Abdominal Abbreviated Injury Scale Score Research Articles

Current status and safety of laparoscopic surgery for patients with blunt abdominal trauma: A multicenter study using the Japan Trauma Data Bank

AbstractIntroductionThis study was performed to examine current status and safety of laparoscopic surgery in adult patients with blunt trauma.MethodsAmong 88 817 trauma patients registered in the Japan Trauma Data Bank from January 2019 to December 2022, we included blunt trauma patients who underwent laparoscopic surgery and/or laparotomy. We excluded patients with non‐blunt trauma, systolic blood pressure (sBP) of 0 mmHg on admission, age of <15 years, and Injury Severity Score (ISS) of 75. First, patients were divided into two groups: he laparoscopic surgery group (including patients transitioned from laparoscopic surgery) and the laparotomy‐only group. Second, missing values were estimated by multiple imputation. Finally, in‐hospital mortality was analyzed using propensity score matching to balance patient characteristics (age, sex, sBP, Glasgow coma scale (GCS) score, abdominal Abbreviated Injury Scale score, and ISS).ResultsWe analyzed 1301 patients [68 (5.2%) in the laparoscopic surgery group and 1233 (94.8%) in the laparotomy‐only group]. After propensity score matching, the in‐hospital mortality rate was 1.5% in the laparoscopy group and 10.0% in the laparotomy‐only group (p < .03). The odds ratio of in‐hospital mortality for the laparotomy‐only group after propensity score matching was 4.06 (95% confidence interval, 0.30–54.9; p = .29) compared with the laparoscopy group. After propensity score matching, there were no deaths occurred with patients of intra‐abdominal hemorrhage. In‐hospital mortality was not significantly different with peritonitis patients (p = .36).ConclusionsLaparoscopic surgical intervention was safely performed for selected adult patients with blunt abdominal trauma without an increase in mortality.

Surgical stabilization of critical abdominal injuries in a mature rural trauma system: A retrospective study.

Worse outcomes following injuries are more likely in rural versus urban areas. In 2001, our state established an inclusive trauma system to improve mortality. In 2015, the trauma system had a consultation visit from the American College of Surgeons' Committee on Trauma, who made several recommendations. We hypothesized that continued maturation of this system would lead to more laparotomies prior to transfer to a higher level of care and better outcomes. Our trauma registry was queried to identify all patients transferred between January 1, 2010, and December 31, 2020, who underwent laparotomy either before transfer or within 4 hours of arrival. The preconsultation (2010-2015) and postconsultation periods (2016-2020) were compared. Categorical and continuous variables were compared using χ2 and Mann-Whitney U tests, respectively. We included 213 patients; 63 had laparotomy before transfer and 150 within 4 hours after transfer. Age, injury severity scores, systolic blood pressure, and mechanism of injury were not different between periods. Proportions of laparotomy before and after transfer and outcomes (mortality, hospital length of stay, intensive care unit length of stay, ventilator days) were also similar (p = 0.368 for laparotomy, p = 0.840, 0.124, 0.286, 0.822 for outcomes). Compared with the preconsultation period, the proportion of laparotomy performed before transfer for severe injuries (abdominal Abbreviated Injury Scale score >3) significantly increased postconsultation (57.1% vs. 30.6%, p = 0.011). Incidence of damage-control laparotomies (43.9% vs. 23.6%; p = 0.020) and transfusion of plasma and platelets (33.6% vs. 13.2%; p < 0.001, 22.4% vs. 8.5%, p = 0.007, respectively) significantly increased. Identification and surgical stabilization of critical patients at the non-Level I facilities prior to transfer, as well as blood product use and damage-control techniques, improved postconsultation, suggesting a shift in the approaches to surgical stabilization and resuscitation efforts in our trauma system. Therapeutic/Care Management; Level IV.

Increased intra-abdominal haemorrhage after thoracic endovascular aortic replacement in patients with concomitant blunt aortic injuries and abdominal trauma: a National Trauma Data Bank analysis.

The role of thoracic endovascular aortic replacement (TEVAR) in patients with concomitant blunt thoracic aortic injury (BTAI) and blunt abdomen trauma (BAT) was evaluated using nationwide real-world data. The risk of post-TEVAR abdominal haemorrhage was studied. Patients with BTAI and BAT in the National Trauma Data Bank were retrospectively studied. Propensity score matching was used to evaluate the effect of TEVAR in delayed abdominal surgeries for haemostasis and the delayed need for blood transfusion. A multivariable logistic regression analysis was used to evaluate the independent risk factors for delayed intra-abdominal haemorrhage in these patients. A total of 928 concomitant BTAI and BAT patients were studied (TEVAR versus non-TEVAR, 206 vs 722). After a well-balanced propensity score matching analysis, patients who received TEVAR had significantly more delayed abdominal surgeries for haemostasis (7.7% vs 4.5%, standardized mean difference = 0.316) and delayed need for blood transfusion (11.6% vs 7.1%, standardized mean difference = 0.299) than those who did not. The multivariable logistic regression analysis showed that TEVAR increased the need for delayed abdominal surgeries (odds ratio = 2.026, P = 0.034). Among the patients who underwent TEVAR, the patients with delayed abdominal surgeries for haemostasis had a significantly higher proportion of severe abdominal injury (abdominal Abbreviated Injury Scale score of 4 or 5) than patients without delayed abdominal surgeries for haemostasis (31.6% vs 15.5%, P = 0.038). Patients with concomitant BTAI and BAT had a higher risk of intra-abdominal haemorrhage after TEVAR, especially patients with severe abdominal trauma.

Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study.

Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. Therapeutic/Care Management, Level III.

Tracheal intubation in traumatic brain injury: a multicentre prospective observational study

BackgroundWe aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity. MethodsData from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests. ResultsIn the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79–1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65–1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower. ConclusionThe benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting. Clinical trial registrationNCT02210221.

The contemporary timing of trauma deaths.

The distribution of trauma deaths was classically described as trimodal. With advances in both technology and trauma systems, this was reevaluated and found to be bimodal in the early 2000s. Over the last decade there have been continued improvements in trauma and intensive care unit (ICU) care, related to damage control techniques and evidence based ICU pathways. A better understanding of the distribution of trauma deaths may be used to improve trauma systems. This study aimed to evaluate the contemporary distribution of trauma deaths after the widespread implementation of modern trauma and critical care principles. This study included patients entered in the NTDB from 2008 to 2014. For dead patients, hospital length of stay was equated to time until death. Additional data was collected to include demographics, mechanism of injury, Injury Severity Score, and Abbreviated Injury Scale score. Histograms were plotted to demonstrate peaks in deaths. Survival analysis was performed with Kaplan-Meier curves and Gehan-Breslow generalized Wilcoxon tests. 4,185,009 patients were analyzed. Thirty-four percent of all deaths occurred within the first 24 hours of admission. The factors most associated with death in the first 24 hours were severe abdominal trauma (73%), penetrating trauma (55%), and severe extremity trauma (58%). Among patients with penetrating trauma and an abdominal Abbreviated Injury Scale score of 4 or higher, 83% of deaths occurred within 24 hours. When plotted, the distribution of deaths was seen to fall rapidly after the first 24 hours and continued to be flat for 30 days in all subgroups analyzed. In this study, the distribution of trauma deaths no longer appears to be trimodal. This may reflect advances in trauma and ICU care, and the widespread adaption of damage control principles. Early deaths, however, remains a significant challenge, specifically from non-compressible abdominal hemorrhage and extremity trauma. Primary prevention and early hemorrhage control must continue to be a focus of research and trauma systems. Epidemiologic, level IV.

Closed-Suction Drain Placement at Laparotomy in Isolated Solid Organ Injury is Not Associated with Decreased Risk of Deep Surgical Site Infection

The purpose of this study was to investigate the role of intra-abdominal closed-suction drainage after emergent trauma laparotomy for isolated solid organ injuries (iSOI) and to determine its association with deep surgical site infections (DSSI). All patients subjected to trauma laparotomy between January 2006 and December 2008 for an iSOI at two Level I urban trauma centers were identified. Patients with isolated hepatic, splenic, or renal injuries were included. Study variables extracted included demographics, clinical characteristics, intra-abdominal injuries, drain placement, DSSI, septic events, intensive care unit and hospital length of stay, and in-hospital mortality. Diagnosis of DSSI was based on abdominal computed tomography scan demonstrating an intra-abdominal collection combined with fever and elevated white blood cell count. For the analysis, patients were stratified based on injury severity. To identify an independent association between closed-suction drain placement and DSSI, stepwise logistic regression analysis was performed. Overall, 142 patients met the inclusion criteria with 80 per cent (n=114) having severe iSOI. In 47 per cent (n=53) of the patients with a severe injury, an intra-abdominal drain was placed. A drain was placed more often in patients with a blunt trauma with more severe injury defined by Injury Severity Score and abdominal Abbreviated Injury Scale Score and those who underwent splenectomy (P<0.05). There was a three-fold increased risk of DSSI in patients subjected to drain placement (odds ratio, 2.8; 95% confidence interval, 1.0 to 8.2; P=0.046). Subgroup analysis demonstrated those who sustained severe hepatic injury receiving a drain had a significantly increase risk of DSSI (P=0.02). There was no statistical difference in the rate of DSSI based on the presence or absence of an intra-abdominal drain after severe splenic injury (17 vs 18%, P=0.88). The use of intra-abdominal closed-suction drains after iSOI is not associated with decreased risk of DSSI.

Over Reliance on Computed Tomography Imaging in Patients With Severe Abdominal Injury: Is the Delay Worth the Risk?

Computed tomography (CT) has a high sensitivity and specificity for detecting abdominal injuries. Expeditious abdominal imaging in "quasi-stable" patients may prevent negative laparotomy. However, the significance of potential delay to laparotomy secondary to abdominal imaging remains unknown. We sought to analyze whether the use of abdominal CT (ABD CT) in patients with abdominal injury requiring laparotomy results in a significant delay and a higher risk of poor outcome. A retrospective analysis of data from the National Trauma Data Bank (version 7.1) was performed. Inclusion criteria were adult patients (age>14 years), a scene admission (nontransfer), hypotension on arrival (emergency department systolic blood pressure<90 mm Hg), an abdominal Abbreviated Injury Scale (AIS) score>3, and undergoing a laparotomy within 90 minutes of arrival. Patients with severe brain injury (head AIS score>3) were excluded. The independent mortality risk associated with a preoperative ABD CT was determined using logistic regression after controlling important confounders. This cohort of patients (n=3,218) was significantly injured with a median Injury Severity Score of 25 ([interquartile range, 16-34]). Patients who underwent ABD CT had similar Glasgow Coma Scale scores, a lower head AIS, longer time delays to the operating room, and a higher crude mortality (45% vs. 30%; p=0.001). Logistic regression revealed that ABD CT was independently associated with more than a 70% higher risk of mortality (odds ratios, 1.71; 95% CI, 1.2-2.2; p<0.001). When stratified by injury mechanism, intubation status and whether or not a head CT was performed, the mortality risk remained significantly increased for each subgroup. When the laparotomy was able to occur within 30 minutes of arrival, an ABD CT was independently associated with more than a sevenfold higher risk of mortality (odds ratios, 7.6; p=0.038). Delay secondary to abdominal imaging in patients who require operative intervention results in an independent higher risk of mortality. ABD CT imaging is an important and useful tool after injury; however, these results suggest that delay caused by overreliance on ABD CT may result in poor outcome in specific patients. Clinicians who take care of critically injured patients should be aware of and understand these potential risks.

Has the Pendulum Swung Too Far? The Impact of Missed Abdominal Injuries in the Era of Nonoperative Management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 +/- 9 days postinjury. Intensive care unit length of stay (26 +/- 24 vs 10 +/- 6 days), hospital length of stay (40 +/- 37 vs 11 +/- 10 days), ventilator days (31 +/- 29 vs 11 +/- 10), and number of abdominal operative procedures (1.9 +/- 1.5 vs 1 +/- 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

The Use of the Wittmann Patch Facilitates a High Rate of Fascial Closure in Severely Injured Trauma Patients and Critically Ill Emergency Surgery Patients

The open abdomen after severe intra-abdominal trauma and emergency surgery is a major operative challenge. It is associated with high morbidity and prolonged hospital stays. Several management strategies have been developed to assist with fascial closure but no single method has emerged as the best. The Wittmann Patch (Starsurgical, Burlington, WI) is a unique device which uses velcro to permit progressive abdominal closure without necessitating serial operations. The purpose of this study was to determine the fascial closure rate using the Wittmann patch. We hypothesized that use of the patch would result in a high closure rate. Hospital billing codes were reviewed to identify those patients who underwent Wittmann patch placement. During the period from June 2002 to May of 2006, 29 patients were identified. These included 19 trauma patients and 10 other surgical patients. Other patients included vascular, bariatric, and emergency general surgery patients. The trauma registry and the patients' medical records were reviewed to determine injury severity, Acute Physiology and Chronic Health Evaluation II scores, fluid requirements, patch placement, management, and patient outcomes. Twenty-two (76%) of the 29 patients survived to discharge. The average Acute Physiology and Chronic Health Evaluation II score was 25 +/- 6 in all patients, 22.9 +/- 6 in survivors, and 31 +/- 3 in those who died (p = 0.004). Mean injury severity scale and abdominal abbreviated injury scale scores in trauma patients were 28 +/- 10 and 3 +/- 2, respectively. The mean volume of fluid given during the 24 hours before having an open abdomen or patch placement was 17.6 L +/- 10.1 L. Twenty-five (86.2%) of 29 patients had at least one abdominal operation before placement of the patch (mean 1.3 +/- 1.0). Eighteen (82%) of 22 patients who survived to discharge had successful facial closure. Three patients (14%) required mesh placement for abdominal closure. The remaining patient had his patch removed and ultimately underwent skin grafting and subsequent component separation closure. Successful fascial closure was achieved after 15.5 days +/- 10.2 days (range, 5-42 days). The skin was left open in half of the patients. There were four abdominal complications that were noted while the patch was in place. Three of four complications were related to the primary disease, and in the fourth complication the patch became infected and had to be removed. There were no eviscerations or enterocutaneous fistulas after primary fascial closure. The median length of stay was 28 days (Interquartile range, 14-39 days). Use of the Wittmann Patch can achieve a high rate of delayed fascial closure in severe trauma and critically ill emergency surgery patients with open abdomens. Most of the complications associated with use of the patch were wound infections after fascial closure and closure of the skin.

The Impact of Safety Belt Use on Liver Injuries in Motor Vehicle Crashes: The Importance of Motor Vehicle Safety Systems

Liver injuries (LIs) are one of the most serious and common consequences of motor vehicle crashes (MVCs). In the unstable patient, early detection of LI based on clinical suspicion will improve acute trauma care and outcomes. The specific objectives of this analysis are to identify crash scene and occupant risk factors for LI from MVC. Crash Injury Research and Engineering Network data were used to identify risk factors for LI; age, sex, safety belt use, air bag deployment, DeltaV (change in velocity), principal direction of force, vehicle crush, and intrusion. Occupants with LI were compared with four control groups without LI; (1) no abdominal (ABD) injury (NO_ABD), (2) any ABD (ANY_ABD), (3) ABD Abbreviated Injury Scale score of 1 to 2 (ABD_1-2), and (4) ABD Abbreviated Injury Scale score of 3 or more (ABD_3+). LI occupants were compared with each control group and odds ratios (OR) for risk of LI were computed. There were 311 Crash Injury Research and Engineering Network subjects aged 5 or more years with LI. The total mean Injury Severity Score was 37.6. LI was strongly and significantly associated with safety belt restraint use without air bag deployment, compared with each control group: Liver injury - restrained + air bag not deployed versus (1) NO_ABD, N = 1,519; OR = 4.4, (2) ANY_ABD, N = 317; OR = 2.6, (3) ABD_1 to 2, N = 155; OR = 3.1, (4) ABD_3+, N = 217; OR = 2.4 (p < 0.001). This association was independent of driver or passenger status and principal direction of force. LIs were also strongly and significantly associated with greater vehicle interior intrusion. LIs were strongly associated with a safety belt restraint in use in the absence of air bag deployment during MVC. This data may have profound importance to the trauma surgeon as an early indicator for LI during resuscitation. These findings also have important implications for future research efforts to improve safety systems in motor vehicles and reduce morbidity and mortality from MVCs in the United States.

Prone Ventilation in Trauma or Surgical Patients With Acute Lung Injury and Adult Respiratory Distress Syndrome: is it Beneficial?

To compare the effectiveness of supine versus prone kinetic therapy in mechanically ventilated trauma and surgical patients with acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). A retrospective review of all patients with ALI/ARDS who were placed on either a supine (roto-rest) or prone (roto-prone) oscillating bed was performed. Data obtained included age, revised trauma score (RTS), base deficit, Injury Severity Score (ISS), head Abbreviated Injury Scale score (AIS), chest (AIS), PaO2/FiO2 ratio, FiO2 requirement, central venous pressure (CVP), days on the bed, ventilator days, use of pressors, complications, mortality, and pulmonary-associated mortality. Data are expressed as mean+/-SE with significance attributed to p<0.05. From March 1, 2004 through May 31, 2006, 4,507 trauma patients were admitted and 221 were identified in the trauma registry as having ALI or ARDS. Of these, 53 met inclusion criteria. Additionally, 8 general surgery patients met inclusion criteria. Of these 61 patients, 44 patients were positioned supine, 13 were placed prone, and 4 patients that were initially placed supine were changed to prone positioning. There was no difference between the groups in age, CVP, ISS, RTS, base deficit, head AIS score, chest AIS score, abdominal AIS score, or probability of survival. The PaO2/FiO2 ratios were not different at study entry (149 vs. 153, p=NS), and both groups showed improvement in PaO2/FiO2 ratios. However, the prone group had better PaO2/FiO2 ratios than the supine group by day 5 (243 vs. 200, p=0.066). The prone group had fewer days on the ventilator (13.6 vs. 24.2, p=0.12), and shorter hospital lengths of stay (22 days vs. 40 days, p=0.08). There were four patients who failed to improve with supine kinetic therapy that were changed to prone kinetic therapy. These patients had significant improvements in PaO2/FiO2 ratio, and significantly lower FiO2 requirements. There were 18 deaths (7 pulmonary related) in the supine group and 1 death in the prone group (p < 0.01 by chi test). ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary-related mortality than did supine positioned patients. The use of a prone-oscillating bed appears advantageous for trauma and surgical patients with ALI/ARDS and a prospective, randomized trial is warranted.

Traffic injuries of the pregnant women and fetal or neonatal outcomes

Objective To investigate the relationship between pregnancy outcome and injury severity of pregnant woman in traffic accidents. Method We reviewed insurance reports of traffic accidents and collected data on injuries of pregnant women and outcomes of their pregnancies. Result A total of 135 pregnant women, with a mean injury severity score of 1.8 ± 4.0, were involved in traffic accidents from 1994 through 2003. Injury severity score, abdominal abbreviated injury scale score were significantly higher in women whose neonates died than in women with healthy newborns. However, neither the likelihood of having been subjected to direct external forces during the accident nor injury severity differed between women with spontaneous abortions and woman with healthy newborns. Conclusion Predicting abortion on the basis of maternal injury severity is difficult. Because unknown variables may contribute to fetal loss, further studies of traffic injuries are needed.

Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair?

Blunt thoracic aortic injury (BTAI) is a severe injury that traditionally has mandated immediate surgical repair. Delaying operative intervention for BTAI can allow other life-threatening injuries to be managed first, but potentially increases the risk of aortic rupture and death. The objective of this study was to evaluate the outcome of delayed repair (DR) compared with early repair (ER) for BTAI and to assess the effectiveness of a protocol for medical control of systolic blood pressure and heart rate in those patients whose repairs were delayed. This study is a retrospective review of University of Michigan Health System (UMHS) data from January 1, 1992, through March 1, 2003. ER was defined as operative repair within 16 hours from the time of injury. A similar analysis was conducted for patients with BTAI selected from the National Trauma Data Bank. For the UMHS data, there were 45 patients in the DR group and 33 patients in the ER group. Mortality in the ER group versus the DR group was 9% versus 20%. Multivariate analysis adjusting for age, Injury Severity Score, abdominal Abbreviated Injury Scale score, Glasgow Coma Scale score, and intubation status demonstrated an odds ratio for death from ER compared with DR of 1.72 (p = 0.57). Patients undergoing DR had an absolute increase in hospital length of stay (33.1 vs. 20.9 days) and complication rate (2.1 vs. 1.5 incidents per patient). A similar result was obtained for multivariate analysis of the National Trauma Data Bank data, with an odds ratio of 1.40 (p = 0.51) for death from ER versus DR. UMHS patients whose repairs were delayed achieved target systolic blood pressure and heart rate for 76% and 74% of the hourly measurements recorded, respectively. Patients with BTAI can safely undergo delayed aortic repair if other injuries warrant a higher treatment priority without increasing their overall risk of mortality. Delayed repair is, however, associated with a higher complication rate.

Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial.

Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

Relative bradycardia in patients with traumatic hypotension.

Tachycardia is considered a physiologic response to traumatic hypotension. The inability of the heart to respond to shock with tachycardia has been described as paradoxical bradycardia or relative bradycardia. The incidence and clinical significance of this condition in major trauma is not known. The objective of this study was to examine the incidence and prognostic significance of tachycardia and relative bradycardia in patients with traumatic hypotension. Relative bradycardia is defined as a systolic pressure < or = 90 mm Hg and a pulse rate < or = 90 beats per minute. This is a retrospective study conducted at a large Level I academic trauma center during a 4-year period. Seventeen demographic and injury severity factors were analyzed for their possible role in tachycardic or bradycardic response in hypotensive patients. Incidence and mortality were derived for each subpopulation. Bivariate analysis of the association of incidence and mortality with each risk factor was performed. Factors with p values < 0.2 were included in stepwise logistic regression analyses that identified significant risk factors and derived adjusted relative mortality risks between tachycardic and bradycardic hypotensive patients. Excluding transfers and patients dead on arrival, 10,833 major trauma patients were seen during the study period. Seven hundred fifty patients (6.9%) had systolic blood pressure < or = 90 mm Hg; 533 patients had tachycardia (overall incidence of 4.9%, or 71.1% of hypotensive patients), and 217 patients had bradycardia (overall incidence of 2.0%, or 28.9% of hypotensive patients). The overall crude mortality was 29.2% among tachycardia patients and 21.7% among bradycardia patients (crude relative risk = 1.34; 95% confidence interval = 1.00-1.81; p = 0.047). The adjusted relative mortality risk between the two groups was 1.23 (95% confidence interval = 0.84-1.73; p = 0.284). Multivariate analysis showed that patients with relative bradycardia in the subgroups with Injury Severity Scores > or = 16, chest Abbreviated Injury Scale scores > or = 3, or abdominal Abbreviated Injury Scale scores > or = 3 had significantly better survival than patients with similar injuries presenting with tachycardia. Relative bradycardia in hypotensive trauma patients is a common hemodynamic finding. Mortality among tachycardic patients was more predictable than among bradycardic patients using commonly used demographic and injury indicators. The presence of relative bradycardia in some subgroups of patients with severe injuries seems to be associated with better prognosis than the presence of tachycardia.

Evolution in the management of the complex liver injury at a Level I trauma center.

Management of the severe liver injury evolved from mandatory surgical repair to a more selective approach. This paper reviews the changes in management of the severe liver injury at a Level I trauma center. We reviewed the records of patients with severe liver injury admitted to a Level I trauma center between January 1984 and December 1995. The patients were divided into two groups, G1 and G2, based on their date of admission before or after January 1991. The two groups were compared for blood products use, management of the liver injury, and outcome. One hundred six patients were compared for age, sex, Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, abdominal Abbreviated Injury Scale score, and the presence of concomitant injuries. There was no difference in management or outcome of the victims of penetrating injury between G1 and G2 (n = 48). The blunt injury patients in G1 (n = 22) had more liver surgery (p = 0.006), blood transfusion (p = 0.040), intra-abdominal sepsis (6 vs. 0), and higher mortality (p = 0.041) than those in G2 (n = 36). Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use.

Computed tomography is inaccurate in estimating the severity of adult splenic injury.

Computed tomography (CT) is increasingly utilized in evaluation of adult splenic injury (SI). CT correlation with operative findings, CT relationship to successful nonoperative (NO) management, and CT reading reproducibility were examined. Records of patients > or = 15 years old admitted over a 3-year period were reviewed. Computed tomography scans were graded by two radiologists blinded to clinical results. Computed tomography scans were performed on 49 of 77 patients with SI. Eighteen underwent initial operation (OR) and 31 initial NO. Operative patients had higher Injury Severity Scores and Abdominal Abbreviated Injury Scale scores (p < 0.0001). Grade II readings predominated in the NO group (55%). Nonoperative management was successful for 9 grade III and 3 grade IV readings. Computed tomography matched OR grade in 10 readings, underestimated it in 18, and overestimated it in 6. Computed tomography missed SI in five patients. Radiologists disagreed on 9 of 45 (20%) scans. Computed tomography poorly predicted operative findings. Interobserver variability was common. SI management should not be based solely on CT severity.