Avoiding cavity surgery in penetrating torso trauma: the role of the computed tomography scan

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.

Diagnostic utility of CT for abdominal injury in the military setting: A systematic review and meta-analysis

BACKGROUND

It is critical to accurately identify patients with abdominal injury who truly need to undergo laparotomy during the war in timely fashion. The diagnostic utility of computed tomography (CT) for evaluating abdominal injury in the military setting remains uncertain.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. Meta-analyses were performed by using a random-effect model. We pooled the area under the summary receiver operating characteristic curves with standard errors, the Q indexes with standard errors, the sensitivities with 95% confidence intervals (CIs), the specificities with 95% CIs, the positive likelihood ratios with 95% CIs, the negative likelihood ratios with 95% CIs, and the diagnostic odds ratios with 95% CIs. The heterogeneity among studies were evaluated by the I2 and P value.

RESULTS

Overall, 5 retrospective studies were included. The area under the summary receiver operating characteristic curve was 0.9761 ± 0.0215 and the Q index was 0.9302 ± 0.0378. The pooled sensitivity was 0.97 (95% CI = 0.92-0.99) without a significant heterogeneity among studies (I2 = 0%, P = .4538). The pooled specificity was 0.95 (95% CI = 0.93-0.97) with a significant heterogeneity among studies (I2 = 90.6%, P < .0001). The pooled positive likelihood ratio was 10.71 (95% CI: 2.91-39.43) with a significant heterogeneity among studies (I2 = 89.2%, P < .0001). The pooled negative likelihood ratio was 0.07 (95% CI = 0.02-0.27) with a significant heterogeneity among studies (I2 = 57.5%, P = .0516). The pooled diagnostic odds ratio was 177.48 (95% CI = 18.09-1741.31) with a significant heterogeneity among studies (I2 = 75.9%, P = .0023).

CONCLUSION

Diagnostic accuracy of CT for abdominal injury is excellent in the military setting. Further work should explore how to shrink CT equipment for a wider use in wartime.

Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making

Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.

The medical and operational impact of the deployment of a scanner within Role 2 in Mali for the French army

INTRODUCTION

According to the NATO classification, the difference between Role 2 and Role 2+ is the presence of extra diagnostic and therapeutic means, including the deployment of a scanner. The aim of this study is to analyze the impact of this deployment at the front, in the Gao French Role 2 (Mali). Our main hypothesis is that the presence of a scanner at the front improves the servicemen's diagnostic and therapeutic management abilities. Secondly that scanner holds strategic relevance by limiting the repatriation of servicemen on medical grounds.

MATERIALS AND METHODS

A prospective analytical observational study was conducted over 6 months within Gao's Role 2. All the French military patients who received a scanner were involved. The collected data was epidemiological, clinical and radiological in nature, and included the results from the scanner and data regarding the operational impact (repatriation). The principal judgment criterion was the rate of modification of the therapeutic decision. The secondary criterion was the modification of the repatriation decision on medical grounds.

RESULTS

Of the 45 patients examined, in 14 cases (31.1%), performing a scanner changed patients' therapeutic management in relation to the management, which would have been conducted in the scanner's absence. For 12 of these patients (85.7%), the indication of the scanner concerned visceral or cranium-spine pathologies. For 33 patients (73.3%), the scanner enabled diagnosis via the elimination of an organic injury or a severity criterion. The repatriation decision remained unchanged for many patients.

DISCUSSION

The scanner appears to be a significant factor in the initial therapeutic decision. Scanning made it possible to clarify the diagnosis and to better adapt the initial therapeutic decision. In contrast, the operational impact was null. The literature highlights the relevance of scanner in surgical abstention (limiting unnecessary operative procedures), and for the visceral, cranium-cerebral and spine pathologies in an emergency.

CONCLUSION

The scanner, a heavy logistic unit deployed within a forward surgical unit, holds therapeutic relevance for French servicemen's management with an important medical service provided for the therapeutic choices, although its operational impact has yet to be demonstrated.

Thoracic trauma now and then: A 10 year experience from 16,773 severely injured patients

Background and purpose

Thoracic trauma remains to be a relevant injury to the polytraumatised patient. However, literature regarding how far changes in clinical guidelines for pre- and in-hospital trauma management and diagnostic procedures affect the outcome of multiple injured patients with severe chest injury during a long-term observation period is sparse.

Methods

Multiple traumatised patients (age≥16y) documented in the TraumaRegister DGU^® (TR-DGU) from January 1^st 2005 to December 31^st 2014 with severe chest trauma (AIS≥3) were included in this study. Demographic data, the pattern of injury, injury severity, radiographic emergency procedures, indication for intubation, duration of mechanical ventilation, emergency surgery, occurrence of complications and mortality were evaluated per year and over time.

Results

A total of 16,773 patients were analysed. The use of whole body computer tomography increased (p<0.001), while the incidence of plain x-rays decreased (p<0.001). Furthermore, incidence of AIS_Thorax = 3 graded injuries increased (p<0.001) while AIS_Thorax = 4 decreased (p<0.001). Both, rate of patients being intubated at the time of ICU admission decreased (p<0.001) and the time of mechanical ventilation decreased (p<0.001). Additionally, need for emergency surgery, lung failure, sepsis, and multi organ failure all decreased (p<0.001). However, mortality remained unchanged.

Interpretation

Severity of severe chest trauma and associated complications decreased while diagnostics and treatment improved over time. However, mortality remained unchanged. Our results are in line with those expected in the context of the incidence of CT diagnostics, which has increased parallel to the clinical outcome Thus, our data demonstrate a positive trend in the treatment of patients with severe chest trauma.

Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma

OBJECTIVE

To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts.

BACKGROUND

FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan.

METHODS

Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management.

RESULTS

A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%.

CONCLUSIONS

FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury

PURPOSE

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

METHODS

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

RESULTS

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

CONCLUSIONS

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.

Pneumoperitoneum without visceral trauma: an under-recognised phenomenon after blast injury?

OBJECTIVES

The management of patients who have sustained blast injuries poses an important challenge for military healthcare professionals. Current military operations are generating large numbers of casualties and modern military healthcare facilities are increasingly using CT scanning to facilitate their management. This small case series serves to draw attention to a rare (or possibly under-reported) phenomenon after blast injury.

METHODS AND RESULTS

We report two patients exposed to blast who had pneumoperitoneum identified by CT scan but who did not have abdominal visceral injury or ballistic peritoneal violation.

DISCUSSION

The use of cross-sectional imaging is leading to the recognition of otherwise occult injury. Military practitioners should be aware of this injury pattern when using CT to help select patients for conservative management after abdominal blast injury.

Extravasated contrast material in penetrating abdominopelvic trauma: dual-contrast dual-energy CT for improved diagnosis--preliminary results in an animal model

PURPOSE

To compare the diagnostic performance of dual-energy (DE) computed tomography (CT) with two simultaneously administered contrast agents (hereafter, dual contrast) with that of conventional CT in the evaluation of the presence and source of extravasation in penetrating abdominopelvic trauma.

MATERIALS AND METHODS

Institutional animal care and use committee approval was obtained, and the study was performed in accordance with National Institutes of Health guidelines for the care and use of laboratory animals. Five rabbits with bowel trauma, vascular penetrating trauma, or both were imaged with simultaneous iodinated intravenous and bismuth subsalicylate enteric contrast material at DE CT. Four attending radiologists and six radiology residents without prior DE CT experience each evaluated 10 extraluminal collections to identify the vascular and/or enteric origin of extravasation and assess their level of diagnostic confidence, first with virtual monochromatic images simulating conventional CT and then with DE CT material decomposition attenuation maps.

RESULTS

Overall accuracy of identification of source of extravasation increased from 78% with conventional CT to 92% with DE CT (157 of 200 diagnoses vs 184 of 200 diagnoses, respectively; P < .001). Nine radiologists were more accurate with DE CT; one had no change. Mean confidence increased from 67% to 81% with DE CT (P < .001).

CONCLUSION

In a rabbit abdominopelvic trauma model, dual-contrast DE CT significantly increased accuracy and confidence in the diagnosis of vascular versus enteric extravasated contrast material.

Utility of admission physiology in the surgical triage of isolated ballistic battlefield torso trauma

BACKGROUND

An assessment of hemodynamic stability is central to surgical decision-making in the management of battlefield ballistic torso trauma (BBTT).

AIMS

To analyse the utility of admission physiological parameters in characterising hemodynamic stability.

SETTINGS AND DESIGN

A retrospective analysis of consecutive admissions, with BBTT, to forward surgical facility in Afghanistan.

MATERIALS AND METHODS

The cohorts' admission physiology, need for operative intervention, and mortality data were collected retrospectively. The cohort was divided into patients requiring surgery for Life-Threatening Torso Hemorrhage (LTTH) and those not requiring immediate surgery (non-LTTH).

STATISTICAL ANALYSIS

Parameters were compared using two sample t tests, Mann-Whitney, Fisher's exact, and Chi-square tests. Receiver operator characteristic curves were used to identify significant parameters and determine optimum cut-off values.

RESULTS

A total of 103 patients with isolated BBTT were identified: 44 in the LTTH group and 59 in the non-LTTH group. The mean New Injury Severity Score ± Standard Deviation (NISS±SD) was 28±14 and 13±12, respectively. The heart rate, systolic blood pressure (SBP), pulse pressure, shock index (SI=heart rate/SBP) and base excess were analysed. SI correlated best with the need for surgical torso hemorrhage control, P<0.05. An optimal cut-off of 0.9 was identified, producing a positive and negative predictive value of 81% and 82%, respectively.

CONCLUSIONS

Shock index (SI) is a useful parameter for helping military surgeons triage BBTT, identifying patients requiring operative torso hemorrhage control. SI performance requires a normal physiological response to hypovolemia, and thus should always be considered in clinical context.

Use of imaging in trauma decision-making

Damage Control Radiology describes the process where imaging aids the decision making process in a trauma setting and is an important part of Damage Control Surgery and Resuscitation. This article outlines how radiology fits in to the primary and secondary surveys and discusses the role of imaging modalities such as ultrasound and CT. The importance of deployed radiology to aid rapid diagnosis and decision making is described.

Critical decision-making and timelines in the emergency department

The resuscitation of severely injured patients has evolved during the last decade. Patients are now surviving injuries that previously were thought to be unsurvivable. Systems have been put in place, that reflect the intensity of workload and severity of injury of patients presenting to deployed medical treatment facilities. This paper aims to describe some of the elements that may differ from routine practice in the resuscitation room, and in particular the role of timelines in the management of such patients.

Abdominal trauma in primary blast injury

BACKGROUND

Blast injury is uncommon, and remains poorly understood by most clinicians outside regions of active warfare. Primary blast injury (PBI) results from the interaction of the blast wave with the body, and typically affects gas-containing organs such as the ear, lungs and gastrointestinal tract. This review investigates the mechanisms and injuries sustained to the abdomen following blast exposure.

METHODS

MEDLINE was searched using the keywords 'primary blast injury', 'abdominal blast' and 'abdominal blast injury' to identify English language reports of abdominal PBI. Clinical reports providing sufficient data were used to calculate the incidence of abdominal PBI in hospitalized survivors of air blast, and in open- and enclosed-space detonations.

RESULTS

Sixty-one articles were identified that primarily reported clinical or experimental abdominal PBI. Nine clinical reports provided sufficient data to calculate an incidence of abdominal PBI; 31 (3·0 per cent) of 1040 hospitalized survivors of air blast suffered abdominal PBI, the incidence ranging from 1·3 to 33 per cent. The incidence for open- and enclosed-space detonations was 5·6 and 6·7 per cent respectively. The terminal ileum and caecum were the most commonly affected organs. Surgical management of abdominal PBI is similar to that of abdominal trauma of other causes.

CONCLUSION

Abdominal PBI is uncommon but has the potential for significant mortality and morbidity, which may present many days after blast exposure. It is commoner after blast in enclosed spaces and under water.