Is positive diagnostic peritoneal lavage an absolute indication for laparotomy in all patients with blunt trauma? The Montreal General Hospital experience

The authors review the use of diagnostic peritoneal lavage (DPL) at The Montreal General Hospital between 1982 and 1987. Fifty-two of 254 patients admitted with a diagnosis of blunt abdominal trauma underwent DPL: results of the procedure were negative in 23 and positive in 29 (grossly positive in 27). Twenty-one of the 23 patients with negative findings were managed nonoperatively; the other 2 underwent laparotomy, which revealed no abnormalities. Nineteen of the 29 patients with positive findings were managed by immediate laparotomy; the other 10 were managed conservatively. The mean (+/- standard deviation) injury severity score (ISS) in the latter group was 13.1 +/- 8.01. The group managed by immediate laparotomy had an ISS of 25.91 +/- 12.81 (p = 0.007). The number of patients suffering from class I or class II shock in the group managed nonoperatively was significantly (p = 0.045) larger than those in the group managed by laparotomy. The authors conclude that a positive result DPL is not a sine qua non for immediate laparotomy in all patients with blunt abdominal trauma. A selective approach can be taken in these patients, considering the severity of the associated injuries and the patient's hemodynamic status. Intensive-care monitoring must be available.     

Abdominopelvic computerized tomography and open peritoneal lavage in patients with blunt abdominal trauma: a prospective study

This prospective trial compares abdominopelvic computerized tomography and open peritoneal lavage in the diagnosis of blunt abdominal trauma. Fifteen patients (group 1) were evaluated by both methods. Another 15 patients (group 2) had only computerized tomography. Criteria for a "positive" scan were hemoperitoneum and evidence of solid organ injury. Criteria for "positive" lavage were a grossly bloody return, erythrocyte count greater than 20.0 X 10(9)/L and leukocyte count greater than 0.5 X 10(9)/L. At laparotomy, only injuries requiring repair or excision were considered "true positive". Patients who did not have laparotomy and had an uncomplicated clinical course were considered "true negative". With tomographic criteria alone for diagnosis there would have been one false-positive and three false-negative results, compared with three false positive and no false negatives for open peritoneal lavage alone. None of the three patients who had negative findings on laparotomy suffered any morbidity or died. Results of computerized tomography and open peritoneal lavage agreed in 8 of 15 patients (kappa value = 0.52), indicating a low level of agreement between the two. The authors believe that open peritoneal lavage remains the diagnostic procedure of choice in blunt abdominal trauma.     

Evaluation of blunt abdominal trauma occurring during pregnancy

Evaluation of abdominal trauma in pregnant patients presents a number of dilemmas. Few series compare the various modalities available in this situation. The present review characterizes various techniques and their results. The charts of all patients with a secondary diagnosis of pregnancy admitted to a Level I trauma center over a 7 1/2-year period were reviewed. Forty were considered to have sustained possible blunt abdominal trauma: 30 were occupants in motor vehicle collisions, five were pedestrians, four sustained falls, and one was riding a motorcycle. Immediate laparotomy for emergency caesarean section or other indications was performed in three cases (7%). In 13 cases (32%) evaluation was accomplished by diagnostic peritoneal lavage (DPL). Three patients (7%) underwent computerized tomography of the abdomen. The remaining 22 patients (55%) were observed with serial physical exams, and hematocrits. The group that was observed had a mean ISS of 5.9. The mean Glasgow Coma Score (GCS) was 14.9. No patients had to undergo exploratory laparotomy for abdominal injury during hospitalization. In the 13 patients undergoing DPL, the mean ISS was 34.6, and the mean GCS was 10.6. Overall accuracy was 92% with no major complications. Pregnant patients sustaining minor injuries and blunt abdominal trauma may be safely observed. Those with major injuries, shock, altered mental status, or neurologic deficit require further studies to rule out intra-abdominal injury. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. CT scan and ultrasonography are other modalities which merit further assessment as a primary diagnostic technique in abdominal trauma occurring during pregnancy.     

Selective peritoneal lavage in the management of comatose blunt trauma patients

Comatose blunt trauma patients undergo diagnostic peritoneal lavage to aid in the management of severe injuries. In deference to routine performance of lavage, patients felt to be a risk for abdominal injury were prospectively studied by using selective criteria for lavage. One hundred consecutive comatose blunt trauma patients were studied; five underwent urgent celiotomy for refractory hypotension. Five criteria for lavage were: history of postinjury hypotension, abdominal physical findings suggestive of underlying abdominal injuries, evidence of fracture of the bones of the trunk and/or femur, blunt trauma of unknown etiology, and operative general anesthesia required for nonabdominal injuries. Fifty-five patients satisfied at least one of the above criteria and underwent peritoneal lavage. Forty patients not satisfying the criteria were observed without peritoneal lavage, as it was felt they had a decreased probability of serious abdominal injury. One of these patients had a minor liver laceration found at the time of autopsy following his death from severe head injury. None of the other patients had evidence of intra-abdominal injury by autopsy or subsequent clinical course. Utilizing the selective criteria, none of the 100 consecutive blunt trauma patients had major delay in abdominal diagnosis or missed significant abdominal pathology defined by operation, clinical course, or autopsy. Routine peritoneal lavage in all comatose blunt trauma patients may subject the patient to unnecessary risk, waste valuable time, increase the cost of care, and alter subsequent diagnostic procedures. Based on this small study, it appears that comatose blunt trauma victims not fulfilling the criteria may be effectively evaluated without the use of peritoneal lavage.(ABSTRACT TRUNCATED AT 250 WORDS)     

98例重型颅脑外伤合并多发伤的院前急救分析

目的探讨如何提高重型颅脑损伤合并多发伤整体救治水平。方法对我院2003年1月至2007年12月救治的98例重型颅脑损伤合并多发伤患者进行回顾性分析。结果在本组98例重型颅脑外伤合并多发伤患者中存活71例,死亡27例（27．6％）。死亡组的病人GCS评分及ISS评分均低于存活组的病人（P〈0．05）,合并器官损伤的数量多于存活组（P〈0．05）,受伤到院前急救时间及受伤到手术时间均长于存活组（P〈O．05）。结论重型颅脑损伤合并多发伤成功救治的关键是重视事发现场与院前的急救,缩短患者受伤到急诊科救治的时间、缩短急诊确诊时间、及时通过绿色通道进行手术治疗。     

Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible     

Mortality in retroperitoneal hematoma

Eighty-one patients sustained retroperitoneal hematoma (RH) from blunt (70%) and penetrating (30%) trauma. Retroperitoneal hematomas were classified into 10 centro-medial Zone I, 25 lateral Zone II, and 46 pelvic Zone III hematomas. The mean injury Severity Score (ISS) for the entire series was 26.4 +/- 14. The mean ISS of nonsurvivors was 37.6 +/- 12. Overall mortality was 20%; if head injury deaths are excluded (six), mortality was 13%. Retroperitoneal hematoma associated with pelvic fracture had a mortality of 19%. Incidence of respiratory failure for entire series, excluding head trauma, was 29%. Respiratory failure occurred in 37% of patients with Zone III injuries. A requirement for ventilatory support greater than 48 hours was associated with a mortality of 35%. PaO2/FIO2 at 48 hours in intubated patients was significantly decreased in nonsurvivors compared to survivors, whereas the mean ISS of this subset of patients did not differentiate between survivors and nonsurvivors.     

Liver lacerations--a marker of severe but sometimes subtle intra-abdominal injuries in adults

Experience with conservative management of solid viscus injuries from abdominal trauma in children has produced the impetus for a similar management in adults. To explore the implications of such a policy, we reviewed the records of 82 patients with hepatic injuries noted at laparotomy. Indications for laparotomy were positive findings on diagnostic peritoneal lavage (DPL) or CT scan, or a history of penetrating trauma. The liver injuries were graded according to severity: grade I, 19 patients; grade II, 20 patients (low severity = LS); grade III, 14 patients; grade IV, 6 patients (high severity = HS). Twenty-three injuries were not classified by the operating surgeon. Of the 53 patients with blunt hepatic trauma, 23 (43%) had concomitant injuries that required operative intervention. Twenty-nine patients had penetrating liver injuries. Fourteen (48%) had associated injuries requiring intervention. Patients most likely to have nonoperative management, those with grade I and grade II liver injuries (LS), comprised 48 of the total. In this subgroup there were 26 (54.2%) associated injuries requiring operative intervention. Shock could not be used as a factor to differentiate patients not requiring operative intervention. Nineteen of the LS patients requiring operative intervention secondary to associated injury were never in shock. In adult trauma victims positive DPL findings secondary to minor hepatic injuries that might not require operative intervention serve as a marker for associated injuries that do require operation. The risk of nonoperative management of hepatic injuries based upon radiologic diagnosis is not the result of complications from the hepatic injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison between operative and nonoperative management of blunt injuries to the liver and spleen in adult and pediatric patients

Nonoperative management of blunt trauma involving the liver and spleen has been accepted in stable pediatric patients but has been controversial in adult patients. The purpose of this study was to compare nonoperative management of blunt liver and spleen injuries in adult patients with a similar group of adult patients treated operatively and with a group of pediatric patients treated nonoperatively. A 5-year retrospective study was carried out on all hemodynamically stable patients who came to our institution with blunt abdominal trauma. There were 20 adults treated operatively (group I), 25 adults treated nonoperatively (group II), and 34 pediatric patients treated nonoperatively (group III). The mean acute physiology and chronic health evaluation score for group I was 5.1; group II, 3.1; and group III, 7.9. Delayed splenectomy was required in four adult patients in group I and in one patient in group III. There were no deaths. The mean total blood requirement was 6.0 units for group I, 2.8 units for group II, and 1.7 units for group III. The average hospital stay was 19.1 days for group I, 12.6 days for group II, and 9.2 days for group III. These data suggest that the outcome of adult patients whose blunt liver and spleen injuries are managed nonoperatively is comparable with that of pediatric patients treated nonoperatively and is as good as that of adults undergoing early laparotomy.     

Abdominal trauma with special reference to hepatic trauma.

Of 882 patients admitted over a 6-year period to the adult trauma service at the Health Sciences Centre in Winnipeg, 325 (37%) suffered from abdominal trauma; 241 (74%) sustained a blunt injury and 84 (26%) a penetrating wound. Laparotomy is indicated when there is evidence of intra-abdominal hemorrhage, perforation of a viscus or penetration of the peritoneum. Peritoneal lavage is extremely useful in the diagnosis of intra-abdominal bleeding; it was used in 79 cases among which were four false-positive and two false-negative results. Fifty-six cases of hepatic injury were treated; 43 of these were caused by blunt trauma. Temporary packing and drainage sufficed as treatment in many of these patients but the placing of suture-ligatures at exposed bleeding points is often called for. Resection of hepatic tissue was required in 10 cases and ligation of the right hepatic artery in 2. Of the seven deaths in the series only one was attributed to the liver injury itself.     

严重多发脏器损伤的临床特点及诊治

目的探讨严重多发脏器损伤的临床特点和诊治方法.方法对1988～1998年间收治的合并有闭合性腹内脏器损伤的严重多发伤、ISS大于16的165例患者进行回顾性分析.结果3个或3个以上部位多发伤占28.5%.63例有腹内多脏器损伤.腹腔穿刺是确诊的主要检查手段,部分病例选用了腹部B超和CT,3项诊断检查阳性率均在90%以上.全组漏诊腹内伤21例(12.7%),死亡29例(17.6%).死亡病例平均ISS41.6,明显高于非死亡病例24.8(t=15.21,P<0.01).结论严重多发伤病例应常规行诊断性腹腔穿刺,酌情选择腹部B超和CT等检查,以排除腹内脏器损伤.对全身多发伤并存腹内伤的病例,要根据伤情确定急救处理顺序.剖腹手术中要注意多脏器损伤.ISS大于40提示预后不良.     

Injuries of the small and large intestine in the traumatized abdomen

Between 1973 and 1989 a total of 388 patients underwent laparotomy because of abdominal trauma. In 98 cases, injuries of the small bowel, the colon or the mesentery were found. The injuries were caused by motor vehicle accidents in 55 patients; 12 had gunshot or stab wounds and 12 committed suicide. There were 78 patients who had sustained a blunt abdominal trauma and 20 patients with a penetrating trauma. Only 21 patients had suffered a solitary injury of the gastrointestinal tract. In 41 patients there were also lesions to other intraabdominal organs, in 11 patients, thoracic injuries and in 24 patients, a craniocerebral trauma. Combined injuries of skull, thorax and abdomen were present in 24 patients. Neither ultrasound nor peritoneal lavage allows reliable prediction of injuries of the gastrointestinal tract. In 51 cases a defect of the mesentery or serosa was repaired. In 54 patients there was a rupture of the small or large intestine: in 20 of these cases primary repair without resection was performed and in 34, resection and anastomosis. Ileostomy or colostomy was done in only 8 patients. An anastomotic leak developed in 2 patients. Lethality is correlated to the extent of concomitant injuries. Solitary injury of the small bowel or colon was followed by lethality of only 4.1%, increasing to 50% in patients with combined injuries of skull, thorax and abdomen.     

Evaluation of staff workload during resuscitation of trauma patients

OBJECTIVE: Evaluating the medical staff workload during resuscitation of trauma patients is one of the important quality assurance activities to provide adequate medical manpower, especially for patients with life-threatening or severe injuries. Nevertheless, there is no method available to measure and calculate the amount of workload during resuscitation. We sought to develop a new framework of Workload Scoring System (WSS) to evaluate and quantify the medical staff workload during resuscitation. METHODS: From July 1996 to July 1998, the records of 11,800 trauma patients were prospectively collected from our computer-stored medical record system. The Workload Scoring System points with reference to age, different triage category on the basis of triage version of the Revised Trauma Score (RTS), level category on the basis of Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) in six body regions were calculated to survey the medical staff workload. RESULTS: The WSS points were 18.51 +/- 0.80 for triage I, 11.88 +/- 0.17 for triage II, and 6.90 +/- 0.04 for triage III trauma patients. The WSS points were 23.10 +/- 0.67 for Level I, 20.34 +/- 0.25 for Level II, 12.87 +/- 0.08 for Level III, and 6.03 +/- 0.02 for Level IV trauma patients. There were statistically significant differences among triage I, II, and III trauma patients, and among Level I, II, III, and IV trauma patients (p < 0.01). The worse the physiologic status and the greater the anatomic damage, the more medical staff workload was needed. Multiple regression with linear model may predict WSS points as an equation of -8.920 + 1.375 ISS + 1.785 RTS + 0.424 Age (r2 = 0.621), which accounts for 62.1% of the variance in WSS points. CONCLUSION: WSS provides a valuable tool to measure and quantify the medical staff workload during resuscitation as a function of -8.920 + 1.375 ISS + 1.785 RTS + 0.424 Age. The greatest benefit of this methodology is to forecast the expected medical staff workload to allocate sufficient medical manpower to provide the desired trauma care.     

Pelvic radiography in blunt trauma resuscitation: a diminishing role

BACKGROUND: An anteroposterior pelvic radiograph (PXR) continues to be recommended by Advanced Trauma Life Support protocol as an early diagnostic adjunct in the resuscitation of blunt trauma patients. At the same time, computed tomographic (CT) scanning has become a practice standard for diagnosis of most abdominal and pelvic injury. The objective of this study was to determine the necessity of obtaining an early PXR in stable trauma patients who will undergo CT scanning during the initial resuscitation. METHODS: A retrospective review of all blunt trauma patients undergoing immediate abdomen and pelvic CT scanning was performed from July 2000 until June 2001 at an urban Level I trauma center. These patients were divided into two groups depending on whether they also received a PXR (group I) or not (group II). At the time of the study, there was no formal protocol to determine which patients underwent pelvic radiography. Radiology reports of all PXRs and CT scans were reviewed. Patient demographics and Injury Severity Scores (ISSs) were abstracted from our trauma registry. The data were analyzed using Student's test. RESULTS: A total of 686 patients with blunt trauma underwent CT scanning of the abdomen and pelvis. Group I consisted of 311 (45%) patients with an average ISS of 12.3 +/- 0.7. In group I, 56 (10%) patients were found to have at least one pelvic fracture on CT scan, 38 of which were also identified on the PXR. Defining CT scanning as the definitive test, the sensitivity and specificity of the PXR in group I was 68% and 98%, respectively. The false-negative rate for pelvic radiography was 32%. In all patients with a positive PXR, the majority (55%) had either additional fractures or an increase in the Young and Burgess grade of fracture diagnosed on CT scan. Group II consisted of 375 patients, with 16 fractures noted in 13 (3%) patients, none of which required treatment. The mean ISS of group II was 8.0 +/- 0.5. CONCLUSION: The PXR has limited sensitivity for detecting pelvic fractures compared with CT scanning. Selected hemodynamically stable patients who undergo CT scanning during their immediate resuscitation do not need a routine PXR. The PXR may continue to be beneficial in unstable patients, those with positive physical findings, or those who cannot undergo CT scanning because of other clinical priorities.     

Abdominal injuries associated with lumbar spine fractures in blunt trauma

BACKGROUND: Specific analysis of the relationship between abdominal injuries and lumbar spine fractures has not yet been reported. METHODS: A retrospective review of 258 blunt trauma patients with lumbar spine fractures treated between 1991 and 1996. RESULTS: 26 patients sustained concomitant lumbar spine fractures and abdominal injuries. The mechanism of injury was motor vehicle collision (73%), pedestrian-struck (11%), fall (8%) and assault (8%) resulting in ISS, RTS and mortality of 27 +/- 4, 6.5 +/- 0.4 and 8%, respectively. Forty-four lumbar spine fractures were identified (1.7/pt) in association with splenic (54%), renal (41%), hepatic (32%) and small bowel (23%) injuries and no retroperitoneal involvement. Multilevel lumbar spine fractures were associated with a higher organ injury/fracture ratio compared with single level fractures (p < 0.01) including a twofold higher incidence of solid organ (spleen, liver and kidney) injury (p < 0.01). The level and type of fracture did not affect the incidence of total and individual organ injury. Patients with abdominal injuries were more severely injured mainly due to increased incidence of associated thoracic injuries although no significant difference in mortality was observed. CONCLUSION: Abdominal injuries occurred only in the minority of blunt trauma patients with lumbar spine fractures. These injuries, which followed a similar distribution pattern as in blunt trauma in general, occurred most commonly due to motor vehicle collisions and in association with multilevel vertebral fractures. No correlation with fracture type or level was identified.     

Computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. Their combined role

We reviewed medical records and films of all 196 trauma patients who underwent computed tomography (CT) between June 1982 and October 1986 to see whether CT achieved the level of accuracy attributed to it, whether diagnostic peritoneal lavage (DPL) performed in conjunction with CT was a useful diagnostic test for blunt abdominal trauma, and whether laparotomy was mandatory when pelvic fluid collections were seen by CT after blunt trauma. A total of 36 patients underwent DPL, 29 before and seven after CT. There were seven false-negative CTs that were clinically significant. Diagnostic peritoneal lavage was positive in three patients who had false-negative CTs. Although overall accuracy was excellent, CT was not reliable in detecting bowel injury. Diagnostic peritoneal lavage was helpful in detecting injuries missed by CT. Most stable patients with moderate or large intraperitoneal fluid collections on CT accompanying solid viscus injury were treated successfully without laparotomy.     

The prognostic significance of thoracic and abdominal trauma in severe trauma patients (Injury severity score > 15)

The aim of the present study was to assess the prognostic significance of thoracic and abdominal trauma in severely injured patients. A retrospective analysis was performed based on data from the period from March 1 2006 to December 31 2007, taken from the Trauma Registry of the University Hospital "SantAndrea" in Rome. A total of 844 trauma patients were entered in a database created for this purpose, and only patients with an Injury Severity Score (ISS) > 15, (163 patients, 19.3%), were selected for the present study. These patients were divided into 2 groups: Group A (103 patients, 63.2%), consisting of patients with at least one thoracic injury, and Group B (46 patients, 28.2%) consisting of patients with concomitant thoracic and abdominal injuries. The impact of thoracic and abdominal trauma was studied by analyzing mortality and morbidity, in relation to patient age, cause and dynamics of trauma, length of hospital stay, and both ISS and New ISS (NISS). In a vast majority of cases, the cause of trauma was a road accident (126 patients, 77.3%). The mean age of patients with ISS > 15 was 45.2 +/- 19.3 years. The mean ISS and NISS were 25.7 +/- 10.5 and of 31.4 +/- 13.1 respectively. The overall morbidity and mortality rates were 18.4% (30 patients) and 28.8% (47 patients) respectively. In Group A the mortality rate was 23.3% (24 patients) and the morbidity rate was 33.9% (35 patients). In Group B mortality and morbidity rates were 369% (17 patients) and 43.5% (20 patients) respectively. It was shown that the presence of both thoracic and abdominal injuries significantly increases the risk of mortality and morbidity. In patients with predominantly thoracic injuries, NISS proved to be the more reliable score, while ISS appeared to be more accurate in evaluating patients with injuries affecting more than one region of the body.     

Evaluation of an evidence-based guideline to reduce CT use in the assessment of blunt pediatric abdominal trauma

PurposeAbout half of pediatric blunt trauma patients undergo an abdominopelvic computed tomographic (CT) scan, while few of these require intervention for an intraabdominal injury. We evaluated the effectiveness of an evidence-based guideline for blunt abdominal trauma at a Level I pediatric trauma center.MethodsPediatric blunt trauma patients (n = 998) age 0–15 years who presented from the injury scene were evaluated over a 10 year period. After five years, we implemented our guideline in which the decision for CT was standardized based on mental status, abdominal examination, and laboratory results (alanine aminotransferase, aspartate aminotransferase, hemoglobin, urinalysis).ResultsThere were no differences in age, GCS, SIPA or ISS scores between the patients before or after guideline implementation. Nearly half of the patients (48.3%) underwent CT scan before guideline implementation compared to 36.7% after (p < 0.0002). There was no difference in ISS (p = 0.44) between CT scanned patients in either group. No statistical differences were found in rate of intervention (p = 0.20), length of stay (p = 0.65), or readmission rate (0.2%) before versus after guideline implementation. There were no missed injuries.ConclusionImplementation of an evidence-based clinical guideline for pediatric patients with blunt abdominal trauma decreases the rate of CT utilization while accurately identifying significant injuries.Level of evidenceIII.     

Improvement in the therapy of multiply injured patients by introduction of clinical management guidelines

A trauma algorithm representing the guidelines for the management of emergency treatment of severe blunt trauma was implemented at our institution in 1994. By comparison of two prospectively recorded cohorts of multiply injured patients, the clinical efficacy of these guidelines was analysed. The algorithm cohort comprised 74 patients over the period January 1994 to June 1996, and the Control cohort 126 patients over the period April 1988 to December 1993. To evaluate procedural quality of early clinical trauma management, nine criteria were applied. After implementation of the algorithm there was an improvement in all parameters reflected by a significant reduction of missed injuries and important time savings. Mortality rates in the cohorts were calculated after subdivision into three groups (I-III) with moderate (ISS: 18-24), high (ISS: 25-49) and very high (ISS: 50-75) injury severity. All cohort subgroups were comparable with respect to ISS values, age, initial loss of consciousness (GCS) and shock rate. In all subgroups of the algorithm cohort mortality rates were reduced: group I: 0 versus 20 per cent (p < 0.05); group II: 8 versus 24 per cent (p < 0.05); group III: 40 versus 71 per cent. Improvements in both therapeutic process and outcome were observed after implementation of the trauma algorithm.     

Prospective evaluation of the role of abdominal echocardiography in the treatment of seriously traumatized patients

The reliability of abdominal ultrasonography (US) in a clinical algorithm for emergency management of blunt trauma was evaluated prospectively. From November 1, 1987 to December 31, 1988, of 111 severe trauma victims admitted to our ICU, 63 were screened according to protocol by US for peritoneal fluid and splenic and/or hepatic injuries. The mean age was 49.6 years. The mean ISS and APACHE II Score was 26.9 and 13.7 respectively. The sensitivity of US for detection of peritoneal fluid was 95%, specificity 97.6%, positive predictive value 95%, negative predictive value 97.6% with a prevalence of 31.7%. For hepatic and splenic injuries instead the results were not as good as for abdominal fluid. Twelve patients underwent laparotomy and 6 with abdominal injuries were successfully treated nonoperatively with serial US examinations. Overall mortality was 12 (19%). No patients died for delayed or missed diagnosis of abdominal injury.