Clinical management of abdominal trauma

Objective： To improve the prognosis of patients with abdominal trauma.
Methods： Between January 1993 and December 2005, 415 patients were enrolled in this research. The patients consisted of 347 males and 68 females with mean age of 36 years （ranging from 3-82 years）. All abdominal traumas consisted of closed traumas （360 cases, 86.7%） and open traumas （55 cases, 13.3%）.Results： A total of 407 cases （98.1%） were fully recov- ered from trauma and the other 8 cases （1.9%） died of mul- tiple injuries. The mean injury severity score （ISS） of all patients was 22 while the mean ISS of the patients who died in hospital was 42. Postoperative complications were seen in 9 patients such as infection of incisional wounds （6 cases）, pancreatic fistula （2 cases） and intestinal fistula （1 case）. All these postoperative complications were cured by the conservative treatment. Conclusion： Careful case history inquisition and physical examination are the basic methods to diagnose abdominal trauma. Focused abdominal ultrasonography is always the initial imaging examination because it is non-invasive and can be performed repeatedly with high accuracy. The doctors should consider the severity of local injuries and the general status of patients during the assessment of abdominal trauma. The principle of treatment is to save lives at first, then to cure the injuries. Unnecessary laparotomy should be avoided to reduce additional surgical trauma.     

Spinal fractures resulting from traumatic injuries

Objective： To illustrate mechanisms of spine fractures and the pattern of spinal injuries characterized by the major mechanisms in urban population of Iran. Methods： Data regarding spinal injuries including demographics, mechanism and level of spinal injury, abbreviated injury score, associated injuries and final fate of the patients were extracted from the Iranian national trauma registry database from 1999 to 2004. Results： A total of 619 patients with traumatic spine fractures were identified, of whom 68.5% were males. The peak frequency of these injuries occurred in the 21-40 year age-group. Accidental falls and road traffic crashes （RTCs） were the most common mechanisms of spinal fractures （47.2% and 44.1%, respectively）. RTCs tended to occur in younger patients compared with accidental falls. The most common spinal region for spinal fracture was the lumbar spine （53.63%）. Cervical spine fractures were significantly more common in RTCs, while lumbar spine fractures were more common in accidental falls （P〈0.001）. A total of 171 （27.6%）patients had associated non-spinal injuries, of whom 127 had associated extremity injuries, and 55 had head injuries. Thirty-six （5.6%） patients had spinal cord injury （SCI）.The injury severity score of the RTC group was significantly higher than that of accidental falls （P=-0.002）. Fifteen （4%） patients died of traumatic injuries. The rate of death was significantly higher in RTCs compared with accidental falls （5.1% vs 2.1%, P=0.039）. Conclusions： The patterns of spinal fractures are similar to those reported from developed countries. RTCs tend to affect the younger age population and are associated with a higher degree of associated injuries and mortality than accidental falls. Therefore preventive strategies should be based on reduction of the number and severity of RTCs.     

Hospital management of abdominal trauma in Tehran, Iran: a review of 228 patients

Objective: Today, trauma is a major public health problem in some countries. Abdominal trauma is the source of significant mortality and morbidity with both blunt and penetrating injuries. We performed an epidemiological study of abdominal trauma (AT) in Tehran, Iran. We used all our sources to describe the epidemiology and outcome of patients with AT.Methods: This study was done in Tehran. The study population included trauma patients admitted to the emergency department of six general hospitals in Tehran during one year. The data were collected through a questionnaire that was completed by a trained physician at the trauma center. The statistical analysis was performed using the SPSS software (version 11.5 for Windows). The statistical analysis was conducted using the chi-square and P＜0.05 was accepted as being statistically significant.Results: Two hundred and twenty-eight (2.8%) out of 8 000 patients were referred to the above mentioned centers with abdominal trauma. One hundred and twenty-five (54.9%)of the patients were in their 2nd and 3rd decades of life and 189 (83%) of our patients were male. Road traffic accidents (RTA) were the leading cause of AT with 119 (52.2%) patients. Spleen was the commonly injured organ with 51 cases. Following the analysis of injury severity, 159 (69.7%) patients had mild injuries (ISS＜16) and 69 (30.3%) patients had severe injuries (ISS= 16). The overall mortality rate was 46 (20.2%).Conclusions: Blunt abdominal trauma is more common than penetrating abdominal trauma. Road traffic accidents and stab wound are the most common causes of blunt and penetrating trauma, respectively. Spleen is the most commonly injured organ in these patients. The mortality rate is higher in blunt trauma than penetrating one.     

Polytrauma with thoracic and/or abdominal injuries： experience in 1 540 cases

Objective:To investigate the early diagnosis and treatment of polytrauma patients with thoracic and/or abdominal injuries. Methods: The data of all polytrauma patients with thoracic and/or abdominal injuries during the past 10 years were studied retrospectively. Results: In the present study, there were 1 540 polytrauma patients, accounting for 65.0% of all 2368 trauma patients. Of these patients, 62.4% were in shock state on admission. The operative rates were 15.0% (181/1206) and 79.9% (612/766) in patients with thoracic and abdominal injury (P<0.01), 5.2% (39/758) and 31.7% ( 142/448 ) in patients with blunt and penetrating chest trauma (P<0.01). and 72.4% (359/496) and 93.7 % (253/270) in patients with blunt and penetrating abdominal injuries (P<0.01), respectively. To deal with abdominal injury, angioembolization was performed in 43 cases, with 42 cured. The overall mortality rate was 6.2%. And in the blunt and penetrating subgroups, the mortalities were 7.9% (75/950) and 3.6% (21/590), respectively (P<0.01). Most patients died from exsanguination. Conclusions: The first "golden hour" after trauma should be grasped, since the treatment in this hour can determine greatly whether the critically-injured victim could survive. Prompt diagnosis and proper treatment contribute more greatly to the survival of the victim than the severity of injury.     

Outcome of selective CT vs. pan-CT scan in elderly trauma patients: A retrospective cohort study in a level 1 trauma center

Purpose: There are currently no clear guidelines for use of pan- or selective CT in elderly trauma patients and this subject matter remains controversial. The aim of this study is to compare the outcome of elderly trauma patients in a level 1 trauma centre who required a pan- or selective CT scan on admission. Methods: The Trauma Audit Research Network database was reviewed to identify eligible patients ( 65 years) over a one-year period, from January 2018 to January 2019. Patients’ demographics, mechanism of injury, injury severity score, length of hospital stay (LOS), mortality and type of CT scans done were recorded. The inclusion criteria were elderly patients 65 years involved in acute trauma setting (less than one day between incident and emergency department presentation and blunt mechanism of injury). Exclusion criteria were patients <65 years, perforating mechanism of injury and patients with delayed presentation more than one day after the incident, and patients who have not got any CT scan at presentation. Statistical analyses were undertaken on SPSS (version 25.0; IBM, New York, USA). Results: In total, 481 patients with the mean age of 80.8 years were evaluated (48.6% male). Among them 232 cases were multiple injuries while 249 were single system injuries. And 235 patients (48.8%) underwent pan-CT in whom 66.8% were multiple injuries; 246 (51.1%) did selective CT scan in whom 69.5% were single system injuries. In multiple injury patients, performing a pan-CT scan on presentation was associated with shorter LOS compared to those who had a selective CT, in which 76.4% patients spent < 21 days in the pan-CT group compared to 16.0% for those investigated by selective CT scan (p < 0.001); and 2.5% spent > 60 days in pan-CT group compared to 64% in selective CT group (p < 0.0001). Performing pan-CT was also associated with lower need to repeat CT (p < 0.01). In patients with a single system injury, no differences were found in LOS or the need to repeat CT if either pan-CT or selective CT were requested. Conclusion: We recommend doing pan-CT scan in all elderly patients with multiple system injuries as it decreases the LOS and the need for another CT during hospital stay. No difference in LOS or the need to repeat another CT if pan-CT or selective CT were requested initially in single system injuries. Although age and injury severity score are poor predictors for the need to do pan-CT, the mechanism of injury may be helpful.     

Pattern of ocular trauma among the elderly in Kashan,Iran

Objective：Ocular trauma is a common cause of visual impairment and accounts for 38% to 52% of all patients presenting as ophthalmic accident and emergency cases to the hospital.The purpose of this study is to describe the pattern of ocular injuries that leads to hospitalization in the elderly in Kashan,Iran.Methods：In the retrospective consecutive case series,a total of 94 geriatric patients （≥ 65 years） who admitted and underwent management for ocular trauma from April 2001 to March 2011 at Matini Hospital of Kashan,the only center of eye surgery in the region of Kashan,were reviewed.The items include age,sex,injury mechanism,site and extent of damage,presenting and final best corrected visual acuity at least 3 months after trauma,which were reviewed and analyzed with SPSS software.Results：During the 10 years,94 eyes of 94 patients with ocular trauma were included.Mean age of patients was （77.5±5.1） years （range 65 to 102 years）.Male to female ratio was 2.76.The mechanism of ocular injury included sharp trauma in 56 patients （59.6%） and blunt in 38 patients （40.4%）.Trauma occurred mostly in males （69 patients,73.4%） and at the work place （38 patients,40.4%）.On admission the visual acuity in 50 patients （53.2%） with damaged eyes was light perception to hand motion.While the final best corrected visual acuity in 36 patients （38.3%） was better than hand motion.Conclusion：Ocular trauma is a serious cause of visual impairment in the elderly.Appropriate and timely management may improve their visual prognosis.     

Orthopedic trauma of limbs associated with vascular injuries

Objective： To evaluate the treatment for patients with major vascular injuries associated with traumatic orthopedic injuries. Methods： A total of 196 patients, aged from 4-67 years with the mean age of 29.88 years, had major vascular injuries associated with traumatic orthopedic injuries and were treated in our hospital in a period of 44 years. The most common mechanism of trauma was blunt trauma （67.3 % ）, open injuries accounted for 32.4 % and 54.5 % of the injuries were located in the lower extremities. The vascular injury frequently happened in the femoral artery （26. 7 % ） and popliteal artery （ 20. 3 % ）. The treatment principle consisted of aggressive resuscitation, Doppler imaging and stable bone internal fixation with subsequent vascular repair and debridement. The vascular repair for injuries included end-to-end anastomosis （80 cases, 39.6 % ）, interpositional vein graft （94, 46.5 % ）, vascular decompression through fracture distraction （ 18, 8.9% ）,arterial ligation （6, 3.0% ）, vein patch （2, 1. 0%）, bypass graft （ 2, 1.0% ）, venous repair including autogenous vein graft （9, 24. 3%） and ligation （28, 75.7% ） and prophylactical fasciotomy （15. 7. 4%）. Postoperative amputation was performed in 16 cases （16.3%）. Results： No intraoperative death was observed and all fractures united within 6 months. Limbs were salvaged in 180 patients （91. 8% ）. Among these patients, early complications were found in 19 patients （9. 7 % ） and late complications were observed in 8 patients （4.1% ）. Conclusions： A well-organized approach, based on a specific treatment principle, not only improves clinical outcome but also does good to excellent functional recovery for patients with severe orthopedic injuries and concomitant vascular lesion.     

Accuracy of the AAST organ injury scale for CT evaluation of traumatic liver and spleen injuries

Objective： Detection of abdominal in- jury is a very important component in trauma management, so a precise assessment of liver and spleen injuries includ- ing their severity degree is necessary. There is a good case to believe that in emergency situations the radiologists＇ performance may profit from a systematic approach using established scoring systems. Score systems as the organ injury scale （OIS） drawn up by the American Association for the Surgery of Trauma are a valuable guidance for objec- tive trauma assessment. Aim of this study was to evaluate retrospectively whether a structured approach using the OIS may help improve trauma assessment. Methods： Fifty-three patients, 38 male and 15 female who underwent CT and laparotomy after abdominal trauma were included in this study. The laparotomy was performed by experienced surgeons with a minimum experience of 6 years. While the original CT reports were written by differ- ent radiologists with a minimum experience of 3 years, and then a radiologist with experience of 4 years reviewed the same original CT pictures, resulting in the structured report. Both the original and structured CT results on liver and spleen injuries were transferred into OIS grades. Finally, the initial and structured CT results were compared with theintraoperative findings gathered from the surgery report. Results： Regarding the original CT report we found a mean divergence of 0.68±0.8 （r=-0.45） to the OIS finding in the surgery report for liver injuries （0.69±1.17 for spleen injuries; r=-0.69）. In comparison with the structured approach, where we detected a divergence of 0.8±0.68; r=-0.63 （0.47±0.77 for spleen injuries; r=0.91）, there was no significant difference. However we detected a lower rate of over-diag- nosis in structured approaches. Conclusion： Our study shows that a structured ap- proach to triage abdominal trauma using an imaging check- list does not lead to a significantly higher detection rate, but a nonsignificant trend to reduce the rate of over- diagnoses, thus being more precise in grading the severity grade. Concerning the bias by retrospective study design, further prospective investigations are needed to evaluate the impact of trauma scores on the workflow in emergency department procedure as structured reporting systems are a valuable guidance in other radiological disciplines.     

Treatment of 209 cases of liver injury

Objective: To summarize the experience of the treatment of traumatic hepatorrhexis. Methods: The clinical data of 209 cases of liver trauma treated in the three affiliated hospitals of the Third Military Medical University from 1989 to 1999 were retrospectively analyzed. Among the 209 patients, 108 (51.7%) had Grade Ⅲ or more severe liver injury. Operative treatment was performed in 186 cases and preservative treatment in 23. Results: In the operated group, 169 patients were cured. The eomplications occurred in 18 patients and 17 of them died. In the non-operated group, the complications occurred in 22 patients and only 1 of them died. Conclusions： Severe injury and delayed treatment are two major factors leading to death from liver injuries.Surgical intervention is still the principal measure to treat traumatic hepatorrhexis. The indications for non-operative treatment should be carefully selected.     

Extremity fractures in children: a hospital based study in Tehran

Objective： Although long bone fracture in children is not life-threatening, it may cause major disability, loss of working days and severe psychological distress. We conducted this study to determine the pattern of extremity fracture due to trauma in children.
Methods： During one year in six general hospitals in Tehran, trauma patients who were hospitalized for more than 24 hours and sustained injuries within seven days before admission were included in the study. The records of children （≤16 years old） hospitalized in six general hospitals in Tehran due to trauma were reviewed prospectively.
Results： During the study period, 1 274 children had sustained extremity fractures. Male to female ratio was 3.6/ 1, with the mean age of （10.3±4.2） years. Falls and traffic crashes were the main causes of injuries, with the percentages of 57.3 % and 37.1%, respectively. Simple fall （falling on the ground） consisted 60% of patients that sustained fall-related injuries. Pedestrians and bicycle riders comprised most of the cases that were injured due to traffic crashes. Of our cases, 56.8% sustained fractures in the upper extremities and 43.2% in the lower extremities. Forearm was the most common fracture site （34.1%）. Comparing our results in preschool and school-age children, falls were the main cause of injuries in both groups, but fractures of lower extremities were significantly more common in preschool children.
Conclusions： Improvement of physical condition of sidewalks and crossings in roads will be necessary for prevention of injuries. More attention to safety of home environment should be paid for control of preschools＇ injury at home. Education of children and adults is necessary to reduce injuries resulting from road traffic crashes.     

Traumatic adrenal injuries

PURPOSE: We determined the prevalence, management and general prognosis of blunt isolated and nonisolated adrenal injuries in a pediatric population. MATERIAL AND METHODS: We analyzed trauma data from a pediatric institution for the period 1991 to 1998 to identify patients with blunt traumatic adrenal injuries diagnosed by computerized tomography. We then performed a detailed chart review to obtain data on the presence of concomitant intra-abdominal and extra-abdominal injuries, transfusion requirements, intensive care unit monitoring requirements, hospital course and the presence of followup studies. RESULTS: Among 9,199 pediatric trauma cases we identified 20 adrenal injuries (0.22%), of which 15 (75%) were nonisolated and 5 (25%) were isolated. The right adrenal gland was injured in 17 (85%) of the 20 patients. In the 15 nonisolated adrenal injuries concomitant injury to the liver (13 cases, 87%) and ipsilateral kidney (8 cases, 53%) were most common. Three (60%) of the 5 patients with isolated adrenal injury required transfusion for adrenal hemorrhage. No patient required intensive care unit monitoring or operative intervention. Only 2 (10%) of the 20 patients underwent followup computerized tomography, both of whom had resolution of the adrenal injury. CONCLUSIONS: In the pediatric population blunt adrenal injuries are rare and typically present as part of a multiorgan trauma. The right adrenal gland is more likely to be injured, with liver trauma as the most commonly associated injury, followed by ipsilateral renal injury. Although there is a possibility of significant adrenal hemorrhage requiring transfusion, adrenal trauma is typically self-limited and does not require intensive care monitoring or operative intervention.     

Management of blunt adrenal gland injury in a community-based hospital

IntroductionInjury of the adrenal gland in blunt trauma is rare. The routine usage of the whole body computed tomography (CT) scan helps in early diagnosis. We aimed to study the incidence, mechanism of injury, management, and outcome of adrenal injury in blunt trauma patients treated in a community-based hospital.MethodsCT scan of the abdomen of all blunt trauma patients who were admitted to our institution between October 2010 and March 2018 were retrospectively reviewed. The files of all the patients with CT scan-detected adrenal injuries were retrieved. Studied variables included demography, mechanism of injury, associated injuries, GCS, ISS, Intensive Care Unit admission, hospital stay, and outcome.Results4991 blunt trauma patients were admitted to the hospital. CT scan of the abdomen was performed for 2359 (47%) patients. Blunt adrenal injuries were diagnosed in eleven male patients (0.22%). The main mechanism of injury was motor vehicle collisions in eight (72.7%) patients. Nine (81.8%) patients had right adrenal gland injury. The mean (range) ISS was 22 (6–50). All patients had intra-adrenal hematoma and periadrenal fat stranding. None of our patients had acute adrenal insufficiency. One patient died (overall mortality 9.1%).ConclusionsThe incidence of blunt adrenal injury, although rare, is similar in a community-based hospital to those reported from trauma I centers. It is associated with severe and multiple organ injuries. Blunt adrenal injuries are usually self-limiting.     

Do signs of abdominal wall injury on computed tomography predict intra-abdominal injury in trauma patients with a seatbelt sign?

BackgroundA seatbelt sign in patients with blunt abdominal injury is associated with both abdominal wall and intra-abdominal injuries. This study aimed to assess the association between signs of abdominal wall injury on computed tomography (CT) and rates of intra-abdominal injury in patients with a blunt abdominal injury and a clinical seatbelt sign.MethodsThis study includes hemodynamically stable trauma patients with blunt abdominal injury and a clinical seatbelt sign who were hospitalized in two regional trauma centers in Israel, during 2014–2019. All data were collected via the medical center's trauma registry in both centers.ResultsWe identified 123 stable blunt abdominal trauma patients with a seatbelt sign, of which 101 (82.1%) and 22 (17.9%) had a low-grade and high-grade abdominal wall injury according to CT findings, respectively. Laparotomy rates were significantly higher in patients with signs of high-grade abdominal wall injury (p<0.0001). No differences in the timing of laparotomy between low and high-grade injuries were found.ConclusionsIn stable patients with blunt abdominal trauma and a clinical seatbelt sign, the severity of abdominal wall injury, as represented by CT findings, may predict a need for surgical treatment.     

Adrenal Injuries: Historical Facts and Modern Truths

Background

Prior to the advent of whole body computed tomography, injuries of the adrenal gland were almost exclusively identified on postmortem examinations and were associated with severe injury. Recent literature has continued to identify an association between adrenal injuries and high ISS. The purpose of this study was to assess the influence of adrenal trauma on ISS and mortality while controlling for potential confounding factors.

Methods

A 15-year retrospective review for all adrenal gland injuries from a Level 1 Trauma Center’s Trauma Registry was performed. Based on the characteristics of that patient population, the same Trauma Registry was then queried for case-matched patients, and the two groups compared to assess the influence of adrenal gland injuries on mortality.

Results

Seventy-two patients with adrenal injuries were identified and compared to 1026 case-matched patients. The adrenal gland injury was not a contributing factor in any of the study group mortalities. The mean ISS for the adrenal gland injured group was higher than the overall Registry ISS (18.7 vs 10.6) but almost identical to the ISS of patients case matched for abdominal injuries.

Conclusion

Case-matched analysis based on multiple clinical variables demonstrates that the ISS of patients with adrenal gland injuries were similar to the ISS of patients with other injuries to the abdominal region and were in fact associated with a 0.02% decrease in mortality.

     

The Role of Multislice Multidetector CT (MDCT) in Abdominal Trauma

Abstract Purpose: To analyze the role of multidetector CT (MDCT) in the management of abdominal highenergy trauma patients using CT classification of organ injury. Materials and Methods: During the past 2 years, 451 patients with abdominal trauma were examined by MSCT. Most were victims of RTA, 400 men and 51 women, between 18 and 80 years old (mean age 38 years). In 78 patients injury to abdominal organs was diagnosed by MDCT. MDCT (GE Light Speed) was performed using 2.5 mm collimation and 7.5 mm table movement with dynamic IV injection of iohexol 350 mg iodine/ml. A workstation was used for 2D and 3D reconstructions. Results: We detected 24 patients with liver rupture. The spleen was ruptured in 20 cases, kidneys in 14 cases; urinary bladder rupture occurred in 4 cases and urethral rupture in 1 case. In 19 patients, more than one organ injuries were observed. In only 23 patients (30% of all injured with grades 3–4), surgery was an imperative treatment, but the majority of victims with abdominal injuries, grades 1–2, were treated conservatively. Conclusion: MDCT plays a crucial role in the management of patients with abdominal trauma. A team approach (traumatologist, surgeon and radiologist) is mandatory in high-energy trauma.     

Severity and treatment of “occult” intra-abdominal injuries in blunt trauma victims

Backgroundto assess the severity and treatment of “occult” intra-abdominal injuries in blunt trauma victims.MethodRetrospective analysis of charts and trauma register data of adult blunt trauma victims, admitted without abdominal pain or alterations in the abdominal physical examination, but were subsequently diagnosed with intra-abdominal injuries, in a period of 2 years. The severity was stratified according to RTS, AIS, OIS and ISS. The specific treatment for abdominal injuries and the complications related to them were assessed.ResultsIntra-abdominal injuries were diagnosed in 220 (3.8%) out of the 5785 blunt trauma victims and 76 (34.5%) met the inclusion criteria. The RTS and ISS median (lower quartile, upper quartile) were 7.84 (6.05, 7.84) and 25 (16, 34). Sixty seven percent had a GCS ≥ 13 on admission. Injuries were identified in the spleen (34), liver (33), kidneys (9), intestines (4), diaphragm (3), bladder (3) and iliac vessels (1). Abdominal injuries scored AIS ≥ 3 in 67% of patients. Twenty-one patients (28%) underwent laparotomy, 5 of which were nontherapeutic. The surgical procedures performed were splenectomy (8), suturing of the diaphragm (3), intestines (3), bladder (2), kidneys (1), enterectomy/anastomosis (1), ligation of the common iliac vein (1), and revascularization of the common iliac artery (1). Angiography and embolization of liver and/or spleen injuries were performed in 3 cases. Three patients developed abdominal complications, all of which were operatively treated. There were no deaths directly related to the abdominal injuries.ConclusionSevere “occult” intra-abdominal injuries, requiring specific treatment, may be present in adult blunt trauma patients.     

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

BackgroundThe precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM).MethodsA ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated.ResultsA total of 212 patients (mean injury severity score = 24, Abbreviated Injury Score for Chest = 3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM.ConclusionsThoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.     

A contemporary prospective review of 205 consecutive patients with penetrating colon injuries

BackgroundManagement of colon injuries has significantly evolved in the recent decades resulting in considerably decreased morbidity and mortality. We set out to investigate penetrating colon injuries in a high-volume urban academic trauma center in South Africa.MethodsAll patients with penetrating colon injuries admitted between 1/2015 and 1/2018 were prospectively enrolled. Data collection included demographics, injury profile and outcomes. Primary outcome was in-hospital mortality. Secondary outcome was morbidity.ResultsTwo-hundred and five patients were included in the analysis. Stab and gunshot wounds constituted 18% and 82% of the cases, respectively. Mean age was 28.9 (10.2) years and 96.1% were male. Median injury severity score (ISS) and penetrating abdominal trauma index (PATI) were 16 (9-25) and 19 (10-26), respectively. A total of 47.8% of the patients had a complication per Clavien-Dindo classification. Colon leak rate was 2.4%. Wound and abdominal organ/space infection rate was 15.1 and 6.3%, respectively. Overall in-hospital mortality was 9.3%. Risk factors for mortality were higher ISS and PATI, shock on admission, need for blood transfusion, intra-abdominal vascular injury, damage control surgery, and extra-abdominal severe injuries.ConclusionsContemporary overall complication rate remains high in penetrating colon injuries, however, anastomotic leak rate is decreasing. Colon injury associated mortality is related to overall injury burden and hemorrhage rather than to colon injuries.     

Evaluation of an evidence-based guideline to reduce CT use in the assessment of blunt pediatric abdominal trauma

PurposeAbout half of pediatric blunt trauma patients undergo an abdominopelvic computed tomographic (CT) scan, while few of these require intervention for an intraabdominal injury. We evaluated the effectiveness of an evidence-based guideline for blunt abdominal trauma at a Level I pediatric trauma center.MethodsPediatric blunt trauma patients (n = 998) age 0–15 years who presented from the injury scene were evaluated over a 10 year period. After five years, we implemented our guideline in which the decision for CT was standardized based on mental status, abdominal examination, and laboratory results (alanine aminotransferase, aspartate aminotransferase, hemoglobin, urinalysis).ResultsThere were no differences in age, GCS, SIPA or ISS scores between the patients before or after guideline implementation. Nearly half of the patients (48.3%) underwent CT scan before guideline implementation compared to 36.7% after (p < 0.0002). There was no difference in ISS (p = 0.44) between CT scanned patients in either group. No statistical differences were found in rate of intervention (p = 0.20), length of stay (p = 0.65), or readmission rate (0.2%) before versus after guideline implementation. There were no missed injuries.ConclusionImplementation of an evidence-based clinical guideline for pediatric patients with blunt abdominal trauma decreases the rate of CT utilization while accurately identifying significant injuries.Level of evidenceIII.     

Traumatic abdominal wall hernias in children: A case for early exploration

PurposeTraumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma (BAT). We examined a series of patients suffering TAWH to evaluate its frequency, rate of associated concurrent intraabdominal injuries (CAI) and correlation with CT, management and outcomes.MethodsA Level 1 pediatric trauma center trauma registry was queried for children less than 18 years old suffering TAWH from BAT between 2009 and 2019.Results9370 patients were admitted after BAT. TAWH was observed in 11 children, at incidence 0.1%. Eight children (73%) were male, at mean age 10 years, and mean ISS of 16. Six cases (55%) were because of MVC, three (27%) impaled by a handlebar or pole, and two (18%) dragged under large machinery. Seven (64%) had a CAI requiring operative or interventional management. Patients with CAI were similar to those without other injury, with 20% and 50% CT scan sensitivity and specificity for detection of associated injury, respectively. Five patients had immediate hernia repair with laparotomy for repair of intraabdominal injury, three had delayed repair, two have asymptomatic unrepaired TAWH, and one resolved spontaneously.ConclusionsChildren with TAWH have high rates of CAI requiring operative repair. CT scans have low sensitivity and specificity for detecting associated injuries. A high suspicion of injury and low threshold for exploration must be maintained in TAWH cases.Level of evidenceIV