Diagnostic options for blunt abdominal trauma

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department

OBJECTIVES

Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period.

METHODS

We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death.

RESULTS

We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported.

CONCLUSION

The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Management and Outcomes of Traumatic Liver Injury: A Retrospective Analysis from a Tertiary Care Center Experience

BACKGROUND

although liver injuries are one of the most critical complications of abdominal trauma, choosing when to operate on these injuries is challenging for surgeons worldwide.

METHODS

We conducted a retrospective analysis of liver injury cases at our institution from 2016 to 2022 to describe the operative and nonoperative management (NOM) outcomes in patients with traumatic liver injuries. Baseline patient characteristics, liver injury details, treatments, and outcomes were analyzed.

RESULTS

Data from 45 patients (male, 77.8%) were analyzed. The mean age was 29.3 years. Blunt trauma was the most common injury mechanism (86.7%), whereas penetrating injuries were 8.9% of cases. Conservative management was associated with 18.9% of complications. The overall complication rate was 26.7%; delirium and sepsis were the most common (13.3%), followed by acute renal failure (4.4%), pneumonia, biliary leaks, and meningitis/seizures.

CONCLUSIONS

Notwithstanding its limitations, this retrospective analysis demonstrated that NOM can serve as a safe and effective strategy for hemodynamically stable patients with liver trauma, irrespective of the patient's injury grade. Nevertheless, careful patient selection and monitoring are crucial. Further investigations are necessary to thoroughly evaluate the management of traumatic liver injuries, particularly in the context of multiorgan injuries.

Combination of Focused Assessment With Sonography for Trauma (FAST) Scan and Detection of Hematuria to Exclude Intra-abdominal Injuries Following Blunt Abdominal Trauma

Background Blunt abdominal trauma (BAT) is the most common pattern of abdominal traumas. It may be associated with intra-abdominal injuries (IAIs). Exploratory laparotomies are only needed in a minority of patients after BAT. Methodology All BAT patients who presented to the El Demerdash Hospital of Ain Shams University, Cairo, Egypt during the study period were traced. Parameters including demographic data, focused assessment with sonography for trauma (FAST) scan, CT scan results, and hematuria were collected. The cohort was divided according to the CT scan results into two groups: patients with IAIs and patients without IAIs. Results Males represented 78.2% of the patients, and the mean age of the recruited patients was 32.1 ± 18 years. Road traffic accidents represented the main cause of trauma (58%). Patients with IAIs detected by CT scan represented 1.62%, and hematuria was detected in 88.9% of them. The specificity of FAST was 97.1%, and that of hematuria was 84.1%, and for the combination of both tests, the specificity was 99.3%. Conclusion IAIs after BAT can usually be excluded if both FAST and hematuria are negative, provided that the patient is stable.

Use of minimally invasive surgery for the management of hollow viscus traumatic injuries

BACKGROUND

The objective of this study is to assess surgical outcomes following the initial use of laparoscopy versus laparotomy when managing patients with hollow viscus injuries due to trauma.

METHODS

Using the database from the American College of Surgeons Trauma Quality Improvement Program we identified all patients from 2015-2017 with ICD-10 Diagnosis codes for hollow viscus trauma. Types of procedures were identified by ICD-10 PCS codes. Patient outcomes were stratified by major trauma(ISS > 15) and minor trauma. Continuous variables were compared by ANOVA and categorical variables compared by Chi-Square. Analysis performed using STATA 16.

RESULTS

We identified 16,284 patients that matched inclusion criteria within the study time frame. Of those, 1986 patients received a surgical intervention, 1911(96%) were open and 75(4%) were laparoscopic. In blunt trauma there were 106 diagnostic procedures, 87(82%) were open and 19(18%) were laparoscopic. There were 574 therapeutic procedures, 543(95%) were open and 31(5%) were laparoscopic. In penetrating trauma there were 223 diagnostic procedures, 215(96%) were open and 8(4%) were laparoscopic. There were 1039 therapeutic procedures for penetrating trauma, 1023(98%) were open and 16(2%) were laparoscopic. For minor trauma, mean length of stay(days) after open surgery was 5 while for laparoscopy it was 2 (p = 0.04). There were 203 complications noted in the open group and 7 in the laparoscopic group (p = 0.19). For major trauma, mean length of stay(days) after open surgery was 5 and 6 for laparoscopy p = 0.54). There were 242 complications in the open group and 1 in the laparoscopic group (p = 0.07). There was no noted significant difference noted in the disposition at discharge in either group in both major and minor trauma.

CONCLUSIONS

For those that required surgery for hollow viscous injury, laparoscopy appeared to be safe, had less adverse outcomes and was underutilized, particularly when only a diagnostic procedure was required.

Exercise-induced traumatic muscle injuries with active bleeding successfully treated by embolization: three case reports

Muscle injuries caused by indirect trauma during exercise are common. Most of these injuries can be managed conservatively; however, further treatment is required in extreme cases. Although transcatheter arterial embolization is a possible treatment modality, its role in traumatic muscle injuries remains unclear. In this case series, we present three cases of exercise-induced muscle hemorrhage treated by transcatheter arterial embolization with successful outcomes. The damaged muscles were the rectus abdominis, adductor longus, and iliopsoas, and the vascular injuries were accessed via the femoral artery during the procedures.

Prehospital FAST reduces time to admission and operative treatment: a prospective, randomized, multicenter trial

BACKGROUND

The focused assessment with sonography in trauma (FAST) exam is an established trauma care diagnostic procedure. Ultrasound performed during prehospital care can improve early treatment and management of the patients. In this prospective randomized clinical trial, we wanted to assess whether a pre-hospital FAST (p-FAST) influences pre-hospital strategy and the time to operative treatment.

METHODS

We studied 296 trauma victims in a prehospital setting. Inclusion criteria were potential abdominal injuries identified either by clinical examination or suggested by the mechanism of injury. Physician-staffed helicopters and emergency ambulances were equipped with portable ultrasound devices. According to a scheme related to calendar weeks, a clinical exam only (CEX) or a clinical exam together with a p-FAST (CEX-p-FAST) was conducted. Outcome variables were prehospital diagnosis and strategy, the time to admission to the trauma room and to operation theater. The study was approved by the university ethical committee (REB#: 46/06).

RESULTS

CEX-p-FAST showed a high sensitivity (94.7%) and specificity (97.6%) in detection of free fluid compared to CEX-only (80.0%, 84.4%). The median time to admission was reduced significantly by 13 min and to operative treatment by 15 min after CEX-p-FAST. We observed a cross-over rate of 30.8% of p-FAST (n = 36) to CEX-p-FAST during the CEX-only weeks.

CONCLUSION

According to the experience of the principal investigators, CEX-p-FAST was superior to CEX-only. Despite the time needed for p-FAST, the relevant admission time was significantly shorter. Thus, p-FAST is recommended in addition to CEX if possible for decision-making in prehospital trauma care.

TRIAL REGISTRATION

German Clinical Trials Register #DRKS00022117-Registered 10 July 2020-Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022117 .