Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure

BACKGROUND

Primary abdominal compartment syndrome (ACS) is a known complication of damage control. Recently secondary ACS has been reported in patients without abdominal injury who require aggressive resuscitation. The purpose of this study was to compare the epidemiology of primary and secondary ACS and develop early prediction models in a high-risk cohort who were treated in a similar fashion.

METHODS

Major torso trauma patients underwent standardized resuscitation and had prospective data collected including occurrence of ACS, demographics, ISS, urinary bladder pressure, gastric tonometry (GAP(CO2) = gastric regional CO(2) minus end tidal CO(2)), laboratory, respiratory, and hemodynamic data. With primary and secondary ACS as endpoints, variables were tested by uni- and multivariate logistic analysis (MLA).

RESULTS

From 188 study patients during the 44-month period, 26 (14%) developed ACS-11 (6%) were primary ACS and 15 (8%) secondary ACS. Primary and secondary ACS had similar demographics, shock, and injury severity. Significant univariate differences included: time to decompression from ICU admit (600 +/- 112 vs. 360 +/- 48 min), Emergency Department (ED) crystalloid (4 +/- 1 vs. 7 +/- 1 L), preICU crystalloid (8 +/- 1 vs. 12 +/- 1L), ED blood administration (2 +/- 1 vs. 6 +/- 1 U), GAP(CO2) (24 +/- 3 vs. 36 +/- 3 mmHg), requiring pelvic embolization (9 vs. 47%), and emergency operation (82% vs. 40%). Early predictors identified by MLA of primary ACS included hemoglobin concentration, GAP(CO2), temperature, and base deficit; and for secondary ACS they included crystalloid, urinary output, and GAP(CO2). The areas under the receiver-operator characteristic curves calculated upon ICU admission are primary= 0.977 and secondary= 0.983. Primary and secondary ACS patients had similar poor outcomes compared with nonACS patients including ventilator days (primary= 13 +/- 3 vs. secondary= 14 +/- 3 vs. nonACS = 8 +/- 2), multiple organ failure (55% vs. 53% vs. 12%), and mortality (64% vs. 53% vs. 17%).

CONCLUSION

Primary and secondary ACS have similar demographics, injury severity, time to decompression from hospital admit, and bad outcome. 2 degrees ACS is an earlier ICU event preceded by more crystalloid administration. With appropriate monitoring both could be accurately predicted upon ICU admission.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Nonoperative management of solid organ injuries. Past, present, and future

All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. Others likely to benefit from a second look at their injuries include patients with subcapsular hematomas, patients with recognized extravasation on the initial scan, and athletes anxious to return to contact sports. Experience from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons must be diligent in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed manifestations of intestinal disruption. Patients with vascular injuries (grade V injuries to the spleen, liver, or kidney) may be candidates for radiologic procedures, such as angioembolization or stenting, but some of these patients are best served by immediate laparotomy. Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.

The effects of hypothermia and injury severity on blood loss during trauma laparotomy

To assess the relationships between core temperature (T) and other factors relating to operating room (OR) blood loss and mortality following abdominal injury, the records of 122 patients undergoing laparotomy for trauma at Detroit Receiving Hospital over a 1-year period (1989) were reviewed. Most injuries were penetrating (86%) and the mortality rate was 8.2%. Overall, 57 of 122 (47%) had hypothermia (T < or = 35 degrees C) upon arrival in the OR. There was a significant correlation between admission blood pressure and lowest intraoperative temperature (r = 0.60; p < 0.001). Multiple regression analysis revealed that the patient's lowest temperature (p < 0.001) and Trauma Score (TS); p < 0.0015), but not Abdominal Injury Severity Score (AISS) (p = 0.25) correlated with OR blood loss. The 28 patients with high TS (15 or 16) and AISS > or = 9 had significantly less blood loss when the OR temperature was maintained above 35 degrees C versus 33 degrees-35 degrees C (540 +/- 580 mL vs. 1820 +/- 1160 mL; p < 0.003). This suggests that hypothermia may exacerbate OR blood loss independent of degree of physiologic or anatomic injury. Thus hypothermia is common in patients undergoing a laparotomy for trauma. Trauma scores and the presence of shock preoperatively correlate with the development of intraoperative hypothermia. Hypothermic patients with similar injury severity have greater blood loss. Prevention and rapid correction of hypothermia during resuscitation and surgery appear to be extremely important in reducing blood loss in this patient population.

Is computed tomographic grading of splenic injury useful in the nonsurgical management of blunt trauma?

Seventy adult and pediatric patients with blunt splenic injury were managed nonsurgically using previously published clinical criteria without regard to the appearance of the spleen on computed tomographic (CT) scans. Seven patients (10%) who underwent delayed surgery were considered failures of nonsurgical therapy; all recovered after total splenectomy. Two radiologists, blinded to patient outcome, retrospectively reviewed the admission CT scans of all 70 patients and graded them according to three published scoring systems. Higher grades of splenic injury on CT were not associated with an increased risk of failure (Fisher's exact test, p > 0.05). Nine of ten patients with very high scores on each of the scales were successfully managed without surgery; conversely, three patients with very low scores required urgent surgery. An elevated Injury Severity Score significantly increased the risk of failure of nonsurgical management (Chi-square test of trend, p = 0.001). No failures occurred in patients under age 17 years. Our data support the hypothesis that properly selected patients can be safely observed regardless of the magnitude of splenic injury on CT scans. A decision to undergo early exploration should be based on clinical criteria, including the patient's age and associated injuries.

CT cystography in the evaluation of major bladder trauma

Computed tomographic (CT) cystography has been advocated in lieu of conventional cystography in the initial work-up of patients with suspected urinary bladder trauma. CT cystography was applied to a classification scheme for bladder injury based on the degree of wall injury and anatomic location and demonstrated characteristic imaging features for each type of injury. In bladder contusion (type 1), findings are normal. In intraperitoneal rupture (type 2), CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds, and in the paracolic gutters. Manifestations of interstitial injury (type 3) include intramural hemorrhage and submucosal extravasation of contrast material without transmural extension. In extraperitoneal rupture (type 4), the path of extravasated contrast material is variable: Extravasation is confined to the perivesical space in simple extraperitoneal ruptures, whereas in complex extraperitoneal ruptures, contrast material extends beyond the perivesical space and may dissect into a variety of fascial planes and spaces. Combined intra- and extraperitoneal rupture (type 5) usually demonstrates extravasation patterns that are typical for both types of injury. Familiarity with these CT cystographic features allows accurate classification of bladder injury and allows prompt, effective treatment with less radiation exposure than and without the added cost of conventional cystography.

Ct findings in blunt renal trauma

Computed tomography (CT) can provide essential anatomic and physiologic information required to determine management of intraabdominal and retroperitoneal injuries sustained during blunt abdominal trauma. It can help in evaluation of the type and severity of parenchymal injury, the extent of perirenal hemorrhage and parenchymal devascularization, and the presence of urinary extravasation. CT can help confirm the presence of major injuries to the vascular pedicle and depict occult renal pathologic conditions. Principal indications for the use of CT in the evaluation of blunt renal trauma include (a) the presence of gross hematuria, (b) microscopic hematuria associated with shock (systolic blood pressure <90 mm Hg), and (c) microscopic hematuria associated with a positive result of diagnostic peritoneal lavage. The majority of renal injuries sustained during blunt abdominal trauma are contusions and minor parenchymal lacerations amenable to nonoperative management. Deep parenchymal lacerations, urinary extravasation, and mild to moderate degrees of parenchymal devascularization may also be treated conservatively. Radiologists should look for coexisting renal lesions such as tumors and traumatic false aneurysms that may alter management.

Temporary intravenous bag silo closure in severe abdominal trauma

Several temporary abdominal wall closure techniques have been described in the literature. We present our experience with an inexpensive and efficient method of temporary abdominal closure when bowel edema and distension preclude safe primary closure. Our technique is a variation of the silon (silo) closure used in the repair of gastroschisis and omphalocele, using a pre-gas-sterilized, soft 3-L plastic cystoscopy fluid irrigation bag cut to an oval shape and stapled or sutured to the skin edges of the wound.

Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center

PURPOSE

Patients with penetrating trauma often have multiorgan involvement that may complicate the management of any single organ system. Here we review the incidence of associated injuries in patients with penetrating renal trauma and our extended experience treating these patients at a busy inner city trauma center.

MATERIALS AND METHODS

All trauma cases presenting to Temple University Trauma Center during a 6-year period were identified through our institutional databases and were reviewed (5,276). Penetrating trauma represented 41% of all cases (2,163). Of these we identified 123 patients with penetrating renal trauma (5.7%). A total of 93 cases were available for review. Multiorgan injury was staged in the operating room if patients were hemodynamically unstable or radiographically if they were stable. Renal injuries were staged by high dose, single shot excretory urogram in patients taken immediately to surgery or by computerized tomography if stable. Renal injuries were classified using the American Association for Surgery of Trauma (AAST) grading system. AAST classifications were subcategorized for purposes of streamlining. Grade 1 and 2 injuries were grouped as low grade, grades 3 and 4 nonvascular injuries were grouped as intermediate grade, and AAST grade 4 vascular and grade 5 injuries were grouped as high grade. Demographic, clinical and intraoperative variables, as well as number and severity of associated injuries, were then assessed to determine the relationship with various renal surgical outcomes including the requirement of surgical intervention, type of surgical intervention, need for nephrectomy and associated adverse outcomes.

RESULTS

The median age of injured patients was 28 years (range 14 to 80). The majority of victims were male (93%). The mechanism of injury was predominantly gunshot wound (GSW, 86%) while 14% were due to stab wounds. Renal injuries were low grade (19%), intermediate grade (44%) and high grade (37%). Nearly all patients with penetrating renal injury had associated multiorgan injury (94.6%). Associated injuries for penetrating renal trauma on the right side predominately involved the liver, small bowel and vertebra while injury to the left kidney was most often associated with trauma to the stomach, colon and spleen. Patients suffered extensive renal injury as evidenced by the high rate of intraoperative urinomas (30.1%) and hematomas (97.5%) identified. In the absence of an expanding hematoma and/or hemodynamic instability, associated injuries by themselves did not increase the risk of nephrectomy. Despite multiorgan penetrating injury 54% of kidneys were salvageable.

CONCLUSIONS

Isolated penetrating trauma to the kidney is rare. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding hematoma with hemodynamic instability, associated multiorgan injuries did not increase the risk of nephrectomy. With appropriate radiographic and/or surgical staging, it is possible to repair and salvage many of these kidneys despite extensive associated intraabdominal trauma.

Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study

BACKGROUND

The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured.

METHODS

Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant.

RESULTS

The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries.

CONCLUSION

Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.

Grade IV renal injuries: evaluation, treatment, and outcome

Of our last 2483 renal trauma patients, 113 had grade IV injuries. In most the mechanism was a penetrating injury (60%: 30% gunshot, 30% stab wounds). Associated injuries were common (80%) and hospital stays prolonged, averaging 16 days. Most of the patients (70%) required transfusion, some massively (average volume 4.4 liters, range 0-30 liters). Surprisingly, not all patients with grade IV renal injuries had gross hematuria: 25% had microhematuria, and 4% had neither microscopic nor gross hematuria. Computed tomography (CT) diagnosed the injury correctly in 100% of the patients in whom it was performed; when CT was not available, "one-shot" intraoperative intravenous pyelography (IVP) demonstrated grossly abnormal findings in 90%. Renal exploration was performed in 78%, resulting in 69% renorrhaphy and 9% nephrectomy rates in our 113 patients. Almost all those with penetrating trauma required exploration (97%), whereas only 50% of those with blunt trauma did so. The overall complication rate and kidney-specific complication rate did not differ significantly between patients who were observed and those who underwent surgery. Complications rates were similar in grade IV renal laceration patients and grade III patients. Delayed complications after hospital discharge were not seen, although follow-up was rare in this inner-city trauma population. Among the 21% of patients in whom postoperative nucleotide renal function scans were available, function was generally good (average 36%). Only patients who underwent concomitant vascular repair had poor function (below 20%).

Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema

Excessive tension in an abdominal incision line may lead to fascial necrosis and wound sepsis. We utilized two alternative approaches to wound closure in 13 patients with severe abdominal trauma (2 blunt, 11 penetrating) whose midline incision could not be closed primarily without excessive tension at the initial operation because of massive visceral edema. In five patients synthetic mesh was used to bridge the fascial defect. Four patients survived the early postoperative period but had large open midline wounds that required one or more delayed procedures to close the wound or cover the visceral mass with skin graft. Two patients currently have large abdominal wall hernias. In the other eight patients the skin was reapproximated over the visceral mass utilizing towel clips at the initial operation. Six patients survived to be reexplored within 48-96 hours. Acute hemorrhage had stopped, the edema of the bowel and retroperitoneum had largely resolved, and the fascia could be closed primarily without excessive tension. All wounds went on to heal satisfactorily. When massive edema makes fascial closure at the initial operation difficult or impossible, closure of the skin over the visceral mass promotes resolution of the edema and often allows satisfactory primary closure within 48-96 hours. Synthetic mesh should be reserved for cases of abdominal wall tissue loss or dehiscence associated with wound sepsis.

Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients

BACKGROUND

Despite the lack of evidence, traditional trauma teaching has suggested that low rib fractures increase the risk of abdominal solid organ injury (ASOI). This study was designed to assess if in fact this is true, and to try and define other factors that increased the risk of ASOI in rib fracture patients.

METHODS

The charts of 476 hospitalized rib fracture trauma patients were reviewed. Data were collected for age; sex; Injury Severity Score (ISS); rib fracture location; and the presence or absence of injuries to the abdominal organs, head, neck, face, thorax, great vessel, heart, thoracolumbar spine, pelvis, and extremities.

RESULTS

The probability of liver injury increased with the presence of any right-sided rib fracture, any low rib fracture, female gender, young age, and an elevated ISS. The probability of splenic injury increased with the presence of left-sided rib fractures only, any low rib fracture, young age, and an elevated ISS.

CONCLUSION

In hospitalized trauma patients, low rib fractures, right-sided rib fractures, female gender, young age, and an elevated ISS increased the probability of liver injury; and low rib fractures, left-sided only rib fractures, young age, and an elevated ISS increased the probability of splenic injury. Associated pelvic fractures and long bone fractures did not increase the likelihood of ASOI in this cohort.

Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma

OBJECTIVE

The current study was undertaken to examine how concomitant injury to liver and spleen after blunt abdominal trauma affects management and outcomes.

METHODS

This study was a retrospective chart review of all blunt abdominal trauma patients admitted with a diagnosis of liver or spleen injury at two Level I trauma centers over a 4-year period. Presentation, injury grade, management, and outcomes were analyzed. Patients with single-organ injury (liver or spleen) were compared with patients having injury to both organs (liver and spleen). Significance was set at 95% confidence intervals.

RESULTS

Of 1,288 patients who met entry criteria, 1,125 had single (spleen, 573; liver, 552) organ injury (group S) and 163 had injury to both organs (group B). Group B patients had significantly higher Injury Severity Score, higher admission lactate, and lower admission systolic blood pressure and base excess. Eighty-one percent (915 of 1,125) of group S and 69% (112 of 163) of group B patients were managed nonoperatively (p < 0.05). Of the nonoperatively managed patients, 5.8% (53 of 915) in group S and 11.6% (13 of 112) in group B failed this form of therapy (p < 0.05). Higher failure rate in group B was because of bleeding from injured solid organ(s), and not non-solid organ related failures. Mortality, intensive care unit and hospital lengths of stay, and transfusion requirements were all significantly higher in group B.

CONCLUSION

Blunt trauma patients with concomitant injury to liver and spleen have higher Injury Severity Score, mortality, lengths of stay, and transfusion requirements. There is a higher failure rate with nonoperative management, and therefore extra vigilance is warranted when choosing this form of therapy in the presence of injury to both organs.

Correlation of abdominal trauma index and injury severity score with abdominal septic complications in penetrating and blunt trauma

The Abdominal Trauma Index (ATI) was designed to stratify patients with penetrating injuries, and has been used to classify patients with blunt trauma. The Injury Severity Score (ISS) was originally designed to stratify victims of blunt trauma, and it has also been used for victims of penetrating trauma. We attempted to validate the use of ISS and ATI for both penetrating and blunt trauma. A total of 592 penetrating and 334 blunt trauma patients who underwent laparotomy over a 5-year period were evaluated. The overall rate of abdominal sepsis was 7.5% for blunt trauma and 7.6% for penetrating trauma. Mortality (excluding deaths within 48 hours) was 7% for blunt trauma and 1% for penetrating trauma. In the penetrating injury population, an ATI value greater than 15 and an ATI value greater than 25 were significantly associated with abdominal septic complications (ASCs) (p less than 0.001, both comparisons). An ISS greater than or equal to 16 was also associated with ASCs (p less than 0.001). The ASC rate for gunshots was higher than that for stab wounds (11% vs. 2%; p less than 0.001). In the blunt group, an ATI value greater than 15 and an ATI value greater than 25 were associated with ASCs (p less than 0.01 and p less than 0.001, respectively). The association of ASCs and ISS was linear with increasing ISS in patients with blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury

BACKGROUND

The recent growth in the volume of civilian blast trauma caused by terrorist bombings warrants special attention to the specific pattern of injury associated with such attacks.

OBJECTIVE

To characterize the abdominal injuries inflicted by terrorist-related explosions and to compare the pattern of injury with civilian, penetrating and blunt, abdominal trauma.

METHODS

Retrospective analysis of prospectively collected data from 181 patients with abdominal trauma requiring laparotomy, who were admitted to the Hadassah Hospital, Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into 3 groups according to mechanism of injury: terror-related blast injury (n = 21), gunshot wounds (GSW) (n = 73) and blunt trauma (n = 87).

RESULTS

Median injury severity score in the blast group was significantly higher compared with GSW and blunt groups (34, 18, and 29, respectively, P < 0.0001). Injury to multiple body regions (> or = 3) occurred in 85.7% of blast group, 28.8% of GSW group, and 59.7% of blunt group (P < 0.001). The pattern of intra-abdominal injury was different between the groups. Bowel injury was found in 71.4% of blast victims, 64.4% of GSW, and 25.3% of blunt group (P < 0.001). Parenchymal injury was found in one third of patients in blast and GSW groups versus 60.9% of patients in blunt group (P = 0.001). Penetrating shrapnel was the cause of bowel injury in all but 1 patient in the blast group (94.4%).

CONCLUSIONS

Terrorist attacks generate more severe injuries to more body regions than other types of trauma. Abdominal injury inflicted by terrorist bombings causes a unique pattern of wounds, mainly injury to hollow organs. Shrapnel is the leading cause of abdominal injury following terrorist bombings.

Prognostic factors and management of civilian penetrating duodenal trauma

OBJECTIVE

This study was designed to investigate risk factors in the final outcome of patients with civilian penetrating abdominal trauma and duodenal injuries, the value of the different surgical approaches used, and to define when more complex procedures are indicated, instead of the simple primary repair.

METHODS

The study design was a retrospective review of prospectively collected data of a 4-year period (July 1992 to June 1996).

RESULTS

A total of 167 patients were admitted with penetrating abdominal trauma and duodenal injuries at San Juan de Dios Hospital in Santafé de Bogotá, Colombia.

CONCLUSION

The independent and significant risk factors that determine the severity of duodenal injury and need for complex procedures, as identified in this series, are preoperative or intraoperative shock; Abdominal Trauma Index higher than 25; and associated injuries to the pancreas, superior mesentric vessels, and colon. These factors are associated with an increased incidence of septic complications, duodenal fistula, and late mortality.

Technology-driven triage of abdominal trauma: the emerging era of nonoperative management

Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.

The open abdomen: aetiology, classification and current management strategies

A new classification system has been devised for open abdominal wounds. This will help identify an appropriate management strategy, and indicate the associated morbidity and outcome. In all cases, early intervention is vital.

Multidetector Computed Tomography and Blunt Thoracoabdominal Trauma

Computed tomography has had an increasing role in the evaluation of patients after blunt trauma. Important findings in thoracic trauma include acute traumatic aortic injury, pneumothorax, hemothorax, pulmonary contusions and lacerations, mediastinal hematoma, and diaphragmatic rupture. The solid abdominal viscera may lacerate; infarct; or suffer vascular, ductal, or pyelocalyceal disruption. The bladder and intestines may rupture. In abdominal pelvic trauma, the direction of applied force often results in an identifiable constellation of injuries. This article reviews how multidetector computed tomography (MDCT) is used in the trauma patient. Technical advances of increased cephalocaudad coverage speed and improved z-axis resolution intrinsic to MDCT, together with effective contrast utilization, make MDCT invaluable in the setting of trauma.

When to operate on abdominal gunshot wounds

Historically, penetrating abdominal trauma was managed expectantly until the late 19th century. In World War I, with the high mortality and morbidity associated with penetrating abdominal trauma, operative management replaced expectant management. It was soon realized that not all penetrating abdominal injuries required an operation. Since the 1960's, selective nonoperative management of stab wounds to the anterior abdomen has become the standard of care. However, gunshot wounds to the abdomen are still treated by mandatory exploration based on an allegedly high incidence of intra-abdominal injuries and low rate of complications, if laparotomy turns out negative. A number of series have recently surfaced, reporting successful outcomes, while decreasing morbidity and hospital length of stay, with selective non-operative management of gunshot wounds to the abdomen. This review will address the current controversies surrounding selective nonoperative management of gunshot wounds to the abdomen and will present our experience and current approaches.

A review of intestinal injury from blunt abdominal trauma

Eighty-five patients who suffered blunt trauma to the small intestine and/or to the colon were treated at either the Royal Brisbane Hospital (RBH), Brisbane, Queensland or the Flinders Medical Centre (FMC), Adelaide, South Australia, between 1980 and 1991. Data were collected by retrospective review of case notes from the medical records departments of both hospitals and analysed with respect to the cause, the anatomical distribution, the diagnostic methods and the mortality of these injuries. There were 129 intestinal injuries (44 colonic and 85 small bowel). Five (5.9%) deaths were recorded. Seventy-two patients (84.7%) were injured in vehicular accidents. Fifty-three patients (62.4%) underwent laparotomy based on clinical findings alone. Diagnostic peritoneal lavage (DPL) was used in 24 cases and was positive in 22 (91.7%). The most common small bowel injury was ¿blowout' perforation on the antimesenteric border of the bowel (55.5%). The most common colonic injury was a serosal tear/bruise (62.2%).

Computed tomography-assisted management of splenic trauma

BACKGROUND

In patients who have suffered an injury to the spleen, preservation of the organ is of the utmost importance. To assist in management, contrast-enhanced computed tomography (CT) has been used. We reviewed our experience with a protocol for nonoperative management of splenic trauma based on CT grading of the injury.

METHODS

During the initial period of the study, 50 CT examinations for blunt abdominal trauma in adults were reviewed by staff radiologists for evidence of splenic injury. The radiologists, blinded to clinical management decisions, graded the CT studies as "A" if there was a subcapsular hematoma or capsular disruption, "B" if there was a parenchymal injury not extending into the hilum, or "C" if there was deep laceration of fracture of the hilum. Following confirmation of the accuracy and reproducibility of the grading scale, the splenic trauma management protocol was instituted, in which nonhilar injuries were managed nonoperatively.

RESULTS

In the initial assessment, patients managed nonoperatively had shorter hospital stays and received fewer blood transfusions than those undergoing operation. Among 30 patients subsequently enrolled in the protocol, those treated nonoperatively remained in the hospital for fewer days than those treated surgically. Again, fewer units of blood and platelets were used in the nonoperative group. Institution of the protocol decreased the incidence of celiotomy.

CONCLUSIONS

The severity of splenic trauma evident on CT staging guides safe nonoperative management. Patients not suffering injury to the splenic hilum (A and B scores) can be managed without operation, resulting in shorter hospital stays and fewer blood products used.