Linear abdominal trauma.

Three cases of blunt abdominal trauma are presented to exemplify the mechanism of trauma and the problems of diagnosis associated with any linear blow to the abdomen. The mechanisms of visceral injury are reviewed, and special attention is directed to the abdominal wall injury that can be present in these patients. This injury has special implications in directing the operative approach and repair. An unusual aortic occlusion is described which is peculiar to this type of injury.     

Kidney injury: an experimental investigation of blunt renal trauma

BACKGROUND: The abdomen ranks third with regard to injured body regions, and urogenital trauma accounts for up to 10% of all abdominal injuries. Predictive numerical models are evolving as important tools for the development of preventative measures and preliminary clinical diagnostics. Such models require accurate biomechanical input data that at present is not sufficiently available. METHOD: The purpose of the present study was to determine the biomechanical response of whole, perfused porcine kidneys to blunt impact. Specifically of interest were the force-displacement characteristics of the organs, as well as the injury thresholds. Thirty nine young, adult pig kidneys (kidney mass 0.17 +/- 0.02 kg) were infused with physiologic saline solution, and impacted on their dorsal surface by a freely swinging right cylindrical pendulum. Two impact masses (2.1 and 4.7 kg) were used at varying impact velocities and corresponding impact energies. Resulting injuries were graded according to the AAST injury scale, and injury was related to impact mass, impact velocity, and impact energy. RESULTS AND CONCLUSIONS: It was determined that injury was best predicted by impact energy, and that for a given impact energy the resulting injury severity was relatively independent of either impact mass or impact velocity. For a moderate to severe injury, an impact energy threshold of 4 J, or a corresponding strain energy density of 25 kJ/m, was established. This information is essential to the development and implementation of accurate, predictive computational trauma models.     

Bedeutung des Lebertraumas für die Inzidenz von Sepsis, Multiorganversagen und Letalität bei Schwerstverletzten

BACKGROUND: The prognosis of multiple injured patients is mainly limited by initial severe hemorrhage causing hemorrhagic shock, subsequent sepsis and multiple organ failure (MOF). Although mechanisms of altered microcirculation, cytokine release etc. have been intensively investigated, little is known about the relevance of severe liver trauma as an independent predictive outcome factor in these patients. This study aimed to clarify the impact of severe liver trauma in one of the largest trauma databases. PATIENTS AND METHODS: The study was based on data from the German trauma register within the German Society for Trauma Surgery (DGU) and 24,711 patients from 113 hospitals were collected for retrospective analysis between 1993 and 2005. Patients with an injury severity score (ISS) >16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to the injury pattern into I liver group (severe damage of the liver, AIS>3 and AIS abdomen <3), II Abdomen group (severe abdominal trauma AIS>3, AIS liver <3) and III Control group (liver and/or abdominal trauma AIS<3, other trauma AIS>3). RESULTS: Out of 24,771 multiple injured patients from 113 trauma centers, 321 individuals were identified which matched the criteria of the liver group. Another 574 patients were allocated to the abdomen group while the majority of patients formed the trauma group (9574). Severe injury of the liver is associated with excessive demands for volume resuscitation and induces a significantly increased risk for sepsis and MOF compared to both other groups (sepsis 19.9% vs 11%; MOF 32.7% vs 16.6%). Furthermore, deleterious outcome is more frequent associated with patients with severe liver trauma (lethality 34.9%) compared to severe abdominal trauma (12%) and the control group (19.5%). CONCLUSIONS: Severe liver trauma is an independent predictor for severe hemorrhage with a substantial increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with severe liver trauma but no hemorrhage is effective, patients with hemodynamic instability seem to form a subgroup where contemporary treatment modalities are not yet sufficient.     

Abdominal CT scanning for trauma: how low can we go?

PURPOSE: computed tomography (CT) of the abdomen is an established, albeit expensive and perhaps overused, diagnostic modality for the evaluation of the injured patient. We developed a practice management guideline for blunt abdominal trauma intended to reduce the percentage of negative CT scans, yet minimize delayed recognition of injury and non-therapeutic laparotomy. PROCEDURES: between April 1996 and March 1997, 1147 adult patients at risk for blunt abdominal injury were admitted to our Level I trauma centre and underwent abdominal evaluation according to the practice management guideline. MAIN FINDINGS: abdominal CT was performed in 522 patients (45%), and 441 scans were negative (85%). Delayed recognition of injury and non-therapeutic laparotomy rates were low, 4% and 1.6%, respectively. PRINCIPAL CONCLUSION: abdominal CT scanning in trauma patients can achieve low non-therapeutic laparotomy and delayed recognition of injury rates but at the expense of high negative CT scan rates. Greater reliance on the physical examination and perhaps abdominal ultrasound may reduce negative CT scan rates and yet preserve low non-therapeutic laparotomy and delayed recognition of injury rates.     

Schockraumdiagnostik: Initiale Diagnostik beim stumpfen Abdominaltrauma

OBJECTIVE: Blunt abdominal trauma is most common in the polytraumatized patient and beside neurocranial trauma one major determinant of early death in these patients. Therefore, immediate recognition of an abdominal injury is of life-saving importance. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Clinical examination is not reliable for evaluation of abdominal injury. Abdominal ultrasound, especially if only focusing on free fluid (FAST) is not sensitive enough. Today, CT-scan of the abdomen is the gold-standard in diagnosing abdominal injury. Diagnostic Peritoneal Lavage (DPL) has a high sensitivity but in our region only is used in exceptional cases. The patient with continuing hemodynamical instability after abdominal trauma and evidence of free intraperitonial fluid has to undergo laparotomy. CONCLUSION: After blunt abdominal trauma, initially ultrasound investigation should be performed in the emergency room. This should not only focus on free intraabdominal fluid but also on organ lesions. Regardless of the findings from ultrasound or clinical examination, the hemodynamically stable patient should undergo a CT-scan of the abdomen in order to proof or exclude an abdominal injury.     

Influence of velocity and forced compression on the severity of abdominal injury in blunt, nonpenetrating lateral impact

Lateral impacts of automobiles frequently result in abdominal injury to the occupants. While there have been important advances in the clinical management of this lateral impact trauma, the abdominal tolerance to injury from lateral impacts remains uncertain. The present report describes a series of 117 experiments in which the effect of changing the impact velocity and the forced abdominal compression upon the abdominal injuries sustained was monitored. The impact velocity was varied from 3 to 15 m/s, and the abdominal compression was varied from 10 to 50%. Serious injuries (AIS greater than or equal to 3) occurred in the following proportions of the total number of serious injuries: renal (54%), hepatic (44%), and splenic (1%). Impact side was a significant factor in hepatic and splenic tolerance, but not in renal tolerance. An abdominal injury criterion (AIC) is proposed which is a function of the impact velocity times the forced abdominal compression, but more work is necessary before it can be applied to human beings.     

Hematuria. A marker of abdominal injury in children after blunt trauma.

The clinical significance of hematuria after blunt trauma was studied in 378 consecutive children evaluated by computed tomography (CT) of the abdomen. Clinical and demographic data, as well as indications for CT (such as hematuria, abdominal tenderness, distention, contusions, and abrasions) were recorded prospectively at the time of CT examination. Hematuria was present in 256 children (68%). Of these, 168 (66%) had microscopic blood (greater than or equal to 10 RBC/HPF), 52 (20%) had a positive dip-stick (less than 10 RBC/HPF), and 36 (14%) had gross hematuria. Both the presence and increasing amount of blood in the urine were associated with significantly higher risk for abdominal injury, multiple organ trauma, and renal injury. Yet when asymptomatic hematuria was the only indication for CT examination, the risk of any abdominal injury was negligible (0 of 41 patients). The presence and severity of hematuria can be useful markers of underlying abdominal injury only in association with other suggestive clinical signs and symptoms. Asymptomatic hematuria is a low-yield indication for abdominal CT in children with blunt abdominal trauma.     

Delayed jejunal perforation following blunt abdominal trauma

Jejunal perforation is a known complication of abdominal trauma. We report two cases of jejunal perforation presenting nearly 2 months following blunt injury to the abdomen and discuss possible mechanisms for delayed small bowel perforation.     

Visceral injuries.

Abdominal visceral injuries are encountered by every surgeon who deals with trauma. It is simple and useful to divide abdominal visceral injuries into those caused by penetrating mechanisms of injury and those due to blunt mechanisms. Determination of the need for operative intervention is generally easier after penetrating trauma. Gunshot wounds to the abdomen should be explored, as should stab wounds to the anterior abdomen that penetrate the fascia. A midline incision is the standard approach to abdominal visceral injuries because of its ease and versatility. Abdominal exploration should be consistent and systemic so as not to miss significant injuries. Hollow viscus injury is most common after penetrating injury, while blunt injury most often results in injury to solid viscera. Diagnostic and operative aspects of the treatment of specific visceral injuries are reviewed.     

Analysis of injury criteria to assess chest and abdominal injury risks in blunt and ballistic impacts

BACKGROUND: The Viscous Criterion (VC) is an experimental measure developed by the automotive industry to assess injury risks for high-speed impacts. The Blunt Criterion (BC) is a prospective measure developed by the Department of Defense to predict injury from blunt projectiles. METHODS: The range of applicability of BC was extended and compared with VC for its ability to assess injury risk using published cadaver and animal data. Department of Defense projectiles were 0.05 to 0.43 kg mass at velocities up to 86 m/s. VC data were generated from impacts with 1.75 to 23.4 kg at 3.6 to 10.2 m/s. Chest and abdominal injuries ranged from Abbreviated Injury Scale scores of 1 to 6. RESULTS: Both criteria correlated very well with the experimental data, demonstrating correlation coefficients of R = 0.84 to 0.96. The correlation between VC and BC was R = 0.99. Logistic probability curves were derived to predict blunt impact injuries of Abbreviated Injury Scale scores of 1 to 6 for the chest and abdomen. CONCLUSION: BC and VC are virtually identical in their ability to assess blunt and ballistic impact injury risks. They are different measures of impact energy absorbed by the body. One is predictive using input parameters, and the other measures the impact response of the body.     

Abdominal trauma: a disease in evolution

BACKGROUND: The last decade has seen many changes in the way we investigate and manage abdominal injuries. This study assessed the pattern of abdominal injury and its investigation in patients admitted to a major trauma centre. METHODS: A retrospective registry review of all adult trauma patients admitted to Liverpool Hospital between January 1996 and December 2003 was undertaken. All adult trauma patients were included, identifying mechanism of injury, injury severity score, abbreviated injury score for the abdomen, investigations and intervention. The study period was divided (period 1 from 1996 to 1999, period 2 from 2000 to 2003) and the two periods compared to assess change. RESULTS: The study involved 1224 patients with abdominal injuries. Of these, 969 (79%) were a result of blunt trauma. The main causes were road accidents (61%), interpersonal violence (24%) and falls (7%). Penetrating injury increased from 16% to 25% between the two periods. There were 1274 intra-abdominal injuries, made up of 607 solid organ (liver (n = 220, 36%), spleen (n = 195, 32%), renal (n = 144, 24%) ), 291 hollow viscus (small bowel (n = 160, 55%), large bowel (n = 104, 36%) ) and 168 vascular. Four hundred and thirty-six (36%) patients underwent laparotomy, 65% for blunt trauma. Between the two periods there was a 46% decrease in the use of diagnostic peritoneal lavage, with a 40% increase in computed tomography and 325% increase in focused assessment with sonography for trauma. CONCLUSIONS: This study defined abdominal injury pattern and identified a significant shift in mechanism of injury and abdominal investigation at a major trauma centre during an 8-year study period. Abdominal trauma is indeed a disease in evolution.     

Renin angiotensin involvement in transient hypertension after renal injury

Transient hypertension occurred in 3 patients shortly after blunt injury to the abdomen. Renal trauma was suspected in all 3 patients and radiological evidence for renal injury was present in 2. Plasma renin activity definitely was elevated in 1 patient and probably was elevated in another. There was a decrease in blood pressure in all 3 patients during infusion of the angiotensin II analogue--saralasin--showing that the hypertension in these patients was angiotensin-mediated. Renal function as reflected by the blood urea nitrogen, creatinine and electrolytes was not impaired significantly. Thus, acute hypertension after blunt abdominal trauma may be angiotensinogenic and is not necessarily sustained.     

Abdominal compartment syndrome in the open abdomen

BACKGROUND: Multiple methods exist to manage in the intensive care unit the patient with an open abdomen. An increasingly common method is the vacuum packed technique. This method accommodates considerable expansion of intra-abdominal contents and should obviate the potential development of the abdominal compartment syndrome (ACS). Despite this, some patients with these temporary abdominal dressings will go on to develop ACS. For the purpose of this study we have defined this clinical entity as the open abdomen ACS. HYPOTHESIS: Patients with an open abdomen who develop ACS have a poor prognosis. Fluid requirements and resuscitative indices may predict which of these patients will develop open abdomen ACS. METHODS: A retrospective review was performed of patients with trauma who had an open abdomen treated with vacuum packed dressings at our urban level I trauma center. Over 1 year (July 1, 1999-June 30, 2000), 5 patients managed with an open abdomen developed ACS. These patients were compared with 15 consecutive patients with an open abdomen who did not develop clinical ACS during that same period. Fluid resuscitation, base deficit, pH, lactate level, systolic blood pressure, prothrombin time, temperature, peak inspiratory pressure, and PCO(2) were abstracted. The Fisher exact test was used for statistical analysis. RESULTS: In patients managed with an open abdomen, ACS developed between 1.5 and 12 hours (mean [SD], 7.5 [3.9] hours) after placement of the vacuum packed dressing. The base deficit, pH, peak inspiratory pressure, PCO(2,) and lactate level were more abnormal and the crystalloid requirements were significantly higher in the ACS group. The systolic blood pressure, temperature, and prothrombin time did not differ between groups. Three patients with ACS developed a second episode of ACS. Mortality in the ACS group was 3 (60%) of 5 patients vs 1 (7%) of 15 patients in the control group. CONCLUSIONS: Management of the open abdomen with the temporary abdominal closure does not prevent the development of ACS. Mortality is high when ACS occurs in this scenario. Severe physiologic derangement and high crystalloid requirements may predict which patients will develop ACS.     

Reinfusion of blood in combined trauma of hollow abdominal organs

The authors performed 122 blood reinfusions in patients with trauma to the chest and abdomen, in 25 of them with associated injury to the hollow abdominal organs. The mean volume of blood loss was 2225 ml, that of reinfusion--1092 ml. Nine patients died, 6 developed complications. The authors substantiate the tactics of transfusion therapy in massive hemoperitoneum in patients with associated trauma to the hollow abdominal organs.     

Blunt Thoracic and Abdominal Vascular Trauma and Organ Injury Caused by Road Traffic Accident

OBJECTIVES: To analyse the relationship between vascular trauma and associated injuries to intra-thoracic and abdominal organs caused by traffic accidents. Design retrospective study in a university hospital. MATERIALS AND METHODS: We investigated 458 consecutive patients who were admitted with blunt thoracic and/or abdominal trauma caused by road traffic accidents between 1986 and 1999. Vascular trauma was encountered in 54 patients (12%). RESULTS: The injured vessels were located in the abdomen in 45 patients and in the chest in nine patients. Mesenteric vessels were the most frequently injured vessels (33/45) in the abdomen, while the aorta and major vessels were most frequently injured (9/9) in the chest. Injury to the large/small intestine was often associated with mesenteric vessel injury (26/27). In the 190 patients with blunt abdominal organ injury, the frequency of mesenteric vessel injury was also highest, regardless of the injured organ. Vascular reconstruction was necessary only in one of 51 patients who underwent operation. CONCLUSIONS: Our results demonstrate that the mesenteric vessels are susceptible to blunt thoracic and abdominal trauma in road traffic accidents. Vascular reconstruction may be indicated for selected patients as long as the injuries to hollow organs are assessed carefully because of their strong association with vascular injury.     

Traumatic renal artery occlusion.

Six cases of complete occlusion of the main renal artery and one case of incomplete renal artery occlusion secondary to blunt abdominal trauma are reported, and the literature reviewed. The reported cases are analyzed as to clinical and radiographic findings, and mechanism of injury. Left renal artery occlusion occurs due to intimal fracture secondary to deceleration forces on the abdomen. Right renal artery occlusion results from direct epigastric trauma and compression of the artery against the vertebral column. An intravenous urogram with nonvisualization of the affected kidney should lead to immediate angiography. Arteriography is diagnostic, showing abrupt occlusion of the renal artery several centimeters beyond its origin, or before occlusion, an intimal flap.     

The distinct and secondary harmful effect of pelvic and extremity injury on the outcome of laparotomy for trauma

HYPOTHESIS: Extra-abdominal injury negatively affects the outcome of abdominal injury following trauma laparotomy. DESIGN: Retrospective review of 920 consecutive patients receiving laparotomy for trauma who survived more than 24 h between January 1989 and May 1998 at a Level 1 trauma center. Major abdominal complications (MAC) were defined as: abdominal compartment syndrome (ACS), abscess/peritonitis, enterocutaneous fistula, necrotizing fasciitis, and necrotizing pancreatitis. METHODS: Univariant and multivariant logistic regression were used to identify predictors of MAC. RESULTS: Sixty-nine patients (7.5%) developed one or more MAC. Patients who developed MAC had higher injury severity scores (ISS), abdominal trauma indices (ATI), and blood transfusions in the first 24 h (PRCs) than patients who did not develop MAC. Patients with MAC were more likely to have suffered a thoracic or pelvic injury with an abbreviated injury scale (AIS) > or =3 and were more likely to have received an extremity injury (AIS > or =3) operation than patients without MAC. Independent predictors of MAC in multivariant analysis included colon injury (AIS > or =3) [odds ratio (OR) = 3.1, 95% confidence interval (CI) 1.5- 6.3)], pelvic injury (AIS > or =3) or operation for extremity injury (AIS > or =3) [OR 2.9, 95% CI 1.5-5.3], and ATI (OR = 1.03 for each 10 unit increase in ATI, 95% CI 1.02-1.05). PRCs did not independently predict MAC. CONCLUSION: The outcome of laparotomy for trauma (both blunt and penetrating) is negatively affected by a severe pelvic injury or a severe extremity injury operation independent of initial hemorrhage and abdominal injury severity.     

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.     

The diagnosis of gastrointestinal tract injuries resulting from blunt trauma.

BACKGROUND: This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). METHODS: MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. CONCLUSIONS: The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.