Penetrating Abdominal Trauma Research Articles

Broken Dreams of Motherhood: Frida’s Pictures of Pain

The ivory carving presented in last month’s issue reminded us both of Henry Ford Hospital, painted by Frida Kahlo in 1932. We hope that the connection between these pieces, created for such different reasons, will stimulate some reflection. Frida was born outside Mexico City in 1907. In a short life riddled with physical and emotional pain, she survived childhood polio and later, when she was a pre-medical student, a devastating tram car accident. (She said she had two major accidents in her life: the first was being hit by a tram and the second, marrying Diego Rivera.) This small painting (16” × 12”) reflects one facet of her struggles: a history of recurrent pregnancy loss. It was painted while her husband Diego Rivera was working on a series of murals for industrialist Edsel Ford in Detroit. The elements of the painting reflect her reality—the snail symbolizing the agonizing slowness of her struggle to bear children. Her fertility problems may have been secondary to both polycystic ovary syndrome and Asherman’s syndrome. She was slim but somewhat hirsute. Although it is a matter of conjecture, her uterus may have been damaged by both infection and direct trauma, following abortions and a penetrating abdominal injury at the time of the crash. Whatever the underlying pathologies of her life, Frida’s paintings stand out as representations of a woman’s struggle with chronic pain as well as infertility.

A prospective study of conservative management in cases of hemoperitoneum in solid organ injuries at tertiary care hospital in western India.

Background: Blunt abdominal trauma is one of the most common causes among solid organ injuries. Morbidity and mortality in blunt abdominal injuries is major cause of concern for surgeons. Aims & Objective: This study was carried out to analyse patient profile, investigations and management of such patients. Material and Methods: 50 patients, who admitted to civil hospital Surat were studied prospectively. Age and gender distribution, Mode of injury, clinical presentation, solid organs injured, and investigations carried out, length of hospital stay, management – conservative or operative and their outcome were studied. Results: Out of 50 patients 46 were male, and 4 female patients. 60% patients are from 20-40 year age group. Majority are due to road traffic accidents (54%), and abdominal pain is the most common mode of presentation. Spleen (46%) and liver (38%) are the 2 most common organs involved. 88% patients are managed conservatively, remaining have to undergo laparotomy. Length of hospital stay (1-10 days in 37 patients) is lower patients who are managed by conservative management in comparison to operative management (11-20 days in 4 patients). 54% patients required 1 or more units of blood during hospital stay. Conclusion: Non penetrating abdominal injuries are major cause of concern. Ultrasonography and CT scan play major role in detecting solid organ injuries. Conservative management is safer and reliable mode of management in solid organ injuries due to blunt abdominal trauma.

The management of penetrating abdominal trauma by diagnostic laparoscopy: A Prospective non-randomized study

Penetrating abdominal trauma (PAT) has been traditionally treated by exploratory laparotomy (EL). The aim of our study was to examine the use of diagnostic laparoscopy (DL) in the management of hemodynamically stable patients with PAT. A prospective study was performed to compare the outcomes of hemodynamically stable patients with suspected intra-abdominal injuries due to abdominal stab wounds who underwent either EL or DL. Data extracted for analysis included demographic information, operative findings, rates of non-therapeutic laparotomy, operation time, length of hospital stay, mortality, and postoperative complications. Fifty-two hemodynamically stable patients were admitted to the trauma service. There were 45 male (86.5%) and 7 female (13.5%) patients. The average age was 34.5 years-old (18-60). 26 (50%) patients underwent EL, and 26 (50%) patients underwent DL. Re-exploration by laparotomy was required in 9 of the 26 cases (34.6%). Patients who underwent DL had significantly shorter hospital stays (1.82±0.63 days vs. 5.4±2.1 days, p<0.05) and shorter operation time (17.9±6.38 vs. 68.4±33.2 min, p<0.05) than patients who underwent EL. Selective use of DL in the hemodinamically stable penetrating trauma patients effectively decreased the rate of negative laparotomies, minimized morbidity, and decreased hospital stay.

Patients with Penetrating Abdominal Stab Wounds Which Require Laparotomy?

BackgroundThe optimal management of hemodynamically stable asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe cost-effective manner. Common evaluation strategies are local wound exploration (LWE), diagnostic peritoneal lavage (DPL), serial clinical assessment (SCAs) and computed tomography (CT) imaging. Making a decision about the right time to operate on a patient with a penetrating abdominal stab wound, especially those who have visceral evisceration, is a continuing challenge.ObjectivesUntil the year 2010, our strategy was emergency laparotomy in patients with penetrating anterior fascia and those with visceral evisceration. This survey was conducted towards evaluating the results of emergency laparotomy. So, better management can be done in patients with penetrating abdominal stab wounds.Patients and MethodsThis retrospective cross-sectional study was performed on patients with abdominal penetrating trauma who referred to Al- Zahra hospital in Isfahan, Iran from October 2000 to October 2010. It should be noted that patients with abdominal blunt trauma, patients under 14 years old, those with lateral abdomen penetrating trauma and patients who had unstable hemodynamic status were excluded from the study. Medical records of patients were reviewed and demographic and clinical data were collected for all patients including: age, sex, mechanism of trauma and the results of LWE and laparotomy. Data were analyzed with PASW v.20 software. All data were expressed as mean ± SD. The distribution of nominal variables was compared using the Chi-squared test. Also, diagnostic index for LWE were calculated. A two-sided P value less than 0.05 was considered to be statistically significant.ResultsDuring the 10 year period of the study, 1100 consecutive patients with stab wounds were admitted to Al-Zahra hospital Isfahan, Iran. In total, about 150 cases had penetrating traumas in the anterior abdomen area. Sixty-three (42%) patients were operated immediately due to shock, visceral evisceration or aspiration of blood via a nasogastric tube on admission. Organ injury was seen in 78% of patients with visceral evisceration. Among these 87 cases, 29 patients’ (33.3%) anterior fascia was not penetrated in LWE. So, they were observed for several hours and discharged from the hospital without surgery. While for the remaining 58 patients (66.6%), whose LWE detected penetration of anterior abdominal fascia, laparotomy was performed which showed visceral injuries in 11 (18%) cases.ConclusionsAll in all, 82 percent of laparotomies in patients with penetrated anterior abdominal fascia without visceral evisceration, who had no signs of peritoneal irritation, were negative. So, we recommended further evaluation in these patients. However, visceral evisceration is an indication for exploratory laparotomy, since in our study; the majority of patients had organ damages.

The demographics and outcome of patients with penetrating abdominal trauma admitted to emergency medicine department: A descriptive cross-sectional study.

Background:This study was performed to determine the demographic and outcome of penetrating abdominal trauma in patients attending to emergency medicine department.Materials and Methods:This was a descriptive cross-sectional study in Imam Hossein Medical Center. Seventy five patients who came to our department with penetrating abdominal trauma during a 1 year period were enroled into this study and their demographic data and outcome (during the hospitalization) were recorded. The study was at Imam Hossein Medical Center, Tehran, Iran, from 2009 to 2010.Results:Our findings indicate these notable results: 84% of patients were less than 40 years old, most patients attended emergency department during the spring and summer, 72 patients (96%) arrived between 7 pm and 7 am, 74 patients (98.7%) had stab wound and one person (1.3%) was shot, eventually 46 patients (61%) had laparatomy performed and 2 patients (2.7%) died. 59 patients out of 75 study cases appealed to police department and legal medicine council.Conclusions:The incidence of abdominal penetrating trauma due to stab wound is much higher than gunshot in our community, which indicates the importance of educating the emergency staff and preparing the emergency department work place to attend to these patients, especially during the night hours.

Military medical revolution

Abstract : The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.

Role of Laparoscopy in Penetrating Abdominal Trauma: A Systematic Review

Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma The PUBMED database was searched with the keywords "Laparoscopy AND Trauma". Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7-100 %, specificity from 33.3-100 % and accuracy from 50-100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28. In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.

Nonoperative Management of Penetrating Kidney Injuries: A Prospective Audit

The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we review the management and outcome of penetrating kidney injuries at a center with a high incidence of penetrating trauma. Data from all patients presenting with hematuria and/or kidney injury discovered on imaging or at surgery admitted to the trauma center at Groote Schuur Hospital in Cape Town, South Africa during a 19-month period (January 2007 to July 2008) were prospectively collected and reviewed. These data were analyzed for demographics, injury mechanism, perioperative management, nephrectomy rate and nonoperative success. Patients presenting with hematuria and with an acute abdomen underwent a single shot excretory urogram. Those presenting with hematuria without an indication for laparotomy underwent computerized tomography with contrast material. A total of 92 patients presented with hematuria following penetrating abdominal trauma. There were 75 (80.4%) proven renal injuries. Of the patients 84 were men and the median age was 26 years (range 14 to 51). There were 50 stab wounds and 42 gunshot renal injuries. Imaging modalities included computerized tomography in 60 cases and single shot excretory urography in 18. There were 9 patients brought directly to the operating room without further imaging. A total of 47 patients with 49 proven renal injuries were treated nonoperatively. In this group 4 patients presented with delayed hematuria, of whom 1 had a normal angiogram and 3 underwent successful angioembolization of arteriovenous fistula (2) and false aneurysm (1). All nonoperatively managed renal injuries were successfully treated without surgery. There were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2) and shattered kidney (3). Post-nephrectomy complications included 1 infected renal bed hematoma requiring percutaneous drainage. Of the injuries found at laparotomy 12 were not explored, 2 were drained and 5 were treated with renorrhaphy. Penetrating trauma is associated with a high nephrectomy rate (24.3%). However, a high nonoperative success rate (100%) is achievable with minimal morbidity (9%).

Evolution-based algorithm for the management of penetrating abdominal stab injury

As an increasing amount of penetrating abdominal stab injuries has been observed in the last few decades, it is important to evaluate the adequacy of the medical systems and surgical education and training to handle this type of injury. The aim of this study was to analyze the outcome of patients with penetrating abdominal stab injuries admitted to the Emergency Unit and to evaluate the effects of using a new treatment algorithm. From January 2009 to April 2009, a standardized education and training system for the surgical team was implemented in order to improve the emergency medical care system. From April 2009 to April 2011, 106 patients with the diagnosis of a penetrating abdominal stab injury were prospectively included in the study. The cohort included 98 males and the mean age was 29.40±10.9 years. Eighty-two percent of the patients were managed conservatively, whereas 18% underwent surgery. Based on the surgical outcomes of the patients, the rate of negative, non-therapeutic, and therapeutic laparotomies was 5, 11, and 84%, respectively. No statistically significant difference between patients who did and did not receive surgery was observed with regards to blood pressure, temperature, hematocrit, hemoglobin, and C-reactive protein (CRP) values. However, a statistically significant difference was observed in the pulse rate, leukocyte, and neutrophil counts. The mortality and morbidity rates were 0.94 and 3.77%, respectively. Selective non-operative management, which has been standardized in trauma centers, may be carefully utilized in order to treat penetrating abdominal stab wounds with caution in well-equipped medical centers with well-trained staff.

Selective non-operative management of abdominal gunshot wounds: Survey of practise

BackgroundThere is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal gunshot wounds. However, much of the research which supports this conclusion has originated from a few centres, and the actual utilisation of SNOM by trauma surgeons is not known. We therefore conducted a survey to assess the acceptance of this strategy and evaluate variations in practise. MethodsElectronic questionnaire survey of trauma surgeons in the United States of America, Canada, Brazil, and South Africa. Responses were compared using Chi2 and Fisher's exact tests. Results183 replies were received. 105 (57%) respondents practise SNOM of abdominal gunshot wounds, but there are marked regional variations in the acceptance of this strategy (p<0.01). Respondents who had completed trauma (p<0.01) or critical care (p<0.01) fellowships, and those who practise in a higher volume centre (defined as >50 penetrating abdominal injuries seen per year) (p<0.01) are more likely to practise SNOM of gunshot wounds.Most surgeons who practise SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient as a contraindication to attempting non-operative management. Almost all regard CT as essential. Respondents’ preparedness to consider SNOM is related to injury extent. ConclusionsSNOM of abdominal gunshot wounds is practised by trauma surgeons in all four countries surveyed, but is not universally accepted, and there are variations in how it is practised.

Penetrating Abdominal Trauma: Experience in A Teaching Hospital, Calabar, Southern Nigeria

Background: Penetrating abdominal trauma (PAT) typically involves the violation of the abdominal cavity by a gun-shot wound (GSW) or stab wound Recently several studies have favored a more conservative approach as opposed to mandatory exploratory laparotomy. Methods: Patients admitted in the University of Calabar Teaching Hospital (UCTH), Calabar, with PAT from January 2008 to December 2010 were prospectively studied based on a questionnaire. The total number of patients with PAT was compared with total number of emergencies, traumatic injuries and abdominal trauma seen during the same period. Results: A total of 48 patients presented with abdominal trauma: PAT 29 (60%) and blunt abdominal trauma (BAT) 19 (40%). The ages of the patients (28 male, 1 female) ranged from 3 - 62 years (mean 28.1 years). Gunshot wound (GSW) 11 (38%) patients, stab wound 8 (27.6%) patients and machete cut 4 (13.8%) patients ranked first, second and third respectively as causes of PAT. The commonest organ injury was perforation of the small intestine. Four (13.8%) patients were managed conservatively while 25 (86.2%) patients had laparotomy. The duration of admission ranged from 2 - 19 days (mean 10.5 days). Morbidity [surgical site infection (SSI)] and mortality were recorded in 2 (6.9%) and 3 (10.3%) patients respectively. Conclusion: Key areas that require attention have been highlighted. Revamping the ailing economy and gainful employment for youths are paramount areas that require prompt, dedicated and sustained intervention for reduction in violent crimes.

Blunt Abdominal Trauma in a Teaching Hospital, Calabar, Nigeria

Background: Road traffic injury remains a major source of blunt abdominal trauma (BAT). Road traffic injury and other forms of trauma have become a major health problem throughout the world especially in low and middle-income countries. In a previous study (2005-2007), abdominal trauma constituted 79 (4.8%) of trauma cases; BAT, 40 (53%) and penetrating abdominal trauma (PAT), 39 (47%). Effective policies on road safety should be developed based on local research and not on adapted models. We present this study to highlight the possible effect of legislation on the ban of the use of motorcycles on blunt abdominal trauma. Methods: Patients that presented to the University of Calabar Teaching Hospital, Calabar with BAT from 2008-2010 were prospectively studied based on a questionnaire following the legislation prohibiting the use of motorcycles. Results: A total of 12,083 patients presented during the study period, trauma patients totaled 4942 (41%), of this, 48 (1%) suffered abdominal trauma: BAT 19 (40%), penetrating abdominal trauma (PAT) 29 (60%). The age range of the patients was from 5 to 48 years (mean 26.6 years) with a M:F = 5.3:1. Road traffic accident (RTA) 17 (90%) [Motorvehicle 7 (37%), motorcycles 10 (53%)] was the commonest cause of trauma. The spleen was the commonest injured organ 14 (74%). Conclusion: Road traffic injury constitutes a public health challenge and the hallmark is prevention. Legislation prohibiting the use of motorcycles may have been responsible for the reduction in BAT.

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database

The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure. The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality. A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups. The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended.

Integrated model for providing tactical emergency medicine support (TEMS): analysis of 120 tactical situations

Various models for organising tactical emergency medicine support (TEMS) in law enforcement operations exist. In Helsinki, TEMS is organised as an integral part of emergency medical service (EMS) and applied in hostage, siege, bomb threat and crowd control situations and in other tactical situations after police request. Our aim was to analyse TEMS operations, patient profile, and the level of on-site care provided. We conducted a retrospective cohort study of TEMS operations in Helsinki from 2004 to 2009. Data were retrieved from EMS, hospital and dispatching centre files and from TEMS reports. One hundred twenty TEMS operations were analysed. Median time from dispatching to arrival on scene was 10 min [Interquartile Range (IQR) 7-14]. Median duration of operations was 41 min (IQR 19-63). Standby was the only activity in 72 operations, four patients were dead on arrival, 16 requests were called off en route and patient examination or care was needed in 28 operations. Twenty-eight patients (records retrieved) were alive on arrival and were classified as trauma (n = 12) or medical (n = 16). Of traumas, two sustained a gunshot wound, one sustained a penetrating abdominal wound, three sustained medium severity injuries and nine sustained minor injuries. There was neither on-scene nor in-hospital mortality among patients who were alive on arrival. The level of on-site care performed was basic life support in all cases. The results showed that TEMS integrated to daily EMS services including safe zone working only was a feasible, rapid and efficient way to provide medical support to law enforcement operations.

Penetrating abdominal injuries in adults seen at two teaching hospitals in Ghana

The incidence of penetrating abdominal injuries (PAI) has increased in the West African sub-region. To determine the pattern and management outcome of penetrating abdominal injuries (PAI) in the two main teaching hospitals in Ghana. A prospective and retrospective descriptive study. Komfo Anokye Teaching Hospital (KATH), Kumasi and Korle-Bu Teaching Hospital (KBTH), Accra. Relevant details of all adult patients admitted with penetrating abdominal injuries over a 11-year period were recorded at KATH and KBTH in Accra. The study in KATH was prospective pro forma based and that in the KBTH was a retrospective case review of all penetrating abdominal injuries. There were 411 patients, mostly men (M: F-8:1). The peak age of patients was 20-29 years, 164 patients (39.9%). Abdominal stab wound injuries accounted for 251 (61.1%). Three hundred and thirty - one patients (80.5%) had an emergency laparotomy. Twelve patients required 16 emergency thoracotomies. The small bowel (23.2%), stomach (12.9%), colon (10.2%), the liver (10.0%), were the most commonly injured organs. In 92 patients (29.0%) no significant intra-abdominal injury was detected at laparotomy Stab wounds are the main penetrating abdominal injuries seen mostly among young male adults in Ghana. Management was by a mandatory laparotomy after clinical assessment. The overall mortality was 4.4%. Selective non-operative management of abdominal stab wounds is possible.

205 NONOPERATIVE VS OPERATIVE MANAGEMENT OF PENETRATING RENAL INJURIES

INTRODUCTION AND OBJECTIVES: There is limited data on conservative management of penetrating renal trauma. The aim of this study was to review the management and outcome of a large patient cohort presenting with penetrating renal trauma to a tertiary center in South Africa. METHODS: All patients presenting with penetrating abdominal trauma and hematuria admitted to the Trauma Center at Groote Schuur Hospital over a 19 month period [Jan 2008 e July 2009] were prospectively evaluated. Mechanism of injury, micro vs macrohematuria, grade of injury(AAST), management decision(non surgical, surgical for other reasons without renal exploration and true renal surgery with Gerotas fascia opened), non-surgical success rate, complications and nephrectomy rate were analysed. RESULTS: Ninety-two patients (84 male and 8 female) presented with haematuria following penetrating abdominal trauma. There were 74 (80.4%) renal injuries proved with imaging or intraoperatively. Median age was 26 years(range 14–51 years). Trauma mechanism was stab wounds in 50(54.3%) and gunshot wounds in 42 cases (45.7%). Microscopic hematuria diagnosed in 39 cases was associated with grade I, II, III, IV and V renal trauma in 5 (12.8%), 16 (41.0%), 12 (30.8%), 5 (12.8%) and 1(2.6%) patients, respectively. Overall, 18/39 patients (46.2%) with microscopic hematuria had grade III injury or worse. A total of 48 patients with 49 proven renal injuries (66.2%) were treated conservatively. Renal injuries were graded I, II, III, IV, and V in 6 (12.2%), 18 (36.7%), 17 (34.7%), 9 (18.4%), and 0 (0%) cases, respectively. 4 patients(8.3%) in this group presented with delayed hematuria. 3 patients had successful angioembolisation of an arteriovenous fistula(2) and a false aneurysm(1), while one patient had a normal angiogram. None of the patients who were elected to undergo conservative management had any delayed surgical intervention during follow-up. In the cohort of 25 patients with renal exploration, there were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2), ‘shattered’ kidney(3). The nephrectomy conversion rate in all patients surgically explored was 72% with the overall nephrectomy rate being 24.3%. 13 nephrectomies were due to gunshotwounds (72.2%). CONCLUSIONS: If the decision for renal exploration is made, the nephrectomy conversion rate is as high as 72%. Conservative management leads to a high organ preserving success rate (100%) with minimal morbidity. This information is crucial for clinical decision making as aggressive surgical management with renal exploration leads to high rate of potentially preventable nephrectomies.

Post-Traumatic Necrohemorragic Pancreatitis Caused by an Air Gun

Penetrating abdominal trauma is the main cause of pancreatic lesions and delay in diagnosis or treatment can increase morbimortality. We present a case of acute necrohemorrhagic pancreatitis (ANHP) secondary to airgun injury associated with pulmonary embolism caused by the projectile in a 36 year old man. He underwent urgent surgery, appreciating pancreatic contusion but not visualizing the projectile, located by CT scan 3mm from the inferior vena cava. The patient underwent further surgery 48 hours later for necrosectomy and the insertion of an irrigation tube, due to ANHP after the migration of the projectile into the lung. This case underlines the clinical relevance of pancreatic lesion in patients with a penetrating abdominal trauma, the diagnostic difficulty and the surgical strategy, as well as the repercussions of the migration of a foreign body through the blood stream, crossing the right heart chambers and becoming lodged in the lung.

Management guidelines for penetrating abdominal trauma

Patients with penetrating abdominal trauma are at risk of harboring life-threatening injuries. Many patients are in need of emergent operative intervention. However, there are clearly patients who can be safely managed nonoperatively. This review evaluates the literature to identify management guidelines for patients with penetrating abdominal trauma. Accumulating evidence supports nonoperative management of patients with stab wounds to the thoracoabdominal region, the back, flank, and anterior abdomen. Furthermore, select patients with gunshot wounds can be safely managed nonoperatively. Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating abdominal trauma. Thoracoabdominal stab wounds should be further evaluated with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the back and flank should be imaged with CT scanning. Anterior abdominal stab wound victims can be followed with serial clinical assessments. The majority of patients with gunshot wounds are best served by laparotomy; however, select patients may be managed expectantly.

Polytrauma in a 'Violent' South Africa: A Short Visit in a Changing Society

It was not without a little trepidation that I flew into OR Tambo Airport to arrive at Johannesburg, South Africa, for my month fellowship in emergency surgery at the Chris Hani Baragwanath Hospital, ('Bara'). My rationale for the trip was that I wanted to experience polytrauma first hand. My exposure to polytrauma has been limited like many UK graduates but a case involving a major penetrating abdominal injury made me realise that as a potential general surgical consultant, this was a necessity. Even in many sedate suburbs, life has the potential to be violent.

Management of Penetrating Abdominal Trauma in the Conflict Environment: The Role of Computed Tomography Scanning

Computed tomography (CT) scanning is a vital imaging technique in selecting patients for nonoperative management of civilian penetrating abdominal trauma. This has reduced the rate of nontherapeutic laparotomies and associated complications. Battlefield abdominal injuries conventionally mandate laparotomy, and with the advent of field deployable CT scanners it is unclear whether some ballistic injuries can be managed conservatively. A retrospective 12 month cohort of patients admitted to a forward surgical facility in Afghanistan who sustained penetrating abdominal injury severe enough to warrant laparotomy or CT scan were studied. Patient details were retrieved from a prospectively maintained operative log and CT logs. Case notes were then reviewed and data pertaining to injury pattern, operative intervention, and survival were collected. A total of 133 patients were studied: 73 underwent immediate laparotomy (Lap group) and 60 underwent CT scanning (CT group). Of those undergoing CT scanning 17 underwent laparotomy and 43 were selected for nonoperative management. There were 15 deaths in the Lap group and none in the CT group. The median New Injury Severity and Revised Trauma Score was 29 and 7.55 in the Lap group and 9 and 7.8408 in the CT group, which is statistically significantly different (p < 0.001). Five patients in the CT-Lap group had nontherapeutic laparotomies and 1 patient failed nonoperative management. Computed tomography scanning can be used in stable patients who have sustained penetrating battlefield abdominal injury to exclude peritoneal breach and identify solid abdominal organ injury that can be safely managed nonoperatively.