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Serious abdominal injuries resulting from sport are rare. The potential for misdiagnosis is significant and the consequences may be serious. Patients with abdominal pain should be taken very seriously and investigated with appropriate diagnostic equipment. Sporting bodies have a responsibility to address safety within a particular sport and to change the rules where necessary as injury patterns are identified.
A multidisciplinary, automobile crash investigation team at the University of Miami School of Medicine, William Lehman Injury Research Center of Jackson Memorial Hospital/Ryder Trauma Center in Miami, Florida, is conducting a detailed medical and engineering study. The focus is restrained (seatbelts, airbag, or both) occupants involved in frontal crashes who have been severely injured. More than 60 crashes have been included in the study to date. Analysis of the initial data supports the general conclusion that restraint systems are working to reduce many of the head and chest injuries suffered by unrestrained occupants. However, abdominal injuries among airbag-protected occupants still occur. Some are found among occupants who appeared uninjured at the scene. Case examples are provided to illustrate abdominal injuries associated with airbag-protected crashes. The challenges of recognizing injuries to airbag-protected occupants are discussed. To assist in recognizing the extent of injuries to occupants protected by airbags, it is suggested that evidence from the crash scene be used in the triage decision. For the abdominal injury cases observed in this study, deformation of the steering system was the vehicle characteristic most frequently observed. The presence of steering wheel deformation is an indicator of increased likelihood of internal injury. This may justify transporting the victim to a trauma center for a closer examination for abdominal injuries.
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OBJECTIVE: To establish the pattern and results of interventions in patients with abdominal injuries requiring admission. DESIGN: A descriptive, prospective, hospital-based study involving observation of patients from admission to final outcome of management as either discharged or deceased. SETTING: Kenyatta National Hospital, a tertiary teaching and referral hospital in Nairobi, Kenya, from November 2004 to February 2005 in the adult general surgical wards. PATIENTS: Eighty consecutive admissions of adult patients with either blunt or penetrating abdominal injuries. MAIN OUTCOME MEASURES: Type and cause of injury, demographic data, temporal parameters, morbidity and mortality. RESULTS: The 80 patients had a male to female ratio of 12.3:1, the majority were in the third decade of life with a range 15-56 years and mean of 28.2 years. Penetrating to blunt abdominal injuries had 2:1 ratio with the leading causes of injury being stab wounds, gunshot wounds and road traffic accidents. Blunt abdominal injuries had a higher tendency to extra-abdominal injuries. Duration prior to presentation to hospital and surgery depended on severity of injury. Modes of management varied between attending surgical firms. There was a 20% change in the mode of management and a 16.1% rate of negative laparotomy. Penetrating injuries had a better interventional outcome. Penetrating abdominal injuries had higher rates of complications while the blunt injuries had higher rates of mortality. Overall, both the complication and mortality rates were 12.5%. Correlates of mortality included delay before surgery, associated injuries, need for blood transfusion, admission to intensive care unit and duration prior to admission. Abdominal injury patients stayed an average of 6.4 days with the blunt injuries with complications staying close to twice as much as their penetrating counterparts. CONCLUSION: Abdominal injuries are a predominantly male disease with the majority in the third decade of life. As opposed to previous studies, gunshot wounds are now a significant cause of abdominal injuries in Kenyatta National Hospital (KNH). The rate-of negative laparotomies has come down by 10% over the past 15 years. The outcome of management depends on the severity and type, of injury sustained.
The initial physical examination is frequently unreliable in identifying patients with blunt trauma at high risk for having serious intra-abdominal injury. Intra-abdominal injury may be associated with specific injuries or risk factors, but the usefulness of such objective clinical criteria in predicting intra-abdominal injury has not previously been determined. The presence or absence of each of 11 clinical indicators and their association with serious intra-abdominal injury were analyzed in 3223 patients with blunt trauma. Linear and logistic regressions were used to determine which factors were significant predictors of an increased probability of intra-abdominal injury. Arterial base deficit less than -3 mEq/L, major chest injury, hypotension, and pelvic fractures were found to significantly increase the chance of intra-abdominal injury. Early diagnostic evaluation of the abdomen using diagnostic peritoneal lavage or computed tomography should be strongly considered in patients with blunt trauma who present with these associated factors.
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The danger inherent to nonoperative management of patients with blunt abdominal injury is that gastrointestinal disruptions will escape timely diagnosis and repair. However, children with blunt abdominal injury have been successfully treated nonoperatively for more than a decade. It has been recently proposed, based upon small series, that adults can be managed nonoperatively in a manner similar to that for children. To assess the likely safety for nonoperative management of adults with blunt abdominal injury, we determined the frequency of blunt gastrointestinal disruption in adults, and reviewed the sensitivity of the diagnosis of gastrointestinal disruption by computed tomography. The salient statistically significant findings, based upon an analysis of 6,301 adults and 1,275 children admitted following blunt trauma, were that blunt abdominal injury, blunt gastrointestinal injury, and blunt gastrointestinal disruption are much more frequent in adults. Based upon these findings and the low sensitivity reported for the diagnosis of gastrointestinal disruption by computed tomography, we conclude that the nonoperative management of adults with blunt abdominal injury is as a matter of routine not justified.
The analysis of the results of treatment of 818 sufferers with severe craniocerebral trauma was carried out. Among the patients, 102 had associated injuries to the abdominal organs. The difficulties of timely diagnosis were related to atypical manifestation of intraabdominal complications, insufficient pronouncement of clinical symptoms; therefore, the special methods of investigation--roentgenologic, instrumental, the use of liquid-crystal colour thermography acquire special value. The lethality was 37.2%.
PURPOSE: The goal of this retrospective study was to evaluate the spectrum of abdominal injuries and the reliability of computed tomography-based diagnosis in patients after polytrauma. MATERIAL AND METHODS: CT findings and clinical reports for 177 patients after polytrauma were evaluated with regard to abdominal injuries. Clinical patient reports at the time of discharge from the hospital were utilized as the standard of reference. Abdominal injuries resulting from an accident, frequent additional traumas and following therapeutic procedures were recorded. In the case of discrepancies in the reports, the CT scans were viewed retrospectively. RESULTS: In 30 out of 177 patients, 42 abdominal injuries were detected. 69 % of the injuries were caused by traffic accidents while 31 % resulted from falls. Liver and spleen injuries were the most common. 50 % of the cases were treated surgically, and the other half of the cases underwent non-surgical conservative therapy. Massive chest traumas, pelvic injuries, cerebral traumas and injuries to extremities were commonly associated with abdominal injuries. Evaluation of the discrepancies in the clinical reports showed that injury to the pancreas and the small intestine were not successfully detected on CT, thus resulting in a false negative diagnosis. Early stages of organ parenchyma laceration were also initially misdiagnosed on CT. CONCLUSION: Contrast-enhanced whole-body MSCT is a reliable and rapid method for diagnosing abdominal injuries in patients after polytrauma. Only very few patterns of injury are not detected on CT. The appearance of fluid collection in the abdomen is an indicator of possible parenchyma injury and requires further evaluation in cases of clinically suspected organ trauma.
Several recent reports have described abdominal injuries occurring as a result of seat belt use, raising concerns about seat belts as an agent of injury in motor vehicle crashes. The purpose of this study was to characterize the distribution of abdominal injuries after motor vehicle crashes in belted and unbelted patients admitted to trauma centers. The mortality was higher in unbelted than belted patients (7% vs. 3.2%, respectively, p less than 0.0001). Unbelted patients also had significantly more frequent and more severe head injuries (50.0% vs. 32.9%, respectively, p less than 0.001). The incidence of abdominal injury was equal in both unbelted patients (13.9%), but the spectrum of organs injured was different in the two groups. Gastrointestinal tract injuries (stomach, small bowel, colon and rectum) were significantly more frequent in belted vs. unbelted patients (3.4% vs. 1.8%, respectively, p = 0.001). The frequency of liver and spleen injuries was the same in both groups. This study demonstrates that in patients admitted to trauma centers after motor vehicle crashes, belted and unbelted patients have an equal incidence of abdominal injury, but belted and unbelted patients have a different spectrum of injuries. Hollow viscus injuries are more common in belted crash victims. Seat belt use was associated with significantly fewer head injuries and deaths. Physicians evaluating trauma victims after motor vehicle crashes should be aware of the fact that the types of abdominal injuries may vary substantially depending on seat belt use.
BACKGROUND: Difficulty with and delays in diagnosis are possible causes of increased morbidity and mortality in small bowel injuries. We assessed whether multiple intra-abdominal injuries led to earlier laparotomy and whether this resulted in improved outcome. METHODS: Patients with small bowel injuries between January 1993 and December 1997 from the trauma database at St. Michael's Hospital in Toronto were assessed after dividing them into those with isolated small bowel injury ("isolated") and those with small bowel injuries in association with other intra-abdominal injuries ("nonisolated"). Parameters compared were age, gender, length of stay, mortality, intra-abdominal complications, mechanism of injury, diagnostic time, and how the diagnosis was made. RESULTS: Of 1,207 patients, 244 sustained abdominal injuries, and 83 had small bowel injuries (30 patients in the isolated group and 53 in the nonisolated group). Groups were similar with respect to age and gender, yet differed significantly with respect to mechanism and mean Injury Severity Scores (isolated, 18 +/- 8 vs. nonisolated, 30 +/- 15). Outcome differed between groups, as mortality (isolated, 0 of 30 vs. nonisolated, 4 of 53 deaths), length of stay (isolated, 13 +/- 2 vs. nonisolated, 22 +/- 3 days), and patients with intra-abdominal complications (isolated, 5 of 30 vs. nonisolated, 14 of 53 patients) were significantly higher in the nonisolated group. Time to diagnosis was significantly less in the nonisolated group. Decision for laparotomy and diagnosis of small bowel injuries were based more on physical findings in the nonisolated group and on computed tomography in the isolated group. CONCLUSION: The presence of associated intra-abdominal injuries significantly affects presentation and outcome of patients with small bowel injuries and the selection of diagnostic modalities.
Diagnostic value of verification methods for abdominal injuries in patients with combined trauma (CT) was analyzed, severity of injuries by Injuries Severity Scale (ISS) was specified. From 503 patients with CT (ISS = 17.6 +/- 9) diagnostic laparocentesis (DLC) was used in 224 (44.6%), USI--in 204 (40.4%), diagnostic laparoscopy (DLS)--in 49 (9.8%). Diagnostic value of each method is not optimal as they do not confirm or exclude injuries of abdominal organs requiring emergency surgery. Absence of clear criteria of diagnosis of intraabdominal catastrophe leads to significant number of unnecessary laparotomies (DLC--39%, USI--43%, DLS--48.6%) that makes graver state of patients with CT and prognosis.
Intestinal blast injuries inflicted by explosive devices were found in 410 wounded hospitalized at the Military Medical Academy. Primary blast perforations were found in 7 (1.7%) cases, and they were certain only in cases of the direct blast. Examination was directed toward the primary non-penetrating blast injuries of intestines not only because of their number 43 (11%), but also because they, if untreated, progressed into secondary perforations. Operative treatment of primary and secondary perforations was performed in accordance with the existing surgical war doctrine. Treatment of the intestinal wall hematoma as primary non-perforating blast injury included surgical procedure and medication. Secondary perforations 11 (3%) developed in untreated primary non-perforating blast injuries of intestines. They were treated operatively except in two cases of enterocutaneous fistulas where conservative treatment was applied.
In a series of 138 closed abdominal trauma, observed during the past 10 years, the authors report their experience of the peritoneal lavage with a Diacath: the method is 97.8% accurate in determining the presence or absence of abdominal injuries. The abdominal signs and symptoms, with an accuracy of 58.7% are hardly contributive, especially in cases of multiple trauma and patients with altered state of consciousness. The peritoneal lavage, as long as the technique and the contra-indications are respected, is an easy, safe and reliable test for the detection of abdominal damage. Positive diagnostic peritoneal lavage allows an earlier diagnosis and operation, and reduces the mortality for intra-abdominal injuries by eliminating deaths from undiagnosed intra-abdominal lesions. If negative, it avoids unnecessary laparotomies, especially in cases of multiple trauma.
OBJECTIVE: To explore the characteristics of closed abdominal injury in pregnancy women and its treatment. METHODS: The clinical data of 37 pregnancy patients with closed abdominal injury treated in our hospital from June 1993 to June 2003 were collected and analyzed. RESULTS: All the 37 patients were treated with operation. Among them 2 early pregnancy patients with intestinal rupture and 1 patient with retroperitoneal hematoma were treated under laparoscope; in other 34 pregnancy patients laparotomy was performed. Of the 34 patients 8 used cesarean section because premature separation of placenta and enlarged womb interrupted the management of intra-abdominal organ injury. In the 37 patients 33 (89.1%) were cured, 4 (10.8%) die, postoperative complication rate was 16.2% (6/37). Two patients (5.4%) suffered from abdominal cavity infection, 3 (8.1%) from pulmonary infection, and 1 (2.7%) had multi-organ failure. CONCLUSIONS: For pregnancy patients with closed abdominal injury, besides obsteric diseases intra-abdominal injury should be given much attention. Accurate diagnosis and timely treatment can gain the time to save the life of both mother and fetus.
This study sought to evaluate injury causes and patient outcomes in young children with abdominal injuries. Cases of blunt abdominal injury (N = 927) to children ages 0 to 4 years were extracted from the National Pediatric Trauma Registry. Measures included hospital utilization (days hospitalized, intensive care unit use, and surgery) and patient outcome (in-hospital fatality, discharge to rehabilitation facility, home rehabilitation, and home nursing). The three most common mechanisms of abdominal injury were motor vehicles (61.27%), child abuse (15.75%), and falls (13.59%). Hospital utilization was higher in patients with multisystem injuries. Patient outcomes were more severe in abused children or those with concomitant central nervous system (CNS) injury; these were the only variables independently associated with increased mortality in this sample. Pediatric abdominal trauma leads to intense use of hospital resources and a high risk of in-hospital mortality. Child abuse, compared to falls, is independently associated with a 6-fold increase in in-hospital mortality.
Diagnosis of abuse in children with internal abdominal injury is difficult because of limited published work. We aimed to ascertain the incidence of abdominal injury due to abuse in children age 0-14 years. 20 children (identified via the British Paediatric Surveillance Unit) had abdominal injuries due to abuse and 164 (identified via the Trauma Audit and Research Network) had injuries to the abdomen due to accident (112 by road-traffic accidents, 52 by falls). 16 abused children were younger than 5 years. Incidence of abdominal injury due to abuse was 2.33 cases per million children per year (95% CI 1.43-3.78) in children younger than 5 years. Six abused children died. 11 abused children had an injury to the gut (ten small bowel) compared with five (all age >5 years) who were injured by a fall (relative risk 5.72 [95% CI 2.27-14.4]; p=0.0002). We have shown that small-bowel injuries can arise accidentally as a result of falls and road-traffic accidents but they are significantly more common in abused children. Therefore, injuries to the small bowel in young children need special consideration, particularly if a minor fall is the explanation.
BACKGROUND: Specific analysis of the relationship between abdominal injuries and lumbar spine fractures has not yet been reported. METHODS: A retrospective review of 258 blunt trauma patients with lumbar spine fractures treated between 1991 and 1996. RESULTS: 26 patients sustained concomitant lumbar spine fractures and abdominal injuries. The mechanism of injury was motor vehicle collision (73%), pedestrian-struck (11%), fall (8%) and assault (8%) resulting in ISS, RTS and mortality of 27 +/- 4, 6.5 +/- 0.4 and 8%, respectively. Forty-four lumbar spine fractures were identified (1.7/pt) in association with splenic (54%), renal (41%), hepatic (32%) and small bowel (23%) injuries and no retroperitoneal involvement. Multilevel lumbar spine fractures were associated with a higher organ injury/fracture ratio compared with single level fractures (p < 0.01) including a twofold higher incidence of solid organ (spleen, liver and kidney) injury (p < 0.01). The level and type of fracture did not affect the incidence of total and individual organ injury. Patients with abdominal injuries were more severely injured mainly due to increased incidence of associated thoracic injuries although no significant difference in mortality was observed. CONCLUSION: Abdominal injuries occurred only in the minority of blunt trauma patients with lumbar spine fractures. These injuries, which followed a similar distribution pattern as in blunt trauma in general, occurred most commonly due to motor vehicle collisions and in association with multilevel vertebral fractures. No correlation with fracture type or level was identified.