Blunt abdominal injuries. Diagnostic peritoneal lavage, ultrasonography and computed tomography scanning

Diagnostic Peritoneal Aspiration or Lavage in Stratified Groups of Hypotensive Blunt Trauma Patients

BACKGROUND

Some reports suggest Diagnostic peritoneal aspiration (DPA) or lavage (DPL) may better select which hypotensive blunt trauma patients (BTPs) require operation, compared to ultrasonography. However, whether both moderately hypotensive (systolic blood pressure [SBP] < 90 mmHg) and severely hypotensive (SBP < 70 mmHg) patients benefit from DPA/DPL is unclear. We hypothesized DPA/DPL used within the first hour increases risk of death for severely vs moderately hypotensive BTPs.

METHODS

The 2017-2019 Trauma Quality Improvement Program database was queried for BTPs ≥ 18 years old with hypotension upon arrival. We compared moderately and severely hypotensive groups. A multivariable logistic regression analysis was performed controlling for age, comorbidities, emergent operation, blood transfusions, and injury profile.

RESULTS

From 134 hypotensive patients undergoing DPA/DPL, 66 (49.3%) had severe hypotension. Patients in both groups underwent an emergent operation (43.9% vs 58.8%, P = .09) in a similar amount of time (median, 42-min vs 54-min, P = .11). Compared to the moderately hypotensive group, severely hypotensive patients had a higher rate and associated risk of death (84.8% vs 50.0%, P < .001) (OR 5.40, CI 2.07-14.11, P < .001). The strongest independent risk factor for death was age ≥ 65 (OR 24.81, CI 4.06-151.62, P < .001).

DISCUSSION

Among all BTPs undergoing DPA/DPL within the first hour of arrival, an over 5-fold increased risk of death for patients with severe hypotension was demonstrated. As such, DPA/DPL within this group should be used with caution, particularly for older patients, as they may be better served by immediate surgeries. Future prospective research is needed to confirm these findings and elucidate the ideal DPA/DPL population in the modern era of ultrasonography.

Evaluation of blunt abdominal trauma: current practice in Taiwan

OBJECTIVE

To gain an overview of the current practice of different major institutions in Taiwan in the evaluation of abdominal injuries. A further comparison was made between general surgeons and emergency physicians in this aspect.

METHOD

A telephone survey was conducted of all emergency departments of 58 major institutions (14 medical centres, 44 district hospitals) that are capable of providing definitive care for trauma victims in Taiwan in June 2002. Respondents were asked to select the diagnostic modality of choice in the evaluation of a haemodynamically abnormal blunt trauma victim with suspected intra-abdominal injuries. In the same study period, this particular telephone scenario was also used to survey 109 individual doctors (45 emergency physicians, 64 general surgeons).

RESULTS

Most respondents preferred ultrasound (also known as focused assessment with sonography for trauma or "FAST") instead of diagnostic peritoneal lavage (DPL) because DPL is invasive and most doctors in Taiwan have limited experience in performing DPL or interpreting the results.

CONCLUSIONS

It seems reasonable to devote greater resources for emergency departments to incorporate a FAST based algorithm into their initial management of trauma victims, and to improve training in its use. It is also suggested that future ATLS teaching in Taiwan should include didactic material on FAST.

Pancreatic trauma in the adult: current knowledge in diagnosis and management

BACKGROUND/AIMS

Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment.

METHODS

The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience.

RESULTS

The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple's procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory.

CONCLUSION

Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Traumatic 'degloving' of the colon in blunt abdominal injury

We describe two cases of traumatic 'degloving' of the colon in blunt abdominal trauma. This is an extremely rare injury with the potential to present late. The mechanism of injury appears to be a combination of focal blunt abdominal trauma associated with a shearing force. The potential diagnostic dilemma posed by colonic 'degloving' is outlined and following review of the literature we conclude that CT scanning is the most reliable way of detecting such injuries, if emergency laparotomy is not indicated.

Detection of pneumoperitoneum by ultrasound examination: an experimental and clinical study

PURPOSE OF THE STUDY

The aim of the study is to show the value and reliability of ultrasound examination in detecting free intraabdominal air after blunt abdominal trauma.

METHODS

The experimental part of this study includes the evaluation of the sonographic morphology of air within liquid and solid tissues. Subsequently air was injected into the abdominal cavities of 10 cadavers and sonography utilized for localization and assessment of the minimal detectable air volume. The clinical part of the study reports on the sonographic detection of hollow viscus perforation in 10 patients, who were admitted to our institution because of acute abdominal problems.

RESULTS

Sonography is a reliable method for the diagnosis of free intraabdominal air. Best position for ultrasound examination of the abdomen is supine with the thorax slightly elevated (10-20 degrees). The optimal probe position is in the right paramedian epigastric area in the longitudinal direction. In all the 10 patients we were able to diagnose pneumoperitoneum preoperatively by ultrasound assessment.

The emerging role of bedside ultrasonography in trauma care

Ultrasonography has emerged as a primary imaging modality in the evaluation of the trauma victim. Both emergency physicians and surgeons have been proven capable of performing this rapid, noninvasive evaluation of the chest and abdomen. This article describes the trauma ultrasound examination and illustrates how bedside ultrasonography can be incorporated into routine trauma care.