Die Problematik primär nicht diagnostizierter Verletzungen nach stumpfem Abdominaltrauma

Abstract

In a retrospective analysis of 134 multiple injured patients (average Injury Severity Score [ISS] 38) 11% of intraabdominal injuries were missed on initial examination (7 out of 18 hollow viscus injuries (HVI), 4 out of 16 diaphragmatic ruptures (DR), and 4 out of 95 liver and splenic lacerations). Morbidity was significantly increased in those patients with little increase in mortality. The data of a prospective study in severely injured patients were analyzed to address this problem. From 1986 to 1992 184 polytraumatized patients (average ISS 39) were prospectively studied according to a standardized diagnostic and therapeutical protocol. 89 patients of the study showed a total of 132 intraabdominal injuries, including 10 HVI and 8 DR. Since 1989 sonography (US) has replaced diagnostic peritoneal lavage (DPL) as the first diagnostic procedure with a comparable accuracy (US: sensitivity 93%, specifity 100%, accuracy 97%; DPL: sensitivity 91%, specifity 98%, accuracy 95%). Among 24 HVI and DR 5 were missed on initial examination (21%): one patient with a gastric perforation, who was transferred from a regional hospital, as well as 4 false negative US (1 combined pancreaticoduodenal laceration, which was finally diagnosed on abdominal computed tomography (CT), 4 DR (2 on the left, 1 on the right side) combined with severe thoracic trauma). All other HVI were diagnosed during emergency laparotomy for intraabdominal bleeding. Isolated HVI and DR can be missed during initial examination of the multiple injured patient inspite of standardized diagnostic protocols. Further diagnostic workup with thoracic CT and contrast media via the nasogastric tube is recommended in all cases with suspected DR. Patients with blunt abdominal trauma, in whom emergency laparotomy is not indicated, should be closely monitored both clinically and with US. In cases of unclear US abdominal CT is recommended for stable patients; intra- or retroperitoneal air or contrast media extravasation indicate HVI and mandate laparotomy.