Blunt hepatic injury

Fifty-six cases with blunt hepatic injuries occurred in 255 laparotomies on patients with multiple injuries. Pre-operatively, one-half of the patients were in profound shock. In these cases hepatic bleeding was often accompanied by bleeding in other sites, usually from a ruptured spleen or into a retroperitoneal haematoma. Diagnosis was aided by laparocentesis and peritoneal lavage. In 3 cases the diagnosis was delayed for 8--12 hours. The lacerations were sutured in 43 cases, a local resection was made in 10 cases and a lobar resection in 3 cases. Manual compression of the liver was the best way of achieving temporary haemostasis. In cases where haemodynamic stability was not achieved post-operatively, immediate re-operation to attain haemostasis was definitely advantageous. The mortality from multiple blunt injuries was high (17%) but especially so in cases with hepatic injury (41%). Liver injuries after blunt trauma can often be managed by suturing, and hepatic resection in seldom necessary.     

Blunt hepatic injury and elevated hepatic enzymes: a clinical correlation in children

During a recent prospective nonrandomized comparison of noninvasive imaging techniques in 100 children with suspected major blunt abdominal injury, an interesting subset of patients was defined. Of 95 hemodynamically stable patients, 44 were found to have immediate elevation of hepatic enzymes (SGOT, SGPT greater than 30 IU). Nineteen of these children (43%) were subsequently shown to have significant liver injuries. No child with a liver injury had normal enzymes on admission. The level of enzyme elevation (SGOT chi 890 +/- 142 IU, SGPT chi 536 +/- 105 IU) in those with liver injuries is significantly greater than those without injury (SGOT chi 273 +/- 44 IU, SGPT chi 115 +/- 19 IU) (P less than or equal to 0.0001 SGOT. P less than or equal to 0.0001 SGPT). Our study has allowed definition of a group of children who are at significant risk for liver injury based on immediately available serum determinations of GOT and GPT. We have begun to use this information in our institution to select children for further noninvasive imaging. We recommend that these studies be obtained emergently in all children with suspected upper abdominal trauma.     

Blunt cardiac injury: is this diagnosis necessary?

The diagnosis of blunt cardiac injury in traumatized patients is problematic and the implications of such a diagnosis are not clear. Although cardiac selective creatine kinase (CK-MB) assays and electrocardiograms (EKG) are the most widely available laboratory investigations, they often correlate poorly with diagnoses made on clinical grounds, or by other laboratory methods. We therefore retrospectively studied the Montreal General Hospital experience with 342 consecutive blunt trauma patients admitted to our surgical intensive care/trauma unit. Using clinical criteria, cardiac injury was diagnosed in 44 patients (13%). Twenty-seven of these patients (61%) developed arrythmias or cardiogenic hypotension, half of which required treatment. Heart injuries contributed to six of the 12 deaths in this group. Many of the patients maintained normal CK-MB levels and/or had normal admission EKG's despite the clinical diagnosis of cardiac injury. However, using our criteria for CK-MB positivity, there was a strong correlation between CK-MB elevation and the development of cardiac complications, and very high CK-MB levels (greater than 200 mu/L) were associated with a 100% incidence of such complications. Focusing on patients who developed cardiac complications serious enough to require treatment, we found combined CK-MB/EKG positivity in all cases (100% sensitivity). This method also provided a negative predictive value of 100%. We conclude that although blunt cardiac injury is an important source of morbidity and mortality its 'diagnosis' is not the issue. Rather, it is more important to recognize which of these clinically identified 'high-risk' patients will actually develop cardiac complications. We feel our approach will enable clinicians to do this.     

Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited

BACKGROUND: Patients with blunt aortic injury (BAI) often have concomitant liver or spleen (L/S) injuries. With increasing use of cardiopulmonary bypass with heparinization in repair of BAI, many advocate operative management of the L/S injury before aortic repair to eliminate risk of hemorrhage. We evaluated the safety of nonoperative management (NOM) of blunt L/S injuries in patients undergoing acute BAI repair with bypass. METHODS: All patients admitted over a 6-year period with BAI were identified from the registry of our Level I trauma center. Patients with isolated L/S injuries without BAI admitted over the same period served as controls. Groups were compared with regard to demographics, injury characteristics, hospital course, and mortality. RESULTS: Eighty-four patients were diagnosed with BAI from 1994 to 2000; 28 (33%) also had blunt abdominal trauma. Three patients with severe brain injury did not undergo BAI repair, and five required laparotomy before BAI repair for other intra-abdominal injuries (two for hemodynamic instability with splenic injury, and three for concomitant bowel injury). Therefore, 20 of 28 (71.4%) BAI patients with grade I or II L/S injury (Aorta L/S group) underwent planned NOM. All BAIs were repaired using partial bypass with full heparinization. These 20 patients are compared with 894 patients with grade I or II L/S injuries with no BAI (L/S group) over the same time period. There was no difference in the nonoperative failure rate of the Aorta L/S group versus the L/S group (0% vs. 1.7%). Both groups had similar complication rates. The Aorta L/S group was also compared with 56 BAIs without solid organ injury (Aorta group). Although the Aorta L/S group was more severely injured than the Aorta group (Injury Severity Score of 35.3 vs. 26.8, < 0.0001), transfusion rates (5.7 U of packed red blood cells vs. 8.0 U of packed red blood cells, p = NS), hospital days (17.9 vs. 19.1, p = NS) and mortality (10% vs. 9%, p = NS) were similar. CONCLUSION: NOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.     

Blunt injury to the thyroid gland: proposed classification and treatment algorithm

BACKGROUND: Traumatic hemorrhage of the thyroid gland is a rare injury with few published case reports. Surgical and nonsurgical management have been advocated but there is no consensus of opinion. METHODS: This study is a retrospective review of published case reports including two own cases. A classification and an algorithm for diagnosis and treatment of thyroid gland injuries is proposed. RESULTS: A literature review reveals 16 case reports. Of these, 11 patients underwent neck exploration for control of hemorrhage and resection of the associated thyroid abnormality while 5 patients were conservatively managed. Of note is the fact that 10 of the 16 patients (63%) had pre-existing thyroid disease. These 10 patients constituted (91%) of the group requiring surgical treatment. CONCLUSION: Our proposed classification and algorithm offers management guidelines for this rather rare injury. Conservative treatment may be successful in selected patients with lower grade injuries and without concomitant thyroid disease.     

Blunt injury to intrahepatic vena cava and hepatic veins with survival

Injuries to the intrahepatic vena cava and hepatic veins are extremely lethal, particularly when caused by blunt trauma. Repair of the vena cava and hepatic veins often will require liver resection before adequate exposure can be obtained. To prevent lethal hemorrhage during resection and vascular repair, total vascular isolation of the liver may be necessary. Anoxic injury under these circumstances may be minimized by local hypothermia. The two patients reported here were successfully treated by direct suture of the vascular injuries without hepatic resection; however, vascular isolation was utilized in one patient.     

Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s

OBJECTIVE: To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. SUMMARY BACKGROUND DATA: Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. METHODS: Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). RESULTS: All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty-four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. CONCLUSIONS: Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.     

Blunt injury to the subclavian artery

This paper reports two cases of closed injury to the subclavian artery, one resulting from avulsion and the other from compression from a seat-belt. Diagnosis may be delayed because of the absence of both haemorrhage and distal ischaemia. The surgical approach may be via a standard supraclavicular incision, but frequently a combined cervicothoracic approach is necessary.     

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.     

Blunt urethral injury: results of initial management

Fourteen men with blunt urethral disruption were treated between 1979-1985. Injuries most commonly resulted from motor-vehicle accidents, as pedestrians or passengers. All patients had additional injuries, including pelvic fracture (13), extremity fractures (10), central nervous system (5), bladder (5) and rectal injury (3); the average injury severity score was 30. Pelvic fracture patterns included ten patients with a crushed pelvis, two with single anterior pelvic ring fractures and one with a double vertical fracture. Blood at the urethral meatus was noted in only five patients, gross hematuria without metal blood in another three, and a displaced prostate on rectal exam was found in 10 cases. All patients had a suprapubic cystostomy for management of the urethral injury. Thirteen of 14 patients survived (93%). The major complication was perineal sepsis. Based on this experience, it is concluded that: 1) the classical findings of urethral injury are not found consistently, 2) certain pelvic fracture patterns, particularly disruption of the anterior pelvic ring, are frequently associated with urethral injury and 3) aggressive and appropriate management of hemorrhage, pelvic fracture and concomitant injuries is important to minimize mortality.     

Blunt injury of the abdominal aorta.

This review of 27 cases of blunt injury of the abdominal aorta includes 24 cases reported in the literature and three new cases. Automobile accidents were the cause of this condition in 19 patients (70%). Clinical presentation was acute in 70% of the cases, and consisted of either acute arterial insufficiency or an acute abdomen. Intimal disruption occurred in 15 patients (55%) and was the most common anatomic lesion. Atherosclerotic involvement of the aorta was found in ten patients (37%), and in four it contributed directly to the development of this condition. The infrarenal aorta was the most affected segment (92%). The mortality rate was 29% (8/27 patients). Associated trauma occurred in 55% of the cases, but did mot increase the mortality rate. Prompt recognition and proper surgical treatment are essential in the management of this condition.     

Blunt splenic injury: operation versus angiographic embolization

BACKGROUND: Splenic injuries, like other blunt traumatic injuries, are increasingly treated with non-operative management. Angiographic embolization (AE) has emerged as an alternative modality for treatment of splenic injuries. We hypothesized that splenic embolization would lead to equivalent, if not improved, outcomes in terms of mortality, total costs, complications, and duration of stay. METHODS: A retrospective review of a prospective data set was performed for all adult splenic injuries admitted to our level I trauma center from 2000 through 2003. Demographics, number of red cell units, emergency department hemodynamics, costs, and outcomes were examined. The operative group included those who underwent computed tomography (CT) first then went to the operating room (OR) (CT+OR) or those who went directly to the OR. RESULTS: There were 25 CT+OR and 24 AE patients of 164 blunt splenic injuries. After univariate analysis, higher injury severity score (ISS), lower systolic blood pressure, lower pH, and higher packed red blood cell transfusions were associated with increased mortality and duration of stay. The splenic Abbreviated Injury Scale (AIS; mean +/- SD) was the same for AE compared to CT+OR patients (3.8 +/- 0.4 vs 3.5 +/- 0.9). Although the AE group was older (50 +/- 20 vs 36 +/- 13 years, P < .01), Glasgow Comma Score (13 +/- 4 vs 11 +/- 5), age, highest heart rate (109 +/- 24 vs 120 +/- 43), and splenic AIS were not predictive of the need for an operation. Abdominal complications were lower in the AE group compared to the CT+OR (13% vs 29%), but mortality was not different (8% vs 4%). Total costs were similar for both groups after adjustment for ISS, GCS, pH, pretreatment transfusions, and spleen AIS (AE, $49,300 +/- $40,460 vs CT+OR, $54,590 +/- $34,760). The non-operative failure rate in this study was 2%. CONCLUSIONS: AE of splenic injuries is safe and associated with fewer complications. The spleen AIS, heart rate, age, and GCS did not correlate with the need for an operation. Higher ISS, lower blood pressure, lower pH, and increased number of packed red blood cell transfusions were better indicators of the need for an operation versus embolization.     

Blunt trauma of hepatic ducts: a difficult diagnostic-therapeutic approach

Traumatic injuries of left and right hepatic ducts are rare, with about 40 cases reported in literature. Preoperative diagnosis is difficult, so that up to 40% of lesions may be undetected at laparotomy. Prompt diagnosis could preserve by high morbidity rate of such injuries. The extremely widespread and routine use of ERCP as well as intraoperative cholangiography may allow reducing dramatically the diagnostic time lag and the percentage of lesions formerly undetected by laparotomy. Therapeutic options are extremely variable. On the basis of the experiences reported for the treatment of iatrogenic lesions of the biliary tract, reconstruction by jejunal Roux-en-Y loop biliodigestive anastomosis is preferred, whenever lacerations of an hepatic duct appear to be complete or nearly so, on account of the high incidence of stenosis and late complications, detected in case of termino-terminal direct biliary anastomosis. However, in selected cases, when the transection appear neat and simple, an end-to-end anastomosis could be performed with low risk. Mortality after blunt biliary duct injury represents nowadays a rare event at least in patients presenting without severe associated traumatic lesions, so that the clinical attention has been progressively focused on the relatively high rate of postoperative complications. These adverse events are often extremely demanding in terms of prolongation of hospital stay, need for multiple invasive procedures and overall costs of patient's management.