Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management

BACKGROUND: During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or spleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and spleen injuries, and missed injuries were reviewed in patients undergoing NOM. METHODS: Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsuspected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or spleen injury. RESULTS: Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or spleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. CONCLUSION: Damage to the pancreas and bowel is significantly associated with liver as opposed to spleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with spleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We speculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the spleen accounts for the greater rate of associated injuries to the pancreas/small bowel.     

Physical examination as a reliable tool to predict intra-abdominal injuries in brain-injured children

BACKGROUND: Brain-injured children have been thought to have an unreliable abdominal examination. This study evaluates the reliability of physical examination in the prediction of intra-abdominal injury in brain-injured children. METHODS: Pediatric patients with a traumatic brain injury or Glasgow Coma Scale (GCS) <15 and intra-abdominal organ injuries were selected. Admission data were reviewed, and findings were tabulated. RESULTS: Fifty patients had an abnormal abdominal examination. Nineteen of 71 patients with head injury and intra-abdominal organ injuries required laparotomy. These 19 patients had abdominal tenderness, distention, abrasions, and/or a positive focused abdominal sonography for trauma (FAST) scan. Seven of 19 patients had a GCS of 3. Of the 12 patients requiring surgery with GSC 4 to 14, all patients had abnormal physical examinations. CONCLUSIONS: Patients who required an operation presented with an abnormal examination and/or a positive FAST. These data suggest that examination and/or FAST may reliably identify patients with intra-abdominal organ injuries in need of an operation.     

Nonsurgical management of solid abdominal organ injury in patients over 55 years of age

Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 +/- 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 +/- 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I-IV), 12 sustained splenic injuries (grades I-III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intra-abdominal solid organ injury.     

Laparotomy and unstable pelvic fractures

The requirement for laparotomy was analysed in 91 patients with unstable pelvic fractures. Laparotomies were classified as positive or negative. Injuries found at laparotomy were compared with the pelvic fracture pattern. Laparotomy was carried out in 28 patients but was unnecessary in 8. Eleven of the 28 patients died, a mortality of 39%. Vertical shear and combined mechanical injury pelvic fracture patterns had the highest incidence of abdominal injuries (28%) but the fracture pattern was not a reliable guide to the presence or nature of intra-abdominal injury. Inadequate preoperative investigations contributed to the eight negative laparotomies and three of these patients died. Laparotomy was only necessary in 22% of our patients. Major pelvic fractures with concomitant intra-abdominal injuries have a high mortality rate. Preoperative CT scanning was 98% accurate in the identification of intra-abdominal injury and was the most useful investigation for determining the need for laparotomy and minimising the risk of negative laparotomy.     

Detection of intra-abdominal injury using diagnostic peritoneal lavage after shotgun wound to the abdomen

BACKGROUND: The utility of diagnostic peritoneal lavage (DPL) as a diagnostic tool specifically for shotgun wound to the abdomen (SGWA) is unknown. This prospective study was undertaken to determine the sensitivity, specificity, and accuracy of DPL for the detection of intra-abdominal injuries following SGWA. METHODS: DPL was performed on all patients sustaining SGWA who lacked a clear indication for laparotomy. Patients exceeding 10,000 red blood cells (RBC)/mm were taken for exploratory laparotomy. A prospective database was kept with information on wound location, DPL result, findings upon laparotomy and outcome. RESULTS: Thirty-two DPLs were performed at our urban Level I trauma center for SGWA. Of these, 8 patients had a positive DPL. Upon laparotomy, 7 patients were found to have intra-abdominal injuries, 6 of which required surgical intervention. One patient had no peritoneal penetration or intra-abdominal injury. Of the 24 patients that had a negative DPL, 1 subsequently developed indications for laparotomy and was found to have operative injuries. For predicting intra-abdominal injuries DPL has a sensitivity, specificity and accuracy of 87.5%, 95.8% and 93.8%, respectively. CONCLUSION: For patients presenting with SGWA who do not present with indications for immediate laparotomy, DPL is a reliable indicator of intra-abdominal injury and need for operative intervention.     

Liver injuries in children: the role of selective non-operative management

INTRODUCTION: This review article on the management of blunt liver injury in children is based on the authors' experience of 311 patients over a 22-year period. MATERIAL AND METHODS: All children presenting to our institution with confirmed blunt liver trauma were studied retrospectively. Hospital folders of 311 patients were analysed. Information was gathered about the clinical presentation, associated injuries, grade of injury, transfusion requirements and haemodynamic stability to examine factors influencing outcome. RESULTS: The age of patients ranged between 3 weeks and 12 years (mean of 7 years). Injuries as a result of motor vehicle accidents (MVAs) were the most common (268; 232 pedestrian and 36 passenger), other causes were falls (26) assaults or child abuse(15), bicycle handle bar injury (2). One hundred and thirty-six patients sustained an isolated hepatic injury and 175 had multiple injuries. Associated injuries included 147 head injuries, 131 fractures, 66 thoracic and 143 intra-abdominal (74 spleen, 45 renal, 4 pancreatic and 4 hollow viscus). Two patients died soon after arrival, 21 underwent laparotomy, 13 of which were liver related, while 288 were treated non-operatively. One hundred and six patients required blood transfusion (mean of 21.3 ml/kg); 30% of the nonoperative group and 100% of the operative group. There were three fatalities from the operative group (1% total mortality), one secondary to a severe, head injury, one liver haemorrhage and one from multi-organ failure DISCUSSION: The vast majority (93%) was successfully treated non-operatively with only 4% coming to liver related laparotomy, complications were lower, transfusions less and the in-hospital occupancy was shorter. Complication rate was 8% and mortality was 1%. CONCLUSION: We confirm the success selective non-operative management of blunt liver trauma as adopted by this institution 20 years ago. It is now proven treatment in an appropriate centre. However, the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy when indicated.     

Treatment priorities in patients with traumatic rupture of the thoracic aorta.

Autopsy studies reveal that 90 percent of patients with traumatic rupture of the thoracic aorta (TRTA) die at the scene of the accident and 25 percent of those reaching the hospital do not survive their injuries. Treatment priorities in patients with TRTA and associated life-threatening head and intra-abdominal injuries have not been adequately studied. The authors reviewed their experience with 57 consecutive patients sustaining TRTA to establish treatment priorities in these multiply injured patients. The mean age of the population was 35 years (43 men, 14 women). Hospital mortality was 24 percent; the most common cause of death was hemorrhage. Fully 95 percent of the patients had associated injuries requiring operative intervention. Abdominal injuries requiring laparotomy were present in 20 patients (35%): 14 splenic injuries, 8 liver injuries, 3 pancreatic injuries, and 3 mesenteric lacerations. Twenty-eight patients (49%) had orthopaedic injuries requiring operative fixation. Maxillofacial injuries requiring surgical repair occurred in 20 patients (35%). Fifteen patients (26%) sustained significant closed head injuries, but only 1 required craniotomy for hemorrhage. Nine hemodynamically unstable patients with intra-abdominal hemorrhage underwent immediate laparotomy for control of bleeding followed by aortography and aortic repair (2 deaths, 22%). Seven hemodynamically stable patients had aortography followed by laparotomy for control of intra-abdominal hemorrhage with subsequent thoracotomy (1 death, 14%). Thirty stable patients underwent aortography followed by immediate thoracotomy; 22 required no further procedures, while 8 required an additional operation (7 death, 23%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Operative intervention for pediatric liver injuries: avoiding delay in treatment.

To identify the physiological and anatomic factors that characterize the need for operative management of blunt pediatric liver injuries, the case records of 106 pediatric trauma victims with liver injuries over a 6-year period were reviewed. Sixty-nine patients were managed without operation (nonoperative) and 37 underwent operation, 7 with penetrating and 30 with blunt liver injuries. Of these 30 patients, 21 underwent laparotomy due to blunt liver injuries (operative); the remaining 9 patients required operation due to associated intraabdominal injuries. Nine (45%) of the 21 operative patients had major hepatic vein or retrohepatic vena caval injuries, 7 of whom died. Overall mortality was 9.4% (10/106). When nonoperative and operative groups were compared, those who underwent laparotomy due to blunt liver injuries: (1) had significantly lower Champion and Pediatric Trauma Scores due to multisystem injury; (2) had 25% or greater lobar disruption with pelvic blood collections on computed tomography scan; (3) underwent early transfusion within 2 hours of admission (18/21); and (4) were frequently found to have a major hepatic vein or retrohepatic vena caval injury at the time of operation. Only one patient successfully managed without operation received greater than 30 mL/kg of blood products within 24 hours of admission. As selective nonoperative management of pediatric liver injuries gains widespread acceptance, the identification of factors that predict the need for operative intervention will limit the potential risks of delay in treatment.     

Importance of the serum amylase level in patients with blunt abdominal trauma

Possible intra-abdominal injuries were sought in 101 patients admitted with blunt abdominal trauma. The serum amylase level was measured in the first 12 hours after the accident. Twenty-five patients had hyperamylasemia; 18 underwent laparotomy and 7 were treated conservatively. At laparotomy all 18 patients exhibited at least one serious intra-abdominal lesion, and there was a total of 28 lesions in the who group (including only four pancreatic injuries). The mean value of the serum amylase for those who had laparotomy was 1190 IU, while it was only 363 IU for those not operated upon. The authors conclude that hyperamylasemia in blunt abdominal trauma is not specific to pancreatic injury, but may suggest the presence of a serious intra-abdominal lesion.     

Immediate surgical management of severe renal injuries in multiple-injured patients

Between 1969 and 1980, 1,132 renal injuries were recorded in 1,120 patients. Of the 129 patients with a severe renal injury (laceration, rupture, pedicle injury), 118 (91%) had associated injuries and 101 (86%) required an immediate laparotomy by general surgeons for intra-abdominal injury. Immediate surgical management was performed on 90 severe renal injuries and resulted in a nephrectomy rate of 5 of 55 lacerations (9%), 16 of 17 ruptures (94%), and 10 of 18 pedicle injuries (56%). Seven of the 18 pedicle injuries (39%) had immediate repair with salvage of the kidney. Conservative management was done on 32 severe renal injuries. Autopsy revealed 10 severe renal injuries in 9 patients who died in the operating room or on admission. A delayed renal operation was required in 9 (28%), and total renal loss (nephrectomy plus main renal artery injury) occurred in 7 of the 32 cases (22%). The severe degrees of renal injury did not all resolve spontaneously. Immediate surgical management of the patient with a severe renal injury resulted in a nephrectomy rate comparable with that of conservatively managed renal injuries.     

TEN YEAR REVIEW OF THORACIC AND ABDOMINAL PENETRATING TRAUMA MANAGEMENT

A ten year review of penetrating thoracic and abdominal trauma examined pattern of injury, patient management and outcome. Ninety-six patients were included in the study, 55 with injury to the abdomen, 31 the thorax and 10 with injury to both areas. Fifty-eight cases were managed non-operatively; 5 combined abdominal and thoracic injuries, 26 thoracic and 27 abdominal. Two cases went on to require operative management for intra-abdominal injury. Thirty-eight cases were managed operatively; 5 combined cavity injuries, 5 thoracic and 28 abdominal. Injuries were found in all of the combined cavity and thoracic cavity cases. Of the 28 abdominal cases, nine were found on laparotomy to have no significant visceral or vessel injury, one, however, was performed for omentum protruding through the wound. While a negative laparotomy was a relatively safe procedure, non-operative management had the advantages of a shorter hospital stay without wound-related morbidity. Selective non-operative management was found to be a relatively safe approach in this series.     

Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment

In order to reassess the value of diagnostic peritoneal lavage (DPL) in patients with blunt abdominal trauma, we conducted a prospective study over a 15-month period involving 138 patients. There were 29 (28.3%) patients with positive DPL and 103 (71.7%) with negative DPL in this series. Of the 29 patients with positive DPL, 28 (96.5%) were found to have significant intra-abdominal injuries; 27 by exploratory laparotomy and in one case at autopsy. One patient with a grossly positive DPL had a negative exploratory laparotomy (3.4% false positive rate). All 109 patients with negative DPL were admitted. In only one case a significant intra-abdominal injury was demonstrated (0.9% false negative rate). The overall mortality in this series was 11.6% and there were no complications related to the DPL. Our results suggest that DPL is indeed an accurate indicator of significant intra-abdominal injuries in patients with blunt abdominal trauma.     

The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.     

Peritoneal lavage in closed abdominal injury

Peritoneal lavage is a sensitive method of detecting intra-abdominal injuries following closed abdominal injury. Our indications for peritoneal lavage are: severe head injury, severe thoracic injury, unexplained hypotension in a patient with possible blunt abdominal injury and patients on artificial ventilation. We present 40 patients with multiple injuries who underwent peritoneal lavage for suspected closed abdominal injury. Twenty-two lavages were positive and 19 laparotomies were performed, of which 18 revealed intra-abdominal injuries. Eighteen lavages were negative; no laparotomy was performed in this group. There was one false positive, but no false negative lavage.     

A critical analysis of blood transfusion requirements in children with blunt abdominal trauma.

Over the past 2 years, 178 children with blunt abdominal trauma were admitted for observation. Fifty-five patients (31.5%) had intra-abdominal injury confirmed by computerized tomography (CT) scan, laparotomy, or postmortem examination. Forty-four children (80%) were managed with observation only; nine had other operations. Eleven patients (20%) required an operation for their intra-abdominal injuries. Thirteen patients died, ten from head or spinal injuries and three from intra-abdominal injuries (5.5%). Of 35 children with intra-abdominal injuries observed without any type of operation, 27 (77%) were not transfused (mean Pediatric Trauma Score [PTS] 8, Injury Severity Score [ISS] 19.3, average low hemoglobin [ALH] 10.1). The other eight were transfused an average of 49 cc/kg (mean PTS 4.5, ISS 26.5 ALH 6.1). Twenty children had operations. Eleven 11 (20%) of these were laparotomies; nine were transfused an average of 200.6 cc/kg (mean PTS 6, ISS 33, ALH 9). Nine had neurosurgical/orthopedic procedures (mean PTS 6.2, ISS 27.7), with six transfusions averaging 84.9 cc/kg (ALH 8.9). There were no significant complications. Blood transfusion was necessary only for 33 per cent of the observed cases, usually with multiple injuries. Blood should be transfused only to maintain hemodynamic stability (normal vital signs and tissue perfusion). Hemoglobin levels as low as 7 gm% do not mandate transfusion in children who are hemodynamically stable.     

A prospective study comparing nuclear scintigraphy and computerized axial tomography in the initial evaluation of the trauma patient

Eighty-five consecutive patients admitted for trauma evaluation and fulfilling criteria suggesting the possibility of intra-abdominal injury underwent both immediate computerized axial tomography of the abdomen and a nuclear medicine evaluation, including a liver-spleen scan with or without a renal scan, in order to delineate their injuries and direct management. The limitations, advantages, and complementary use of each modality in the initial evaluation of the trauma patient is described. Overall, nuclear scintigraphy excelled in instances of contusion, in the evaluation of the restless or uncooperative patient, and in children. With computerized tomography, the retroperitoneal structures were well defined and multiple abdominal injuries could be seen. Neither modality demonstrated the presence of intra-abdominal fluid consistently. No patient with assumed isolated liver, spleen, or renal injury on the basis of the above studies, who was managed nonoperatively, required subsequent laparotomy.     

Blunt liver trauma in children

From 1978 to 1988 228 children under 13 years of age with liver injury following blunt abdominal trauma were studied prospectively. Motor vehicle related accidents were responsible for 85 per cent of the injuries. Isotope liver scan established the diagnosis and identified the pattern of injury. Multiple injuries were seen in 157 patients--predominantly head injuries. The liver was the only intra-abdominal organ injured in 119 patients. There were 69 associated splenic, 33 renal, 21 pancreatic and 3 bowel injuries. There were two deaths (0.88 per cent). Management was non-operative in 215 patients, with resolution of the liver injury in 214. Blood was transfused in 92 patients (40 per cent) (mean volume 20 ml/kg). There were 10 complications; two liver abscesses responded to antibiotics. Follow-up showed complete resolution of the liver injuries. Eight underwent laparotomy because of instability, deterioration or other extrahepatic visceral injuries. All required blood transfusion (mean volume 30 ml/kg). There were eight complications following surgery.     

Diagnosis and treatment of traumatic injuries of the duodenum and pancreas: 21 cases

Twenty one consecutive patients who sustained injuries to the duodenum or/and pancreas were admitted to our hospital over a ten year period. Sixteen blunt injuries and 5 penetrating injuries were encountered. Penetrating injuries were always suspected and treated by time; following blunt injury diagnostic delay was encountered in 7 patients and insufficient surgical procedure because of intraoperative misinterpretation in 2 patients. Most of the patients had associated intra-abdominal organ injuries. Adjuncts to diagnosis such as abdominal roentgenograms, serum amylase levels and gastroduodenography were not helpful. CT-Scan and ultrasound allowed to confirm the suspected diagnosis in 3 cases only. Intraoperative diagnosis was also challenging. Complete mobilization of the structures surrounding the duodenum and the pancreas to provide entire exposure was necessary. In 6 patients treated first in a peripheral hospital, diagnosis of the injury have been missed at first laparotomy and reoperation was necessary in all of them. Suture closure of the duodenum and drainage of the pancreatic region were the most common reparative technique used. More complicated procedures with pancreatic and/or duodenal resection were performed in 6 patients. Overall mortality in patients surviving more than 24 hours was 14% (suture line dehiscence after delayed operation and one death due to brain injury).     

Hepatic angiography in patients undergoing damage control laparotomy

OBJECTIVE: Patients undergoing damage control (DC) laparotomy require intensive and aggressive resuscitation, and may require additional maneuvers to control parenchymal bleeding. Those patients suffering significant liver injury are at high risk for arterial bleeding deep within the liver, and many require hepatic angiography in addition to hepatic packing. We reviewed our experience with hepatic angiography, and sought to determine its safety in the DC population of penetrating and blunt trauma patients. METHODS: A 3-year (June 1997-May 2000) retrospective review generated 37 DC patients. Patients sustaining hepatic trauma constituted the study group. Patients undergoing angiography in addition to DC laparotomy were compared with the group of patients not undergoing angiography. Data regarding mechanism of injury, patient demographics, extent of hepatic injury, and presence of associated injuries were collected. Physiologic parameters including vital signs at admission, lowest pH and base excess in the operating room, and lactate levels in the intensive care unit, as well as volumes of fluid resuscitation throughout all phases of DC were examined. Complications including death, intra-abdominal processes, acute respiratory distress syndrome and/or multiple organ dysfunction syndrome, and acute renal failure were reviewed. RESULTS: Nineteen patients (51%) had hepatic trauma and underwent perihepatic packing as a part of DC laparotomy. Eleven had sustained penetrating injury and 8 had blunt injury. There was 1 American Association for the Surgery of Trauma grade I, 5 grade II, 3 grade III, and 10 grade IV injuries. Nine patients in the study population underwent angiography, and eight of these were hepatic artery angiograms. One hepatic angiogram was obtained before operation and seven were obtained in the immediate postoperative period. Six underwent embolization of bleeding hepatic vessels, for a therapeutic liver angiography rate of 75%. There was no statistical difference in physiologic parameters or fluid requirements between the patients who underwent angiography and those who did not. There were no mishaps or complications from angiography or while in the angiography suite. CONCLUSION: Hepatic angiography is a safe adjunct to the principles of damage control. It has a high therapeutic ratio, with no significant untoward effect in this small study population.     

Suicide bombing attacks: Can external signs predict internal injuries?

OBJECTIVE: To report the distribution and types of injuries in victims of suicide bombing attacks and to identify external signs that would guide triage and initial management. SUMMARY BACKGROUND DATA: There is a need for information on the degree to which external injuries indicate internal injuries requiring emergency triage. METHODS: The medical charts and the trauma registry database of all patients who were admitted to the Hadassah Hospital in Jerusalem from August 2001 to August 2004 following a suicide bombing attack were reviewed and analyzed for injury characteristics, number of body areas injured, presence of blast lung injury (BLI), and need for therapeutic laparotomy. Logistic analysis was performed to identify predictors of BLI and intra-abdominal injury. RESULTS: The study population consisted of 154 patients who were injured as a result of 17 attacks. Twenty-eight patients suffered from BLI (18.2%) and 13 patients (8.4%) underwent therapeutic laparotomy. Patients with penetrating head injury and those with > or =4 body areas injured were significantly more likely to suffer from BLI (odds ratio, 3.47 and 4.12, respectively, P < 0.05). Patients with penetrating torso injury and those with > or =4 body areas injured were significantly more likely to suffer from intra-abdominal injury (odds ratio, 22.27 and 4.89, respectively, P < 0.05). CONCLUSION: Easily recognizable external signs of trauma can be used to predict the occurrence of BLI and intra-abdominal injury. The importance of these signs needs to be incorporated into triage protocols and used to direct victims to the appropriate level of care both from the scene and in the hospital.