Abdominal Solid Organ Injuries Research Articles

American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, Liver, and Kidney, Validation Based on the National Trauma Data Bank

This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB). All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred. There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades. This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Blunt Abdominal Trauma: Diagnostic Performance of Contrast-enhanced US in Children—Initial Experience

To prospectively compare the sensitivity and specificity of ultrasonography (US) with those of contrast material-enhanced US in the depiction of solid organ injuries in children with blunt abdominal trauma, with contrast-enhanced computed tomography (CT) as the reference standard. The study protocol was approved by the ethics board, and written informed consent was obtained from parents. US, contrast-enhanced US, and contrast-enhanced CT were performed in 27 consecutive children (19 boys, eight girls; mean age, 8.9 years +/- 2.8 [standard deviation]) with blunt abdominal trauma to determine if solid abdominal organ injuries were present. Sensitivity, specificity, agreement, accuracy, number of lesions correctly identified, and positive and negative predictive values were determined for US and contrast-enhanced US, as compared with contrast-enhanced CT. In 15 patients, contrast-enhanced CT findings were negative. Contrast-enhanced CT depicted 14 solid organ injuries in 12 patients. Lesions were in the spleen (n = 7), liver (n = 4), right kidney (n = 1), right adrenal gland (n = 1), and pancreas (n = 1). Contrast-enhanced US depicted 13 of the 14 lesions in 12 patients with positive contrast-enhanced CT findings and no lesions in the patients with negative contrast-enhanced CT findings. Unenhanced US depicted free fluid in two of 15 patients with negative contrast-enhanced CT findings and free fluid, parenchymal lesions, or both in eight of 12 patients with positive contrast-enhanced CT findings. Overall, the diagnostic performance of contrast-enhanced US was better than that of US, as sensitivity, specificity, and positive and negative predictive values were 92.2%, 100%, 100%, and 93.8%, respectively. Contrast-enhanced US was almost as accurate as contrast-enhanced CT in depicting solid organ injuries in children.

Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children

Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children. After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed. All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 microg/kg (1 patient had 24 microg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration--2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa. Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.

Nonoperative management of blunt trauma in abdominal solid organ: a prospective study to evaluate the success rate and predictive factors of failure

Over the past several years, nonoperative management (NOM) has increasingly been recommended for the care of selected blunt abdominal solid organ injuries. No prospective study has evaluated the rate of NOM of blunt abdominal trauma in the northwest of Iran. The objective of our study was to evaluate the success rate of this kind of management in patients who do not require emergency surgery.

Diagnosis and management of blunt abdominal solid organ injury

Nonoperative management of solid organ injuries has become the standard of care for over 25 years. Benefits of this practice include reduced operative complications, reduced transfusions, lower infectious morbidity, and shorter length of stay. Patients eligible for this management practice include those who are hemodynamically stable and who do not have associated injuries that require celiotomy. Operative interventions need to occur expeditiously in hemodynamically unstable patients with hepatic and splenic injuries. Recent literature has focused on the continued success with nonoperative management of blunt solid organ injuries. The role of angioembolization for both splenic and hepatic injuries continues to be explored. Other authors are also questioning the appropriateness of clinical decisions for selection of hemodynamically unstable patients for nonoperative management. Operative management of blunt pancreatic trauma remains the rule. Nonoperative management of solid organ injuries continues to have high success rates in the appropriate patient population. Minimally invasive adjuncts have a definite role in management of this patient population. Pancreatic trauma remains an operative injury. Surgeons must, however, temper the enthusiasm for nonoperative management of patients with solid organ injury, and exclude from this management scheme patients who would best be treated with surgery.

Contrast-Enhanced Ultrasound for Blunt Abdominal Trauma

Sonography is widely used in the initial diagnostic assessment of blunt abdominal trauma in adults and children. It has been formally incorporated worldwide into the routine armamentarium available for emergency diagnosis and treatment as a means of rapid detection of free abdominal fluid, normally referred to as FAST (Focused Assessment with Sonography in Trauma). However, there is some controversy regarding its value because free abdominal fluid may be lacking in patients with abdominal organ injuries from blunt trauma. More recently, a new ultrasound technique has been developed using contrast agents. Contrast-enhanced ultrasound performs better than the non-contrast-enhanced technique for the detection of abdominal solid organ injuries and can play an important role in the prompt evaluation of patients with blunt trauma. Furthermore, contrast-enhanced ultrasound can be used in the follow-up of patients who have solid organ lesions and are managed with nonoperative treatment, avoiding radiation and iodinated contrast medium exposure.

Failure of nonoperative management of abdominal solid organ injuries

Nonoperative management of the spleen has been the conventional approach for dealing with blunt splenic injury in children for 25 years. Following acceptance in the field of pediatric surgery, nonoperative management of blunt injury to the liver and spleen became the template in adult trauma surgery. It has proven to be of unequivocal benefit to the majority of hemodynamically stable pediatric and adult patients who have suffered blunt liver or splenic trauma. Offsetting these gains, has been the presence of failures. The recent literature has focused on factors which may impact the nonoperative management success or failure rate. These factors include initiation of guidelines, risk of overwhelming postsplenectomy infection, character of clinical judgment, role of computed tomography in detecting associated intraabdominal injuries, the presence of more than one solid organ injury, risk of associated hollow viscus injury, and the drawbacks of angioembolization. Despite the failures of nonoperative management outlined in this review, the approach has been generally successful. Efforts at improving organ salvage rates and diminishing failures with this approach continue. Notwithstanding our enthusiasm to advance this method of patient care, we must avoid imperiling a subpopulation of patients in our attempt to improve nonoperative management success rates.

Current advances in the surgical approach to abdominal trauma

The management of abdominal injury has changed dramatically during the past two decades. This review examines the historic perspectives and recent developments of diagnosis and treatment of liver injuries, splenic injuries, and pancreatic injuries. The incorporation of non-operative management for liver injuries has had a very positive effect on mortality. Likewise, splenic conservative therapy is routinely used. The early treatment of pancreatic injury has changed very little; however, the ability to recognize these difficult injuries has improved with higher quality CT scanning. The authors present their preferred treatment for these three common types of abdominal solid organ injury and present an illustrative case example.

Major Blunt Liver Injury with Contrast Pooling and Abdominal Compartment Syndrome: Report of a Case

The abdominal compartment syndrome (ACS), broadly defined as organ dysfunction due to intra-abdominal pressure beyond some cut-off point, can occur in patients with severe blunt abdominal solid organ injury with massive hemoperitoneum. Here, we report a 20-year-old man sustaining major liver laceration with contrast extravasation and massive hemoperitoneum. He subsequently developed ACS and was successfully treated with angioembolization and needle paracentesis. We suggest that bed-side ultrasonography and needle paracentesis be considered as an expedient alternative for decompression of intra-abdominal hypertension in patients with blunt solid visceral organ injury with massive hemoperitoneum and ACS.

Trauma Surgeons Practice What They Preach: The NTDB Story on Solid Organ Injury Management

Recent studies advocate a nonoperative approach for hepatic and splenic trauma. The purpose of this study was to determine whether the literature has impacted surgical practice and, if so, whether or not the overall mortality of these injuries had changed. The American College of Surgeons' National Trauma Data Bank (NTDB 4.0) was analyzed using trauma admission dates ranging from 1994 to 2003. All hepatic and splenic injuries were identified by ICD-9 codes. As renal trauma management has not changed during the study period, renal injuries were included as a control. Nonoperative management (NOM) rates and overall mortality were determined for each organ. Proportions were compared using chi analysis with significance set at p < 0.05. There were 87,237 solid abdominal organ injuries reported and included: 35,767 splenic, 35,510 hepatic, 15,960 renal injuries. There was a significant (p < 0.00000000005) increase in percentage of NOM for hepatic and splenic trauma whereas renal NOM remained stable for the study period. Despite an increase in NOM for splenic and hepatic injuries, mortality has remained unchanged. This study demonstrates that the management of hepatic and splenic injuries has significantly changed in the past 10 years with no appreciable effect on mortality. NOM has become the standard of care for the management of hepatic and splenic trauma. The NTDB can be used to monitor changes in trauma care in response to new knowledge regarding improved outcomes.

Color power Doppler US and contrast-enhanced US features of abdominal solid organ injuries

Utilization of color power Doppler and sonographic contrast agents to basic ultrasound (US) further improve the detection and characterization of abdominal injuries, increasing the diagnostic accuracy and value of US as an important technique in the evaluation of the abdominal trauma. This paper provides an illustrated summary of our clinical experience with color power Doppler US (CD-US) and contrast-enhanced US (CE-US) in the evaluation of abdominal solid organ injuries, involving 32 documented cases over a 2-year period. The findings of the CD-US and CE-US were compared with those provided by state-of-the-art contrast-enhanced multidetector 16-row CT.

Blunt Abdominal Trauma: Emergency Contrast-Enhanced Sonography for Detection of Solid Organ Injuries

The objective of our study was to prospectively compare the diagnostic value of sonography and contrast-enhanced sonography with CT for the detection of solid organ injuries in blunt abdominal trauma patients. Sonography, contrast-enhanced sonography, and CT were performed to assess possible abdominal organ injuries in 69 nonconsecutive hemodynamically stable patients with blunt abdominal trauma and a strong clinical suspicion of abdominal lesions. Sonography and contrast-enhanced sonography findings were compared with CT findings, the reference standard technique. Thirty-two patients had 35 abdominal injuries on CT (10 kidney or adrenal lesions, seven liver lesions, 17 spleen lesions, and one retroperitoneal hematoma). Sixteen lesions were detected on sonography, and 32 were seen on contrast-enhanced sonography. The sensitivity and specificity of sonography were 45.7% and 91.8%, respectively, and the positive and negative predictive values were 84.2% and 64.1%, respectively. Contrast-enhanced sonography had a sensitivity of 91.4%, a specificity of 100%, and positive and negative predictive values of 100% and 92.5%, respectively. Contrast-enhanced sonography was found to be more sensitive than sonography and almost as sensitive as CT in the detection of traumatic abdominal solid organ injuries. It can therefore be proposed as a useful tool in the assessment of blunt abdominal trauma.

Selective Nonoperative Management of Penetrating Abdominal Solid Organ Injuries

To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries. Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs. Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay. During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications. In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.

Outcomes from pediatric solid organ injury: role of standardized care guidelines

Recent advances in the delivery of trauma and critical care in children have resulted in improved outcome following major injuries. It is imperative that physicians who treat injured children familiarize themselves with current treatment algorithms for abdominal trauma. Important contributions have been made in the diagnosis and treatment of children with abdominal injury by radiologists and endoscopists. This report examines the impact of consensus guidelines in the treatment of blunt abdominal solid organ injuries. Consensus guidelines for treatment of children with isolated spleen and liver injury are reviewed demonstrating conformity of care and significant reduction of resource utilization without adverse sequelae. Review of large datasets indicate contrasting rates of splenectomy depending on the expertise of the institution, emphasizing the need for wide dissemination of guidelines. Clinical experience and published reports addressing specific concerns about the nonoperative treatment of children with solid organ injuries and recent radiologic and endoscopic contributions have made pediatric trauma care increasingly nonoperative. Although the trend is in this direction, the pediatric surgeon should remain the physician-of-record in the multidisciplinary care of critically injured children.

No License Required: Severe Pediatric Motorbike-Related Injuries in Ohio

Motorbikes (MBs), including motorcycles and dirt bikes, are becoming increasingly popular among children and adolescents. MBs are intended for off-road use. Although children who are younger than 16 years cannot be licensed to drive cars, they can drive MBs off-road without licenses. The objective of this study was to determine the epidemiology of severe MB injuries to children who are younger than 16 years in Ohio. Eight hospitals that admit the majority of pediatric trauma patients in Ohio were approached to participate. Cases were identified using hospital trauma registries and were defined as any hospitalized child who was younger than 16 years and sustained MB injuries between January 1, 1995, and December 31, 2001. Six hospitals participated. A total of 182 children were hospitalized with a mean age of 11.4 years (range: <1-15 years). A total of 89.6% were male, 89.0% were white, 68.7% had commercial medical insurance, and 71.4% were from urban areas. From 1995 to 1997, there were an average of 20 annual admissions; however, from 1998 to 2001, there were an average of 30 per year. Of the 85% of patients with injury events documented, 35.5% were riding in streets and 53.3% were unhelmeted. One patient died; 8 required rehabilitation. The mean injury severity score was 9.9 (median: 9), and mean length of hospitalization was 4.6 days (median: 3). Unhelmeted riders had significantly higher injury severity scores than helmeted ones (11.5 vs 8.4). The difference in mean length of hospitalization of unhelmeted compared with helmeted riders approached statistical significance (6.1 vs 3.7 days). Of the 163 patients with documented diagnoses, there were 510 injuries; 68.7% of patients sustained multiple injuries. Of all injuries, the most commonly injured body parts were lower extremity (23.4%), head (22.2%), abdomen/pelvis (13.4%), upper extremity (12.4%), and face (11.8%). The most common injuries were fractures (37.1%), abrasions/contusions (24.4%), lacerations (13.4%), intracranial injuries (7.5%), and solid abdominal organ injuries (7.5%). Central and Southwest Ohio had higher numbers of hospitalized injuries than other areas. Urban, white boys with commercial medical insurance predominated among children with MB-related injuries in Ohio. Most injured children did not wear a helmet and sustained multiple injuries. Not wearing a helmet resulted in significantly increased injury severity and a trend toward increased lengths of stay in the hospital. MB-related injuries increased by approximately 50% during the study period. Children should not operate MBs until they are old enough to obtain a motor vehicle driver's license, which occurs at a minimum of 16 years of age. High-risk populations need to be targeted to reduce these injuries, and requiring helmet use while operating MBs should be pursued.

Endovascular repair of traumatic descending thoracic aortic disruptions: should endovascular therapy become the gold standard?

Acute arterial disruptions of the thoracic aorta are rare and often lethal. They are most often due to blunt trauma and occur most commonly just distal to the left subclavian artery origin in the setting of multisystem injuries. The very proximal nature of the lesion in survivors makes open surgical repair hazardous, with mortality rates reaching over 20%. Endovascular therapy is a new and attractive option for the treatment of those challenging patients. Since March 2002, 3 patients with blunt and 1 patient with a stable iatrogenic descending aortic injury were successfully treated at this institution. Spiral computed tomography followed by angiography was used for diagnosis. No preexisting aortic pathology was present. Major associated injuries included unstable thoracic spinal fractures, abdominal solid organ injuries, and hip fractures, making the subjects poor surgical candidates. The Talent Endovascular Graft was deployed via open femoral or iliac artery access under fluoroscopic guidance. All 4 patients underwent successful exclusion of their thoracic pseudoaneurysm with use of the Talent endovascular graft. One patient required partial coverage of the left subclavian artery, and a second patient had an iliac artery stent deployed after traversal of an area of stenosis with the delivery system. There were no cardiac, neurologic, pulmonary, or peripheral vascular complications. Acute aortic disruption, with its associated high surgical morbidity and mortality, is an excellent indication for endovascular therapy to improve patient outcomes. More long-term data are needed on repair durability.

High-intensity ultrasound treatment of blunt abdominal solid organ injury: an animal model.

High-intensity focused ultrasound (HIFU) is effective in producing hemostasis in injuries from organ lacerations and punctures in animals but has not been evaluated in impact injuries. High-energy blows were applied to 11 heparinized and anesthetized pigs, resulting in solid organ injury. HIFU was applied to injuries via laparotomy. The animals were closed, administered saline, observed under general anesthesia for 3.6 +/- 0.4 hours, reopened, and inspected, and abdominal free fluid was aspirated. Organ hemostasis was achieved (mean +/- SD) with 15 +/- 6 minutes of HIFU treatment and 54 +/- 3 minutes of operating time, and 18.8 +/- 13.1 mL/kg of blood was recovered from the abdomen. One animal died from an untreated occult injury to a large vein. HIFU-treated sites were hemostatic at relaparotomy, with 8.6 +/- 6.2 mL/kg abdominal serosanguinous fluid recovered. HIFU is effective in producing hemostasis by direct treatment of injured parenchyma in blunt trauma.

Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study.

Nonoperative management (NOM) of injuries to the liver, spleen, and kidney is highly successful, as shown in retrospective studies, but needs prospective validation. Patients in whom NOM is likely to fail can be identified by specific criteria. Prospective observational study. Academic level I trauma center at a county hospital. Two hundred six patients with injuries to the liver (n = 99), spleen (n = 103), and/or kidney (n = 40). Failure of NOM. Fifty-seven patients (28%) underwent immediate operation; among the other 149, NOM failed in 33 (22%). The rate of failure for spleen injury (34%) was higher than for liver (17%) or kidney injury (18%) (P<.01). Failure of NOM was due to delayed bleeding from a solid viscus in 20 of the 33 patients. Intestinal injury was detected in only 1 patient initially selected for NOM. Specifically among patients with liver injury, no failure was due to delayed bleeding from the liver. Patients with failed NOM were more likely to have a positive abdominal ultrasonographic finding (61% vs 22%; P<.01), a grade of splenic injury of at least III on computed tomographic scan (CT) (n = 20 [17%] vs n = 16 [48%]; P<.01), and an amount of free fluid of greater than 300 mL on CT (36% vs 8%; P<.01) and to receive blood transfusions during NOM (58% vs 16%; P<.01). The groups were not different with regard to associated extra-abdominal injuries (including head injuries). Mortality was not different, but morbidity was marginally higher in patients with failed NOM (29% vs 45%; P =.08). We identified the following 4 independent risk factors of failure by means of stepwise logistic regression: nonliver (splenic or renal) injury, positive abdominal ultrasonography findings, amount of free fluid on CT of greater than 300 mL, and need for blood transfusion. According to a statistical model, the presence of all 4 independent risk factors predicted NOM failure in 96% of the patients, and the absence of all predicted success in 98%. In a prospective study, the rate of NOM failure for solid abdominal organ injuries is higher than the rates reported in retrospective studies. Nonoperative management is less likely to fail in liver injuries than in splenic or kidney injuries. Use of NOM should be exercised with caution if blood transfusion is needed, fluid is identified on the screening ultrasonogram, or a significant quantity of blood is discovered on CT.

The changing face of trauma management and its impact on surgical resident training.

The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.

Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes.

We examined the relationship between survival and time in the emergency department (ED) before laparotomy for hypotensive patients bleeding from abdominal injuries. Patients in the Pennsylvania Trauma Systems Foundation trauma registry with isolated abdominal vascular, solid organ, or wall injuries grade 3 to 6 and hypotension were identified. Deaths were predicted from the prehospital time, systolic blood pressure (SBP) on ED admission, and time in the ED before either laparotomy or ED death. Two-hundred forty-three patients met the criteria. SBP ranged from 30 to 90 mm Hg. Time to the ED ranged from 7 to 185 minutes. Time in the ED ranged from 7 to 915 minutes. Overall, 98 patients died (40%). The risk ratio for the SBP increased, as expected, as SBP dropped. The risk ratio for time spent in the ED before laparotomy increased until 90 minutes, then significantly decreased below all earlier values. Logistic regression on the 165 patients spending 90 minutes or less in the ED showed that the probability of death increased with time in the ED. The increase was as much as 0.35% per minute. Among patients in a trauma registry who were hypotensive on arrival in the ED and had major injuries isolated to the abdomen requiring emergency laparotomy, the probability of death showed a relationship to both the extent of hypotension and the length of time in the ED for patients who were in the ED for 90 minutes or less. The probability of death increased approximately 1% for each 3 minutes in the ED.