Isolated abdominal trauma: diagnosis and clinical management considerations

Comparison of Clinical Characteristics, Therapy, and Short-Term Prognosis between Blunt and Penetrating Abdominal Trauma: A Multicentric Retrospective Cohort Study

Objective

Large-scale studies on the characteristics and management of abdominal trauma in megacities in China are lacking. The aim of this study was to analyze and present the clinical patterns and treatment status of abdominal trauma in regional medical centers.

Methods

Cases of abdominal trauma treated at seven medical centers in Beijing from 2010 to 2021 were collected. Clinical information about age, sex, injury cause, geographic distribution, abbreviated injury scale/injury severity score (AIS/ISS) value, injury-hospital time, preoperative time, surgically identified organ injuries, type of surgery, causes of reoperation and 90-day mortality was included in this study. Clinical characteristics, treatment methods, and short-term prognoses (90-days survival) were compared between blunt abdominal trauma (BAT) and penetrating abdominal trauma (PAT) cases. Non-normally distributed data are described as medians (IQR), and the Mann‒Whitney U test was performed; qualitative data were analyzed using the X2 test. Univariate and multivariate survival analyses were performed by the Cox proportional hazards model.

Results

A total of 553 patients (86.98% male) with a median age of 36.50 (27.00-48.00) years were included. The BAT group had a significantly higher proportion of serious injury (P=0.001), lower initial hemoglobin level (P=0.001), and a lower laparoscopy surgery rate (P=0.044) compared to the PAT group. Additionally, more BAT cases were from the area around Beijing (P=0.008) and a longer injury-regional hospital time (10.47 (5.18-22.51) hours vs. 7.00 (3.80-15.38) hours, P=0.001). In the hollow viscus injury subgroup, the BAT group had a significantly longer injury-regional hospital time and preoperative time compared to the PAT group (injury-regional hospital time: 10.23 (6.00-21.59) hours vs. 7.07 (3.99-13.85) hours, P=0.002; preoperative time: 3.02 (2.01-5.58) hours vs. 2.81 (1.85-3.63) hours, P=0.047). The overall 90-day mortality was 11.9%, and longer injury-regional hospital time (HR: 1.01, 95% CI: 1.00-1.02, P=0.008), receipt of ICU treatment (HR: 4.69, 95% CI: 2.54-8.65, P=0.001), and severe ISSs (ISS > 25 vs. ISS < 16, HR: 2.78, 95% CI: 1.38-5.601, P=0.004) had a worse impact on survival.

Conclusion

More patients with BAT were transferred to higher-level hospital, leading to significantly longer prehospital and preoperation time. In the subgroup of hemodynamically stable individuals, more patients with BAT experienced hollow viscus injuries. For those patients, aggressive diagnostic laparoscopic exploration may be beneficial. Patients with longer injury-regional hospital intervals, the need for ICU care, and higher injury severity scores (ISSs) suffered from worse prognoses.

Temporal-spatial organ response after blast-induced experimental blunt abdominal trauma

Abdominal trauma (AT) is of major global importance, particularly with the increased potential for civil, terroristic, and military trauma. The injury pattern and systemic consequences of blunt abdominal injuries are highly variable and frequently underestimated or even missed, and the pathomechanisms remain still poorly understood. Therefore, we investigated the temporal-spatial organ and immune response after a standardized blast-induced blunt AT. Anesthetized mice were exposed to a single blast wave centered on the epigastrium. At 2, 6, or 24 h after trauma, abdominal organ damage was assessed macroscopically, microscopically, and biochemically. A higher degree of trauma severity, determined by a reduction of the distance between the epigastrium and blast inductor, was reflected by a reduced survival rate. The hemodynamic monitoring during the first 120 min after AT revealed a decline in the mean arterial pressure within the first 80 min, whereas the heart rate remained quite stable. AT induced a systemic damage and inflammatory response, evidenced by elevated HMGB-1 and IL-6 plasma levels. The macroscopic injury pattern of the abdominal organs (while complex) was consistent, with the following frequency: liver > pancreas > spleen > left kidney > intestine > right kidney > others > lungs and was reflected by microscopic liver and pancreas damages. Plasma levels of organ dysfunction markers increased during the first 6 h after AT and subsequently declined, indicating an early, temporal impairment of the function on a multi-organ level. The established highly reproducible murine blunt AT, with time- and trauma-severity-dependent organ injury patterns, systemic inflammatory response, and impairment of various organ functions, reflects characteristics of human AT. In the future, this model may help to study the complex immuno-pathophysiological consequences and innovative therapeutic approaches after blunt AT.

Factores asociados a sepsis abdominal en pacientes con laparotomía por trauma abdominal penetrante

Introducción. Los pacientes que sufren algún tipo de trauma tienen una presentación clínica muy variable, por lo que se han diseñado pautas diagnósticas y terapéuticas con el fin de disminuir el número de laparotomías innecesarias. Las herramientas actuales para la predicción de infección intraabdominal, permiten intervenciones tempranas en los pacientes con alto riesgo y un mejor seguimiento clínico posoperatorio. El objetivo de este trabajo fue realizar un estudio de los factores asociados al desarrollo de las infecciones intraabdominales o sepsis abdominal posterior a laparotomía por trauma penetrante. Métodos. Estudio descriptivo de una cohorte de pacientes atendidos por trauma abdominal penetrante en el Hospital Universitario de Santander, Bucaramanga, Colombia, entre enero de 2016 y diciembre de 2018. El análisis de datos se realizó en el software Stata®, versión 14 (StataCorp. LP, College Station, TX, USA). Resultados. Se incluyeron 174 pacientes con edad media de 32 años, el 10,9 % (n=19) de los pacientes presentaron sepsis abdominal, de este grupo el 94,7 % (n=18) requirieron reintervención quirúrgica (p < 0,0001). La mortalidad general del grupo fue de 5,1 % (n=9), sin diferencia significativa entre los pacientes con o sin sepsis abdominal. Discusión. Dentro de los diferentes desenlaces asociados a laparotomía por trauma, se describe la sepsis abdominal como una de las complicaciones que genera morbilidad significativa, con aumento en la estancia hospitalaria, necesidad de reintervención, aumento en los costos de atención y disminución en la calidad de vida, factores en concordancia con los hallazgos del presente estudio.

The bridge stenting-based internal drainage in pancreatic trauma patients with main pancreatic duct injury

Pancreatic trauma is associated with high mortality and morbidity, especially in main pancreatic duct (MPD) injuries. Here, we introduce a novel technique via the placement of bridge stenting-based internal drainage (BSID) along the injured MPD to restore pancreatic tissue integrity. Twelve patients with MPD injury underwent unobstructed BSID as physical support for healing. Six patients with peripheral organ injuries underwent operative end-to-end anastomosis of the MPD by using a polyurethane central venous catheter for the BSID, and the other six patients with isolated proximal MPD rupture received BSID via endoscopic pancreatic stent placement. The BSID technique was successfully performed in all pancreatic trauma patients without the need for a second open surgery. With this simplified BSID-based operation, a short procedure duration (242.7 ± 38.71 min in the surgical group and 100.2 ± 16.24 min in the endoscopic group) and a short hospital stay (13.0 ± 7.05 days) were achieved. However, a few complications (41.67%) still occurred, including pancreatitis, fistula, abscess, pseudocyst, cholangitis, and haemorrhage. Except for the deceased case, all postoperative courses were marked by decreases in the peripancreatic fluid collection, blood amylase recovery, and normal endocrine function. The BSID approach is a feasible surgical approach for the treatment of MPD injury and can be used endoscopically in isolated MPD injuries for its safety and convenience.

A Legal and Forensic Medicine Approach to Police Physical Intervention Techniques in High-Risk Situations

Background: The physical intervention techniques (PITs) typically used by the police in troublesome situations are examined in terms of injuring potential depending on whether they target a body zone of high, medium or low vulnerability. Based on legal and forensic considerations, and principles of congruence, opportunity and proportionality, a need exists to favor opponent locking and arrest techniques targeting non-vulnerable zones to minimize the risk of severe damage. Methods: A search of the training manuals for the different kind of law of enforcement officers was carried out. Revision of injuries was available from electronic databases of academic o medical journals. Results: Three different locking and arrest PITs based on operational tactical procedures (OTP) that avoid zones of high or medium vulnerability are proposed. The new techniques use blocking, diverting and grabbing of the upper and lower limbs, followed by dislocation and locking of the same targets. Conclusions: The damaging potential of such PITs was assessed in terms of anatomical region and most were found to have a high risk of severe damage. The alternative PITs proposed here, which rely on OTP, improve in legal and forensic medical terms on existing choices and dramatically reduce the risk of injuring arrestees.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery

BACKGROUND

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes.

METHODS

Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com.

RESULTS

Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid.

CONCLUSIONS

Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications.

LEVEL OF EVIDENCE

III (Retrospective therapeutic study and systematic literature review).