bowel injury: are isolated lesions riskier than associated lesions?

PURPOSE

The objective of this study was to compare patients with "isolated" blunt small bowel injury (SBI) to patients with multiple intra-abdominal injuries and analyze whether delayed laparotomy affected outcome.

METHODS

Medical records of patients that suffered a blunt SBI between 1994 and 2005 were reviewed. The patients were divided into two groups: those with isolated SBI and those with other associated intra-abdominal injuries ("non-isolated"). The method of diagnosis, time to operation, small bowel Organ Injury Scale (OIS) assessment (grade >or= 2), injury severity score (ISS), morbidity, and mortality were analyzed.

RESULTS

A total of 90 patients met the inclusion criteria, including 62 (68.9%) isolated cases and 28 (31.1%) non-isolated cases. Isolated cases required more supplementary diagnostic methods than the non-isolated cases. Non-isolated cases had a shorter diagnosis to treatment period (p < .01) and a higher ISS (mean 22.5 vs. 17.2 in "isolated" group). Morbidity (51.6% and 53.6%) and mortality (16.1% and 28.6%) did not differ significantly between the isolated and non-isolated groups. Delays in diagnosis were common in the isolated group, but this did not affect outcome. Patients with associated injuries, and higher ISS, had higher mortality.

CONCLUSIONS

The presence of associated intra-abdominal injuries significantly affected the presentation and time to diagnosis of patients with SBI, but not morbidity or mortality. Delayed surgical treatment in the isolated cases was not associated with an increased incidence of complications. Patients inflicted with more severe associated injuries were less likely to survive the trauma.

Hollow viscus injury

BACKGROUND

Hollow viscus injuries are uncommon and occur in approximately 1% of all blunt trauma patients.

DISCUSSION

These injuries are often not suspected and are difficult to diagnosis. Morbidity and mortality are high, and a negative abdominal computed tomography is not sufficient to rule out these injuries in certain clinical scenarios.

CONCLUSION

Using a case-based approach, the epidemiology and diagnostic pathways to manage hollow viscus injuries are reviewed.

The evolution of the diagnostic work-up for stab wounds to the back and flank

BACKGROUND

Stab wounds to the back and flank infrequently cause injuries requiring operative treatment. Triple-contrast CT scan (3CT) has essentially replaced diagnostic peritoneal lavage (DPL) as the primary means of identifying patients who require operative intervention. This study aims to review the evolution of the diagnostic work-up for stab wounds to the back and flank.

METHODS

We performed a retrospective review of haemodynamically stable patients with stab wound to the back or flank treated at a single Level 1 trauma centre over a 10-year period. Diagnostic accuracy of DPL and 3CT screening tests were evaluated against the patient's subsequent clinical course. The elapsed time between emergency department (ED) presentation and test results was recorded and compared.

RESULTS

A total of 177 patients were identified. 76 patients had stab wounds isolated to the back, 90 had stab wounds isolated to the flank and 11 had wounds in both locations. CT ultimately became the predominant initial diagnostic test during the study period. Although less frequently used over time, DPL retained good sensitivity and specificity for injuries requiring operative intervention (92% and 83%, respectively). 3CT identified all injuries requiring laparotomy (100% sensitivity) and had a specificity of 96%. 3CT was a more time-consuming process, with results available at a median of 3:31h after arrival to the ED, as compared to 1:03h for DPL (p<0.01).

CONCLUSIONS

3CT diagnosed all injuries requiring operative intervention, and its use was associated with a lower rate of non-therapeutic laparotomies. However, average time to diagnosis by 3CT was prolonged compared to DPL. Although 3CT has become the predominant diagnostic test when evaluating patients with stab wounds to the back and flank at our institution, efforts to further expedite the diagnostic work-up are necessary.

The role of video-assisted laparoscopy in management of patients with small bowel injuries in abdominal trauma

BACKGROUND

Patients with small bowel injuries (SBI) in abdominal trauma have no clear clinical or radiological signs on initial examination. This leads to delay in appropriate surgical interventions with consequent high morbidity and mortality. In this paper we demonstrate the role of video-assisted laparoscopy (VAL) in management of such patients.

METHODS AND MATERIALS

819 patients with SBI were evaluated retrospectively between 1994 and 2003. The mechanism of the trauma was blunt in 146 (17.8%) patients and stab wounds in 640; routine investigations and VAL were used for triage of the subjects. All the victims underwent laparotomy or video-assisted laparoscopy. Demographic information, incidence of organs injuries, types of surgery, complications, associated injuries, and hospital mortality were analyzed.

RESULTS

Diagnostic video laparoscopy was sufficient for 518 (63.2%) patients. Small bowel repair was performed in 332 (40.6%) patients, clipping of mesenteric blood vessels in 27 (3.4%) patients, and coagulation and ligation of omental blood vessels in 48 (5.9%) patients. Ninety-seven (11.8%) patients with small bowel injury were associated with postoperative complications. There were 19 (2.3%) deaths associated with hemoperitoneum, severe head injury, and multiple ribs fracture. Generalized peritonitis was revealed in one case and focal abscesses between intestinal loops were identified in another one patient.

CONCLUSION

The DVAL findings of visceral injuries give optimal approach for management of small bowel injuries in abdominal trauma.

Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.

Blunt Gastric Injuries

Gastric rupture after blunt abdominal trauma is a rare injury with few reports in the literature. The purpose of this study was to review our experience with blunt gastric injuries and compare outcomes with small bowel or colon injuries. All patients with hollow viscus perforations after blunt abdominal trauma from 1992 to 2005 at our level I trauma center were reviewed. Of 35,033 blunt trauma admissions, there were 268 (0.7%) patients with a total of 319 perforating hollow viscus injuries, 25 (0.07%) of which were blunt gastric injuries. When compared with the small bowel or colon injuries, the blunt gastric injury group had a higher Injury Severity Score (22 versus 17, P = 0.04), more patients with a chest Abbreviated Injury Score greater than 2 (36% versus 12%, P < 0.01), and a shorter interval from injury to laparotomy (221 versus 366 minutes, P = 0.017). Multivariate analysis identified five independent risk factors for mortality: age older than 55 years, head Abbreviated Injury Score greater than 2, chest Abbreviated Injury Score greater than 2, the presence of hypotension on admission, and Glasgow Coma Scale 8 or less. The results of this study suggest that mortality in patients with blunt hollow viscus injuries can be attributed to concurrent head and chest injuries, but not the specific hollow viscus organ that is injured.

Fatores preditivos de morbimortalidade no trauma de intestino delgado

OBJETIVO: Os objetivos deste estudo foram avaliar o diagnóstico e o tratamento das lesões de intestino delgado e determinar os fatores que influenciaram a morbimortalidade. MÉTODO: Estudo retrospectivo incluindo 410 pacientes com lesão de intestino delgado operados entre janeiro de 1994 e dezembro de 2004. Os dados coletados incluíram: mecanismo de trauma, métodos diagnósticos, tempo transcorrido até a intervenção cirúrgica, grau das lesões, índices de trauma, conduta cirúrgica (sutura ou ressecção e anastomose), morbidade (especialmente fístula) e mortalidade. A comparação entre os grupos foi feita usando os testes de Fisher e Yates. RESULTADOS: O mecanismo de trauma foi penetrante em 321 pacientes (78,3%) e fechado em 89 (21,7%). Houve mais pacientes tratados cirurgicamente com intervalo maior que 6 horas após o trauma no grupo trauma contuso se comparados com trauma penetrante (p<0,05). Sutura da lesão foi feita em 52,2% dos pacientes e ressecção e anastomose em 46,8%, e ambos procedimentos apresentaram a mesma incidência de fístula (4,7%). A morbidade foi de 35,1%. A incidência de fistula foi maior nos pacientes submetidos à laparotomia com mais de 12 horas após o trauma quando comparados com aqueles operados com menos de 12 horas (8,3% vs. 4,3%; sem diferença estatística), mas isto não foi fator determinante para maior mortalidade. A mortalidade foi de 13,7% e foi relacionada com escores de gravidade mais elevados. CONCLUSÃO: A lesão de intestino delgado é freqüente após o trauma abdominal, sendo mais comum nos traumas penetrantes. O diagnóstico desta lesão após trauma fechado pode ser difícil, com demora para o tratamento cirúrgico. A ocorrência de fistula não esteve relacionada aos seguintes fatores analisados: mecanismo de trauma, tempo transcorrido entre o trauma e a operação, conduta cirúrgica, lesões intra-abdominais associadas ou gravidade das lesões. A mortalidade esteve relacionada com lesões associadas.

Forensic considerations of missed diagnoses in trauma deaths

Injuries missed at initial diagnoses or operations have the potential to cause disastrous complications in trauma patients. Understanding the etiology of unrecognized injuries is essential in minimizing its occurrence. For this purpose, we scrutinized the treatment and the autopsy records of the trauma deaths from 2000 to 2004 to determine the frequency, body regions, severity and causes of injuries that escaped recognition during the initial assessment, primary, secondary and tertiary surveys by the clinical team in patients who died of trauma. We also examined the accuracy of the cause of death as recorded on death certificates. The frequency of unrecognized injuries was found to be 11% in all trauma deaths. Abdomen (40%) and head (29%) were the more common regions of the body where injuries were frequently missed. System related errors (68%) and patient related factors (32%) were responsible for the injury remaining unrecognized. It was concluded that the injuries may be missed at any stage of the management of patients with major trauma and repeated assessments both clinical and radiological are mandatory not only to diminish the problem but to avoid litigation as well.

Blunt colon injury sustained during a kickboxing match

Emergency physicians routinely evaluate patients for injury from blunt abdominal trauma. Most serious injuries result from high energy mechanisms such as motor vehicle collisions. This case report describes a patient who sustained blunt trauma to the descending colon during a martial arts match, necessitating a hemicolectomy.

Small bowel perforation resulting from blunt abdominal trauma: interval change of radiological characteristics

PURPOSE

We analyzed radiography and computed tomography (CT) findings of small bowel perforation due to blunt trauma to identify the keys to diagnosis.

MATERIALS AND METHODS

Twelve patients with surgically proven small bowel perforation were retrospectively studied. All patients underwent radiography and CT, and five underwent presurgical follow-up CT. Radiological findings were evaluated and correlated to the elapsed time from the onset of the trauma retrospectively.

RESULTS

Radiography demonstrated free air in only 8% (1/12) and 25% (3/12) at the initial and follow-up examinations, respectively. In contrast, the initial and follow-up CT scans detected extraluminal air in 58% (7/12) and 92% (11/12), respectively. Mesenteric fat obliteration was seen in 58% (7/12) and 75% (9/12) at initial and follow-up CT, respectively. The incidence of both extraluminal air and mesenteric fat obliteration on CT increased as time elapsed, particularly after 8 h. High-density ascites was seen in 75% at initial CT, including two patients without extraluminal air, but was observed in all but one patient at follow-up CT.

CONCLUSION

The chance of detecting extraluminal air increases as time elapses. High-density ascites may be seen without extraluminal air and might be an indirect or precedent sign of small bowel perforation. Radiologists need to be familiar with these radiological features.

Critical care issues in the early management of severe trauma

Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. Preventability of trauma deaths has been reported as high as 76% and as low as 1% in mature trauma systems. Critical care errors may occur in a half of hospital trauma deaths, in most of the cases contributing to the death. The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.

Blunt bowel and mesenteric injuries in children: Do nonspecific computed tomography findings reliably identify these injuries?

OBJECTIVE

Abdominal computed tomography has proven accurate for the detection of pediatric solid organ injuries following blunt abdominal trauma but is less reliable in detecting blunt bowel and mesenteric injuries (BBMI). The purpose of this study was to determine the significance of nonspecific findings on abdominal computed tomography (CT) scan in children at risk for BBMI.

DESIGN

Retrospective chart review.

SETTING

Regional pediatric trauma center.

PATIENTS

All patients who received an abdominal CT scan as part of their evaluation following blunt abdominal trauma over a 10-yr period (September 1991 to September 2001).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Individual records were reviewed by one of the authors and analyzed for age, gender, mechanism of injury, diagnostic studies and procedures, results of initial CT scan, treatment, surgical procedures, complications, and outcome. Patients were excluded if they suffered penetrating trauma, had an abdominal CT scan performed at another institution, had a surgical procedure before CT scan, or had incomplete records. A total of 2,114 patients met inclusion criteria. Sixty-five percent were male and ages ranged from 3 wks to 18 yrs. There were 178 patients who had at least one nonspecific finding on abdominal CT scan suggestive of BBMI; 151 patients had one finding, 24 patients had two findings, and three had three findings. The risk of BBMI increased with the number of nonspecific findings (positive predictive value = 11% with at least one finding and 44% with two or more findings). This increase in positive predictive value, however, was accompanied by a reduction in sensitivity (62% and 37%, respectively). A total of 32 patients had surgically proven BBMI. Of these, eight had a single nonspecific finding on CT scan, ten had two findings, and two had three findings (12 patients had no CT findings suggestive of BBMI). There were complications in four of the 32 patients with BBMI and one death (due to laceration of the superior mesenteric artery). The complications appeared to occur independent of the time to surgical intervention.

CONCLUSIONS

The presence of multiple nonspecific findings on abdominal CT scan does not reliably predict BBMI in children. Children also appear to suffer complications from BBMI less frequently than adults, regardless of the time to surgery. Therefore, nonspecific findings alone do not warrant surgical exploration. The decision to operate should instead be based on clinical data that include serial physical examinations.

Mesenteric Injuries after Blunt Abdominal Trauma: Delay in Diagnosis and Increased Morbidity

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.

Melaena as the presenting symptom of gastric mucosal injury due to blunt abdominal trauma

Blunt abdominal trauma is a common cause of admission to the typical trauma centre. Hollow viscus injury from blunt trauma, however, is unusual and rarely involves the stomach. A 15 year old boy sustained a bicycle handle bar injury to the abdomen and presented to the casualty department four days later with melaena. A computed tomography (CT) scan of the abdomen showed normal findings but endoscopy revealed two "kissing" areas of mucosal ulceration on the anterior and posterior wall of the gastric antrum. The patient received a blood transfusion for anaemia but was otherwise treated conservatively and made a full recovery. The authors believe this to be the first reported case of melaena as the primary presenting symptom of gastric ulceration secondary to blunt abdominal trauma. Diagnosis of hollow viscus injuries due to blunt abdominal trauma requires a high index of suspicion and thorough investigation, particularly if the presentation is delayed.

Isolated jejunal perforation after blunt thoracoabdominal trauma

A case report of isolated jejunal perforation secondary to a relatively unique mechanism of blunt thoracoabdominal trauma is presented. A thorough and concise review of the multimodal approach that may be necessary to diagnose such a rare clinical problem is discussed.

Chest and Abdominal Injuries Caused by Seat Belt Wearing

The authors report an original case of seat belt syndrome. Sternal fractures are common in patients with seat belt injuries. Its association with blunt bowel trauma is rarely related in the literature. Distracted injury has contributed to delay the diagnosis of intestine injury. The presence of a seat belt sign must lead to the consideration of occult injuries especially abdominal. Close observation and serial examination should be the rule.

Paediatric lap-belt injury: A 7 year experience

OBJECTIVE

To highlight the injuries that result from lap-belt use and make recommendations for prevention, the recent experience of a regional paediatric trauma centre was reviewed.

METHODS

Retrospective review of admissions to Starship Children's Hospital from 1996 to 2003, with significant injury following involvement in a motor vehicle crash, while wearing a lap-belt. Patients were identified from two prospectively collected databases and discharge coding data.

RESULTS

In total, 19 patients were identified over the 7 year period. The morbidity sustained includes 15 patients with hollow viscus injury, 13 laparotomies, 7 spinal fractures, 2 paraplegia and 1 fatality. A total of 11 patients required laparotomy with a median delay of 24 h. Of patients in the present series, 58% were aged less than 8 years and thus were inappropriately restrained.

CONCLUSIONS

Lap-belt use can result in a range of life-threatening injuries or permanent disability in the paediatric population. The incidence of serious lap-belt injury does not appear to be decreasing. Morbidity and mortality could be reduced by the use of three-point restraints, age appropriate restraints and booster seats.

Abdominal trauma: a disease in evolution

BACKGROUND

The last decade has seen many changes in the way we investigate and manage abdominal injuries. This study assessed the pattern of abdominal injury and its investigation in patients admitted to a major trauma centre.

METHODS

A retrospective registry review of all adult trauma patients admitted to Liverpool Hospital between January 1996 and December 2003 was undertaken. All adult trauma patients were included, identifying mechanism of injury, injury severity score, abbreviated injury score for the abdomen, investigations and intervention. The study period was divided (period 1 from 1996 to 1999, period 2 from 2000 to 2003) and the two periods compared to assess change.

RESULTS

The study involved 1224 patients with abdominal injuries. Of these, 969 (79%) were a result of blunt trauma. The main causes were road accidents (61%), interpersonal violence (24%) and falls (7%). Penetrating injury increased from 16% to 25% between the two periods. There were 1274 intra-abdominal injuries, made up of 607 solid organ (liver (n = 220, 36%), spleen (n = 195, 32%), renal (n = 144, 24%) ), 291 hollow viscus (small bowel (n = 160, 55%), large bowel (n = 104, 36%) ) and 168 vascular. Four hundred and thirty-six (36%) patients underwent laparotomy, 65% for blunt trauma. Between the two periods there was a 46% decrease in the use of diagnostic peritoneal lavage, with a 40% increase in computed tomography and 325% increase in focused assessment with sonography for trauma.

CONCLUSIONS

This study defined abdominal injury pattern and identified a significant shift in mechanism of injury and abdominal investigation at a major trauma centre during an 8-year study period. Abdominal trauma is indeed a disease in evolution.

Multidetector CT evaluation of abdominal trauma

CT is the imaging modality of choice to evaluate blunt abdominal trauma. With the advent of multidetector CT (MDCT), scanning times have progressively decreased while image resolution has increased owing to thinner collimation and reduced partial volume and motion artifacts. MDCT also allows high quality two-dimensional and three-dimensional multiplanar reformatted images to be obtained, which aid in the diagnosis of the complex multisystem injuries seen in the trauma patient. This article describes the authors' current imaging protocol with 16-detector MDCT, the spectrum of CT findings seen in patients with blunt abdominal injuries, and the role MDCT has in guiding injury management.

Perforating small bowel injuries in children: influence of time to operation on outcome

The purpose of this study was to determine whether delay in the diagnosis of small bowel injury (SBI) affected the outcome of paediatric patients who required surgical interventions in the treatment of small bowel injuries. A retrospective chart review was performed on children with traumatic SBI requiring surgical management between January 2000 and December 2002. Diagnostic interval was defined as the time from presentation to operative treatment and delay was an interval of greater than 8 h. Thirteen patients were admitted for operative treatment of SBI. Nine cases were the result of motor vehicle trauma. The mean diagnostic interval for all patients was 9.1 h+/-7.4 h (range 0.6 h-22.5 h). Six patients had a diagnostic delay with a mean diagnostic interval of 15.5 h+/-5.5 h. There was no statistically significant difference found between the prompt and delayed diagnosis groups in terms of complications or length of hospital stay. Our finding of no difference between the prompt and delayed diagnosis groups and a diagnostic delay no longer than 22.5 h may suggest that our local methods of diagnosis and treatment assist in the prevention of unnecessary complications and death.

Missed diagnoses in trauma patients vis-à-vis significance of autopsy

Post-mortem examination is considered to be the gold standard for the critique of medical practice, providing a quality control tool for the retrospective evaluation of diagnoses and treatment. Performing autopsies also facilitates new insight about the pathogenesis of disease and effects of therapy, gives feedback to clinical research protocols, provides epidemiological information and occasionally helps to console and reassure grieving families that death was inevitable. Its significance becomes paramount in cases of missed diagnosis in trauma-related deaths. The true incidence of missed diagnoses in trauma-related deaths is unknown, because autopsy is conducted in only about 50% of injury-related deaths. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. The present study is an attempt to evaluate the incidence and nature of missed injuries and complications in trauma-related deaths given an autopsy rate of close to 100%. This study also sought to identify the primary factors contributing to each missed injury. However, the study is in no way intended to assigning blame to human or system errors. Rather, it is focussed specifically on the issue of whether autopsy can be useful to provide feedback in identifying clinical problems of trauma patients.

Computed tomographic scanning and selective laparoscopy in the diagnosis of blunt bowel injury: a prospective study

BACKGROUND

We prospectively evaluated whether computed tomographic (CT) scanning and selective laparoscopy (LP) for the diagnosis of blunt bowel injury (BBI) could prevent nontherapeutic laparotomy and delayed diagnosis.

METHODS

Between April 1994 and May 2002, hemodynamically stable patients suspected of having BBI were enrolled in this study. Patients with hemodynamic instability or solid organ injuries with hemoperitoneum were excluded. All patients underwent a physical examination and contrast CT scanning at admission and once again approximately 12 hours (range, 6-24 hours) after admission. LP was performed under general anesthesia in patients who had local peritoneal signs and indirect CT signs (bowel thickening or isolated intraperitoneal fluid) or in whom abdominal pain or tenderness increased or intraperitoneal fluid increased on the repeat CT scan. The indications for a celiotomy were diffuse peritonitis, pneumoperitoneum on the abdominal CT scan, or bowel perforation visible on LP.

RESULTS

During the study period, 399 of 1,074 patients admitted for blunt torso injuries were enrolled in this study. Eleven patients underwent emergency celiotomy and 11 underwent LP immediately after admission to the emergency department. One nontherapeutic laparotomy was performed among the patients who underwent celiotomy. The LPs revealed seven bowel perforations and one mesenteric laceration. After a repeat CT scan, three and seven of the patients underwent laparotomy and LP, respectively. Four bowel perforations were found by LP. The remaining 198 patients were treated conservatively, and no complications related to a delayed BBI diagnosis occurred.

CONCLUSION

CT scanning and selective LP can prevent nontherapeutic laparotomy and delayed diagnosis in patients with suspected BBI.

Large Animal-Related Abdominal Injuries

BACKGROUND

This study investigated injuries to the abdominal area of the body caused by large animals, as well as the management of this problem.

METHODS

All the patients with large animal-related abdominal injuries over a 10-year period were identified retrospectively through the general surgery registrations.

RESULTS

Overall, 113 patients were hospitalized after large animal encounters during the 10-year study period, 33 (30%) of which had large animal-related abdominal injuries. These patients comprised 10 women (30%) and 23 men (70%) with a mean age of 56 +/- 14 years. Of the 33 patients, 31 (93.9%) sustained blunt injuries and 2 (6.1%) experienced penetrating abdominal trauma. The mean Injury Severity Score was 12.7 +/- 4.0, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 10.6 +/- 3.2. The mean intensive care unit stay was 0.8 +/- 2.2 days, and the total hospital length of stay was 7.3 +/- 5.6 days. Whereas 12 patients (36.4%) were managed nonoperatively, 21 patients (63.6%) required surgery. Laparotomy showed injuries to the jejunum in three patients (9.1%), to the ileum in 13 patients (39.4%), to the ileal mesenterium in 1 patient (3%), to the liver in 4 patients (12.1%), and to the spleen in 2 patients (6.1%). One patient died of myocardial infarction on the second day after admission.

CONCLUSIONS

Large animal-related injuries to the abdominal area can be serious. Immediate transportation and early diagnosis of abdominal insults are important because of the frequencies of small bowel and mesenteric injuries, which are difficult to diagnose using currently available diagnostic tools.

Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries

STUDY OBJECTIVE

We describe the performance of helical abdominal computed tomography (CT) scan without oral contrast for the detection of blunt gastrointestinal injuries.

METHODS

We retrospectively reviewed the records of a consecutive series of patients who underwent helical abdominal CT scanning for evaluation of blunt intra-abdominal injury and were admitted to a Level I trauma center from May 1996 to September 2001. Abdominal CT scans were performed with intravenous contrast but without oral contrast. Patients were considered to have gastrointestinal injuries if an injury was identified to the gastrointestinal tract from the duodenum to the sigmoid colon or associated mesentery and considered to have major gastrointestinal injuries if gastrointestinal perforation, active mesenteric hemorrhage, or mesenteric devascularization occurred. All gastrointestinal injuries were confirmed by laparotomy, autopsy, or additional imaging studies.

RESULTS

Six thousand fifty-two patients underwent abdominal CT scan (mean age 35.5 +/- 21.1 years), and 106 (1.8%) patients had gastrointestinal injuries identified by laparotomy, autopsy, or additional (nonabdominal CT) imaging studies. Abdominal CT scan result was abnormal in 91 (86%; 95% confidence interval [CI] 78% to 92%) of the 106 patients with gastrointestinal injuries and revealed findings suggestive of gastrointestinal injury in 81 (76%; 95% CI 67% to 84%) patients. Abdominal CT scan demonstrated findings suggestive of gastrointestinal injury in 58 of 64 (91%; 95% CI 81% to 96%) patients with major gastrointestinal injuries. Two hundred thirty-eight (4.0%) patients had findings suspicious for gastrointestinal injuries on abdominal CT scan, but gastrointestinal injury was never confirmed.

CONCLUSION

Helical abdominal CT scan without oral contrast identified nearly three fourths of patients with blunt gastrointestinal injuries who were selected for abdominal CT scanning. Sensitivity of this diagnostic test improves in the subset of patients with major gastrointestinal injuries.

The role of computed tomography in diagnosis of blunt intestinal and mesenteric trauma (BIMT)

Blunt intestinal mesenteric trauma (BIMT) is a rare injury with a high morbidity and mortality. It is a diagnostic dilemma for Trauma Surgeons and Emergency Physicians. This study was undertaken to assess the role of computed tomography (CT) in BIMT. Data were analyzed from 1995 to 2002. Thirty-six cases of BIMT were identified: 16 isolated and 20 non-isolated injuries. Initial CT scan was abnormal in 74% (17 out of 23), and 83% on retrospect (2 additional cases). CT scans were abnormal (initial and repeat) in 96% (22 out of 23). The most common abnormalities were free fluid (78%), mesenteric stranding or edema (39%), bowel wall hematoma, or edema (30%). Free air was seen in 31% and oral contrast extravasation in 15% of cases of bowel perforation. CT scan findings in BIMT can be subtle and non-specific. Suspicion of BIMT warrants close observation and probably further diagnostic testing.

Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes

BACKGROUND

Children involved in motor vehicle crashes (MVC) can sustain bruising of the abdominal wall associated with seat belt restraint. The incidence of bruising and its relationship with significant intraabdominal injuries are not known.

METHODS

An analysis of children involved in MVC between December 1998 and November 2002 was performed, using the crash surveillance database from the Partners for Child Passenger Safety (PCPS) project. Optimally (OR) or suboptimally (S-OR) restrained children aged 4 to 15 years were selected. The incidence of abdominal wall bruising was calculated then correlated with the type of restraint as well as any intraabdominal injury with an Abbreviated Injury Scale score > or =2.

RESULTS

A total of 147,985 children in 102,548 crashes met study criteria. An abdominal bruise was noted in 1.33% of the children (n = 1,967; 881 OR and 1,086 S-OR). Significant intraabdominal injury was present in 309 children (0.21%, 95% CI 0.13 to 0.33), including 69 OR and 240 S-OR. The sensitivity, specificity, and positive and negative predictive values of abdominal wall bruising for a significant intraabdominal injury were 73.5%, 98.8%, 11.5%, and 99.9%, respectively. Children with a bruise were substantially more likely to have an intraabdominal injury than children without a bruise. (Odds Ratio 232.1, 95% CI, 75.9 to 710.3) Among those children with an abdominal bruise, 1% required an abdominal operation (n = 20).

CONCLUSIONS

Abdominal wall bruising was relatively uncommon in both OR and S-OR children. Among restrained children involved in MVC, those with a bruise were 232 times more likely to have a significant intraabdominal injury when compared with those without a bruise. It is imperative to pursue intraabdominal injury in children with a bruise of the abdominal wall after MVC.

Hollow viscous injury in the pediatric patient

Injuries to the gastrointestinal tract account for 1% to 15% of intraabdominal injuries in children. Most hollow visceral injuries occur following some form of blunt trauma and motor vehicle accidents remain the most common mechanism of injury. The diagnosis of blunt intestinal injury is difficult and often delayed. Current imaging modalities are imprecise and contribute to delay. Delay is associated with morbidity and mortality in both children and adults, but the length of delay remains controversial. The purpose of this review is to examine the current diagnosis and management of hollow visceral injury in children.

Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma

BACKGROUND

Computed tomographic (CT) scanning using intravenous and oral contrast material has traditionally been advocated for the evaluation of intra-abdominal injury, including blunt bowel and mesenteric injuries (BBMIs). The necessity of oral contrast in detecting these injuries has recently been called into question. The purpose of this study was to determine the sensitivity and specificity of CT scanning without oral contrast for BBMIs.

METHODS

We prospectively enrolled 500 consecutive blunt trauma patients who received CT imaging and interpretation (CT-Read1) of the abdomen from July 2000 to November 2001. All patients were imaged without oral contrast, but with intravenous contrast. CT images were reviewed within 24 hours of admission by a research radiologist (CT-Read2) blinded to CT-Read1. For study purposes, true BBMI was determined to be present if either laparotomy or autopsy identified bowel or mesenteric injury, or both CT-Read2 and the hospital discharge summary described bowel or mesenteric injury. Three-month telephone follow-up was also completed.

RESULTS

CT-Read1 detected 19 of 20 bowel and mesenteric injuries. CT-Read1 missed one duodenal perforation. There were two patients with false-positive interpretations of CT-Read1 for bowel injury. The sensitivity and specificity of CT imaging for the detection of BBMIs were 95.0% and 99.6%, respectively.

CONCLUSION

CT imaging of the abdomen without oral contrast for detection of BBMIs compares favorably with CT imaging using oral contrast.

Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma

BACKGROUND

Computed tomographic (CT) scanning using intravenous and oral contrast material has traditionally been advocated for the evaluation of intra-abdominal injury, including blunt bowel and mesenteric injuries (BBMIs). The necessity of oral contrast in detecting these injuries has recently been called into question. The purpose of this study was to determine the sensitivity and specificity of CT scanning without oral contrast for BBMIs.

METHODS

We prospectively enrolled 500 consecutive blunt trauma patients who received CT imaging and interpretation (CT-Read1) of the abdomen from July 2000 to November 2001. All patients were imaged without oral contrast, but with intravenous contrast. CT images were reviewed within 24 hours of admission by a research radiologist (CT-Read2) blinded to CT-Read1. For study purposes, true BBMI was determined to be present if either laparotomy or autopsy identified bowel or mesenteric injury, or both CT-Read2 and the hospital discharge summary described bowel or mesenteric injury. Three-month telephone follow-up was also completed.

RESULTS

CT-Read1 detected 19 of 20 bowel and mesenteric injuries. CT-Read1 missed one duodenal perforation. There were two patients with false-positive interpretations of CT-Read1 for bowel injury. The sensitivity and specificity of CT imaging for the detection of BBMIs were 95.0% and 99.6%, respectively.

CONCLUSION

CT imaging of the abdomen without oral contrast for detection of BBMIs compares favorably with CT imaging using oral contrast.

Injuries to the colon from blast effect of penetrating extra-peritoneal thoraco-abdominal trauma

Although rare, blast injury to the intestine can result from penetrating thoraco-abdominal extra-peritoneal gunshot (and shotgun) wounds despite the absence of injury to the diaphragm or to the peritoneum. Injuries of the spleen, small intestine and the mesentery by this mechanism have been previously reported in the world literature. This paper reports the first two cases of non-penetrating ballistic trauma to the colon.