Concomitant aortic valve and internal mammary artery injuries in blunt chest trauma: Report of a case

We report a case of concomitant injury to the aortic valve and internal mammary artery (IMA) from nonpenetrating chest trauma. To our knowledge, this is the first such case to be reported. Transcatheter arterial embolization (TAE) following diagnostic angiography offers an effective and minimally invasive treatment for traumatic IMA injuries. Because there might be an asymptomatic interval after traumatic aortic valve injuries, serial physical examinations and repeated echocardiography should be mandatory for patients with de novo heart failure after blunt chest trauma. Transesophageal echocardiography can provide a clearer image of cardiac injuries than transthoracic echocardiography, particularly if there is extensive anterior mediastinal hematoma resulting from IMA trauma.     

Assessment of nonoperative management of blunt spleen and liver trauma

An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18-54), and 49 older adults (> or = 55). Nineteen patients who failed resuscitations died within 0-60 minutes of arrival and were excluded from treatment analysis. Operative management (OM) was done in 39 (15%) and NOM in 221 (85%) patients with failure (NOMF) in 11 (5%). NOM and NOMF was 82 per cent and 5.6 per cent in spleen, 74 per cent and 14.3 per cent in combined spleen/liver, and 96 per cent and 1.5 per cent in liver trauma (P value <0.001). NOM was done in 99 per cent of children, 81 per cent of younger adults, and 68 per cent of older adults with 0 per cent, 8 per cent, and 10 per cent NOMF. Higher grades of splenic trauma and CT fluid had higher OM rate. NOM success rates were 93.8 per cent in grade 3 and 90.3 per cent in higher grades of spleen trauma. There was no NOMF in higher grades of liver trauma. CT fluid grade had no impact on NOMF. Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.     

Major bowel and diaphragmatic injuries associated with blunt spleen or liver rupture

The incidence of major bowel and diaphragm injuries occurring in association with blunt spleen and liver ruptures in adults was studied. Of 142 patients with splenic injuries, five had major bowel injuries and 12 had diaphragmatic ruptures. Of 102 patients with blunt hepatic injury, 13 had either bowel or diaphragm ruptures or both. Six bowel and diaphragm injuries occurred in 42 patients with blunt ruptures of both the liver and spleen. Anatomically minor spleen injuries were associated with a 4.8% risk of bowel or diaphragm rupture. Anatomically major splenic lacerations had associated bowel or diaphragm wounds in 16.4% of cases (p = 0.024). A 20% incidence of partial-thickness bowel wounds was found in patients with hepatic or splenic injury, but the natural history of these wounds is unknown.     

Outcome and management of blunt liver injuries in multiple trauma patients

Background: In Germany, abdominal trauma in multiple- trauma patients can be observed in about 25–35% of all cases. Due to major bleeding complications, the initial treatment of blunt abdominal trauma in multiple-trauma patients has high priority. The aim of this study was to discuss management, treatment and outcome of blunt liver injury in multiple-trauma patients treated in our department. Methods: The clinical records of 1192 multiple-trauma patients [injury severity score (ISS) 3–18] treated at the Surgical Department of the University Clinic of Essen from January 1975 to February 1998 were reviewed. Seventy-five patients with an ISS above 18 operated on due to a blunt liver injury could be included. The mean age was 29.82±1.80 years (60 males and 15 females). The degree of injury in this group was high (ISS 37.12±1.06). Results: Twenty-three of the 75 (30.6%) patients died during their hospital stay. Deceased patients were older (27±2 years versus 37±4 years; P<0.01) and had a higher ISS (ISS=34.5±1 versus 43.2±2; P<0.01). In nine cases, death was strongly related to liver injury. Operational blood loss was higher in the group of multiply injured patients with liver injury and in those patients who did not survive (P<0.05). An increased mortality could be seen in this selected patient group when compared with our large collective of multiply injured patients. The age of the patients, the ISS and operative blood loss were the significant factors that influenced the operative mortality after blunt hepatic injuries in our study. Received: 28 October 1998 Accepted: 22 April 1999     

Aspirin does not increase the need for haemostatic interventions in blunt liver and spleen injuries

PurposeThe prohemorrhagic effect of aspirin may cause concern about worse prognoses when treating blunt hepatic or splenic injuries. This study investigated whether preinjury aspirin yields an increasing need for haemostatic interventions.MethodsAdmission and outpatient records were extracted from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with splenic or hepatic injuries were identified, and those with preinjury nonaspirin APAC or with penetrating injuries were excluded. The primary outcome measurement was the necessity of invasive procedures to stop bleeding, including transarterial embolization (TAE) and surgeries. One-to-two propensity score matching (PSM) was used to minimize selection bias. Multilogistic regression (MLR) analysis was used to identify factors associated with haemostatic interventions.ResultsA total of 20,470 patients had blunt hepatic injuries, and 15,235 had blunt splenic injuries, of whom 691 (3.4%) and 667 (4.4%) used preinjury aspirin, respectively. In the blunt hepatic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (6.1% vs 6.1%, p = 1.000), exploratory laparotomy (3.3% vs 4.3%, p = 0.312), hepatectomy (3.0% vs 2.7%, p = 0.686) or hepatorrhaphy (14.3% vs 15.0%, p = 0.683)). Regarding the blunt splenic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (11.5% vs 10.6%, p = 0.553), splenectomy (43.5% vs 41.4%, p = 0.230) or splenorrhaphy (3.0% vs 3.3%, p = 0.117)). An MLR analysis showed that preinjury aspirin did not increase the need for haemostatic interventions in either cohort.ConclusionsPreinjury aspirin use is not associated with increased haemostatic procedures in blunt hepatic or splenic injuries.     

Therapeutic laparoscopy for blunt abdominal trauma with bowel injuries

In the setting of abdominal trauma, laparoscopy is used mainly for diagnosis, and its role in definitive operative repair is still debated. We report the case of a 50-year-old woman who underwent diagnostic and therapeutic laparoscopy after being subjected to blunt abdominal trauma in a traffic accident. Multiple injuries to the small bowel and colon were repaired laparoscopically with a favorable outcome. Surgeons with experience in advanced laparoscopy and trauma care can use laparoscopy in the diagnosis and treatment of selected patients with blunt abdominal trauma.     

Predicting inpatient mortality for pediatric trauma patients with blunt injuries: a better alternative

PURPOSE: The aim of this study was to identify significant independent predictors of inpatient mortality rates for pediatric victims of blunt trauma and to develop a formula for predicting the probability of inpatient mortality for these patients. METHODS: Emergency department and inpatient data from 2,923 pediatric victims of blunt injury in the New York State Trauma Registry in 1994 and 1995 were used to explore the relationship between patient risk factors and mortality rate. A stepwise logistic regression model with P<.05 was developed using survival status asthe dependent variable. Independent variables included are elements of the Pediatric Trauma Score (PTS), additional elements from the Revised Trauma Score (RTS), the motor response and eye opening components of the Glasgow Coma Scale (GCS), age-specific systolic blood pressure, the AVPU score, and 2 measures of anatomic injury severity (the Injury Severity Score [ISS] and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]). RESULTS: The only significant independent predictors of severity that emerged were the ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component from the AVPU score. The statistical model exhibited an excellent fit (C statistic = .964). The specificity associated with the prediction of inpatient mortality rate based on the presence of 1 or more of these risk factors was .926, and the sensitivity was .944. CONCLUSION: The best independent predictors of inpatient mortality rate for pediatric trauma patients with blunt injuries include variables not specifically contained in the PTS or the RTS: ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component of the AVPU score.     

Nonoperative management of liver injuries following blunt abdominal trauma in children

In a 4-year span, 12 patients with hepatic trauma were treated at our institution. After initial resuscitation, three underwent emergency celiotomy because of the severity of their injuries. This communication analyses the other nine. All of these had significant liver injuries and were managed nonoperatively. Hepatic injury was diagnosed and the severity defined by ultrasonography, radionuclide scintigraphy, or computed tomography (CT). These stable patients were initially admitted to the intensive care unit (ICU) and upon transfer to the ward, maintained on restricted activities. Seven of the nine children received blood transfusions. Although liver enzymes were initially elevated in each case, they returned to normal in 1 week. In-hospital and post-discharge imaging documented healing of the hepatic injuries in each case. Eight children are well at 3 months to 4 years follow-up. Only one of the nine nonoperatively managed patients died and this was secondary to severe head injuries. To date, there are no complications. Our nine children are added to the 23 nonoperatively treated pediatric hepatic injuries found in the literature.     

腹腔镜联合微波治疗闭合性肝外伤的临床体会

目的:探讨腹腔镜联合微波治疗闭合性肝外伤的可行性及效果。方法:前瞻性随机对照将47例闭合性肝外伤患者分为腹腔镜联合微波组(A组,n=25)与开腹手术组(B组,n=22);对比两组手术情况、术后恢复情况及术后并发症。结果:A组术中出血量明显减少,术后无严重并发症发生,患者康复时间明显缩短。结论:相对传统开腹手术,腹腔镜微波治疗闭合性肝外伤具有患者创伤小、康复快、并发症少及住院时间短等优点,可作为治疗闭合性肝外伤的另一选择。     

Occult injuries of the liver, bile duct, and pancreas after blunt abdominal trauma

Blunt trauma to the abdomen may produce a wide range of intra-abdominal injuries. Subcapsular hematoma of the liver, disruption of the common bile duct, and subcapsular disruption of the pancreatic duct are three injuries discussed; all are rare, isolated injuries frequently accompanied by minimal initial abdominal signs and symptoms. Each injury, however, has serious potential late complications. The diagnosis and treatment of these conditions are discussed with a view toward preventing or minimizing the late complications.     

Early-onset liver abscess after blunt liver trauma: report of a case

A 23-year-old male patient underwent nonoperative management for his blunt liver trauma as he was hemodynamically stable without any signs of peritonitis initially after injury. A fever of 39.5°C and severe right upper quadrant abdominal pain developed on the second day, and an abdominal computed tomography (CT) scan showed the formation of a gas-containing liver abscess in the traumatized liver. An emergency laparotomy revealed a foul-smelling liver abscess at the traumatized site, which was finally disclosed to be the result of a Clostridium species infection. A liver abscess is a rare complication following the nonoperative management of liver injury, and such an occurrence is even more rare within 1 day after injury. A Clostridium species infection is responsible for the fulminant progressing nature of the disease because the devitalized, ischemic liver parenchyma is ideal for such growth, and this is the first time that a such condition has been shown by CT images. Close observation with a high degree of suspicion is required for the successful treatment of such abscesses. Received: March 28, 2002 / Accepted: July 2, 2002 Reprint requests to: C.-H. Hsieh     

Screening for blunt cerebrovascular injuries in pediatric trauma patients

BackgroundAdult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients.Study designAt our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria.ResultsOf 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI.ConclusionOur study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population.Level of evidenceIV.     

Anatomic resection for severe blunt liver trauma

Despite recent advances in management of severe blunt liver trauma, the operative mortality rate in patients with complicated blunt liver trauma (grades IV and V) is still high. The purpose of this study was to assess the results of anatomic liver resection for severe liver trauma in the institution in which liver transplant surgeons are responsible for the management of liver injuries.     

Small-bowel and mesentery injuries in blunt trauma.

BACKGROUND: The purpose of this study was to identify factors that would aid in the diagnosis of small-bowel and mesentery injuries (SBMI) in blunt trauma patients. METHODS: Retrospective review of 15,779 blunt trauma patients admitted to a Level I trauma center between January 1991 and December 1996. RESULTS: A total of 5,303 patients sustained abdominal injuries, 70 of whom had more than 111 SBMI. Seventy-nine percent were victims of motor vehicle collisions. Thirty patients had isolated SBMI and 40 had associated intra-abdominal injuries. Twelve patients arrived with systolic blood pressure < 90 mm Hg, eight of whom died. Mean base deficit was -7.3 +/- 6.3 in 52 patients who had arterial blood gases determined. Fifty-three of 60 patients had hematuria. Sixty-seven patients required laparotomy. Delayed exploration occurred in 15 patients who underwent initial computed tomography but had subsequent changes in physical status. Two of 20 patients had negative diagnostic peritoneal lavage on admission and were eventually explored based on abdominal computed tomographic findings and changes in physical examination. There were 15 deaths. Delay in diagnosis (>12 hours after arrival) occurred in nine patients with no deaths or significant morbidities. Mean Injury Severity Score was 29 +/- 16.7: 43 +/- 17 in nonsurvivors and 25 +/- 14.3 in survivors (p < 0.05). CONCLUSION: The diagnosis of SBMI is often made in the presence of associated intra-abdominal injuries. Isolated SBMI are common, however, and special attention to the mechanism of injury, abdominal examination, presence of hematuria, and significant base deficit should raise suspicion to the possibility of SBMI. Findings on abdominal computed tomography that may suggest SBMI and should prompt further evaluation include free fluid, thickened bowel, and extraluminal air. Because delay in diagnosis does not seem to affect morbidity or mortality, dedication to observation and serial physical examinations will aid in the proper identification of elusive SBMI. Mortality, however, does appear to be related to the presence of hypotension on admission and associated injuries.     

Management of kidney injuries in children with blunt abdominal trauma

BACKGROUND/PURPOSE: The authors analyzed the incidence and the course of renal injuries encountered in a cohort of pediatric patients with blunt abdominal trauma. This review focuses on the early diagnostic and therapeutic approach rather than the long-term outcome and draws conclusions for an effective initial management. METHODS: From 1976 to 1996, the charts of 308 children with blunt abdominal trauma that were admitted to the authors' department were reviewed. The patients initially were evaluated using urinalysis, ultrasonography, and abdominal paracentesis (until 1984) and in specific cases iv-urography, computed tomography (CT), and angiography. The authors retrospectively classified the renal trauma after the widely used Organ Injury Scaling (OIS) into 5 grades and correlated the diagnostic value of various techniques as well as the diagnostic approach. RESULTS: Sixty-nine serious abdominal traumas were encountered. Thirty-six patients suffered renal lesions grade 2 (G2) or higher; 20 children were polytraumatized. There were 67 renal lesions including 28 G1, 22 G2, 8 G3, 5 G4, 1 G5, and 3 lesions of the lower urinary tract. Ultrasonography and urinalysis were found to be the optimal diagnostic methods for screening and following the course of renal injury. CT scan proved to be most reliable for detecting and exactly classifying renal lesions grade 2 or higher and superseded consecutively iv-urography. In cases in which CT scan failed to show renal excretion of contrast agent, angiography was performed. Ten patients proceeded to operative therapy. CONCLUSIONS: Ultrasonography and urinalysis proved to be the optimal initial evaluation tool for excluding renal injury both as a screening method and for further controls. Exact classification was possible by CT scan. During the reviewed time period a shift from surgical to conservative management was notable. If lesions were G4 or G5, surgical treatment with tendency toward minimally invasive therapy always was indicated.