PARAPARESIS FOLLOWING ABDOMINAL CRUSH INJURY IN CHILDREN.
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Abdomen↗
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Selection of patients with abdominal stab wounds for laparotomy.
The roles of local wound exploration (LWE) and peritoneal lavage (PL) in the selective management of stab wounds to the lower chest and abdomen were evaluated prospectively in 53 patients. Twenty-four patients underwent immediate laparotomy for obvious clinical signs of intra-abdominal injuries. Twenty-nine patients with evidence of anterior abdominal fascia penetration or equivocal LWE had PL before laparotomy. Operative findings were correlated with the preoperative assessment of LWE and PL. Twenty patients in this group had intra-abdominal injuries. All patients with positive PL were found to have an intra-abdominal injury. Six patients with a negative PL and a positive LWE had visceral injuries. Three of these injuries were considered significant with an overall false negative PL of 15%. Laparotomy performed on the basis of LWE resulted in nine patients (31%) having an unnecessary laparatomy. Careful physical examination, the results of local wound exploration, and peritoneal lavage should be considered in selecting patients with abdominal stab wound for laparotomy.
Abdominal Injuries↗
Blunt abdominal trauma--injury assessment in relation to early surgery.
One hundred and thirteen patients sustaining blunt abdominal trauma over a 24-month period were retrospectively divided into three groups to assess parameters of three diagnostic methods and the time-lapse before implementing surgical treatment. Diagnosis was based in group A patients (n = 20) on physical findings, plain radiology, and blood and urine examinations. Diagnostic methods in group B patients (n = 35) and in group C patients (n = 58) were as in group A but with the addition of diagnostic peritoneal lavage (DPL) in group B or with the addition of diagnostic abdominal ultrasonography (DAU) in group C. Sixty-five patients underwent abdominal exploration. The time-lag from commencement of examination to surgery was 332.33 +/- 48.90 min, 251.82 +/- 29.08 min and 570.89 +/- 133.80 min respectively in groups A, B and C. It was significantly shorter in group B compared with group C (P = 0.03). DPL had a sensitivity of 95%, a specificity of 81% and an accuracy of 89% whilst DAU had a sensitivity of 79%, a specificity of 85% and an accuracy of 83% in detecting significant injury. The conclusion is that DPL in combination with DAU would facilitate early assessment and treatment of intra-abdominal injuries.
Abdominal Injuries↗
Not so FAST.
BACKGROUND: Focused assessment with sonography for trauma (FAST) as a screening tool in the evaluation of blunt abdominal trauma will lead to underdiagnosis of abdominal injuries and may have an impact on treatment and outcome in trauma patients. METHODS: From October 2001 to June 2002, a protocol for evaluating hemodynamically stable trauma patients with suspected blunt abdominal injury (BAI) admitted to our institution was implemented using FAST examination as a screening tool for BAI and computed tomographic (CT) scanning of the abdomen and pelvis as a confirmatory test. At the completion of the secondary survey, patients underwent a four-view FAST examination (Sonosite, Bothell, WA) followed within 1 hour by an abdominal/pelvic CT scan. The FAST examination was considered positive if it demonstrated evidence of free intra-abdominal fluid. Clinical, laboratory, and imaging results were recorded at admission, and FAST examination results were compared with CT scan findings, noting the discordance. RESULTS: Patients with suspicion for BAI were evaluated according to protocol (n = 372). Thirteen cases were excluded for inadequate FAST examinations, leaving 359 patients for analysis. There were 313 true-negative FAST examinations, 16 true-positives, 22 false-negatives, and 8 false-positives. Using CT scanning as the confirmatory test for hemoperitoneum, FAST examination had a sensitivity of 42%, a specificity of 98%, a positive predictive value of 67%, a negative predictive value of 93%, and an accuracy of 92%; chi analysis showed significant discordance between FAST examination and CT scan (5.85%, < 0.001). Six patients with false-negative FAST examinations required laparotomy for intra-abdominal injuries; 16 patients required admission for nonoperative management of injury. Of the 313 true-negative FAST examinations, 19 patients were noted to have intra-abdominal injuries without hemoperitoneum and 11 patients were noted to have retroperitoneal injuries. CONCLUSION: Use of FAST examination as a screening tool for BAI in the hemodynamically stable trauma patient results in underdiagnosis of intra-abdominal injury. This may have an impact on treatment and outcome in trauma patients. Hemodynamically stable patients with suspected BAI should undergo routine CT scanning.
Abdominal Injuries↗
Evaluation of blunt abdominal trauma occurring during pregnancy.
Evaluation of abdominal trauma in pregnant patients presents a number of dilemmas. Few series compare the various modalities available in this situation. The present review characterizes various techniques and their results. The charts of all patients with a secondary diagnosis of pregnancy admitted to a Level I trauma center over a 7 1/2-year period were reviewed. Forty were considered to have sustained possible blunt abdominal trauma: 30 were occupants in motor vehicle collisions, five were pedestrians, four sustained falls, and one was riding a motorcycle. Immediate laparotomy for emergency caesarean section or other indications was performed in three cases (7%). In 13 cases (32%) evaluation was accomplished by diagnostic peritoneal lavage (DPL). Three patients (7%) underwent computerized tomography of the abdomen. The remaining 22 patients (55%) were observed with serial physical exams, and hematocrits. The group that was observed had a mean ISS of 5.9. The mean Glasgow Coma Score (GCS) was 14.9. No patients had to undergo exploratory laparotomy for abdominal injury during hospitalization. In the 13 patients undergoing DPL, the mean ISS was 34.6, and the mean GCS was 10.6. Overall accuracy was 92% with no major complications. Pregnant patients sustaining minor injuries and blunt abdominal trauma may be safely observed. Those with major injuries, shock, altered mental status, or neurologic deficit require further studies to rule out intra-abdominal injury. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. CT scan and ultrasonography are other modalities which merit further assessment as a primary diagnostic technique in abdominal trauma occurring during pregnancy.
Abdominal Injuries↗
Evaluation of a microcrystalline bovine collagen hemostatic agent in canine solid viscera injury using abdominal impedance plethysmography.
Bioelectric impedance as a sensitive noninvasive technique for detecting and monitoring changes in compartmental body fluid volume was used to compare the efficacy of two hemostatic agents in controlling postoperative abdominal bleeding following surgically induced solid viscera injury. Gelatin foam-oxidized cellulose sponge and bovine MCHH were both effective topical hemostatic agents. It appears that MCCH has certain advantages over conventional agents.
Abdominal Injuries↗
Nonsurgical management of solid abdominal organ injury in patients over 55 years of age.
Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 +/- 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 +/- 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I-IV), 12 sustained splenic injuries (grades I-III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intra-abdominal solid organ injury.
Abdominal Injuries↗
Secondary abdominal compartment syndrome: a potential threat for all trauma clinicians.
Post-injury abdominal compartment syndrome (ACS) is an increasingly recognised phenomenon in critical care. During the last decade, ACS had also been characterised in patients without abdominal injuries, referred to as secondary ACS. Recent investigation has described this elusive syndrome better, with up to 70% mortality. Regardless of the cause of the syndrome and the nature of any extra-abdominal injuries, secondary ACS is invariably associated with massive fluid resuscitation. With a reliable, predictive model and new monitoring techniques, trauma clinicians should be able to identify the high-risk patient and attenuate the impact of this syndrome.
Abdominal Injuries↗
Effectiveness of peritoneal lavage in blunt abdominal trauma.
To analyze the effectiveness of peritoneal lavage and to define its limitations in the evaluation of patients who have sustained blunt abdominal trauma, a prospective study of 500 such patients was undertaken by the Trauma Service at the Naval Hospital, San Diego. Utilizing a qualitative colorometric method to evaluate the degree of hemoperitoneum, patients could rapidly be divided into three clinical groups: strongly positive, weakly positive, and negative. Using this method, patients with a strongly positive peritoneal lavage had a 94% incidence of significant intra-abdominal injuries. In 333 patients with a negative lavage, there was no documented incidence of significant intra-abdominal injuries. Visceral angiography and abdominal echography were utilized in this group of patients to identify those with significant intra-abdominal injuries. By utilizing this approach, there were only eight unnecessary celiotomies in the total group of 500 patients. It is concluded, therefore, that peritoneal lavage is a safe, rapid, and effective means of evaluating patients who have sustained blunt abdominal trauma.
Abdomen↗
[Resuscitation in severe hepatic injuries].
Hepatic injuries account for about 45% of all abdominal traumas and for 30 to 40% of penetrating abdominal injuries. In 60% of the cases, they are associated with other lesions, especially life-threatening head injuries. Abdominal ultrasonography, a short and safe procedure enabling guided puncture, has developed rapidly relegating to the second rank other diagnostic techniques such as peritoneal lavage and CT scan. First line treatment of severe trauma complicated by haemorragic shock combines fluid resuscitation, prevention of hypothermia and administration of broad spectrum antibiotics. Surgical care, relying mainly on perihepatic packing and vascular exclusion techniques must remain as conservative as possible. Once haemodynamics have been stabilized in patients who do not present any other abdominal lesion requiring laparotomy, the non-interventional attitude is often successful and bears lower morbidity.
Abdominal Injuries↗
The inadequacy of peritoneal lavage in diagnosing acute diaphragmatic rupture.
Thirty-eight patients with acute diaphragmatic rupture secondary to blunt trauma have been reviewed. Peritoneal lavage is diagnostically inexact in patients with diaphragmatic rupture. One-fourth of the patients had falsely negative peritoneal lavages during their initial evaluation. All four patients without associated intra-abdominal injuries had falsely negative peritoneal lavages, as did four of 30 patients (13%) with significantly associated intra-abdominal injuries. We conclude from these data that: 1) peritoneal lavage is falsely negative in patients with isolated diaphragmatic rupture; 2) positive peritoneal lavage in patients with diaphragmatic rupture results from associated intra-abdominal injuries; and 3) peritoneal lavage may be falsely negative despite significant intra-abdominal injuries; because of herniation of injured organ(s) into the thoracic cavity, thus bleeding is excluded from the peritoneal cavity.
Abdominal Injuries↗
Crush accident resulting in isolated abdominal aortic injury.
The case history is presented of a patient with isolated abdominal aortic trauma due to blunt injury of the abdominal wall. Survey of the literature shows a typical clinical manifestation of this rare injury. When present, prompt recognition and proper treatment are essential in the management of this condition.
Abdominal Muscles↗
Peritoneal lavage in the evaluation of penetrating abdominal trauma.
Peritoneal lavage has become widely accepted in the management of blunt abdominal trauma, but its role has not been clearly established in the evaluation of penetrating abdominal injuries. The interpretation of lavage effluent analysis and the criterion for laparotomy are also unclear. A review of our recent experience and that of other indicates that peritoneal lavage has a significant role in detecting intra-abdominal injury from abdominal stab wounds and penetrating injuries of the lower part of the chest. Peritoneal lavage has a limited role in the evaluation of abdominal gunshot wounds, that is, when penetration of the peritoneum is equivocal. It is of negligible value in the evaluation of penetrating trauma to the back and flank. Quantitation of erythrocytes in the lavage effluent is the most reliable indication of intra-abdominal injury, and the level of significance varies according to the mechanism and location of the injury. The usefulness of other analysis of the effluent remains undetermined.
Abdominal Injuries↗
Aspiration of free blood from the peritoneal cavity does not mandate immediate laparotomy.
The objective was to establish the relationship between the aspiration of free blood (+ASP) versus diagnostic peritoneal lavage (DPL), abdominal injury severity, hemodynamic instability, and the need for immediate operative intervention. We prospectively compared the significance of +ASP to +DPL in our level I trauma center. Consecutive patients received sequential needle tap, catheter aspiration (ASP), and DPL. If gross blood was withdrawn during the tap or ASP, it was returned to the peritoneal cavity before completing the DPL. The DPL was considered positive if there were > 100,000 RBCs for blunt injuries or anterior abdominal stab wounds, or > 10,000 RBCs for other penetrating injuries. During a 12-month period, 566 patients fulfilled the study criteria; they were 50 per cent blunt and 50 per cent penetrating trauma. There were 70 patients with both +ASP/+DPL, 30 with -ASP/+DPL and 4 with +ASP but -DPL. Exploratory laparotomy was performed on these 104 patients (18.4%), 22 of which were considered nontherapeutic. The ATI was statistically higher in the +ASP patients (14.9 +/- 12.9 versus 8.5 +/- 8.2, P < 0.05) but was not clinically different. Overall injury severity and hemodynamic stability were not different in the two groups. The sensitivity of DPL at detecting intra-abdominal injury was higher than the ASP group (98% versus 72%), but the specificities were equal (98%). Because +ASP patients are not more critically injured or unstable than +DPL patients, and because DPL is more accurate in detecting the need for operative intervention, aspiration should be abandoned as part of the DPL procedure in patients with abdominal trauma.
Abdominal Injuries↗
Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma.
INTRODUCTION: Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum. METHODS: We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings. RESULTS: Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p < 0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p < 0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum. CONCLUSION: A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.
Abdomen↗
Atrial natriuretic factor release during hypovolemia and after volume replacement.
OBJECTIVE: To examine plasma atrial natriuretic factor activity during hypovolemia and after vascular volume replacement. DESIGN: Prospective, descriptive study. SETTINGS: Scene of emergency, Emergency Department, and the ICU of a university hospital. PATIENTS: A total of 47 trauma patients with evidence of hypovolemia were grouped according to their major injury into a thoracic injury group (15 patients; mean Injury Severity Score = 38.5 +/- 3.1 [SEM], Hospital Trauma Index = 14.1 +/- 0.7), an abdominal injury group (14 patients; Injury Severity Score = 36 +/- 3.3, Hospital Trauma Index = 14 +/- 0.9), and a severe head injury group (18 patients; Injury Severity Score = 23 +/- 1.5, Hospital Trauma Index = 10 +/- 0.6). MEASUREMENTS AND MAIN RESULTS: Measurements were taken at the scene of emergency; after volume replacement in the Emergency Department; and after 3, 7, 12, 24, 36 hrs and on day 5 in the ICU. In all groups, the average plasma atrial natriuretic factor levels were increased at the scene of emergency and declined significantly to normal values with volume replacement. In the thoracic injury group, plasma atrial natriuretic factor activity decreased from 253 +/- 73 to 115 +/- 83 pg/mL (p less than .0017); in the abdominal injury group, plasma atrial natriuretic factor activity decreased from 194 +/- 42 to 91 +/- 24 pg/mL (p less than .006); in the severe head injury group, plasma atrial natriuretic factor activity decreased from 167 +/- 28 to 70 +/- 13 pg/mL (p less than .02) with volume replacement. Plasma atrial natriuretic factor levels at the scene of emergency were significantly (252 +/- 73 vs. 167 +/- 28 pg/mL; p less than .05) higher in the thoracic injury group and in the abdominal injury group (194 +/- 42 vs. 167 +/- 28 pg/mL; p less than .05), as compared with the severe head injury group. CONCLUSIONS: In trauma patients, plasma atrial natriuretic factor concentrations were markedly increased in patients with untreated hypovolemia and were decreased to normal values with vascular volume replacement. Thus, atrial natriuretic factor seems to play an important physiologic role during hypovolemia.
Abdominal Injuries↗
[Management of abdominal stab injuries].
This is a retrospective study of 56 abdominal stab wounds analysed with reference to aetiology, pattern of injury, diagnostic and therapeutic procedures and indications for surgery. Indications for mandatory laparotomy were a manifest haemorrhagic shock (n = 20), evisceration (n = 13) and persisting presence of a weapon in the abdomen (n = 2). All patients who did not undergo immediate surgery were observed closely in repeated physical examination, in some cases complemented by ultrasound examination or peritoneal lavage. The indications for surgery were then based on the development of clinical signs. As a result of this selective approach, 31 patients underwent surgery immediately, 21 patients within 4 h and 4 patients more than 4 h after the initial assessment. The unnecessary laparotomy rate was 10.8%. The mortality rate was 3.5%, but in no case did death result from the selective approach.
Abdominal Injuries↗
Does body armor protect from firearm injuries?
BACKGROUND: Bullet-proof vests and helmets protect from harm in combat and military engagements. The use of armor against shrapnel has been studied, yet little has been documented as to how they protect from high velocity gunshots. This study aims to describe the medical consequences of high velocity firearm injuries and to differentiate between patients injured while using protective wear and those injured unprotected. STUDY DESIGN: National trauma registry data on injury characteristics, treatment and outcomes between October 1, 2000 and December 31, 2003 were retrieved and analyzed. RESULTS: There were 669 terror-related firearm injuries recorded: 236 (37.8%) in soldiers (protected) and 433 (62.2%) in civilians (unprotected). Injury severity was notably higher in civilian patients (31% versus 16% with Injury Severity Score>or=16). Civilians had more ICU care (26% versus 20%, p=0.06), and double the inpatient mortality (8.6% [n=37] versus 3.4% [n=8] patients). Protected body regions such as abdomen, chest, and brain, were injured less frequently. Once a traumatic brain injury was sustained, no statistical differences were found in severity distribution, ICU stay, or inpatient death between protected and unprotected patients. But injury severity in patients with chest injuries was much higher in those who were unprotected (Injury Severity Score>or=25, 41% versus 23%, respectively, p=0.08). This increased severity could be attributed partly to more multiple injuries involving the chest. Abdominal injuries showed a similar pattern. CONCLUSIONS: Body armor has a protective effect on victims of high velocity gunshot wounds; lower rates of head, brain, chest, and abdominal injuries are seen. In addition, armor reduces the severity of injuries to the chest and the abdomen.
Chi-Square Distribution↗