Hollow Viscus Injury in Geriatric Trauma: Damage Control, Surgical Management, and Critical Care

Abstract

Hollow viscus injuries (HVI) are the source of significant morbidity and mortality in trauma patients, especially in patients with poor physiologic reserve which is common in the extremes of age. Though HVI is more common in penetrating trauma, over 50% of hollow viscus injuries from blunt trauma are caused by motor vehicle crashes (MVCs). Because of seatbelt syndrome and improper belt placement, small bowel injuries are threefold more likely to occur than large bowel injuries in MVCs. Blunt traumatic injuries of the stomach and rectal injuries are even less common. Because of synergy between increased metabolic demands, age-related decline in end-organ function, comorbidities, and associated sequelae in frail patients, HVI leads to lower chances for survival compared to younger patients. Abdominal ultrasound and diagnostic peritoneal lavage (DPL) are important adjuncts in the initial diagnosis and management of posttraumatic hemorrhage and HVI in hemodynamically unstable patients. Computed tomography (CT) scans are useful in the detection of HVI in stable trauma patients. Serial assessments of organ perfusion must be performed because occult hypoperfusion is common in advanced aged patients, especially those with frailty syndrome. Delay in operative management of HVI in the geriatric patient leads to more morbidity and mortality compared to younger patients. Massive transfusion protocols, damage control resuscitation, and staged surgical procedures are mission critical not only for survival of the hypothermic, acidotic, and coagulopathic patient, but also for successful management of HVI. Complex duodenal and rectal injuries are the most difficult to surgically repair and have higher rates of complications than other HVI. As is done in pediatric patients, to decrease preventable MVC-related HVI in the elderly, campaigns focused on the education of adult and older patients need to be created and implemented in the correct use and placement of lap and harness belts.