Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when?

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds

INTRODUCTION

This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso.

METHODS

Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020.

RESULTS

A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study.

CONCLUSIONS

Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa

INTRODUCTION

The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade.

MATERIALS AND METHODS

A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022.

RESULTS

Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed.

CONCLUSIONS

Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.

Management of a Transaxial, Tricompartmental Gunshot Injury in a Low-Resource Tertiary-Care Center in the Anglosphere Caribbean

Trauma, both penetrating and blunt, consists of a significant percentage of surgical admissions in Caribbean hospitals. Due to financial constraints, ideal resources for optimal surgical management are not always available. Despite these disadvantages, successful outcomes for complex, emergent cases are achieved through a combination of timely clinical assessment, intervention, and ingenuity in using the resources at hand. In this case report, we describe a 17-year-old male who suffered major visceral injuries and presented in extremis from a single gunshot wound. While fleeing the scene of a crime, he was shot in his right pelvis, with the projectile exiting his left thorax. Injuries matching a transaxial gunshot trajectory that crossed the diaphragm and involved the pelvic, abdominal, and thoracic cavities were found on exploratory laparotomy. He survived through prompt surgical intervention and aggressive resuscitation during his postoperative intensivist care, a resource often unavailable in this setting. The patient's prognosis would have been guarded even in a developed country setting. This case highlights the potential that Caribbean healthcare institutes possess, and that given an improvement in resources, we can aim to match a developed country's standard of healthcare.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

Abstract

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

Graphical Abstract

Risk factors for posttraumatic empyema in diaphragmatic injuries

Background

Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.

Methods

This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.

Results

We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22–35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18–44) and 17 (10–27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77–23. 43), and visible contamination (OR 5.13, 95% IC 1.26–20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.

Conclusion

The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.

Thoracoabdominal injury with evisceration from a chainsaw assault: a case report

The usual cause of penetrating thoracoabdominal injuries with evisceration are stab wounds with knives and other sharp weapons used during fights and conflicts. Evisceration of the abdominal viscera as a result of trauma, with its attendant morbidity and mortality, requires early intervention. Gunshot wounds can also cause penetrating thoracoabdominal injuries. We report the case of a 52-year-old male patient, a worker at a timber-processing factory, who was assaulted with a chainsaw by his colleague following a disagreement. He was seen at the accident and emergency department of Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria with a thoracoabdominal injury about 1.5 hours after the attack. He had a left thoracoabdominal laceration with abdominal evisceration and an open left pneumothorax. He was managed operatively, made a full recovery, and was discharged 16 days after admission. He was readmitted 4 months after the initial surgery with acute intestinal obstruction secondary to adhesions. He underwent exploratory laparotomy and adhesiolysis. He made an uneventful recovery and was discharged on the 9th postoperative day for subsequent follow-up.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds

BACKGROUND

This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients.

MATERIALS AND METHODS

A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included.

RESULTS

Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013.

DISCUSSION

Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.

Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study

BACKGROUND

Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH.

METHODS

This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality.

RESULTS

There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04).

CONCLUSION

Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level III.

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®

AIM OF THE STUDY

Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated.

METHODS

All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded.

RESULTS

99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries.

CONCLUSION

Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.

An Unusual Case of Homicide by Impalement With a Battering Ram

Impalement injuries occur when a large foreign body traverses or penetrates a body cavity or extremity. Nowadays, impalement injuries are uncommon and are usually a consequence of a fall onto a blunt object or a road accident. The authors report a case of a woman found dead in her apartment, seemingly killed by a firearm injury to the abdomen. However, after the autopsy was carried out, it became clear that the injuries had the features of an impalement. After the inquiry, the murder weapon was identified as a battering ram, used by the robbers to break into the house of the woman. This is the first case ever described in literature where a battering ram has been used to impale someone. This case emphasizes the importance of an accurate description of injuries, also with photographs, in order to achieve effective recognition of the wound patterns as they may correspond to specific and unusual weapons.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

A systematic review of 3251 emergency department thoracotomies: is it time for a national database?

PURPOSE

Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world.

METHODS

Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications.

RESULTS

Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012).

CONCLUSIONS

Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.

Penetrating cardiac trauma: analysis of 240 cases from a hospital in Bogota, Colombia

Background

Trauma characteristics and its management is influenced by socioeconomic context. Cardiac trauma constitutes a challenge for surgeons, and outcomes depend on multiple factors including initial care, characteristics of the wounds, and surgical management.

Methods

This is a retrospective cross-sectional case series of patients with penetrating cardiac injuries (PCI) from January 1999 to October 2009 who underwent surgery in a trauma referral center in Bogotá, Colombia. Demographic variables, trauma characteristics, treatment, and outcomes were analyzed.

Results

The study included 240 cases: 96.2% males, mean age of 27.8 years. Overall mortality was 14.6%: 11.7% from stab wounds and 41.2% from gunshot wounds. Upon admission, 44% had a normal hemodynamic status and 67% had cardiac tamponade. About 32% had Grade II injuries and 29% Grade IV injuries. In 85% of the cases, there were ventricular compromise and 55% of patients had associated lesions. In 150 cases, a pericardial window was performed. Highest mortality occurred in wounds to the right atrium. In tamponade patients, mortality was 20% being higher for gunshot wounds (54.5%) than for stab wounds (18%) (p = 0.0120).

Conclusions

The study evidenced predominance of stab wounds. Based on characteristics of the trauma, patients, and survival rate, there is most likely a high pre-hospitalization mortality rate. The difference in mortality due to stab wounds and those produced by gunshots was more related to technical difficulties of the surgical repair than with the type of injury established by the Injury Grading Scale. Mortality was higher in patients with cardiac tamponade. Surgical management was satisfactory using pericardial window as the diagnostic method and sternotomy as the surgical approach.

Trauma and critical care III: chest trauma

Patients requiring intensive care for chest trauma are often severely injured and may have suffered trauma elsewhere. The single largest cause of significant blunt chest trauma is road traffic accidents (RTAs). RTAs account for 70-80% of such injuries. Falls and acts of violence are other causative mechanisms. Blast injuries can also result in significant blunt thoracic trauma. Penetrating chest trauma comprises a broad spectrum of injuries and severity. Particular challenges occur in patients with associated polytrauma, as well as those with a combination of blunt and penetrating chest trauma. Chest injury is the most important injury in polytrauma patients with reported incidences of 45-65% and an associated mortality of up to 60%. The treatment of these patients can be prolonged and the initial injury may become of secondary importance to the effects of systemic inflammatory response syndrome, acute lung injury (ALI), nosocomial infection and intercurrent multiorgan dysfunction syndrome (MODS). Multiply-injured patients with thoracic injuries require significantly longer periods of mechanical ventilation and longer intensive care unit lengths of stay compared with nonthoracic injury trauma patients. The use of a variety of therapeutic interventions may have to be considered during management of the disease process.

Basic data underlying clinical decision-making and outcomes in emergency department thoracotomy: tabular review

BACKGROUND

Emergency department thoracotomy (EDT) is a formidable and dramatic last attempt by the trauma surgeon to save the life of a patient in extremis. The aim of this report is to provide a benchmark for comparison with past results by reviewing all available published data since the American College of Surgeons Committee on Trauma review article in 2001, which reviewed literature from 1966 to 1999 regarding indications for and outcomes of EDT.

METHODS

A comprehensive literature search in MEDLINE Library databases was performed for EDT. Data were extracted by three independent reviewers.

RESULTS

We identified 37 papers with a total of 3466 patients. A total of 85.2% (1720 of the 2018) had penetrating trauma, 58.3% (372 of the 638) had cardiac injuries, 43.0% (251 of the 584) had thoracic injuries and 26.2% (143 of the 546) had abdominal injuries. The overall rate survival in this review was 8% (267 of the 3466, range 0-33.3%). Of 25 papers reporting cases of EDT for penetrating traumas, their survival rate was 9.8% (169 of the 1719, range 0-45.5); similarly, of 14 papers assessing EDT for blunt injuries, the survival rate was 5.2% (24 of the 460, range 0-12.2). Of 15 papers reporting neurological outcomes 84.6% (143 of the 169, range 50-100%) of patients returned to baseline. The survival outcome of EDT in US experience versus non-US experiences was 6.3% (164 of the 2612, range 0-14.9) versus 11.9% (89 of the 745, range 0-33.3) respectively.

CONCLUSION

The authors intend this review to serve as a practical and prompt literature search tool for all surgeons who encounter resuscitative thoracotomy in their practice.

[Blunt and penetrating trauma the abdomen: retrospective analysis of 175 cases and review of literature]

Les traumatismes abdominaux sont relativement fréquents mais graves dans les pays en développement. Le but de cette étude était de décrire les aspects épidémiologiques, diagnostiques, thérapeutiques et évolutifs des contusions et plaies pénétrantes de l'abdomen prises en charge dans un pays à faibles ressources. Patients et méthodes: Il s'agissait d'une étude rétrospective et descriptive de 2 ans (2011-2012) ayant colligé 175 cas de traumatisés abdominaux au CHU-JRA Tananarive Madagascar. Parmi ces blessés (144 hommes et 31 femmes), il existait 122 vivants (69,7%) et 53 décès (30,3%) avant tout geste thérapeutique hospitalier. Les étiologies étaient dominées par les accidents à responsabilité civile (52,5%) et de la voie publique (38,5%). Les contusions et plaies pénétrantes représentaient respectivement 41,8% et 58,2%. Parmi les blessés vivants, 112 ont été opérés (91,8%). L’évolution hospitalière était favorable dans 94,3%. Quatre patients avaient des suites opératoires compliquées (3,6%). Sept patients étaient décédés (5,7%). Parmi les décès préhospitaliers, nous avons observé 73,6% de polytraumatisme (n = 39) et 26,4% de traumatismes abdominaux isolés (n = 14). A l'autopsie, les lésions abdominales étaient hémorragiques dans 94,3% incluant des plaies vasculaires rétropéritonéales, des ruptures hépatospléniques et des traumatismes graves du bassin. En situation précaire, les traumatismes abdominaux ont une mortalité préhospitalière assez importante. A l'hôpital, l’évolution était généralement favorable au prix d'un acte opératoire invasif.

[Penetrating injury of two body cavities with a 20 cm long dagger-like sliver after falling into a glass door]

In Germany the numbers of penetrating thoracic injuries are rare compared to Anglo-American countries; however, the number of cases has increased in recent years due to an increase in violent incidents. This article reports the case of a patient who suffered such a penetrating thoracic injury after a domestic accident. Operative treatment was performed according to the well-established standard treatment algorithms. Contrary to the initial assessment of the emergency doctor, substantially more severe injuries were found.

Penetrating trauma

Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.

An elusive bullet in the gastrointestinal tract: a rare case of bullet embolism in the gastrointestinal tract and a review of relevant literature

Bullet embolism within the gastrointestinal system is extremely rare. Such bullet injuries are infrequently covered in the general literature, but the surgeon should be aware of the phenomenon. Smaller caliber bullets are more common in civilian gunshot wound (GSW) events. These bullets are able to tumble through the gastrointestinal tract and cause perforation of the intestinal lumen which is small enough to be easily missed. Bullets retained in the abdominal cavity should not be dismissed as fixed and should be carefully monitored to ensure that they do not embolize within the bowel and cause occult lesions during their migration. We present a unique case wherein a bullet caused a minute perforation in the small bowel, before migrating to the distal colon, which resulted in late presentation of sepsis secondary to peritonitis.

Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma

BACKGROUND

An occult cardiac injury may be present in patients with an acute abdomen after penetrating thoracoabdominal trauma. This study assessed the use of a subxiphoid pericardial window (SPW) as a diagnostic manoeuvre in this setting.

METHODS

This was a retrospective review of a trauma database (2001-2009). Patients presenting with a penetrating thoracoabdominal injury with an acute abdomen, and in whom there was concern about a potential cardiac injury from the site or tract of the injury, were included.

RESULTS

Fifty patients with an indication for emergency laparotomy underwent a SPW for a possible cardiac injury. An occult haemopericardium was present at SPW in 14 patients (28 per cent) mandating, median sternotomy. Nine cardiac injuries (18 per cent) were identified including five tangential injuries and four perforations. The specific complication rate relating to the SPW was 2 per cent.

CONCLUSION

The SPW is a useful technique at laparotomy to identify cardiac injuries in patients with penetrating thoracoabdominal injuries.

[Management of penetrating abdominal trauma: what we need to know?]

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.

Difficult decisions in the surgical care of military casualties with major torso trauma

Testing and difficult decision-making is a sine qua non of surgical practice on military operations. Better pre-hospital care protocols, reduced evacuation timelines and increased scrutiny of outcome have rightfully emphasised the requirement of surgeons to "get it right, first time and every time" when treating patients. This article addresses five contentious areas concerning severe torso trauma, with relevant literature summarised by a subject matter expert, in order to produce practical guidance that will assist the newly deployed surgeon in delivering optimal clinical outcomes.

Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study

INTRODUCTION

Non-invasive systolic blood pressure (SBP) measurement is a commonly used triaging tool for trauma patients. A SBP of <90mmHg has represented the threshold for hypotension for many years, but recent studies have suggested redefining hypotension at lower levels. We therefore examined the association between SBP and mortality in penetrating trauma patients.

METHODS

We conducted a prospective cohort study in adult (≥16 years) penetrating trauma patients. Patients were admitted to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The main outcome measure was the association between SBP and mortality at 30 days. Multivariate logistic regression models adjusted for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality were used.

RESULTS

3444 patients with a median age of 30 years (IQR 22.5-41.4), SBP of 126mmHg (IQR 107-142), ISS of 9 (IQR 9-14) and GCS of 15 (IQR 15-15), were analysed. Multivariable logistic regression analysis adjusted for age, gender, severity of injury and level of consciousness showed a cut-off for SBP at <110mmHg, after which increased mortality was observed. Compared with the reference group with SBP 110-129mmHg, mortality was doubled at SBP 90-109mmHg, was four-fold higher at 70-89mmHg and 10-fold higher at <70mmHg. SBP values ≥150mmHg were associated with decreased mortality.

CONCLUSION

We recommend that penetrating trauma patients with a SBP<110mmHg are triaged to resuscitation areas within dedicated, appropriately specialised, high-level care trauma centres.

Ballistic thoracoabdominal injury: analysis of recent military experience in afghanistan

BACKGROUND

Military surgery has seen the arrival of the critical care provision and cross-sectional imaging enjoyed by civilian trauma surgeons. Ballistic injury to the thoracoabdominal region is uncommon but potentially devastating. The aim of this study was to analyze recent military experience of managing this injury complex.

METHODS

The study is a retrospective analysis of patients, admitted over a 12-month period, to the British Military Hospital in Afghanistan with ballistic thoracoabdominal injuries.

RESULTS

In total, 27 patients sustained combined thoracoabdominal injury with a mean new injury severity score of 29±12, revised trauma score of 5.94±2.93 and predicted survival of 71.1%±39.1%. In all, 20 (74%) patients underwent immediate operation, and 7 (26%) were initially managed nonoperatively. Of those requiring surgery, 11 required laparotomy and tube thoracostomy, and 9 required thoraco-laparotomy. Of the seven casualties who were initially observed and/or further investigated, two required laparotomy following computed tomography scanning, and five were managed conservatively, two of whom required delayed surgery. There were nine fatalities, all within 16 days of being wounded. Four patients died from exsanguination, one from a traumatic brain injury, and four from multiorgan failure. Five patients presented with cardiac arrest, two of whom survived.

CONCLUSIONS

Exploration remains the default treatment. Resuscitative thoracotomy may yield unexpected survivors, even if subsequent laparotomy is required. Nonoperative management appears to be feasible in a small proportion of patients but requires careful selection supported by cross-sectional imaging.

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center

BACKGROUND

Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality.

METHODS

A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded.

RESULTS

A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 9.33 (range, 15–54) years. The mean LOS was 10.65 8.30 (range, 5–65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 9.92 days; stab wound, 8.76 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 36.702 mm Hg) compared with those who survived (83.96 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality.

CONCLUSION

Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.

Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

INTRODUCTION

In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.

METHODS

All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.

RESULTS

Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.

CONCLUSION

Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.

Operational critical care. Intensive care and trauma

Trauma management involves good prehospital, emergency, surgical, anaesthetic and intensive care decision-making. Optimal outcome depends on keeping abreast of the latest thinking in an ever-changing and increasingly technology-rich environment. The intensive care unit needs to represented as early as possible in the damage-control resuscitation phase. Improved trauma system care has resulted in an increasing number of multiply injured military patients surviving their initial trauma. These patients require intensive care and are at risk from sepsis and multiple organ failure. Attention to detail is important, preservation of organ function, infection control and nutrition to maintain muscle strength allowing normal metabolic function to return. Multiply injured patients often require lengthy periods of mechanical ventilation and a variety of therapeutic interventions may have to be considered during management of the disease process. As we are now seeing more survivors in the military trauma system the focus now needs to be morbidity reduction in order for these survivors to be best prepared for their rehabilitation phase of care.

A civilian perspective on ballistic trauma and gunshot injuries

BACKGROUND

Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities.

METHODS

A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed.

RESULTS

Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference.

CONCLUSION

The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.

Incidence of postoperative acute renal failure among violence-related cardiovascular trauma patients: a review of our experience in 117 cases

BACKGROUND

The purpose of this retrospective study was to determine the incidence of renal failure and hemodialysis (HD) in postoperative period after cardiovascular surgery associated with trauma.

METHODS

One hundred and seventeen cases of violence-related cardiovascular trauma patients had emergent surgery between 1996 and 2009. Cases were reviewed in three main groups: Cardiac trauma in 11 patients (Group A), vascular trauma in 78 patients (Group B), and cardiovascular trauma in 28 patients (Group C). Postoperative incidence of HD requirements with acute renal failure (ARF) was investigated in these groups of patients postoperatively.

RESULTS

Multiorgan deficiency developed in 10 patients from Group A, in 45 patients from Group B, and in 26 patients from Group C. Overall mortality was 81 cases in 117 patients. Total hospitalization periods were 21 +/- 2, 17 +/- 3, and 27 +/- 1 days for Group A, Group B, and Group C, respectively. HD administrations were indicated in 3 patients in Group A, 41 patients in Group B, and 9 patients in Group C. No statistically significant difference presented in any study parameter between groups.

CONCLUSIONS

Cardiovascular trauma is a common reason for emergent cardiovascular surgery. Postoperative renal failure occurs among these patients in a wide percentage. We strongly advocate a close and detailed follow-up of renal functions in these patients during the hospitalization period and immediate HD at indication.

Ultrasound in trauma

Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. Assessment of the basic haemodynamic state is a very important part of ultrasound use in trauma, but is discussed in more detail elsewhere. Focussed assessment with sonography for Trauma (FAST) rapidly assesses for haemoperitoneum and haemopericardium, and the Extended FAST examination (EFAST) explores for haemothorax, pneumothorax and intravascular filling status. In regional trauma, ultrasound can be used to detect fractures, many vascular injuries, musculoskeletal injuries, testicular injuries and can assess foetal viability in pregnant trauma patients. Ultrasound can also be used at the bedside to guide procedures in trauma, including nerve blocks and vascular access. Importantly, these examinations are being performed by the treating physician in real time, allowing for immediate changes to management of the patient. Controversy remains in determining the best training to ensure competence in this user-dependent imaging modality.

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile

INTRODUCTION

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent.

PATIENTS AND METHODS

We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury.

RESULTS

Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis.

CONCLUSION

Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.

Surgical management of penetrating pulmonary injuries

Chest injuries were reported as early as 3000 BC in the Edwin Smith Surgical Papyrus. Ancient Greek chronicles reveal that they had anatomic knowledge of the thoracic structures. Even in the ancient world, most of the therapeutic modalities for chest wounds and traumatic pulmonary injuries were developed during wartime.

The majority of lung injuries can be managed non-operatively, but pulmonary injuries that require operative surgical intervention can be quite challenging. Recent progress in treating severe pulmonary injuries has relied on finding shorter and simpler lung-sparing techniques. The applicability of stapled pulmonary tractotomy was confirmed as a safe and valuable procedure.

Advancement in technology have revolutionized thoracic surgery and ushered in the era of video-assisted thoracoscopic surgery (VATS), providing an alternative method for accurate and direct evaluation of the lung parenchyma, mediastinum, and diaphragmatic injuries.

The aim of this article is to describe the incidence of the penetrating pulmonary injuries, the ultimate techniques used in its operative management, as well as the diagnosis, complications, and morbidity and mortality.

Factors affecting mortality and morbidity after traumatic diaphragmatic injury

PURPOSE

We review our 11-year experience of treating diaphragmatic injury (DI), to identify the factors determining mortality and morbidity.

METHODS

We analyzed the effects of demographic characteristics, type of injury (blunt or penetrating), number of injured organs, injury severity score (ISS), revised trauma score (RTS), Glasgow coma score, and intensive care unit and hospital stay, on complications and mortality, in 51 patients treated for DI between January 1995 and December 2005.

RESULTS

Twenty-six (51%) patients suffered blunt injury and 25 (49%) suffered penetrating injury. The left diaphragm was injured in 40 (78%) patients, the right in 10 (19%), and both sides in 1 (2%). Only three (5.8%) patients had no concomitant injury. The diagnosis was made by the findings of laparotomy on 34 patients (65%), preoperative chest X-ray on 13 (25%), computed tomography on 2 (3.9%), and laparoscopy on 2 (3.9%). Complications developed in 23 (44%) patients and overall mortality was 19.6% (10/51). An ISS > 13 was found to be an independent prognostic factor for morbidity, whereas an RTS < or = 11, age > or = 48 years, and a major postoperative complication were independent prognostic factors for mortality.

CONCLUSION

Establishing a preoperative diagnosis of DI is still problematic. Aggressive treatment and close monitoring of patients with an ISS > 13, an RTS < or = 11, an age > or = 48 years, or a postoperative complication may decrease morbidity and mortality.

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.

Clinician-performed focused sonography for the resuscitation of trauma

Traumatic death remains pandemic. The majority of preventable deaths occur early and are due to injuries or physiologic derangements in the airway, thoracoabdominal cavities, or brain. Ultrasound is a noninvasive and portable imaging modality that spans a spectrum between the physical examination and diagnostic imaging. It allows trained examiners to immediately confirm important syndromes and answer clinical questions. Newer technologies greatly increase the fidelity, accessibility, ease of use, and informatic manipulation of the results. The early bedside use of focused ultrasound as the initial imaging modality used to detect hemoperitoneum and hemopericardium in the resuscitation of the injured patient has become an accepted standard of care. Widespread dissemination of basic ultrasound skills and technology to facilitate this brings ultrasound to many resuscitative and critical care areas. Although not as widely appreciated, the focused use of ultrasound may also have a role in detecting hemothoraces and pneumothoraces, guiding airway management, and detecting increased intracranial pressure. Intensivists generally utilize a treating philosophy that requires the real-time integration of many divergent sources of information regarding their patients' anatomy and physiology. They are therefore positioned to take advantage of focused resuscitative ultrasound, which offers immediate diagnostic information in the early care of the critically injured.

EMERGENCY THORACIC SURGERY FOR PENETRATING, NON-MEDIASTINAL TRAUMA

BACKGROUND

Penetrating thoracic injury is commonly found in South Africa. A review of our recent experience was undertaken to assess the effectiveness of our protocols for this type of injury.

METHODS

A retrospective study of 61 consecutive patients with penetrating, non-mediastinal trauma to the chest was conducted over 32 months at a single trauma unit. Patient details, mechanism of injury, operative procedure and in-hospital mortality and morbidity rates were recorded.

RESULTS

Two thousand and nineteen patients presented with penetrating chest injury of which 61 patients (3%) underwent thoracic surgery for non-mediastinal injury. Twenty-six patients had stab wounds and 35 had gunshot wounds. Overall mortality was 17/61 (28%). Gunshot wounds were more likely to result in death than stab wounds (relative risk = 11.9; 95% confidence interval 1.7-84.0) and thoracoabdominal injury resulted in death more commonly than chest injury (relative risk = 4.8; 95% confidence interval 2.2-10.3) resulted in death.

CONCLUSION

Penetrating chest injury is common and most patients can be managed without formal thoracic surgical intervention. However, the patients who do merit surgical intervention have a relatively high mortality and a rapid and practised operative approach is required to achieve acceptable results.

Hemothorax Related to Trauma

Management of hemothoraces related to trauma follows basic tenets well-respected by both trauma and cardiothoracic surgeons. In most, a nonoperative approach is adequate with a defined group of patients requiring only tube thoracostomy. It is only in a true minority of individuals that operative intervention is necessary. In blunt thoracic injuries, the underlying organ damage may be the more life-threatening process, not the presence or absence of a hemothorax. For both blunt and penetrating injuries, the presence of retained hemothorax is well-treated by early intervention with thoracoscopic techniques, shown to decrease hospital stay and costs. Controversial areas including the use of prophylactic antibiotics, sequence of operative intervention in patients with combined thoracoabdominal trauma, and the use of emergency department thoracotomy, remain a challenge but recent literature can serve to guide the clinician.