Sonographic assessment of blunt abdominal trauma: a 4-year prospective study

PURPOSE: Emergency abdominal sonography has become a common modality worldwide in the evaluation of injuries caused by blunt trauma. The sensitivity of sonography in the detection of hemoperitoneum varies, and little is known about the accuracy of sonography in the detection of injuries to specific organs. The purpose of this study was to determine the overall accuracy of sonography in the detection of hemoperitoneum and solid-organ injury caused by blunt trauma. METHODS: From January 1995 to October 1998, 3,264 patients underwent emergency sonography at our institution to evaluate for free fluid and parenchymal abnormalities of specific organs caused by blunt trauma. All patients with intra-abdominal injuries (IAIs) were identified, and their sonographic findings were compared with their CT and operative findings, as well as their clinical outcomes. RESULTS: Three hundred ninety-six (12%) of the 3,264 patients had IAIs. Sonography detected free fluid presumed to represent hemoperitoneum in 288 patients (9%). The sonographic detection of free fluid alone had a 60% sensitivity, 98% specificity, 82% positive predictive value, and 95% negative predictive value for diagnosing IAI. The accuracy was 94%. Seventy patients (2%) had parenchymal abnormalities identified with sonography that corresponded to actual organ injuries. The sensitivity of the sonographic detection of free fluid and/or parenchymal abnormalities in diagnosing IAI was 67%. CONCLUSIONS: Emergency sonography to evaluate patients for injury caused by blunt trauma is highly accurate and specific. The sonographic detection of free fluid is only moderately sensitive for diagnosing IAI, but the combination of free fluid and/or a parenchymal abnormality is more sensitive.     

Importance of evaluating organ parenchyma during screening abdominal ultrasonography after blunt trauma.

OBJECTIVE: To determine the benefit of screening ultrasonography for parenchymal abnormalities as well as free fluid during screening abdominal ultrasonography in patients with blunt trauma. METHODS: A total of 2693 patients with blunt trauma who were triaged to a level 1 trauma center underwent screening abdominal ultrasonography in the resuscitation suite. Examinations were performed by experienced sonographers and included a screen for free intraperitoneal fluid and evaluation of the abdominal organ parenchyma and heart for traumatic injury. Screening ultrasonographic findings were reviewed and compared with findings from autopsy, laparotomy, diagnostic peritoneal lavage, computed tomography, repeated ultrasonography, cystography, and clinical outcome. Imaging studies of all patients with confirmed or suspected injuries were reviewed to identify those in whom parenchymal findings aided diagnosis. RESULTS: One hundred seventy-two patients were found to have evidence of abdominal injury due to blunt trauma on the basis of clinical data, imaging, laparotomy, or autopsy. Forty-four of these patients had no sonographic evidence of hemoperitoneum at the time of initial ultrasonography. Screening ultrasonographic findings were positive for injury in 19 of 44 patients on the basis of parenchymal findings or small retroperitoneal collections of fluid thought to be indicative of trauma. In the remaining 25 patients, screening ultrasonography showed no abnormalities, and injuries were detected by repeated ultrasonography, subsequent computed tomography, or diagnostic peritoneal lavage performed for suspected occult injury on the basis of clinical parameters. In addition, 47 of 126 injured patients with sonographically detected free fluid had parenchymal findings that helped localize injury. Sixteen of those patients were taken to the operating room on the basis of clinical and sonographic findings without undergoing computed tomography. CONCLUSIONS: The inability to show injuries with no hemoperitoneum or with delayed hemoperitoneum has been shown to be a limitation of ultrasonography in patients with blunt trauma. In our series, 26% of all patients with documented injuries had no free fluid visible on screening ultrasonography Attention to findings other than free fluid allowed detection in 43% of injured patients without sonographic evidence of hemoperitoneum.     

Use of ultrasonography in the patient with acute abdominal trauma.

The purpose of this study was to assess the use of ultrasonography in patients with acute abdominal trauma. Five hundred prospective patients, who came to the Emergency Department with acute trauma, were evaluated with ultrasonography and included in this study. The ultrasonographic examination focused on detection of free fluid but included evaluation of parenchymal organs for injury. The physical examination was not used in the statistical analysis of the sonographic findings. In comparing ultrasonography to computed tomography, diagnostic peritoneal lavage, or operative findings, we obtained 24 true positive, 79 true negative, four false positive, and 14 false negative results. Sensitivity of ultrasonography in detecting free fluid in comparison to computed tomography, diagnostic peritoneal lavage, and surgery was 63%, specificity was 95%, accuracy was 85%, positive predictive value was 86%, and negative predictive value was 85%. The most common reason for false negative sonographic results was identification of free fluid in the pelvis on computed tomograms but not on ultrasonograms owing to lack of a full bladder. In none of these instances were the sonographic false negative results of clinical significance. Ultrasonography allowed detection of solid organ injury of the liver in one of seven cases, of the kidney in one of four cases, and in the bowel in zero of three cases. In the three instances of bowel injury, free fluid was noted on ultrasonograms. Ultrasonography fared better in cases of splenic laceration, permitting detection in nine of 14 cases. The emergent ultrasonogram may be used to detect free fluid in the abdomen of the acutely traumatized patient. However, sonography is limited in detecting free fluid in the pelvis using the present technique and does not allow visualization of organ injury. Limitations of this examination should be recognized for appropriate triage of the acutely traumatized patient.     

Sonographic patterns of intraperitoneal hemorrhage associated with blunt splenic injury.

OBJECTIVE: To determine the correlation between sonographic detection of free fluid in the left upper quadrant and blunt splenic injury. METHODS: A retrospective review was conducted of all consecutive emergency blunt trauma sonograms obtained at a level I trauma center from January 1995 to January 2001. Data were collected on demographics, free fluid location, and patient outcome. Injuries were determined from computed tomography, diagnostic peritoneal lavage, laparotomy, or a combination thereof. RESULTS: A total of 4320 blunt trauma sonograms were obtained, and 596 patients (14%) had intra-abdominal injuries. The mean age was 33.7 +/- 19.1 years (range, 1-95 years), with 294 (49%) male and 302 (51%) female. There was no statistical difference between age, sex, or mechanism for all subgroups. There were 409 true-positive, 187 false-negative, 88 false-positive, and 3636 true-negative findings. Sensitivity of sonography for detecting all intra-abdominal injuries was 68%, and specificity was 97.6%; sensitivity for detecting isolated splenic injuries was 73.8%. Locations of free fluid in patients with nonsplenic injuries were compared with those in patients with splenic injuries. Isolated left upper quadrant free fluid was significantly associated with splenic injury (odds ratio = 3.0; P = .002), followed by diffuse free fluid (odds ratio = 2.1; P = .005). A subanalysis of isolated splenic injuries also revealed a significant association with left upper quadrant free fluid (odds ratio = 3.1; P = .007) and diffuse free fluid (odds ratio = 2.7; P = .0007). CONCLUSIONS: Free fluid in the left upper quadrant is significantly associated with splenic injury. This finding should triage patients more rapidly to computed tomography, angiography, embolization, and laparotomy.     

Reevaluation of ultrasonography for solid-organ injury in blunt abdominal trauma.

OBJECTIVE: To reevaluate the usefulness of ultrasonography for detecting and classifying solid-organ injuries from blunt abdominal trauma by comparing ultrasonography with computed tomography (CT) and laparotomy. METHODS: Six hundred four patients with blunt abdominal trauma were examined by both B-mode ultrasonography and CT for a study period of 14 years. The ultrasonographic examiners were divided into 2 groups depending on their experience with ultrasonography. The ultrasonographic results were then compared with CT and surgical findings. This was a retrospective study. RESULTS: In 198 patients, solid-organ injuries were identified on CT, laparotomy, or both. Sensitivity values in group A (experts) were 87.5% for hepatic injuries, 85.4% for splenic injuries, 77.6% for renal injuries, and 44.4% for pancreatic injuries. Sensitivity values in group B were 46.2% for hepatic injuries, 50.0% for splenic injuries, and 44.1% for renal injuries. The detection rates in group A were 80% to 100% for different types of hepatic injuries except superficial injuries (20%) and 70% to 100% for different types of splenic injuries. The detection rates for renal parenchymal and pancreatic duct injuries were 53.3% and 80%, respectively. The detection rates for injuries requiring intervention were 86.1% in group A and 66.7% in group B. CONCLUSIONS: The sensitivity of ultrasonography with the use of CT and surgical findings as reference standards decreased compared with our prior study. However, ultrasonography was found to enable experienced examiners to detect and classify parenchymal injuries efficiently, despite disadvantages in detecting superficial and vascular injuries. Ultrasonography should be used to explore not only free fluid but also solid-organ injuries.     

Contrast-enhanced US evaluation in patients with blunt abdominal trauma

IntroductionTo evaluate the use of contrast-enhanced ultrasonography (CEUS) in patients with blunt abdominal trauma.Materials and methodsA total of 133 hemodynamically stable patients were evaluated using ultrasonography (US), CEUS and multislice Computer Tomography (CT) da eliminare.ResultsIn 133 patients, CT identified 84 lesions: 48 cases of splenic injury, 21 of liver injury, 13 of kidney or adrenal gland injury and 2 of pancreatic injury. US identified free fluid or parenchymal abnormalities in 59/84 patients positive at CT and free fluid in 20/49 patients negative at CT. CEUS revealed 81/84 traumatic injuries identified at CT and ruled out traumatic injuries in 48/49 negative at CT. Sensitivity, specificity, positive and negative predictive values for US were 70.2%, 59.2%, 74.7% and 53.7%, respectively; for CEUS the values were 96.4%, 98%, 98.8% and 94.1%, respectively.ConclusionsThe study showed that CEUS is more accurate than US and nearly as accurate as CT, and CEUS can therefore be proposed for the initial evaluation of patients with blunt abdominal trauma.     

Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury.

The objectives of this study were to define where fluid accumulation is shown on screening ultrasonography after blunt abdominal trauma and to determine how fluid accumulation patterns are associated with the site of injury. From 1994 to 1998, 2,693 screening examinations for blunt abdominal trauma were performed, in which 7 regions were examined for fluid. On the basis of a preliminary analysis of patients with solitary injuries, all 194 patients with sonographically detected fluid were grouped by fluid accumulation pattern. Fluid patterns were compared with sites of injury. The patterns differed between hepatic and splenic injuries. Fluid in the left upper quadrant, in both upper quadrants, or diffusely distributed suggested splenic injury, whereas fluid in the right upper quadrant or the right upper quadrant and lower recesses suggested hepatic injury (P < .0001). Fluid accumulation was random after enteric injury. Patients with extraperitoneal injury had no fluid or had fluid focally at the injury site. The ability to predict the injury site on the basis of fluid patterns should expedite treatment of hemodynamically unstable patients with blunt abdominal trauma.     

Distracting Painful Injuries Associated with Cervical Spinal Injuries in Blunt Trauma

Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography. OBJECTIVE: To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography. METHODS: This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries. RESULTS: Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34%) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6%) additional cases. Fractures accounted for a majority of DPIs (154, or 58%), 42 (16%) were soft-tissue injuries or lacerations, and 86 (34%) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5%) patients with an acute cervical spinal injury, 20 (54%) had a DPI, including three (8%) who had DPI as the only indication for cervical radiography. CONCLUSIONS: A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI.     

Quantification of fluid on screening ultrasonography for blunt abdominal trauma: a simple scoring system to predict severity of injury.

A simple ultrasonographic method of fluid quantification, which counted the number of fluid recesses, was developed to predict the severity of injury after blunt abdominal trauma. From 1994 to 1998, 2,693 screening ultrasonographic examinations were performed for blunt abdominal trauma. Of this group, 2,499 patients had a fluid score of 0 (no fluid), and 1.4% had injuries (0.4% requiring surgery); 110 had a score of 1 (fluid in a single examined region), and 59% had injuries (13% requiring surgery); 33 had a score of 2, and 85% had injuries (36% requiring surgery); 30 had a score of 3, and 83% had injuries (63% requiring surgery); and 21 had a score of 4, and 95% had injuries (81 % requiring surgery). Patients with scores of 3 or greater had significantly higher rates of injury (P < .002) and injury requiring surgery (P < .0001) than patients with lower scores. The ability to predict injury severity on the basis of a simple ultrasonographic scoring system should expedite treatment of patients with severe trauma.     

Ultrasound detection of free intraperitoneal fluid associated with hepatic and splenic injuries

BACKGROUND: The objective of this study was to compare the sensitivity and specificity of 5 abdominal views for detecting free intraperitoneal fluid in trauma patients later diagnosed with hepatic or splenic injuries. METHODS: This retrospective study conducted over a 17-month period enrolled patients with trauma. A Focused Abdominal Sonogram for Trauma (FAST) examination was done using 5 abdominal views. Exploratory laparotomy or computed tomography (CT) confirmed the presence of intraperitoneal fluid and associated injuries. The sensitivity and specificity were determined. RESULTS: Of the 245 study patients, 29 had injuries to the liver or spleen or both. The 5-view FAST examination's sensitivity for detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 77%, 90%, and 100%, respectively. The sensitivity of the single Morison's pouch view in detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 38%, 20%, and 67%, respectively. CONCLUSION: For identifying free intraperitoneal fluid associated with hepatic or splenic injuries, no single view of the FAST examination could match the sensitivity provided by the 5-view technique.     

Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients

PURPOSE: The use of focused abdominal sonography for trauma (FAST), which detects free fluid in the abdomen and pelvis, for the assessment of blunt abdominal trauma is gaining acceptance worldwide and has been described extensively in the general medical literature. The precise application of this technique in pediatric patients, however, has yet to be established. The aim of this study was to assess the utility of FAST in pediatric trauma patients by comparing the results of this technique with those of CT and explorative laparotomy (ELAP). METHODS: We retrospectively reviewed the medical records and sonographic examinations of pediatric patients who had sustained multiple traumatic injuries for which they were treated at our hospital during a 20-month period. For all patients, FAST had been the initial screening examination for blunt abdominal trauma. We compared the FAST findings, which had been recorded as positive or negative, with the findings on CT or ELAP, which were considered definitive. RESULTS: A total of 313 patients (204 boys and 109 girls) with a mean age of 7.1 years were included in the study. The FAST finding had been negative in 274 patients, of whom 201 had had no clinical signs of abdominal injury and had been managed conservatively without complications. CT had been performed in 109 patients and ELAP in 11. FAST had yielded 3 false-negative and 2 false-positive results. The sensitivity, specificity, and accuracy of FAST were 92.5%, 97.2%, and 95.5%, respectively. CONCLUSIONS: FAST is an effective tool in screening pediatric trauma patients for blunt abdominal trauma.     

Distracting injuries in patients with vertebral injuries

To describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. A prospective cohort study was conducted at an urban Level I trauma center. All patients undergoing radiographic evaluation of the cervical, thoracic, or lumbar vertebrae after blunt trauma were enrolled. Patients had a data collection form completed by the treating physician before radiographic imaging and were evaluated for the following upon initial presentation: tenderness to the cervical, thoracic, or lumbar spine, distracting injuries, altered mental status, alcohol or drug intoxication, or neurological deficits. Patients with distracting injuries as the sole documented indication for vertebral radiographs were reviewed for the types of injuries present. A total of 4698 patients were enrolled in the study. There were 336 (7.2%) patients who had distracting injuries as the sole documented indication for obtaining radiographic studies of the vertebrae. Eight (2.4%, 95% CI 1.0-4.6%) of the 336 patients had 14 acute vertebral injuries including compression fractures (5), transverse process fractures (7), spinous process fracture (1), and cervical spine rotatory subluxation (1). There were 13 thoracolumbar injuries and one cervical spine injury. Distracting injuries in the eight patients with acute vertebral injuries included 13 bony fractures. Distracting injuries in those patients without vertebral injuries included bony fractures (333), lacerations (63), soft tissue contusions (62), head injuries (15), bony dislocations (12), abrasions (11), visceral injuries (8), dental injuries (5), burns (3), ligamentous injuries (3), amputation (1), and compartment syndrome (1). In conclusion, in patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries.     

钝性外伤性小肠穿孔的CT诊断价值

目的评价CT对钝性外伤性小肠穿孔的诊断价值。方法对15例经手术证实的钝性外伤性小肠穿孔的CT表现进行回顾性分析。结果 15例患者中11例CT上腹部见游离气体,术前正确诊断小肠穿孔11例,诊断正确率为73.3%;4例漏诊患者因腹腔内均未见明确游离气体,且由于合并其他损伤,忽略了小肠周围渗出情况,导致漏诊。结论 CT对于钝性外伤性小肠穿孔具有较高的术前诊断价值。     

Immediate and follow-up management of hepatic trauma

There has been a considerable evolution in the management of patients with hepatic injuries in the past 5-10 years. CT is now the mainstay of diagnosis for stable patients with blunt hepatic injuries. This allows for nonoperative therapy in many patients with lacerations, intrahepatic hematomas, or subcapsular hematomas. Simple operative techniques are used in 60% of patients with blunt injuries, and any deaths in this group are usually due to associated injuries. In patients requiring advanced techniques of repair, postoperative management emphasizes basic techniques including correction of hypothermia and coagulopathies and early use of enteral feeding. Postoperative complications are not rare when Class III, IV, or V hepatic injuries have been treated, but can be managed with the assistance of the interventional radiologist, blood bank, or by use of early reoperation. Mortality depends on mechanism of injury and magnitude of hepatic injury, and ranges from 14-31% for patients with blunt trauma.     

Surfactant protein A (SP-A) is decreased in acute parenchymal lung injury associated with polytrauma.

To further investigate if the pulmonary surfactant system is altered in acute parenchymal lung injury of adults following polytrauma we measured SP-A level and phospholipid composition in 150 sequentially obtained lung lavage samples from poly-traumatized patients (n = 19) beginning at the day of trauma and ending 18 days later or when the patient was extubated. Out of the 19 patients studied 10 had severe parenchymal lung injury (ARDS), nine had moderate lung injury. SP-A was measured using a two-monoclonal sandwich ELISA-assay. Phospholipids were separated using high-performance liquid chromatography and their composition was calculated by comparison with standard phospholipid mixtures. We found immunoreactive SP-A concentrations ranging from 0.1 micrograms ml-1 to 8.5 micrograms ml-1 lung lavage fluid obtained from all patients. The mean SP-A concentration in patients who had severe parenchymal lung injury (ARDS) was 1.06 +/- 0.16 micrograms ml-1 lavage fluid, the mean concentration in patients who had only moderate parenchymal lung injury was 1.92 +/- 0.18 micrograms ml-1 lavage fluid. Both concentrations were lower than in healthy controls (2.74 +/- 0.3 micrograms ml-1 lavage fluid; n = 12). In patients who had moderate lung injury the SP-A level normalized, but in patients who had severe lung injury the SP-A level remained low during the timespan examined. SP-A alterations did not correlate to changes in phospholipid composition as determined in lung lavage samples of individual patients. We conclude that alveolar SP-A concentrations decrease in polytraumatized patients who have acute parenchymal lung injury soon after the trauma occurs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis

Injuries to the diaphragm muscle occur in penetrating and severe blunt trauma and can lead to delayed hernia formation. Computed tomography is the mainstay in the diagnosis of these injuries, which may be subtle at presentation. Imaging findings differ between blunt and penetrating trauma. Key features in blunt trauma include diaphragm fragment distraction and organ herniation because of increased intra-abdominal pressure. In penetrating trauma, herniation is uncommon, and the trajectory of the object is critical in making the diagnosis of diaphragm injury in these patients. Radiologists must keep a high index of suspicion for injury to the diaphragm in cases of trauma to the chest or abdomen.

     

Scalp laceration: an obvious 'occult' cause of shock

Scalp lacerations are often present in patients requiring emergency care for blunt trauma. These injuries are most commonly seen in unrestrained drivers or occupants involved in motor vehicle crashes in which the victim is partially or totally ejected. Patients with scalp lacerations often have associated injuries that redirect the clinician's attention to other injury sites. Some scalp lacerations are severe enough to cause hypovolemic shock and acute anemia. If the patient arrives in shock, the perfusion pressure may be low, and there may be minimal active scalp bleeding. Under such circumstances, the scalp wound may be initially dismissed as trivial and attention appropriately turned to assuring an adequate airway, establishing intravenous lines, initiating volume resuscitation, and searching for more "occult" sources of blood loss. However, as the blood pressure returns toward normal, bleeding from the scalp wound becomes more profuse and presents a hemostatic challenge to the clinician. A case presentation illustrates some of these issues and confirms the effectiveness of an often overlooked but simple technique to control scalp hemorrhage--Raney clip application.     

Incidence and significance of injuries on secondary CT imaging after initial selective imaging in blunt trauma patients

ObjectiveIt is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients.MethodsThis was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system. Inclusion criteria: age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management.Results537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient).ConclusionWhile a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.     

Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury

OBJECTIVE: To examine the effects of associated injuries on death, disability, rehabilitation needs, and cost in patients with blunt traumatic brain injury. DESIGN: A retrospective case series analysis of 1,709 patients with blunt traumatic brain injury, or 37.2% of 4,590 consecutive blunt trauma patients, was combined with a prospective study of a subset of 202 of the 1,709 brain-injured patients obtained during the same time period with regard to need for rehabilitation services, residual disability, and costs at 1 yr after discharge from the acute trauma center. SETTING: A level I regional trauma center that is also the statewide neurotrauma and multiple trauma unit serving a population of more than 3 million persons. RESULTS: Contingency table analysis showed the Glasgow Coma Scale to be highly predictive (p less than .0001) of likelihood of mortality, need for postacute inpatient rehabilitation, or discharge home. Of the blunt traumatic brain injury patients, 40.4% (691) had an isolated brain injury and 59.6% (1,018) had brain plus at least one other systemic injury. The mortality rate of the isolated brain injury group was 11.1% compared with 21.8% in all brain plus systemic injury groups (p less than .0001). Spine, lung, visceral, pelvis, or extremity injuries in blunt traumatic brain injury all increased mortality rate to greater than 25% (all simultaneously significant, p less than .0001). Analysis of the interaction of brain injury (quantified by Glasgow Coma Scale) with blood replacement in the initial 24 hrs showed that at any Glasgow Coma Scale range, percent mortality increased as the volume of blood increased. Hypovolemic shock increased the mortality rate from 12.8% to 62.1% (p less than .0001). The need for postacute inpatient rehabilitation in survivors also increased as blood replacement increased, and shock increased the percent of patients requiring post-acute inpatient rehabilitation from 39.7% to 60.3%. In 202 consecutive surviving brain trauma patients followed for 1 yr, isolated brain-injured patients with moderate brain injuries had a 4% need for posttrauma, postacute inpatient rehabilitation with a total cost per case of $12,489 compared with the brain plus extremity injury group, who had a 23% postacute inpatient rehabilitation rate and a total cost per case of $36,177 at 1 yr. With severe brain injury, isolated brain injury increased postacute inpatient rehabilitation to 29% and 1-yr cost to $59,274, but with the brain plus extremity injury group, postacute inpatient rehabilitation increased to 49% and cost to $84,950. CONCLUSIONS: In blunt traumatic brain injury, the addition of major visceral or extremity injuries, with need for blood replacement or shock, increases the risk of death, the need for rehabilitation, and the costs of disability.     

Definitive management of acute cardiac tamponade secondary to blunt trauma

Blunt cardiac injuries are a leading cause of fatalities following motor-vehicle accidents. Injury to the heart is involved in 20% of road traffic deaths. Structural cardiac injuries (i.e. chamber rupture or perforation) carry a high mortality rate and patients rarely survive long enough to reach hospital. Chamber rupture is present at autopsy in 36-65% of death from blunt cardiac trauma, whereas in clinical series it is present in 0.3-0.9% of cases and is an uncommon clinical finding. Patients with large ruptures or perforations usually die at the scene or in transit--the rupture of a cardiac cavity, coronary artery or intrapericardial portion of a major vein or artery is usually instantly fatal because of acute tamponade. The small, rare, remaining group of patients who survive to hospital presentation usually have tears in a cavity under low pressure and prompt diagnosis and surgery can now lead to a survival rate of 70-80% in experienced trauma centres. As regional trauma systems evolve, patients with severe, but potentially survivable cardiac injury are surviving to ED. Two distinct syndromes are apparent--haemorrhagic shock and cardiac tamponade. Any patient with severe chest trauma, hypotension disproportionate to estimated loss of blood or with an inadequate response to fluid administration should be suspected of having a cardiac cause of shock. For patients with severe hypotension or in extremis, the treatment of choice is resuscitative thoracotomy with pericardotomy. Closed chest cardiopulmonary resuscitation is ineffective in these circumstances. Blunt traumatic cardiac injury presenting with shock is associated with a poor prognosis. The majority of survivors of blunt or penetrating cardiac injury present to the ED/trauma centre with vital signs. The main pathophysiologic determinant for most survivors is acute pericardial tamponade. The presence of normal clinical signs or normal ECG studies does not exclude tamponade. In recent years the widespread availability and use of ultrasound for the initial assessment of severely injured patients has facilitated the early diagnosis of cardiac tamponade and associated cardiac injuries. Two cases of survival from blunt traumatic cardiac trauma are described in the present paper to demonstrate survivability in the context of rapid assessment and intervention.