Multiple Intra-abdominal Injuries Research Articles

The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries

BackgroundNonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC). MethodsThis was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00–865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS). Results5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ± 0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001). ConclusionsPTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend. Level of evidenceII Type of studyRetrospective.

Successful Non-Operative Management of Multi-Trauma Patient Suffering from Multiple Intra-Abdominal Injuries - A Case Report

Successful Non-Operative Management of Multi-Trauma Patient Suffering from Multiple Intra-Abdominal Injuries - A Case Report

Traumatic posterolateral abdominal wall hernia in a pediatric patient

Abstract Traumatic abdominal wall hernia (TAWH) is a relatively uncommon injury, with incidence estimates ranging from 1% to 9% of blunt abdominal trauma patients (1). Traumatic posterolateral abdominal wall hernia is an even less common subset of TAWH, in which intra- or extra-peritoneal contents herniate through a defect in the lumbar region within the superior or inferior lumbar triangles (2). The clinical presentation of traumatic posterolateral abdominal wall hernias range greatly, from abdominal wall ecchymosis to frank peritonitis. There is a paucity of reported cases in the pediatric surgical literature of traumatic abdominal wall hernias, and most of these cases are so-called ‘handle-bar injuries,’ resulting from bicycle crashes (3). We present a case report of a child who presented with a traumatic posterolateral abdominal wall hernia following a motor vehicle collision (MVC) and was found to have multiple intraabdominal injuries as well as a diffuse lumbar hernia with incarcerated bowel.

Risk factors for mortality in blunt abdominal trauma with surgical approach.

identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma. retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed. of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002). the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

Unexpected multiple intra-abdominal injuries after projectile fragmentation: report of three cases

Explosives create and energize particles that act as projectiles prone to further fragmentation or create other secondary missiles in the body. These fragments may result in secondary injuries. This has been repeatedly described in the orthopedic and neurosurgical literature. We report the same process for abdominal injuries after fascial penetration in the military setting. This is an observational case series study. Local wound exploration as a standard approach was performed in conscious patients who sustained abdominal wall injuries. Patients with negative physical examination were excluded from the study. An intraperitoneal injury was assumed in those with a full-thickness fascial defect, and laparotomy was performed. Twenty patients met the study eligibility criteria. Of those 20 patients, 12 had negative wound exploration and were excluded from the study, while abdominal organ injuries were found in eight (40%) patients. During laparotomy, projectile-induced injuries in a sprayed distribution were found in three (38%) of these patients. These injuries were far from the predictable trajectory and in the absence of bone fragmentation. The overall mean number of peritoneal defects was 1.7, and a mean 6.8 intra-abdominal injuries for each peritoneal defect were found when through-and-through injuries were excluded.Despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. Under mass casualties, wound exploration with a full-thickness fascial defect could serve as an indicator of possible intra-abdominal injuries, and consequently indicate exploratory laparotomy.

Pancreatic Trauma-12-Year Experience From a Tertiary Center

Pancreatic trauma is rare and often missed during initial assessment of patients with abdominal trauma. This study reviews our experience of managing pancreatic trauma at a tertiary referral center and discusses the diagnostic and therapeutic challenges. A retrospective study of our prospectively maintained hepato-pancreatico-biliary database for 12 years preceding December 2007. Twenty-eight patients (23 males, 10 children) with a median age of 11.5 years (range, 6-16 years) in children and 27.5 years (range, 17-54 years) in adults were identified. Nineteen of the 28 had pancreatic duct injury of which 15 were missed on initial evaluation and referred after conservative management (n = 9) or laparotomy (n = 6). Twenty-one patients developed complications including abdominal collections (n = 10), pancreatic fistulae (n = 9), and pseudocysts (n = 2). There were 2 deaths (7%), both of which were associated with multiple intra-abdominal injuries. At a median follow-up of 7.5 months (range, 3-44 months), 19 of 23 patients were asymptomatic and had been discharged from follow-up. Pancreatic trauma in the United Kingdom is mainly the result of blunt trauma and most commonly affects young males. The presence of pancreatic duct disruption accounts for most of the complications, and in the absence of associated injuries, mortality is rare.

Blunt abdominal trauma with small bowel injury: are isolated lesions riskier than associated lesions?

PURPOSE: The objective of this study was to compare patients with "isolated" blunt small bowel injury (SBI) to patients with multiple intra-abdominal injuries and analyze whether delayed laparotomy affected outcome. METHODS: Medical records of patients that suffered a blunt SBI between 1994 and 2005 were reviewed. The patients were divided into two groups: those with isolated SBI and those with other associated intra-abdominal injuries ("non-isolated"). The method of diagnosis, time to operation, small bowel Organ Injury Scale (OIS) assessment (grade &gt; 2), injury severity score (ISS), morbidity, and mortality were analyzed. RESULTS: A total of 90 patients met the inclusion criteria, including 62 (68.9%) isolated cases and 28 (31.1%) non-isolated cases. Isolated cases required more supplementary diagnostic methods than the non-isolated cases. Non-isolated cases had a shorter diagnosis to treatment period (p &lt; .01) and a higher ISS (mean 22.5 vs. 17.2 in "isolated" group). Morbidity (51.6% and 53.6%) and mortality (16.1% and 28.6%) did not differ significantly between the isolated and non-isolated groups. Delays in diagnosis were common in the isolated group, but this did not affect outcome. Patients with associated injuries, and higher ISS, had higher mortality. CONCLUSIONS: The presence of associated intra-abdominal injuries significantly affected the presentation and time to diagnosis of patients with SBI, but not morbidity or mortality. Delayed surgical treatment in the isolated cases was not associated with an increased incidence of complications. Patients inflicted with more severe associated injuries were less likely to survive the trauma.

A Novel Approach to the Treatment of Gunshot Injuries to the Sacrum

Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5-9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.

Abdominal seat belt marks in the era of focused abdominal sonography for trauma.

Focused abdominal sonography for trauma (FAST) is an unreliable method for assessing intra-abdominal injury in patients with seat belt marks. Retrospective review of trauma patients with intestinal injury and seat belt marks during a 3-year period. Records were reviewed for patient demographics, FAST results, computed tomographic (CT) scan results, and operative findings. The CT scan results were considered positive if bowel wall thickening, extraluminal air, or free fluid without solid organ injury were present. University hospital designated as a level I trauma center. Twenty-three patients who required operation for intestinal or mesenteric injury and who had an abdominal seat belt mark. Sensitivity of FAST in these patients. All patients were evaluated using both FAST and CT scan of the abdomen and pelvis. Eighteen patients (78%) had either negative or equivocal FAST results when significant intestinal injury was present. All 23 patients had CT scan findings suggestive of bowel or mesenteric injury. Moderate-to-large free intraperitoneal fluid without solid organ injury was the most common finding (n = 21, 91%). Operative findings included small-bowel perforation (n = 18, 78%), colonic perforation (n = 7, 30%), bowel deserosalization (n = 8, 35%), and isolated mesenteric injury (n = 5, 22%). Sixteen patients (70%) had multiple intra-abdominal injuries. All patients were taken directly from the emergency department to the operating room. Seventeen percent of operative explorations (4/23) were nontherapeutic (no repairs required). This study confirms that FAST cannot reliably exclude intestinal injury in patients with seat belt marks.

Effects of other intra-abdominal injuries on the diagnosis, management, and outcome of small bowel trauma.

Difficulty with and delays in diagnosis are possible causes of increased morbidity and mortality in small bowel injuries. We assessed whether multiple intra-abdominal injuries led to earlier laparotomy and whether this resulted in improved outcome. Patients with small bowel injuries between January 1993 and December 1997 from the trauma database at St. Michael's Hospital in Toronto were assessed after dividing them into those with isolated small bowel injury ("isolated") and those with small bowel injuries in association with other intra-abdominal injuries ("nonisolated"). Parameters compared were age, gender, length of stay, mortality, intra-abdominal complications, mechanism of injury, diagnostic time, and how the diagnosis was made. Of 1,207 patients, 244 sustained abdominal injuries, and 83 had small bowel injuries (30 patients in the isolated group and 53 in the nonisolated group). Groups were similar with respect to age and gender, yet differed significantly with respect to mechanism and mean Injury Severity Scores (isolated, 18 +/- 8 vs. nonisolated, 30 +/- 15). Outcome differed between groups, as mortality (isolated, 0 of 30 vs. nonisolated, 4 of 53 deaths), length of stay (isolated, 13 +/- 2 vs. nonisolated, 22 +/- 3 days), and patients with intra-abdominal complications (isolated, 5 of 30 vs. nonisolated, 14 of 53 patients) were significantly higher in the nonisolated group. Time to diagnosis was significantly less in the nonisolated group. Decision for laparotomy and diagnosis of small bowel injuries were based more on physical findings in the nonisolated group and on computed tomography in the isolated group. The presence of associated intra-abdominal injuries significantly affects presentation and outcome of patients with small bowel injuries and the selection of diagnostic modalities.

Lethal abdominal gunshot wounds at a level I trauma center: analysis of TRISS (revised trauma score and injury severity score) fallouts

Background: The TRISS methodology (composite index of the Revised Trauma Score and the Injury Severity Score) has become widely used by trauma centers to assess quality of care. The American College of Surgeons recommends including negative TRISS fallouts (fatally injured patients predicted to survive by the TRISS methodology) as a filter to select patients for peer review. The purpose of this study was to analyze the TRISS fallouts among patients with lethal abdominal gunshot wounds admitted to a level I trauma center. Study Design: All patients categorized as TRISS fallouts admitted from January 1995 through December 1996 were analyzed. Results: During the study period, 848 patients with abdominal gunshot wounds were admitted. Of the 108 patients with any sign of life on admission who subsequently died, 39 (36%) were TRISS fallouts. The patients were largely young (mean age, 29 years) and male (87%), received rapid transport (mean scene time, 11 minutes), and had an attending-led trauma-team response (<5 minutes, 87%). Major vascular (80%) and multiple intraabdominal injuries (90%) predominated. The mean Penetrating Abdominal Trauma Index was 40.3. The mean TRISS probability of survival was 89%. The peer-review process deemed the deaths to be nonpreventable in 38 patients (97%) and potentially preventable in one patient (3%). Conclusions: “TRISS fallouts” were predominantly patients who died despite receiving rapid prehospital transport, rapid senior-level trauma-team response, and surgical intervention for a serious complex of injuries. We conclude that without regional adjustment of coefficients used to predict the probability of survival, the TRISS methodology is of limited use in patients with abdominal gunshot wounds.

Factors affecting survival of children after abdominal trauma in Lebanese civil war

To evaluate the risk factors affecting the survival of children with war injuries involving the abdomen, 270 children under 16 years of age with abdominal injuries during the civil war in Lebanon were studied. One hundred and ninety (70%) sustained penetrating injuries and 80 (30%) blunt trauma. The overall infection rate was 7.8%. There were 13 deaths (4.8%), 7 early and 6 late. Mortality was higher in patients with shock on admission than in those without shock (P = .009). Multiple logistic-regression analysis showed that inadequate initial treatment requiring a second laparotomy (P = .01), severe hypovolemia requiring large blood transfusions (P = .0001), and multiple intra-abdominal injuries (P = .001) were the three independent risk factors that influenced the outcome of treatment. Wound infection was associated with a higher mortality in patients with penetrating injuries (P = .0001). This study suggests that in children with war injuries involving the abdomen, multiple injuries associated with excessive bleeding led to early death and wound infection in penetrating injuries to late death.

Traumatic duodenal hematoma in the pediatric patient

Twenty children with duodenal hematomas secondary to blunt trauma were treated between 1953 and 1983. The duodenal injury was isolated in ten cases and associated with intra-abdominal injuries in the others. In ten, the duodenal injury was suspected on admission and the diagnosis was confirmed within 24 hours by radiographic contrast studies. All ten were managed successfully with nasogastric suction and intravenous fluids. Ten patients underwent laparotomy for increasing abdominal tenderness and guarding. An isolated duodenal hematoma was found in four and treated by evacuation and/or gastroenterostomy. In five of the remaining six surgical patients, all of whom had multiple intra-abdominal injuries, the duodenum was left untouched. Three of these patients had postoperative contrast studies that showed early resolution of the duodenal hematoma. No duodenal stricture or leak developed in any patient. The children with isolated duodenal hematomas who were treated conservatively had a mean hospital stay of six days, whereas those treated surgically had a mean stay of 17 days. The ten patients with multiple intra-abdominal injuries had a mean hospital stay of 32 days. In this group, eight required total parenteral nutrition or nasojejunal feeds for nutritional support. In these patients, an isolated duodenal hematoma resulted in minimal morbidity and nonoperative management was usually successful. The presence of associated intra-abdominal injuries was responsible for the prolonged hospitalization and delayed return of normal intestinal function in some patients.

Gunshot wounds of the left upper abdominal quadrant associated with multiple intraabdominal injuries

This study reviews low velocity gunshot wounds of the left upper quadrant of the abdomen and presents four cases recently treated at Boston City Hospital. All patients sustained multiple intraabdominal organ injuries and underwent prompt exploration. Hypotension on admission seemed to be the most reliable sign for a prolonged and complicated hospital course. The essential preoperative studies in stable patients should include a chest x-ray and intravenous pyelogram. Intraoperatively, injury to the body or tail or the pancreas is best managed by distal pancreatectomy and sump drainage. Exploration of the retroperitoneum is warranted for bleeding from the kidney. Initial maneuvers should be designed to control hemorrhage from the renal pedicle. If this is unsuccessful or the renal parenchyma is badly fragmented, nephrectomy should be performed. The complications noted in our patients, infection (pneumonia and left subphrenic abscess) and hemorrhage, are comparable to those reported in most large series. Pancreatic complications (fistulas, pseudocysts, and pancreatitis) were not noted.

Trends in Blunt Abdominal Trauma among Hospital In-patients: Developments in a Swedish Rural District over 30 Years

To analyse changes in background factors, injury pattern, and prognosis regarding blunt abdominal trauma in Sweden, the 30-year postwar (1946--75) development was investigated in a rural district. 396 patients were treated, showing a great increase during the last 5 years. The highest frequency was seen in patients aged 11--30 years. Abdominal trauma occurred most commonly during July and August. The growing aetiological importance of road accidents is shown. Equestrian accidents were common early in the period and again towards the end. The incidence of cerebrally confused patients increased. The organs most commonly traumatized were kidney, liver, and spleen. The frequency of multiple intra-abdominal injuries and also associated extra-abdominal injuries increased with time. There was a tendency towards shorter hospital stays. Mortality rates did not change during the period, even though injuries have become increasingly severe (judged by the Injury Severity Score). It is concluded that the improved care of patients compensated precisely for the increased severity of injuries, as reflected in mortality.

Controversial aspects of diagnosis and management of blunt abdominal trauma

Controversial factors from the literature in the diagnosis and management of blunt abdominal trauma have been discussed in relation to experiences with 278 patients during the past sixteen years. There should be little controversy over the need for a team approach in the management of these patients. The frequency of multiple intra-abdominal injuries requires broad experience with all abdominal surgery or close cooperation between general surgeon and urologist. A transperitoneal approach through a midline incision seems preferable to more limited procedures. The frequency of extraabdominal injury further encourages close consultation with the orthopedist, thoracic surgeon, and neurosurgeon. Special diagnostic procedures do not replace repeated clinical evaluation in diagnostic accuracy. Realization that roentgenograms are of very limited value except in injuries of the genitourinary tract may decrease controversy regarding their routine use. The value of the white blood cell count as an aid to diagnosis of visceral injury is lessened in the light of the frequent leukocytosis which occurs with injuries to the extremities and head in the absence of abdominal injury. Needle paracentesis is of value only when performed carefully and when negative aspirations are not considered of diagnostic significance. Controversies regarding the management of injuries to specific organs have been discussed. Pancreatic fistulas continue to occur after external drainage procedures; further evaluation of internal drainage with the initial operation is encouraged. Liver resection should present no controversy if it is performed when necessary to accomplish adequate debridement. Double catheter drainage after repair of injury to the bladder seems less important than assurance that the drainage tube remains open. Much of the controversy regarding management of abdominal injuries may arise from combining statistically those patients with blunt and open injuries or failure to appreciate the importance of multiple injury.