The efficacy and limitations of transarterial embolization for severe hepatic injury

BACKGROUND: The efficacy of transarterial embolization (TAE) for severe blunt hepatic injury has been reported. We performed a prospective study evaluating the efficacy and the limitation of TAE from January 1996 to December 2000. METHODS: All patients with blunt abdominal injury who could be stabilized by fluid resuscitation underwent computed tomographic (CT) scan examinations. Patients with CT scan evidence of hepatic injury were classified into five grades according to CT scan findings on the basis of the injury scale of the American Association for the Surgery of Trauma (Mirvis classification). All patients with CT scan grade 3 to 5 injury underwent angiography. When angiography showed extravasation of contrast medium extending from hepatic arterial branches, TAE was performed. RESULTS: Of 612 patients with blunt abdominal trauma, 51 had CT scan grade 3 to 5 injury. Thirty-seven of these patients had a CT scan grade 3 injury and 18 underwent TAE. One of 19 patients who did not undergo TAE developed a delayed hemorrhage on day 6 and required a laparotomy. All 13 patients with a CT scan grade 4 injury had angiographic findings of the extravasation. TAE was successful in 11 patients and unsuccessful in 2. Five patients with a CT scan grade 4 injury required laparotomy. One developed a delayed hemorrhage on day 4. The remaining four patients had a major venous injury (a right lobectomy was performed in two with inferior vena cava injury, and a gauze packing in two with hepatic venous injury). One patient with a CT scan grade 5 injury underwent immediate laparotomy after TAE. Laparotomy revealed inferior vena cava injury and a right lobectomy was performed. Only two patients who underwent a lobectomy died of an uncontrollable hemorrhage. All CT scans of patients with hepatic venous or inferior vena cava injury showed a large low-density area (> or = 10 cm) with involvement of these vessels. The volumes of fluid resuscitation needed from admission until TAE ranged from 2,109 to 2,638 mL/h. CONCLUSION: It was considered that the combination of the presence of a CT scan grade 4 or 5 lesion and the fluid requirements of more than 2,000 mL/h to maintain normotension indicated the absolute necessity of surgery. We felt that these patients were not candidates for TAE, and should undergo immediate laparotomy.     

Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study

Blunt trauma to the pancreas is an uncommon injury, which can be difficult to diagnose. Most studies are multi-institutional, include both helical and axial CT, and report sensitivities of 40 to 67 per cent. We evaluated the efficacy of spiral CT for the diagnosis of blunt pancreatic injury in a single large-volume institution. We retrospectively reviewed 22,000 blunt trauma patients seen between 1996 and 2000. Pancreatic injury was identified in 40 patients (0.2%). All patients evaluated with spiral CT were given both oral and intravenous contrast. A total of 40 blunt pancreatic injuries were identified. The mean age was 35 years. Seventy-five per cent were male. Mean Injury Severity Scale score was 29 and overall mortality 12.5 per cent. Thirty-one patients (78%) underwent laparotomy. Twelve patients went directly to the operating room for urgent exploration and 19 had a preoperative CT. CT was positive for pancreatic injury in 13 patients (sensitivity 68%). All 13 patients had confirmed pancreatic injury at the time of surgery (positive predictive value = 100%). Using the American Association for the Surgery of Trauma grading system operative findings and CT correlated in 68 per cent of those patients who had both CT and laparotomy. CT underestimated pancreatic injury in the remaining 31 per cent. Nine patients were managed nonoperatively without complication, and six had pancreatic injury on CT. The other three had a negative CT but had clinical and laboratory evidence of pancreatic injury. Overall CT scan was 68 per cent (19 of 28) accurate in diagnosing pancreatic injury. We conclude that CT scan is only moderately sensitive and can underestimate or miss pancreatic injury. Although CT moderately correlated with injury grade it was highly predictive for presence of injury. The new multidetector helical scanner may improve our diagnostic ability.     

Nonoperative management of blunt splenic injury: a 5-year experience

OBJECTIVES: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. METHODS: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. RESULTS: A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. CONCLUSION: Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.     

Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma

BACKGROUND: Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management. METHODS: During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material. RESULTS: The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable. CONCLUSION: With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.     

Conservative... and non conservative... treatment of renal blunt injuries

Whether patients with blunt renal trauma should be managed conservatively without surgery or undergo surgery is often hard to decide. We describe three clinical cases of blunt renal trauma, all involving the left kidney. All three patients had abdominal ultrasound studies and computerized tomographic (CT) scans. In the first case, an accidental fall led to severe injury of the renal hilus causing massive retroperitoneal extravasation. The patient underwent emergency nephrectomy and survived. The second case concerned a patient who was involved in a road accident, suffered injuries mainly affecting the spleen, and underwent splenectomy. A postoperative CT scan showed left renal vein thrombosis functionally excluding the inferior pole of the kidney. The patient received conservative non surgical treatment. A follow-up imaging study showed that although the thrombosis had resolved the renal pole had failed to regain normal function. In the third case, mild apparently unimportant trauma led to a massive hemorrhage responsible for a severe shock state. Despite prompt nephrectomy, renal failure and and pulmonary complications developed and one month after the injuries the patient died. The medical history referred to a "chronic hematoma" secondary to a childhood injury. In this case, the pre-existing hematoma probably led to a permanent communication with the vascular and excretory tree thus resulting in a kind of "silent" fistula that the relatively mild injury unexpectedly disrupted. For the two left nephrectomies we used a midline approach after isolating the renal Treitz vessels; special care was taken to mobilize the left colon. Although blunt renal trauma often responds to non surgical conservative treatment, some patients should undergo prompt surgery. All patients must be scheduled for long-term clinical and imaging follow-up.     

The impact of computed tomography scanning on the child with renal trauma

A six-year experience using computed tomography (CT) in the diagnosis of blunt abdominal trauma was reviewed to assess the impact of CT scanning on a patient with renal injury. Three questions were evaluated: Does the increased sensitivity of the CT scan alter the indications for surgery? Does the CT scan help predict the course and eventual outcome of nonoperative therapy? Are there circumstances when the CT scan is not the most efficient and cost effective method of diagnosis? One hundred seventy six consecutive patients with suspected renal trauma were reviewed. One hundred thirty eight were evaluated by CT scan and IVP, the other 38 by excretory urogram alone. Forty four renal injuries were identified. Four of these patients required urgent surgery and four others required later operation for unsuspected congenital anomalies. The injuries sustained by the other 36 cases resolved without surgery. Each patient has been followed for 1 to 5 years following their trauma, and their status assessed by questionnaire and physical examination. The CT technique provides better definition of the injury upon which to base the decision to operate or to enter the patient into nonoperative management. The extravasation seen on CT scan is frequently exaggerated and should not be an absolute indication for exploration. The scan provides improved follow-up data as to completeness of healing and allows directions to be given to the parents concerning resumption of full physical activities. The patients with asymptomatic posttraumatic hematuria, have in our experience, a very low incidence of intraperitoneal or retroperitoneal injuries. Therefore, these patients do not require the advantages of CT scan and may be screened by the less expensive intravenous pyelogram.     

Grade 4 renal injury: current trend of management and future directions

The management of blunt renal trauma has been evolving. The past management largely based on American Association for Surgery of Trauma (AAST) grading system, i.e. necessitated a computed tomography (CT)scan. Although the CT scan use is increasing and becomes the standardized mode of investigation, AAST grading no longer plays the sole role in the decision of surgical interventions. Two case reports of blunt renal trauma managed successfully by conservative methods are presented.Case one was an 18 year-old boy who had a fall when riding a motorbike at 20 km/h with a helmet and full protective equipments. He was landed by his left flank onto a rock.Contrast abdominal CT revealed a 4 em, grade Ⅲ splenic tear and a grade Ⅳ left kidney injury with large perirenal haematoma. His international severity score (ISS) was 34.He was managed conservatively with bed rest and frequent serum haemoglobin monitoring. Subsequent CT with delayed contrast revealed stable perirenal haematoma with urine extravasation which was consistent with a grade Ⅳ renal injury. Case two was a 40 year-old male who had a motor bike accident on a racetrack when he was driving at 80 to 100 km/h, wearing a helmet. He lost control and hit onto the sidewall of the racetrack. Contrast abdominal CT revealed a grade Ⅳ left renal injury with a large urine extravasation. His renal injury was managed conservatively with interval delayed phase CT of the abdomen. A repeat CT on abdomen was performed five months after the initial injury which revealed no residual urinoma.In this study, moreover, a review of the literature to the management of blunt renal trauma was conducted to demonstrate the trend of increasing conservative management of such traumas. Extra radiological parameters may guide future decision making. However, the applicability of data may be limited until randomized trials are available.     

Management of patients with indeterminate diagnostic peritoneal lavage results following blunt trauma.

The management of blunt trauma victims with indeterminate diagnostic peritoneal lavage (DPL) findings remains controversial. We reviewed 1,196 patients undergoing DPL to identify patients with indeterminate DPL (red cell counts of 20,000 to 99,999 rbc/mm3). Only 4% (48%) had indeterminate DPL results. Repeat DPL (R-DPL) was performed in 31 patients. Six repeat DPLs produced positive results (greater than 100,000 rbc/mm3), 15 produced indeterminate results, and 10 produced negative results (less than 20,000 rbc/mm3). A review of the nine laparotomies performed in this group revealed only two operations that were therapeutic. Twelve patients had abdominal CT scans following indeterminate DPL. Six patients had negative CT scans and were successfully managed without operation. The findings were positive on six other CT scans. Four patients with positive CT scans, including two splenic injuries, one liver injury, and one renal laceration, were managed successfully without surgery. The remaining two patients with positive CT scans underwent laparotomy. The first had a renovascular injury diagnosed from the CT scan after negative findings on repeat DPL. The second had a minor splenic injury diagnosed from the CT scan. A subsequent repeat DPL produced a positive result prompting a nontherapeutic operation. Eleven patients were observed without repeat DPL or CT scanning. Of these, four eventually underwent laparotomy on the basis of clinical suspicion alone. Only one of these patients required therapeutic intervention at the time of laparotomy. Intra-abdominal injury was common in patients with indeterminate DPL results, however, only four (8%) of the patients required a therapeutic operation. Both negative repeat DPL results or negative findings on CT scans predicted successful nonoperative management.(ABSTRACT TRUNCATED AT 250 WORDS)     

Investigation and management of blunt renal injuries in children: a review of 11 years' experience

Over an 11-year period, 333 patients aged 6 months to 13 years were investigated for suspected blunt renal trauma. Ninety-one renal injuries were demonstrated. All patients who had preexisting pathology sustained major (ie, grade III or IV) injuries and all those who required surgery presented with 4+ or macroscopic hematuria with or without loin signs. Intravenous pyelography (IVP) showed no injury in 140 (89%) of 157 patients who had 0 to 3+ microscopic hematuria, and did not influence management in the remaining 17 patients. Seventy-eight (84%) patients were treated nonoperatively, with one death and few complications. Thirteen (14%) patients underwent early laparotomy, with a nephrectomy rate of 92%. No patient with a renal pedicle injury was considered suitable for vascular reconstruction. We conclude that (1) contrast studies are of little value in pediatric patients with asymptomatic microscopic hematuria after blunt trauma; (2) IVP remains the most cost-effective means of investigating renal injuries; and (3) laparotomy is only indicated for ongoing hemorrhage from the severely injured kidney and in a few selected patients with renal pedicle injuries.     

多层螺旋CT增强扫描对肾损伤的诊断价值

目的探讨多层螺旋CT（MSCT）增强扫描在肾损伤中的诊断价值。 方法回顾性分析2012年1月至2017年12月间我院收治116例肾损伤患者的MSCT扫描和超声检查资料,其中增强扫描92例,延迟期扫描41例,比较二者在肾损伤临床分级诊断的符合率。 结果根据美国创伤外科协会肾损伤分级标准,对所有患者进行明确诊断和分级,本组116例患者中Ⅰ级26例,Ⅱ级27例,Ⅲ级39例,Ⅳ级14例,Ⅴ级10例;MSCT对Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级、Ⅴ级闭合性肾损伤的分级诊断符合率分别为88.5%、88.9%、89.7%、92.8%、100.0%,显著高于超声的诊断符合率80.7%、81.5%、84.6%、85.7%、90%,二者比较差异具有统计意义（P<0.05）。MSCT平扫有1例考虑右肾损伤行探查发现肾脏完整,而增强扫描与手术结果符合率100%。 结论MSCT增强扫描能快速明确患者肾损伤的程度及合并伤情况,对肾损伤诊断和分级具有重要临床指导价值。     

Traumatisme de la rate : facteurs prédictifs d’échec du traitement non-opératoire

Introduction

Non-operative management of blunt splenic injury in adults has been applied with increasing frequency. However, predictive criteria for successful non-operative management are still a matter of debate.

Methods

we retrospectively reviewed all cases of blunt splenic injury in adult patients from 1997 to 2006.

Results

Of 190 patients with blunt splenic trauma (median age: 33 years, range 16-98), 43.7% (n=83) underwent emergency surgical intervention (Group I), and 56.3% (n=105) of patients were admitted for conservative treatment of splenic trauma. Conservative treatment was successful in 76.6% (n=82) (Group II), while 23.4% (n=25) of patients required a laparotomy (Group III). Ultimately, 43.2% of patients were successfully managed non-operatively, and 56.9% underwent laparotomy. Mechanism of injury was not significantly different among three groups. Group I patients presented significantly more frequently with hypovolemic shock (p<0.01), associated injuries (p<0.01), and high grade of splenic injury (p<0.01). All patients with active bleeding as evidenced by extravasation on CT scan, underwent exploratory laparotomy. Failure of non-operative management increased significantly with splenic trauma grade (grade I (0%), grade II (22.6%), grade III (27.6%) and grade IV (40%), (p<0.01) and with quantity of hemoperitoneum (10.4% of patients with small, 22.2% of patient with moderate, and 47.8% with large hemoperitoneum). The median interval for conservative treatment failure was 3 days (range: 1-15).Splenic injuries were operatively controlled by splenectomy (91.6%) and splenorrhaphy (8.4%).

Conclusion

Suitability of adult patients with blunt splenic injury for non-operative management may be predicted at initial presentation, based on hemodynamic status and associated injuries. The quantity of hemoperitoneum and magnitude of splenic injury are predictive factors for failure of conservative treatment. Early definition of these factors may help identify those patients likely to be successfully treated without laparotomy.     

Significance of Computed Tomography Finding of Intra-Abdominal Free Fluid Without Solid Organ Injury after Blunt Abdominal Trauma: Time for Laparotomy on Demand

Background

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial.

Objective

The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy.

Methods

During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome.

Results

A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures.

Conclusion

Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.     

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.     

Admission angiography for blunt splenic injury: advantages and pitfalls.

BACKGROUND: To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury. METHODS: Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999. RESULTS: One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries. CONCLUSION: Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including "second-look" angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.     

Management of grade IV renal injury in children

PURPOSE: Conservative nonsurgical management of major renal trauma in children is well established. However, when blunt trauma is accompanied by significant urinary extravasation, options are less than clearly defined. Endoscopic techniques, such as stents and percutaneous drainage, have not been widely used because of small caliber. We present our experience with endoscopic management of grade IV renal trauma. MATERIALS AND METHODS: From 1983 to 1996, 15 children satisfied the criteria for grade IV renal trauma. We retrospectively reviewed the charts to assess the mechanism of injury, associated injury, treatment, hospital stay and transfusion requirement. Patients were followed clinically with blood pressure and creatinine monitoring, and by radiograph with computerized tomography. RESULTS: Nine patients with isolated kidney injury were successfully treated with observation, 1 underwent early partial nephrectomy for persistent anemia and hypotension, and 5 had a urinoma, which was successfully treated with percutaneous drainage only in 2. The other 3 patients underwent cystoscopy and ureteral stent placement for high drainage output, leading to the resolution of urine leakage. In 1 patient who underwent percutaneous drainage only renovascular hypertension developed, requiring partial nephrectomy 3 months after the original injury. The remaining 13 patients had complete radiographic resolution of the injury and no evidence of hypertension. CONCLUSIONS: In the pediatric population grade IV blunt renal trauma usually resolves without intervention. When a symptomatic urinoma develops, percutaneous drainage, accompanied at times by ureteral stenting provides the complete resolution of persistent urine leakage.     

Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma

BACKGROUND: Although the presence of a contrast blush (CB) on computed tomographic (CT) scan is associated with an increased failure rate of nonoperative management in adults with blunt splenic injury, little information is available for the pediatric population, where nonoperative management is the standard of care. Our aim was to determine whether the finding of CB on CT scan could predict failure of nonoperative therapy in children with blunt splenic injury. METHODS: A retrospective analysis of 343 patients admitted with blunt splenic injury to our Level I pediatric trauma center over a 7-year period was performed. All CT scans were reviewed by a radiologist who was blinded to the patient outcome. We excluded 127 patients who either underwent immediate laparotomy without a CT scan or whose CT scans were unavailable at the time of this review. We divided the patients into two groups on the basis of the presence or absence of CB on the updated reading of the CT scan. Demographic variables analyzed included age, sex, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score, initial hemoglobin and hematocrit, and emergency department pulse rate and systolic blood pressure. Outcome measures compared include length of stay, length of intensive care unit stay, the need for splenic intervention, and mortality. Continuous variables were compared using Student's t test for normally distributed data and the Mann-Whitney test for skewed data. Categorical data were compared using chi2 analysis or Fisher's exact test. Statistical significance was assigned to values of p < 0.05. RESULTS: Among the study population (N = 216), 27 patients (12.5%) had CB on CT scan. Patients with CB had significantly lower hematocrit (p = 0.0004) and required operative intervention more frequently than those without CB (22% vs. 4%;p = 0.0008). Among patients with CB, mean pulse rate at presentation was higher in those that required splenic intervention (SI) (129 +/- 20.1) compared with those who underwent successful nonoperative therapy (100.4 +/- 23.1; p = 0.01). Only grade V injuries correlated with the need for laparotomy. CONCLUSION: Children with blunt splenic injury who have CB on CT scan are more likely to require SI than those without CB. However, because the majority of patients with CB did not require SI, in the absence of hemodynamic instability, this finding may be insufficient to determine the need for SI. CB is a specific marker of active bleeding that may predict the need for early splenic intervention in a specific subset of patients at presentation.     

Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.

OBJECTIVE: To assess in randomized prospective format sensitivity, laparotomy rate, and cost-effectiveness of using diagnostic peritoneal lavage (DPL) in a complementary role with computed tomography (CT) in the evaluation of blunt abdominal trauma. METHODS: Blunt trauma patients greater than 18 years of age were eligible for entry in the study. The study period was from February 1999 to July 2000 at an urban Level I trauma center. All patients were hemodynamically stable upon study entry and had abdominal tenderness with Glasgow Coma Scale (GCS) scores > 13 or GCS < 14. Patients were randomized to a DPL arm (DPL-CT) versus a CT arm. If randomized to the CT arm, patients underwent abdominal/pelvis CT. If CT was positive for solid organ injury, patients were observed. If free fluid was identified on CT without solid organ injury, patients were explored. If randomized to DPL-CT, patients underwent closed infraumbilical DPL, except pelvic fractures that were done with the open supraumbilical technique. If the DPL result was > 20,000 RBCs/mm3, patients underwent abdominal/pelvis CT. If the CT following DPL was consistent with solid organ injury, patients were observed. If the CT following DPL identified free fluid without solid organ injury and DPL was > 100,000 RBCs/mm3, patients were explored. RESULTS: Two hundred fifty-two patients were entered; 127 patients were randomized to DPL-CT and 125 to CT. Of the 125 patients randomized to CT, 102 (82%) CT scans were negative, 19 (15%) were positive for solid organ injury, and 3 (2%) had free fluid. Three (2%) of the initial negative CT scan patients underwent delayed laparotomy for missed injuries. Of the 127 patients randomized to DPL-CT, 26 (20%) required CT scan, of which 13 (10%) were positive for solid organ injury and 13 (10%) for free fluid. Positive DPL results that were indications for CT ranged from 21,000 to 1 million RBCs/mm3. Eight of the 13 DPL-CT patients with free fluid on CT had DPL results less than 100,000 RBCs/mm3 and did not require laparotomy. There were no known missed injuries in the DPL-CT arm. Seven (6%) laparotomies were performed in the DPL-CT arm and 10 (8%) in the CT arm. The average cost to the patient for abdominal evaluation in the CT arm was 1611 dollars and 650 dollars in the DPL-CT arm. CONCLUSION: Screening DPL with complementary CT has a low nontherapeutic laparotomy rate and is a sensitive and cost-effective method for the evaluation of blunt abdominal trauma.     

Nonoperative management of pediatric blunt hepatic trauma

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children < or = 16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean +/- standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 +/- 1.0 years (range 3-16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 +/- 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.     

Predicting Hollow Viscus Injury in Blunt Abdominal Trauma with Computed Tomography

Background

Evaluation of blunt abdominal trauma is controversial. Computed tomography (CT) of the abdomen is commonly used but has limitations, especially in excluding hollow viscus injury in the presence of solid organ injury. To determine whether CT reports alone could be used to direct operative treatment in abdominal trauma, this study was undertaken.

Methods

The trauma database at Auckland City Hospital was accessed for patients who had abdominal CT and subsequent laparotomy during a five-year period. The CT scans were reevaluated by a consultant radiologist who was blinded to operative findings. The CT findings were correlated with the operative findings.

Results

Between January 2002 and December 2007, 1,250 patients were evaluated for blunt abdominal injury with CT. A subset of 78 patients underwent laparotomy, and this formed the study group. The sensitivity and specificity of CT scan in predicting hollow viscus injury was 55.33 and 92.06 % respectively. The positive and negative predictive values were 61.53 and 89.23 % respectively. Presence of free fluid in CT scan was sensitive in diagnosing hollow viscus injury (90 %). Specific findings for hollow viscus injuries on CT scan were free intraperitoneal air (93 %), retroperitoneal air (100 %), oral contrast extravasation (100 %), bowel wall defect (98 %), patchy bowel enhancement (97 %), and mesenteric abnormality (94 %).

Conclusions

CT alone cannot be used as a screening tool for hollow viscus injury. The decision to operate in hollow viscus injury has to be based on mechanism of injury and clinical findings together with radiological evidence.     

Management of severe blunt renal trauma in adult patients: a 10-year retrospective review from an emergency hospital

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Immediate surgery for major renal trauma has led to a high rate of nephrectomy in comparison with an expectant management. We reviewed our case material on the management of severe blunt renal trauma in adults with emphasis on conservative management. Only shattered kidneys and pedicle avulsion required immediate surgery.

OBJECTIVE

• ? To review retrospectively the management of major blunt renal truma in adult patients admitted to our level I trauma centre.

PATIENTS AND METHODS

• ? Among 1460 blunt abdominal trauma cases collected from January 2001 to December 2010, 221 (15%) affected the kidneys.
• ? All patients, except seven who needed immediate laparotomy, underwent a computed tomography scan to stage the injuries.
• ? Renal injuries were graded according to the American Association for the Surgery of Trauma Grading System; grade 4 and 5 injuries were subclassified based on vascular or parenchymal injury.

RESULTS

• ? Only 45/221 patients (20%) suffered major blunt renal trauma (21 grade 3, 18 grade 4 and six grade 5); 43% of the patients had associated lesions and 77% had gross haematuria.
• ? Nephrectomy rates were 9% for grade 3, 22% for grade 4 and 83% for grade 5 with an exploration rate of 26% for major renal trauma.

CONCLUSIONS

• ? Conservative management of grade 3–5 blunt renal trauma in haemodynamically stable patients yields more favourable results with high renal salvage rate.
• ? Grade 5 injuries still result in a nephrectomy rate of more than 80%.
• ? The absence of data on long‐term outcomes and a potential inclusion bias due to the retrospective nature of the data represent major limitations of this review.