Abdominal injuries associated with penetrating trauma in the lower chest

Criminal death by stabbing in the region of Kairouan, Tunisia: A retrospective study, 2008-2018

INTRODUCTION

Homicides by stabbing are the most common forensic form of criminal death in Tunisia. These homicides represent a type of violent death that requires investigation in a forensic setting.

AIM

To describe the epidemiological and forensic profile of stab wounds in the region of Kairouan, Tunisia Methods: We conducted a retrospective study of stab-wounds autopsy cases collected at the Forensic Department at the Ibn El Jazzar University Hospital in Kairouan over eleven years (01/01/2008 to 31/12/2018).

RESULTS

Forty-seven cases of homicide were retained. A male predominance was observed with a sex ratio of 22 (45H/2F, 96%). The mean age of the victims was 33.3±10.84 with ages ranging from 12 to 63 years. Most victims (79%) were of rural origin, singles (62%), and daily-laborers (89%). The months that recorded the highest numbers of homicides were November and August. The most common reason for the assault was a settling-score on the street. The perpetrator was known by the victim in 90% of cases, having used a knife as a weapon in 90% of cases. The thorax was the most frequently affected area, resulting in fatal heart wounds in 28 cases.

CONCLUSION

Autopsy remains an essential tool for drawing up a detailed injury assessment in homicides by stabbing and determining the injury mechanism of the wounds. The comparison of the autopsy findings with the data of the judicial investigation is of great help in the legal qualification of the facts and the determination of the responsibility of the aggressors.

Abdominal Trauma Revisited

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

Sudden Death in an Adult Due to Nontraumatic Diaphragmatic Hernia

Sudden death due to diaphragmatic hernia in an adult is exceptionally rare. A 43-year-old man was found dead by his cohabiting mother, lying supine on the floor in his house. He had complained of epigastric discomfort for 1 month, and respiratory symptoms occurred 1 day before his death. He had no history of trauma. Postmortem computed tomography scan revealed the enlarged fluid-filled stomach herniated into the left pleural cavity, compressing the left lung with a mediastinal shift to the right. At autopsy, the left pleural cavity was occupied by herniated abdominal contents with mediastinal shift. The herniation of the stomach, the whole spleen, a portion of the colon, and omentum into the left pleural cavity had occurred through a smooth oval 9 × 5-cm defect in the posterolateral part of the light diaphragm. The stomach was markedly distended and contained 1600 mL of yellowish brown liquid with food residue. Ischemic changes of the herniated organs were not observed. Death was attributed to respiratory failure from abdominal viscera herniation into the left pleural cavity.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

INTRODUCTION

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France.

METHODOLOGY

Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis.

RESULTS

One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM.

CONCLUSION

Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Current technology: laparoscopic surgery in trauma

There has been a rapid increase in the use of laparoscopy in general surgery over recent years. However in the field of trauma its role has not been defined and its regular use remains limited to a select group of enthusiasts. We present a review of the current literature on laparoscopic surgery in trauma including therapeutic procedures and a brief synopsis of the alternative methods of investigation for abdominal injury, and our interpretation of the current role of laparoscopic surgery in trauma today.

Colorectal trauma

The management of traumatic injuries to the colon and rectum has undergone a significant change since World War II. Penetrating injuries are the most common cause of trauma to the colon and rectum. Colon and rectal perforation after blunt trauma are uncommon but not rare. For years, colostomy formation was considered the only acceptable form of treatment for injuries penetrating the colonic mucosa. With the realization that dictums governing colonic injuries during military conflicts were, for the most part, not applicable to civilian injuries, the pendulum has swung from mandatory colostomy to immediate repair in the management of uncomplicated cases. Accompanying these changes in management together with improvement in perioperative care, trauma service and the use of more powerful antibiotics, a significant reduction of mortality rates to less than 5% has been seen in many centres. In the presence of other risk factors, for example multiple associated injuries, severe shock, Penetrating Abdominal Trauma Index (PATI) of more than 25, colostomy is still an option to be considered.

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.

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.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Delayed traumatic diaphragmatic hernias presenting with strangulation

Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.

Gunshot Wounds of Abdomen: Evaluation of Stable Patients with Triple-Contrast Helical CT

PURPOSE

To assess helical computed tomography (CT) with contrast material administered intravenously, orally, and rectally (triple contrast helical CT)) in the prospective evaluation of stable patients with abdominal gunshot wounds in whom there is no clinical indication for immediate exploratory laparotomy.

MATERIALS AND METHODS

The study was conducted for 19 months. All patients met the following inclusion criteria: age of 16 years or older, hemodynamic stability, no clinical signs of peritoneal irritation, and signed consent to participate. Patients with obvious indications for laparotomy, such as gastrointestinal bleeding or evisceration, were excluded from the study. Forty-seven patients fulfilled the criteria and underwent abdominal triple-contrast helical CT. CT findings were evaluated by one of four radiologists for evidence of peritoneal penetration and injury to solid organs or hollow viscera. Patients were followed up clinically for 13 weeks. CT findings were compared with those at surgery and/or clinical follow-up.

RESULTS

CT demonstrated abnormalities in 27 (57%) patients. Laparotomy was performed in 11 (23%) patients; 10 procedures were therapeutic and one was nontherapeutic. The remaining 20 patients had a negative CT scan. These patients were treated conservatively. One injury was missed at CT. For prediction of the need for laparotomy, sensitivity of CT was 96%; specificity, 95%; positive predictive value, 96%; negative predictive value, 95%; and accuracy, 96%.

CONCLUSION

In stable patients with gunshot wounds to the abdomen in whom there is no indication for immediate surgery, triple-contrast helical CT can help reduce the number of cases of unnecessary or nontherapeutic laparotomy (negative laparotomy) and can help identify patients with injuries that may be safely treated without surgery.

Laparoscopy in the Evaluation of Penetrating Thoracoabdominal Trauma

The evaluation of penetrating thoracoabdominal trauma for the presence of a diaphragmatic injury presents a diagnostic challenge to the trauma surgeon. The use of diagnostic laparoscopy (DL) in this setting was reviewed at a level-one trauma institution. Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. This subset of patients underwent a mandatory celiotomy to rule out an associated intra-abdominal injury. Seventeen out of 22 (77.2%) patients had a positive exploration requiring surgical intervention, representing an associated intra-abdominal injury rate of 21.2 per cent. Intra-abdominal injuries requiring repair included small bowel, colon, spleen, liver, and stomach, in descending order. There were no missed injuries or deaths. One patient with a left diaphragmatic injury secondary to a stab wound developed a subdiaphragmatic abscess. Respiratory insufficiency secondary to atelectasis was the most common complication. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoracoabdominal trauma.

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

The aims of this study were to (1) define characteristics for the thoracoabdominal injury patient population; (2) describe sequences of surgical interventions with combined procedures (i.e., thoracotomy and laparotomy); and (3) describe pitfalls leading to inappropriate sequencing of surgical interventions for thoracoabdominal injuries. It was a retrospective 4-year study (January 1995 to December 1998) conducted at an urban level I trauma center. The study population comprised 254 patients who had sustained thoracoabdominal injuries requiring surgical intervention: 187 (73%) gunshot wounds (GSWs), 64 (25%) stab wounds (SWs), and 3 (2%) shotgun wounds (STWs). The mean revised (RTS) was 6.04; the mean Injury Severity Score (ISS) was 27; the mean estimated blood loss (EBL) was 3000 ml. The overall survival was 175 of 254 (69%). Of the 254, 51 (20%) underwent emergency department (ED) thoracotomy. Altogether, 73 (29%) underwent combined thoracotomy and laparotomy: 59 (81%) GSW, 13 (18%) SW, 1 (1%) STW (mean RTS 5.2, mean ISS 34, mean EBL 6800 ml). Overall survival was 30 of these 73 (41%). A total of 21 of the 73 (29%) underwent ED thoracotomy. In group I (laparotomy then thoracotomy: Lap + Thor, n = 34) the initial procedure was interrupted in 18 (53%). In group II (thoracotomy then laparotomy: Thor + Lap, n = 39) the initial procedure was interrupted in 14 (36%). Pitfalls leading to inappropriate surgical sequencing were persistent hypotension (13/73, 18%) and misleading chest tube output (8/73, 10%). It was concluded that penetrating thoracoabdominal injuries incur high mortality (31%), and the mortality doubles for patients who require combined procedures (59%). Inappropriate surgical sequencing occurred in 32 of 73 (44%) patients undergoing combined procedures. Persistent hypotension, indicating that the wrong cavity was accessed, and misleading chest tube output are the leading pitfalls in thoracoabdominal injury management.

Penetrating chest injuries in the firearm era

BACKGROUND

firearm wounds of the chest are now common at our institution. The management algorithm for firearm wounds has not been evaluated for this mode of injury.

METHODS

records of all patients with penetrating chest injuries admitted to an urban tertiary hospital over 1 year were retrieved and analysed.

RESULTS

there were 473 stab and 116 firearm wounds. In comparison to stab injuries firearm wounds had significantly more normal X-rays (14 vs. 5%), fewer pneumothoraces (15 vs. 37%), and more contusions (43 vs. 2%). The frequency of haemothoraces (34 vs. 23%) and haemopneumothoraces (36 vs. 35%) was similar in both groups. Stabbing caused all the 18 cardiac injuries. Associated abdominal injuries occurred in 8% of stab and 34% of firearm injuries. Pneumothoraces due to firearms were uncommon and rarely required drainage. More pneumothoraces were treated nonoperatively among firearm injuries in contrast to stabbing injuries where the opposite applied. The management of haemothorax and haemopneumothorax was similar in both groups that fulfilled the criteria for drainage. The rate of ICU admission was higher and the hospital-stay longer following firearm injuries. Fifty-nine patients died (10% of the total), 33 (28%) from the firearm injuries and 26 (6%) from stab-wounds. Early deaths were 1 and 3% for stabs and firearms, respectively.

CONCLUSIONS

patients with firearm injuries reaching hospital suffered three times higher mortality and a longer ICU and hospital stay than those with stab injuries. However, early mortality was similar for both modes of injury and validates the continued application of the stab wound derived management algorithm to all modes of injury.

Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries

BACKGROUND

The diagnostic workup in stable patients with penetrating thoracoabdominal injuries can be extremely difficult. Conventional diagnostic tests such as plain chest radiography, computed tomography scan, digital exploration, and diagnostic peritoneal lavage can be misleading. Classically, most of these patients have undergone exploratory laparotomy to determine whether there is a diaphragmatic injury.

METHODS

In this study, 52 patients with penetrating thoracoabdominal trauma, and without any indication for immediate surgery, underwent video-assisted thoracoscopy to determine the presence of diaphragmatic injuries.

RESULTS

Of the 52 patients, 48 were men. The left hemithorax was involved in 38 patients (73%). Chest x-ray was normal in 40 patients (77%) who were clinically asymptomatic. Stab wounds were responsible for 80% of the injuries. At the time of the thoracoscopy, 35 patients (67%) were found to have a diaphragmatic injury. All 35 diaphragmatic injuries were successfully repaired thoracoscopically. The procedure was completed in 50 patients (96%). There were no deaths or complications.

CONCLUSIONS

The incidence of diaphragmatic injuries is higher than anticipated in asymptomatic patients with penetrating thoracoabdominal wounds. Video thoracoscopy can be used as a safe, expeditious, minimally invasive, and extremely useful technique to facilitate the diagnosis of these injuries in asymptomatic patients. Furthermore, diaphragmatic injuries can be repaired easily through a thoracoscopic approach with no complications.

Non-operative treatment of abdominal gunshot injuries

BACKGROUND

Non-operative treatment is a management option that challenges the traditional mandatory laparotomy for abdominal gunshot injuries.

METHODS

All published relevant clinical reports were retrieved by searching through the Medline database and manually. The theoretical arguments in favour of non-operative management as well as the results of the reviewed reports are analysed and evaluated.

RESULTS AND CONCLUSION

Patients with proven non-penetration of the abdominal cavity can be offered conservative treatment with a satisfactory outcome. Greater caution should be exercised in the presence of a documented visceral injury until the safety of this option has been established by further clinical trials.

Imaging of penetrating thoracic trauma

The management of penetrating chest injuries has evolved significantly over the past few years, with an increasing emphasis on less invasive diagnostic and therapeutic modalities. Only 15% of patients need a therapeutic operative procedure. The challenge is to detect and treat these injuries rapidly while maximizing the use of noninvasive examinations and decreasing costs. The areas potentially at risk for injury include the heart, major vessels, thoracoabdomen, neck, spine, and aerodigestive tract. A review of injuries to these areas, including the use of new diagnostic modalities such as echocardiography and computed tomography (CT) scans, are discussed.

Surgical embryology and anatomy of the diaphragm with surgical applications

This article reviews the development, surgical anatomy, and teratology of the diaphragm, and discusses the diagnostic procedures, surgical therapy, and prognosis of congenital disturbances. Special attention is paid to the traumatic rupture of the diaphragm, concerning incidence, cause, diagnosis, prognosis, and surgical repair.

Ferimentos penetrantes tóraco-abdominais e de tórax e abdome: análise comparativa da morbidade e mortalidade pós-operatórias

Analisamos 145 doentes portadores de ferimentos penetrantes tóraco-abdominais e de tórax e abdome, operados no Serviço de Emergência da Santa Casa de São Paulo de julho de 1987 a fevereiro de 1996, sendo 72 (49,7%) produzidos por arma branca e 73 (50,3%) por projétil de arma de fogo. Foram estudados fatores relacionados à ocorrência de complicações pós-operatórias (pleuropulmonares, abdominais e sistêmicas), ao prolongamento do tempo de permanência hospitalar e à mortalidade ocorrida durante a internação. Caracterizamos os doentes quanto a sua gravidade, através da aplicação de índices objetivos de trauma, tanto fisiológico (RTS) quanto anatômicos (ISS, PATI, PTTI e PTI). Tanto nos ferimentos tóraco- abdominais quanto de tórax e abdome, o tratamento de escolha foi a drenagem pleural associada à laparotomia exploradora. Os ferimentos tóraco-abdominais apresentaram maior incidência de complicações em geral, em relação aos de tórax e abdome, quando a variável controle foi o ferimento produzido por arma branca. A análise por tipo de complicação mostrou que essa diferença foi dada pelo empiema pleural. Não encontramos diferença significante entre esses ferimentos com relação às demais complicações pleuropulmonares infecciosas, abdominais e sistêmicas. Os fatores que se correlacionaram com a evolução para empiema foram: o tipo de órgão lesado (estômago, esôfago e reto), a presença de fístula digestiva, o ferimento produzido por arma branca e a presença de lesão diafragmática. O prolongamento do tempo de permanência hospitalar foi determinado pela ocorrência de complicações e não pela lesão diafragmática. Houve doze (8,3%) mortes no estudo, sendo que a mortalidade correlacionou-se com maior média de lesões orgânicas por doente, com as lesões de rim, grandes vasos e esôfago, com a ocorrência de complicações especialmente de natureza infecciosa e com o ferimento produzido por projétil de arma de fogo. A análise dos nossos resultados permitiu concluir que os ferimentos penetrantes tóraco-abdominais apresentam maior número de lesões orgânicas por doente quando comparados aos ferimentos de tórax e abdome (sem lesão diafragmática), mas esses ferimentos não diferem quanto à mortalidade pós-operatória. Com relação à morbidade, a lesão diafragmática não foi fator determinante do prolongamento do tempo de permanência hospitalar e, na comparação dos ferimentos tóraco-abdominais e de tórax e abdome, a lesão diafragmática produzida por arma branca foi fator determinante do aparecimento de empiema pleural.

Penetrating thoracoabdominal trauma

Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.

Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries

OBJECTIVE

The objective of this study was to (1) determine the incidence of diaphragmatic injuries in penetrating left thoracoabdominal trauma and (2) evaluate the role of laparoscopy in detecting clinically occult diaphragmatic injuries.

PATIENTS AND METHODS

One hundred nineteen consecutive patients with penetrating injuries to the left thoracoabdominal region presenting to Los Angeles County-University of Southern California Medical Center were prospectively evaluated during an 8-month period. Either celiotomy (with hemodynamic instability or peritonitis) or laparoscopy was performed. Results of the clinical examination and roentgenographic findings were recorded preoperatively.

RESULTS

One hundred seven patients were fully evaluated. Fifty patients required emergent celiotomy. Fifty-seven patients underwent laparoscopy. The overall incidence of diaphragmatic injuries was 42% (59% for gunshot wounds, 32% for stab wounds). Among the 45 patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had a normal chest roentgenogram, and 49% had an associated hemopneumothorax. Fifteen of the patients undergoing laparoscopy (26%) had occult diaphragm injuries.

CONCLUSION

(1) The incidence of diaphragmatic injuries in association with penetrating left thoracoabdominal trauma is high. (2) The clinical and roentgenographic findings are unreliable at detecting occult diaphragmatic injuries. (3) Laparoscopy is a vital tool for detecting occult diaphragmatic injuries among patients who have no other indications for formal celiotomy.

A method of determining peritoneal penetration in gunshot wounds to the abdomen

BACKGROUND

It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA.

METHODS

DPL was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoracoabdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL was 10,000 red blood cells (RBC)/mm3. A prospective data base was kept with information on the location of the wound, DPL result, findings at laparotomy, and outcome.

RESULTS

During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/mm3. Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm3, 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication (n = 7) or by uneventful inpatient observation for 24 hours (n = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively.

CONCLUSION

For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.

Management of 240 cases of penetrating thoracic injuries

We present a review of 240 patients with penetrating thoracic injuries seen in a period of 10 years at a general university hospital in Lima, Peru. The majority of the patients were young males who suffered stab wounds (76.2 per cent). The most frequent symptoms were thoracic pain (N = 202) and dyspnoea (N = 138); and the commonest physical findings were diminished respiratory sounds (N = 192) and tachypnoea (N = 167). Haemopneumothorax (N = 92), haemothorax (N = 81) and pneumothorax (N = 59) were the most frequent lesions. Cardiac lesions were present in 11 patients. The commonest extrathoracic associated lesions was penetrating abdominal injury (N = 43). The majority of the patients only required tube thoracostomy as definitive therapy (N = 143). There were 31 thoracotomies and 54 laparotomies. The most frequent complications were respiratory (N = 34) and neurological (N = 8). Gunshot wounds were more destructive than stab wounds. The first group of patients had a longer hospital stay (11.7 and 7.25 days), longer time with tube thoracostomy (5.98 and 4.18 days), more injured abdominal organs (3.8 and 2.38 organs) and higher mortality (7.01 per cent and 3.82 per cent) than the second group. The overall mortality was 4.58 per cent. The patients with a cardiac lesion had a higher mortality (27.27 per cent) than those who did not (3.49 per cent).

Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest

The role of thoracoscopy in assessing the status of the diaphragm in penetrating knife wounds of the left lower chest was studied prospectively in 55 patients. Those with positive thoracoscopic findings (n = 22) proceeded to exploratory laparotomy and those with an uninvolved diaphragm (n = 32) were observed. Thoracoscopy was inconclusive in one patient and two were lost to follow-up. With operative findings or 30-month follow-up data as evaluation endpoints, thoracoscopy in 52 patients was 100 per cent sensitive, 90 per cent specific and 94 per cent accurate. A projected negative laparotomy rate of 63 per cent would have occurred with a policy of mandatory laparotomy; using thoracoscopy the actual rate was 6 per cent. Thoracoscopy is a safe and reliable method of evaluating the diaphragm in patients with left lower thoracic stab wounds.

Objective determination of the optimal red blood cell count in diagnostic peritoneal lavage done for abdominal stab wounds

The purpose of this study was to determine objectively the optimal value or positivity criterion for red blood cell counts in diagnostic peritoneal lavage in stab wounds to the anterior abdomen. Our study group consisted of 91 consecutive adults with abdominal stab wounds who underwent peritoneal lavage. We excluded those patients who met criteria for immediate laparotomy and those with negative stab wound exploration. We divided the patients into two groups based on outcome. Group 1 consisted of those who had undergone laparotomy and had findings that required surgical intervention. Group 2 patients had either undergone laparotomy but had no injury requiring surgical intervention or had no surgery and a benign hospital course and follow-up. Receiver operator characteristic analysis was done on the diagnostic peritoneal lavage RBC counts for both groups. The overlap between the groups was minimal, with 75% of patients in Group 1 having > 120,000 RBC/mm3 and 75% of patients in Group 2 having < 486 RBC/mm3 in the lavage effluent. Using the observed probability of 23.1% of patients with abdominal stab wounds requiring surgery, a RBC count of 50,000/mm3 discriminated best those patients who required surgery from those who did not.

Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for suspected penetrating abdominal stab wounds

Thirty-five patients with abdominal stab wounds in whom clinical examination was equivocal on 2 separate occasions underwent diagnostic peritoneal lavage (DPL) prior to laparotomy. The red and white blood cell counts (cells/mm3) of the lavage effluent were compared with the operative findings. There were 26 positive and 9 unnecessary laparotomies, the latter consisting of 4 negative and 5 non-therapeutic operations. Use of the standard quantitative criteria for red cells in DPL failed to identify significant injury in eight patients (31%), while the standard white cell count missed six injuries (23%). Their combined use resulted in three missed injuries (12%). Two false-positive results occurred using the red cell count alone and four using the white cell count alone, producing a combined false-positive result in four patients (11%). Reducing the cell threshold level to exclude missed injuries would increase dramatically the rate of unnecessary laparotomies. Although the standard quantitative criteria for DPL are superior to clinical assessment in patients with equivocal findings, their use in penetrating trauma does not achieve the same diagnostic accuracy as in blunt abdominal trauma.

Small bowel injuries

Small bowel injuries are becoming more commonplace. Difficult to diagnose and treacherous when missed, small bowel injuries should be searched for assiduously in all patients at risk. Use of DPL or CT scanning, coupled with a low threshold for exploration, improves the diagnosis and treatment of small bowel injuries. A delayed diagnosis results in a progressive septic insult and markedly increased mortality. Early diagnosis is the key. After addressing life-threatening problems, the operation should include a thorough and systematic exploration to identify all injuries. Sound surgical technique includes debridement of nonviable tissue, restoration of small bowel continuity, generous irrigation, and placement of enteral feeding catheters. By adhering to the preceding principles and by exercising meticulous postoperative care and maintaining a low threshold to reoperate, catastrophic complications can be avoided.

Delayed traumatic diaphragmatic hernia simulating acute tension pneumothorax

The diagnosis of acute diaphragmatic injury is difficult to establish in the immediate posttraumatic period. Patients with delayed diaphragmatic herniation frequently present months to years after the initial injury with manifestations of visceral incarceration, obstruction, ischemia from strangulation, or perforation. Patients with diaphragmatic herniation presenting with clinical tension pneumothorax are rare. We describe the case of a 23-year-old female who 16 weeks following a stab wound to the low chest presented with this clinical picture caused by herniation of abdominal viscera into the chest. A review of this entity and methods of discovery of delayed traumatic diaphragmatic herniation are described.

Penetrating wounds to the posterior chest: analysis of exigent thoracotomy and laparotomy

Most reports of penetrating chest wounds include all regions of the thoracic wall. Recent studies of abdominal wounds stratified by entrance site have demonstrated significant differences in injury pattern that influence initial assessment and management. This is an analysis of 135 consecutive patients admitted to the Denver General Hospital with penetrating injuries to the posterior chest, done in an effort to elucidate operative indications. Fifteen of these patients required emergency department (ED) thoracotomy and were excluded from the study. In the remaining 120 patients, mechanism was gunshot (GSW) in 20% and stab wound (SW) in 80%; 89% were men, and the mean age was 26 years. For analysis, the posterior chest was further divided into upper and lower at the inferior tip of the scapula line. Overall, 28 patients (23%) with posterior penetrating chest wounds required early surgical intervention; 38% following a GSW compared to 20% due to a SW. Only 9 patients (8%) required thoracotomy while 19 (15%) underwent laparotomy. The most frequent indication for thoracotomy was persistent chest hemorrhage, and for laparotomy, positive diagnostic peritoneal lavage.

Colorectal trauma

Colorectal injury remains a source of significant morbidity and mortality. Gunshot and stab wounds are the most common etiologic agents. Diagnosis is usually established on clinical grounds. For the purposes of management, the large bowel can be considered as colon and rectum. Minor colon injuries can be repaired primarily; management of major colon injuries or injuries associated with multiple organ involvement, significant blood loss, or massive contamination should be individualized. Diversion or exteriorization remains the gold standard of treatment when there is any doubt. Rectal injury should be repaired when feasible and diverted and the presacral space drained. Distal rectal washout is of proven merit. Antibiotics provide an important adjunct to therapy. They should be initiated early (preoperatively), ended quickly (12 to 72 hours postoperatively), and provide a broad spectrum of coverage. The treatment of established infection should be guided by bacterial culture. Postoperatively, aggressive support is important for a good outcome. The significant incidence of complications even in the face of optimal management demands continued vigilance and aggressive intervention by the operating surgeon.

Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients

From July 1983 through December 1987, 300 consecutive patients with penetrating gunshot wounds of the abdomen causing visceral or vascular injuries were treated. Resuscitative thoracotomy was required in 20 patients (6.6%), and only two survived. The most commonly injured organs were the small bowel (60%), colon (41.6%), liver (29.3%), vascular structures (24.6%), stomach (17.3%), and kidney (17.0%). The overall survival rate for the series was 88.3%; however, if only the 226 patients without vascular injuries are considered, the survival rate was 97.3%. In the 35 patients who died, the blood pressure on admission was 51 mmHg, 18 required a resuscitative thoracotomy, four visceral or vascular injuries were present, and the median blood replacement was 18 units. The cause of death was perioperative shock in 30 patients (85.7%), whereas five patients (14.3%) died of sepsis and multiple organ failure. The most common postoperative complication in survivors and patients who died later in the study was an intra-abdominal abscess (3.0%). Rapid conservative operative techniques for civilian gunshot wounds leads to few postoperative complications and an excellent survival rate, especially if vascular injuries are not present.

Management of stab wounds to the thoracoabdominal region. A clinical approach

We studied 324 patients admitted to Harlem Hospital Center from July 1981 to June 1986 with stab wounds of the thoracoabdominal region (area limited by a coronal circle through the fifth interspaces anteriorly and seventh interspaces posteriorly from above to a subcostal circle 5 cm caudad to the costal margins and 12th ribs from below). We divided this region into 12 zones (six symmetrical zones on each side) using the above upper and lower limits and the costal margins, the midlines, and the anterior and posterior axillary lines. This study was conducted to determine the incidence of transdiaphragmatic penetration for the thoracoabdominal region stab wounds in each of the 12 zones identified for the first time and applied in this study, and the reliability and safety of surgical management based mainly on physical examination. The highest incidence of transdiaphragmatic penetration occurred in stab wounds of the left anterior lower thoracic zone (21.7%). The lowest incidence was 0% and the overall incidence was 11%. Physical examination was accurate in making the diagnosis in 95.4% of all cases and no mortality was associated with a delay in diagnosis that may have resulted from the serial physical examinations. We conclude that this method of selective operative management based on physical examinations is accurate and safe.

Penetrating wounds to the anterior chest. Analysis of thoracotomy and laparotomy

This study of the records of 193 consecutive patients admitted for penetrating anterior chest wounds was carried out to specifically define the need for emergent thoracotomy or laparotomy. The mechanism of injury was a stab wound in 119 patients and a gunshot wound in 74 patients. Seventy-three of the patients (38 percent) required either early thoracotomy (21 percent) or laparotomy (17 percent). In the upper chest region, 83 percent of the operations were thoracotomies, whereas in the lower chest region, 81 percent were laparotomies. Pericardial tamponade, chest tube output, and hypovolemic shock comprised 91 percent of the decisive signs for thoracotomy. The predominant reason for laparotomy was diagnostic peritoneal lavage (63 percent of patients). Plain abdominal roentgenograms were helpful to confirm diaphragmatic missile traverse. Our findings support selective operative management of anterior chest wounds as guided by injury mechanism and entrance location.

Delayed presentation of traumatic diaphragmatic hernia

More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.4 years. Seven injuries were on the left side; one was on the right side. The mechanism of injury was equally divided between penetrating and blunt trauma. Chest roentgenographic abnormalities were seen in all patients. Visceral reduction and diaphragmatic repair, despite strangulation in four patients, was accomplished without mortality and with minimal morbidity. Delayed presentation of TDH is reviewed, emphasizing diagnostic features encountered in the emergency department (ED).

Five hundred open taps or lavages in patients with abdominal stab wounds

From 1980 to 1984, 500 asymptomatic patients with anterior abdominal stab wounds found to have penetrated the anterior peritoneal cavity on local wound exploration in the emergency center were evaluated by the technique of open peritoneal tap, quantitative diagnostic peritoneal lavage, or both. The technique was found to have several advantages, including earlier diagnosis of intraperitoneal visceral injuries in asymptomatic patients and a significant lowering of the incidence of unnecessary celiotomies in a busy county hospital. Also, it was extremely cost-effective. The major disadvantages were the number of false-positive results of taps and lavages based on red blood cell counts of more than 100,000/mm3, all of which resulted from bleeding from abdominal wall stab wound sites. An accuracy rate of approximately 91 percent was maintained throughout the period of the study, whereas there were only 1.8 false-negative results of lavage per year. Local wound exploration coupled with open peritoneal tap and diagnostic peritoneal lavage is recommended as a rapid, safe, and cost-effective technique for the evaluation of large numbers of asymptomatic patients who present with anterior abdominal stab wounds.