Applicability of the trimodal distribution of trauma deaths in a Level I trauma centre in the Netherlands with a population of mainly blunt trauma

BACKGROUND: Death due to trauma is assumed to follow a trimodal distribution. Since 1995 measures have been taken to regulate organisations involved in trauma care systems in the Netherlands. In estimating the effect of this system we have evaluated the time of death distribution in the University Medical Centre Utrecht (UMCU). STUDY DESIGN: Prospectively collected databases of all trauma victims between January 1996 and December 2005 were retrospectively reviewed. All traumatic deaths were included. Cause of death was divided into exsanguination, thorax, CNS, organ failure, pneumonia, other and unknown. RESULTS: Nine thousand eight hundred and five patients were admitted after trauma; of these patients 659 (6.7%) died. Blunt trauma occurred in 615/659 (93.3%) patients. The temporal distribution did not show a trimodal distribution. One predominant peak was observed, /=14 days, 28% and 29%, respectively. CONCLUSION: No trimodal distribution was confirmed. Only one predominant peak, with a rapid decline, was observed within the first hour after trauma. Even analysed for different causes of death, the trimodal distribution could not be demonstrated. In particular death due to CNS injury showed a complete absence of any peaks.     

Potentially preventable trauma deaths: A retrospective review

BackgroundReviewing prehospital trauma deaths provides an opportunity to identify system improvements that may reduce trauma mortality. The objective of this study was to identify the number and rate of potentially preventable trauma deaths through expert panel reviews of prehospital and early in-hospital trauma deaths.MethodsWe conducted a retrospective review of prehospital and early in-hospital (<24 h) trauma deaths following a traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria (AV) in the state of Victoria, Australia, between 2008 and 2014. Expert panels were used to review cases that had resuscitation attempted by paramedics and underwent a full autopsy. Patients with a mechanism of hanging, drowning or those with anatomical injuries deemed to be unsurvivable were excluded.ResultsOf the 1183 cases that underwent full autopsies, resuscitation was attempted by paramedics in 336 (28%) cases. Of these, 113 cases (34%) were deemed to have potentially survivable injuries and underwent expert panel review. There were 90 (80%) deaths that were not preventable, 19 (17%) potentially preventable deaths and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 20% of those cases that underwent review and 7% of cases that had attempted resuscitation.ConclusionsThe number of potentially preventable or preventable trauma deaths in the pre-hospital and early in-hospital resuscitation phase was low. Specific circumstances were identified in which the trauma system could be further improved.     

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

BackgroundOver the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center.MethodsRecords at an urban Level 1 trauma center were reviewed. Two time periods (2005–2006 and 2012–2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05.Results7080 patients (498 deaths) were examined in 2005–2006, while 8767 patients (531 deaths) were reviewed in 2012–2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for >91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p < 0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24 h. Unadjusted mortality dropped from 7.0% to 6.1 (p = 0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p < 0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9–8.2) to 5.8% (95% CI: 5.3–6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0–7.2) to 4.7 (95% CI: 4.2–5.1).ConclusionsOver the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.     

Preventability of trauma deaths in a Dutch Level-1 trauma centre

Background

Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability.

Methods

All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus.

Results

Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies.

Conclusions

The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.     

Splenic preservation in adults after blunt and penetrating trauma

This study was carried out to evaluate the possibility and safety of splenic preservation in adults subjected to both blunt and penetrating trauma. In an 18 month period there were a total of 36 splenic injuries studied (in 36 patients): 18 due to blunt trauma, 11 due to gunshot wounds, and 7 due to stab wounds. A total of 18 spleens were repaired: 8 (45 percent) in the blunt trauma group, 4 (36 percent) in the gunshot group, and 6 (85 percent) in the stab wound group. There were no deaths in the entire group nor were there any complications associated with splenic salvage. Splenic preservation after both blunt and penetrating trauma is both safe and feasible in the adult population, except in those instances specified herein.     

Predictors of blunt abdominal aortic injury in trauma patients and mortality analysis

ObjectiveBlunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI.MethodsThe Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI.ResultsFrom 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001).ConclusionsIn the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.     

Pneumatoceles in pediatric blunt trauma: Common and benign

Introduction

Traumatic pneumatoceles are reported to be rare in children and to have an uncertain clinical significance. We report a single institution series of traumatic pneumatoceles to better define their frequency and clinical significance.

Epidemiology of trauma: A population-based study of geographical risk factors for injury deaths in the working-age population of Norway

Introduction

Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality.

Methods

All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16–66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates.

Results

The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths.

Conclusion

Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.     

Laparoscopy in penetrating abdominal trauma

Summary BACKGROUND: Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. There is no doubt that persistent hemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy. If the patient is hemodynamically stable and has equivocal abdominal examination findings, diagnosis may be obtained by laparoscopy. METHODS: The goal of this article is to evaluate the role of laparoscopy in the management of PAT. RESULTS: Patients with penetrating trauma to the thoracoabdominal and anterior abdominal wall are good candidates for laparoscopic evaluation. The peritoneal cavity and its contents, including the retroperitoneal space, can be thoroughly examined easily and safely. The main benefits of laparoscopy include the reduction of nontherapeutic laparotomies, identification of mostly intra-abdominal injury, and provision of potential therapy for some cases. Diagnostic laparoscopy has a high overall diagnostic accuracy, reduced morbidity, and shortened hospital stay and is also cost-effective. While laparoscopy has some limitations in the diagnosis of hollow viscus injury, it can detect and repair diaphragmatic injuries accurately and exclude the risk of nontherapeutic laparotomy due to a nonbleeding injury of the solid organs. CONCLUSIONS: The use of laparoscopy as a diagnostic or therapeutic method in patients with PAT is reserved only for hemodynamically stable patients and uncertain findings of peritonitis. Laparoscopy is an efficient and effective diagnostic tool when used by a well-trained surgeon. With experience, an increasing number of surgeons are using laparoscopy as an additional diagnostic tool for PAT in stable patients. With more experience and skills, laparoscopy may be used more therapeutically in selected patients. Minimally invasive surgery has already established itself as a useful tool in the management of PAT. The future seems to be promising for this field of surgery by innovative developments in computer technology and robotic systems.     

Pediatric blunt trauma: a retrospective analysis in a Level I trauma center

This study consisted of an 8-year retrospective trauma registry analysis of blunt trauma and comprised of 2458 children (<18 years of age) and 4568 adults (18-64 years of age). Falls and motor vehicular crashes were seen in 30.4 per cent (749) and 23 per cent (566) of children, and 25.4 per cent (1158) and 41.9 per cent (1914) of adults. Children had a higher mean revised trauma score (7.69 vs 7.66) and Glasgow Coma Score (14.5 vs 14.3), and a lower Injury Severity Score (ISS; 6.68 vs 7.83 and hospital length of stay (2.8 vs 3.8 days) with P < 0.05. Overall mortality was 1.3 per cent in children and 1.9 per cent in adults (P = 0.05). Pedestrian accidents resulted in a 3.8 per cent (6/161) mortality rate. Pediatric nonsurvivors had a 6.4-fold higher ISS than survivors compared with a 5.2-fold increase in adults. Mortality progressively increased with higher ISS; 0.09 per cent in <15, 1.3 per cent, in 15 to 24, and 17 per cent in children with > or = 25 ISS. Mortality in multiple chest injuries was 19 per cent. The presence of chest trauma resulted in a 46-fold higher mortality in children. Most lethal injuries were combined head, chest, and abdomen trauma with a 25 per cent mortality in children and 28 per cent in adults. Admission Glasgow Coma Score <9 and systolic blood pressure below 100 mm Hg carried high mortality: 39 and 6 per cent in children vs 31 and 24 per cent in adults. Ninety-seven per cent of children and 89 per cent of adults were discharged home.     

Development and validation of a new simplified anatomic trauma mortality score

BackgroundMost trauma mortality prediction scores are complex in nature. GAP (Glasgow Coma Scale, Age, Systolic blood pressure) and mGAP (mechanism, Glasgow Coma Scale, Age, Systolic blood pressure) scores are relatively simple scoring tools. However, these scores were not validated in low and middle income countries including Malaysia and its accuracies are influenced by the fluctuating physiologic parameters. This study aims to develop a relevant simplified anatomic trauma scoring system for the local trauma patients in Malaysia.MethodA total of 3825 trauma patients from 2011 to 2016 were extracted from the Hospital Sultanah Aminah Trauma Surgery Registry. Patients were split into a development sample (n = 2683) and a validation sample (n = 1142). Univariate analysis is applied to identify significant anatomic predictors. These predictors were further analyzed using multivariable logistic regression to develop the new score and compared to existing score systems. The quality of prediction was determined regarding discrimination using sensitivity, specificity and receiver operating characteristic [ROC] curve.ResultsExisting simplified score systems (GAP & mGAP) revealed areas under the ROC curve of 0.825 and 0.806. The newly developed HeCLLiP (Head, cervical spine, lung, liver, pelvic fracture) score combines only five anatomic components: injury involving head, cervical spine, lung, liver and pelvic bone. The probabilities of mortality can be estimated by charting the total score points onto a graph chart or using the cut-off value of (>2) with a sensitivity of 79.2 and specificity of 70.6% on the validation dataset. The HeCLLiP score achieved comparable values of 0.802 for the area under the ROC curve in validation samples.ConclusionHeCLLiP Score is a simplified anatomic score suited to the local Malaysian population with a good predictive ability for trauma mortality.     

Pediatric trauma deaths: a three-part analysis from a nonacademic trauma center

A three-part analysis was undertaken to assess pediatric trauma mortality in a nonacademic Level II trauma center at Parkview Hospital in Fort Wayne, Indiana. Part I was a comparison of Parkview trauma registry data collected from 1999 through 2003 with those of pediatric and adult trauma centers in Pennsylvania. The same methodology used in Pennsylvania was used for the initial evaluation of pediatric deaths from trauma in our trauma center. Part II was a formal in-depth analysis of all individual pediatric deaths as well as surgical cases with head, spleen, and liver injuries from the same time frame. Part III proposes a new methodology to calculate a risk-adjusted mortality rate based on the TRISS model for the evaluation of a trauma system. The use of specific mortality and surgical intervention rates was not an accurate reflection of trauma center outcome. The proposed risk-adjusted mortality rate calculation is perhaps an effective outcome measure to assess patient care in a trauma system.     

Predictors of mortality following severe pelvic ring fracture: results of a population-based study

Introduction

Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system.

Methods

Cases aged ≥ 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated.

Results

There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged ≥ 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres).

Conclusions

The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.     

Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience

BACKGROUND: State-legislated trauma systems have been enacted in an attempt to improve trauma care. Blunt splenic injury incidence without a legislated trauma system was examined for changes in care with a hypothesis that a voluntary system may perform equally with a legislated system. METHODS: Data from a statewide discharge database for the years 1993 to 2002 were examined. RESULTS: There were 276,425 trauma admissions overall, with blunt splenic injury occurring in 1.76%. Average Injury Severity Score (ISS) increased in trauma centers and decreased in the community. Trauma centers (TC) had more multisystem injuries. Splenic injury diagnosis increased 44% in TC between the early and late periods but only 7% in community facilities. Splenectomies increased 16% in TC but declined 16% in community hospital. Splenic salvage rate improved at both types of facilities. CONCLUSIONS: Splenic salvage rates improved over time in hospitals with no formal trauma system. Community hospitals cared for more than 50% of splenic injuries but transferred complex multisystem injuries, including splenic injuries, suggesting evolving care. Non-invasive imaging has increased the recognition of splenic injuries in both community hospitals and TC. Splenectomies are performed less, but have increased in TC with increasing ISS scores.     

Emergency pneumonectomy for penetrating and blunt trauma

Emergency pneumonectomy for penetrating and blunt trauma has an attendant high mortality. Patients with major lung injuries presenting with prolonged shock followed by control of bleeding, resuscitation with or without aortic cross-clamping and pneumonectomy have had uniformly unsatisfactory results. From 1972 to 1982, eight patients at the University of Louisville Hospital underwent emergency pneumonectomy. All patients underwent expeditious evaluation, resuscitation, and thoracotomy with pneumonectomy. Three patients died of exsanguination (2 patients had major associated intra-abdominal injuries). Three other patients died due to pulmonary edema and right ventricular failure 2 to 3 hours after hemorrhage had been controlled and intravascular volume restored. Aortic cross-clamping was employed in four patients due to persistent hypovolemia with 100 per cent mortality. Of the two surviving patients, one presented with stable blood pressure and had pneumonectomy for tracheobronchial disruption, while the other had pneumonectomy for tangential laceration of the lung at the hilum. Pulmonary edema and right ventricular failure were responsible for mortality following emergency pneumonectomy and control of hemorrhage and restoration of blood volume. The addition of aortic cross-clamping did not seem to alter survival and may, indeed, hinder therapy due to increased vascular afterload and increased heart failure and pulmonary edema.     

Laparoscopy in blunt abdominal trauma

Summary BACKGROUND: The decision in favor of surgery or nonoperative conservative treatment in abdominal trauma requires a precise diagnosis that is not always possible with imaging techniques. As there is particular danger that an injury to the diaphragm or intestines be overlooked, the indications for exploratory laparotomy should be generous. Owing to this circumstance, however, up to 41% of exploratory laparotomies turn out to be nontherapeutic and could be, or could have been, avoided with laparoscopy. METHODS: A diagnostic laparoscopy with therapeutic option in blunt abdominal trauma should only be attempted in stable patients. Usually three trocars are used and the exploration of the abdomen is systematic, beginning with the right upper quadrant and continuing clockwise. Small lacerations of the intestines and mesentery can be detected and sutured endoscopically, as well as injuries to the diaphragm. Injuries to parenchymal organs are not a primary indication for laparoscopy, but they can be sealed with tissue adhesive and collagen tamponade to prevent further bleeding. RESULTS: Routine use of laparoscopy can achieve a sensitivity of 90–100% in abdominal trauma. This can reduce the number of unnecessary laparotomies and the related morbidity. CONCLUSIONS: Laparoscopy can be performed safely and effectively in stable patients with abdominal trauma. The most important advantages are reduction of morbidity, shortening of hospitalization and cost-effectiveness. In the future, new developments in laparoscopy equipment and the introduction of computer technology and robotic devices can be expected to have a decisive influence on the treatment of trauma patients.     

The utility of focused abdominal ultrasound in blunt abdominal trauma: a reappraisal

BACKGROUND: Focused assessment with sonography for trauma (FAST) has become commonplace in the management of blunt abdominal trauma. However, newer computed tomography (CT) scanners have decreased imaging time for trauma patients and provide more detailed examination of abdominal contents. It was the aim of the current study to evaluate practice patterns of FAST and abdominal CT in blunt trauma victims. METHODS: This was a retrospective study of all blunt trauma patients (N = 299) who received at least 1 FAST examination in the emergency department by surgeons and were admitted. Patients were tracked for subsequent CT scanning, disposition from the emergency department, any operative findings, and survival. RESULTS: Twenty-one of 299 patients (7%) had a positive FAST. There were 7 deaths and 14 patients were taken directly to the operating room (OR) for control of abdominal bleeding. Thirty-one of 299 (10%) had equivocal FAST. There were 4 deaths and 8 patients were taken to the OR for control of abdominal bleeding. A total of 247 of the 299 patients had a negative FAST. CT scans were performed in 193: 15 showed a visceral injury. There were 13 deaths and 29 patients were taken to the OR (4 for bleeding). Patients with a positive FAST had a higher mortality than FAST-negative patients (P < .001) and greater likelihood for operation (P < .001). Those with equivocal FAST had a greater likelihood for operation than FAST-negative patients (P < .05). CONCLUSIONS: FAST examinations can identify patients at risk for hemorrhage and in whom operation may be needed and, therefore, can guide mobilization of hospital resources. FAST-negative patients can be managed expectantly, using more specific imaging techniques.     

Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis

Objective

The objective of the study was to obtain the best estimates of the test performance of abdominal ultrasonography (US) for identifying children with intraabdominal injuries (IAIs).

Methods

We gathered studies on the use of abdominal US in injured children from the following sources: a MEDLINE and Embase search, hand searches of 5 specialty journals and 4 clinical textbooks, the bibliographies of all identified articles, and contact with experts. Both prospective and retrospective studies were included if they used abdominal US for the detection of intraperitoneal fluid or IAIs in blunt trauma patients less than 18 years of age. All authors independently abstracted data from the selected studies. Disagreements between abstractors were resolved by mutual agreement.

Results

Twenty-five articles met the inclusion criteria, and 3838 children evaluated with abdominal US were included. Abdominal US had the following test characteristics for identifying children with hemoperitoneum: sensitivity, 80% (95% confidence interval [CI] 76%-84%); specificity, 96% (95% CI 95%-97%); positive likelihood ratio, 22.9 (95% CI 17.2-30.5); and negative likelihood ratio, 0.2 (95% CI 0.16-0.25). Using the most methodologically rigorous studies, however, yielded the following test characteristics of abdominal US for identifying children with hemoperitoneum: sensitivity, 66% (95% CI 56%-75%); specificity, 95% (95% CI 93%-97%); positive likelihood ratio, 14.5 (95% CI 9.5-22.1); and negative likelihood ratio, 0.36 (95% CI 0.27-0.47).

Conclusions

Abdominal US has a modest sensitivity for the detection of children with hemoperitoneum; however, its test performance characteristics worsen when only the most methodologically rigorous articles are included. A negative US examination has questionable utility as the sole diagnostic test to rule out the presence of IAI. Because of the high risk of IAI, a hemodynamically stable child with a positive US examination should immediately undergo abdominal computed tomographic scanning.     

Systematic review of blunt abdominal trauma as a cause of acute appendicitis

INTRODUCTION

Acute appendicitis commonly presents as an acute abdomen. Cases of acute appendicitis caused by blunt abdominal trauma are rare. We present a systematic review of appendicitis following blunt abdominal trauma. The aim of this review was to collate and report the clinical presentations and experience of such cases.

SUBJECTS AND METHODS

A literature review was performed using PubMed, Embase and Medline and the keywords ‘appendicitis’, ‘abdominal’ and ‘trauma’.

RESULTS

The initial search returned 381 papers, of which 17 articles were included. We found 28 cases of acute appendicitis secondary to blunt abdominal trauma reported in the literature between 1991 and 2009. Mechanisms of injury included road-traffic accidents, falls, assaults and accidents. Presenting symptoms invariably included abdominal pain, but also nausea, vomiting and anorexia. Only 12 patients had computed tomography scans and 10 patients had ultrasonography. All reported treatment was surgical and positive for appendicitis.

CONCLUSIONS

Although rare, the diagnosis of acute appendicitis must be considered following direct abdominal trauma especially if the patient complains of abdominal right lower quadrant pain, nausea and anorexia. Haemodynamically stable patients who present shortly after blunt abdominal trauma with right lower quadrant pain and tenderness should undergo urgent imaging with a plan to proceed to appendicectomy if the imaging suggested an inflammatory process within the right iliac fossa.