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PubMed2001

Factors affecting mortality rates in patients with abdominal vascular injuries.

BACKGROUND: Major vessel injury is seen in 5% to 25% of patients admitted to hospitals with abdominal trauma, and this is the most common cause of death in these patients. METHODS: Data on 470 patients with abdominal vascular injuries seen at a Level I trauma center were reviewed retrospectively. RESULTS: The overall mortality rate was 45%. The incidence of various types of trauma were blunt in 51 patients (11%), gunshot wounds in 329 patients (70%), shotgun wounds in 21 patients (4%), and stab wounds in 69 patients (15%). The three vessels with the highest mortality rates were aorta (at and proximal to the renals) (32 of 35 [91%]), hepatic veins and/or retrohepatic vena cava (36 of 41 [88%]), and portal vein (25 of 36 [69%]). The most significant risk factors (p < 0.001) for death were a trauma score of 9 or less, initial operating room (OR) systolic blood pressure (SBP) < 90 mm Hg, final OR core temperature < 34 degrees C, 10 or more blood transfusions in the first 24 hours, and an initial emergency department SBP < 70 mm Hg. Of 120 patients with an initial OR SBP < 70 mm Hg, 103 (86%) died. Of 29 patients with a good response to a prelaparotomy thoracotomy with thoracic aortic cross-clamping (SBP > 90 mm Hg within 5 minutes), 11 (38%) survived. Of the remaining 87 patients, only 6 (7%) survived (p = 0.01). CONCLUSION: Rapid control of bleeding sites (to keep blood transfusions to < 10 units) and urgent correction of hypothermia seem to be the main factors improving survival over which the surgeon has some control.

Abdomen↗
PubMed1997

[Traumatic injuries of the abdominal organs].

The injuries of abdominal cavity organs are analyzed in 1158 injured persons with isolated and concomitant trauma. It is established that the injury frequency of parenchymatous organs is two times more then of cavitial.

Abdominal Injuries↗
PubMed1984

[Reflux and stool frequency in the artificial feeding of traumatized intensive care patients].

The effect of intragastric nutrion and its complications, especially the reflux pattern, were studied in 104 patients, who had to be intensively treated for more than 10 days. Patients suffering from polytrauma without abdominal injury (group I) or with abdominal injury (group III) and patients with isolated head/brain injury (group II) were included in this study. Parenteral nutrition was changed to intragastric administration as soon as possible and enteral nutrition was softly increased from 327 calories per day during the first week to 1800 calories or more in the next weeks. The general duration of feeding by nasogastric tube was between 16,1 and 19,8 days. The occurrence of reflux varied from 23,2% in patients of group II to 29,4% in patients of group I. Significant changes of reflux pattern were seen during the different weeks of treatment. The amount of reflux fluid was between 184,8 ml in group II and 355,4 ml in group III. The percentage of reflux fluid, if compared with the total enteral fluid administration revealed the maximum (16,6%) in patients of group III. Patients in group I had the highest frequency of defecation, the highest incidence of diarrhea was in all the groups really the same. Diarrhoea was seen in 6,7% of all patients. The underlying mechanism for these complications were discussed.

Abdominal Injuries↗
PubMed1988

Intra-abdominal vascular injury secondary to penetrating trauma.

There were 85 patients in this series. The overall mortality was 17.6%. Gunshot wounds were responsible for 51 injuries, with a 21% mortality. There were three stabbings and three shotgun blasts, with a mortality of 10% and 33%, respectively. There were 127 intra-abdominal vascular injuries. The majority were to the SMA and its branches: 34. The highest mortality occurred with protal vein and combined aortic and vena caval injuries (80%). Fatalities averaged twice as many vascular injuries as survivors. There were 194 organ injuries. A liver injury predicted the highest mortality as did injuries to the spleen, lung, and pancreas. The presence of shock and the ability to rapidly control the source were the major predictors of survival. Fatalities averaged a Trauma Score of 7.5; survivors averaged a score of 14.0. There were 12 deaths which occurred intra-operatively and three postoperatively, for a total of 15 deaths. Once the patients made their way from surgery, their survival was 96% assured. Early suspicion of an intra-abdominal vascular injury followed by rapid exposure and control of hemorrhage are the keys to successful management.

Abdominal Injuries↗
PubMed2005

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.

Abdominal Injuries↗
PubMed2000

Non-operative treatment of abdominal gunshot injuries.

BACKGROUND: Non-operative treatment is a management option that challenges the traditional mandatory laparotomy for abdominal gunshot injuries. METHODS: All published relevant clinical reports were retrieved by searching through the Medline database and manually. The theoretical arguments in favour of non-operative management as well as the results of the reviewed reports are analysed and evaluated. RESULTS AND CONCLUSION: Patients with proven non-penetration of the abdominal cavity can be offered conservative treatment with a satisfactory outcome. Greater caution should be exercised in the presence of a documented visceral injury until the safety of this option has been established by further clinical trials.

Abdominal Injuries↗
PubMed1998

Trauma in pregnancy: maternal and fetal outcomes.

OBJECTIVE: Pregnancy imposes significant physiologic demands that may confuse and complicate the evaluation, resuscitation, and definitive management of pregnant women who sustain trauma. Accurate prediction of fetal outcome after trauma remains elusive. The objective of this study was to characterize patterns of injury in pregnant women, to determine if pregnancy affects maternal morbidity and mortality after trauma, and to identify predictors of fetal death. METHODS: We performed a retrospective, case-control analysis of all injured pregnant patients admitted to the Trauma Service at the University of California San Diego Medical Center from 1985 to 1995. RESULTS: We identified 114 injured pregnant patients. Motor vehicle crashes accounted for 70% of injuries, and of these, 46% of patients were not using seat belts or helmets. Violence accounted for 12% of injuries. Injured pregnant women with Injury Severity Scores > 8 demonstrated similar mortality, morbidity, and length of stay to matched nonpregnant control patients. Pregnant women were more likely to sustain serious abdominal injury and were less likely to sustain severe head injury. Identified risk factors for fetal loss include maternal death, overall maternal injury severity, the presence of severe abdominal injury, and the presence of hemorrhagic shock. CONCLUSION: There appears to be a group of pregnant women in San Diego at high risk for traumatic injury who should be targeted for preventative strategies including improved seat belt use. Pregnancy does not increase mortality or morbidity after trauma but influences the pattern of injury. Maternal death, high Injury Severity Score, serious abdominal injury, and hemorrhagic shock are risk factors for fetal loss.

Abdominal Injuries↗
PubMed1987

Penetrating trauma to the back and flank. A reassessment of mandatory celiotomy.

The optimum management of penetrating wounds to the back and flank remains controversial. Since 1980 our institution has followed a policy of mandatory celiotomy for back and flank wounds with evidence of fascial penetration. Following this policy, 34 patients underwent celiotomy for back (8), flank (22), or combined (4) area penetrating injuries. Four patients sustained shotgun blasts, eight sustained handgun or rifle injuries, and 22 patients were stabbed. All shotgun blasts caused multiple intra-abdominal injuries and five (63%) of the eight gunshot victims had significant intra-abdominal injuries. Only one (5%) of the 22 stab victims had significant intra-abdominal injury. Four (12%) patients died, three of shotgun injuries. One patient had a small bowel obstruction 1 month after a noncontributory abdominal examination. Based on this review, the authors recommend selective management of stab wounds to the back and flank. Gunshot wounds continue to warrant mandatory exploration.

Abdomen↗
PubMed1992

Gallbladder and extrahepatic biliary duct injury following abdominal trauma.

Extrahepatic biliary tract and gallbladder injuries are rare, but many occur after both blunt and penetrating abdominal trauma. During a 5-year period, 24 patients requiring laparotomy for abdominal trauma were found to have an extrahepatic biliary tract injury, representing 13 per cent of all patients admitted with hepatic trauma during the same period. The majority of patients had injury to the gallbladder; only one case of common bile duct injury was identified. Of the patients, 50 per cent had an associated hepatic injury; 17 per cent had important pancreatic trauma. Isolated gallbladder injury occurred in only 8 per cent of patients. The overall mortality associated with gallbladder trauma was 16 per cent. This uncommon injury usually results from severe trauma and is associated with a high incidence of other major visceral injuries.

Adolescent↗
PubMed1999

[Duodenal injuries in abdominal trauma].

BACKGROUND: We retrospectively reviewed our patients between 1988 and 1996 with duodenal injuries to demonstrate the diagnostic and therapeutic management. MATERIAL AND METHODS: The charts of six patients treated in the Division of Traumatology of the University Hospital of Zurich between 1988 and 1996 have been retrospectively reviewed. The mean age was 25 years. In four patients a blunt trauma and in two patients a two gunshot caused the duodenal injury. The injury was classified with the "Duodenum Organ Injury Scale". RESULTS: The primary repair was successful in three patients, twice a Roux-en-Y duodenojejunostomy with repair of the biliary tract was performed and once a conservative treatment was chosen. No surgery related complications occurred. Two patients died postoperatively because of associated injuries. CONCLUSIONS: Duodenal injuries are rare and therefore correct diagnosis and treatment is difficult. In case of penetrating trauma or hemodynamic instable patients following blunt trauma the emergent laparotomy is mandatory. CT scan is recommended in cases of hemodynamic stable patients after blunt trauma. Primary repair is the treatment of choice in the majority of duodenal injuries.

Abdominal Injuries↗
PubMed2003

Trauma laparotomy in a rural setting before transfer to a regional center: does it save lives?

BACKGROUND: In the rural setting, long distances may necessitate that a patient undergo emergency laparotomy before transfer to a regional trauma center for definitive management. The purpose of this study was to review the experience of three regional trauma centers with such treated patients. METHODS: This study was a retrospective chart review of patients who underwent emergency laparotomy for trauma before transfer, identified from the respective databases of participating centers over a 6-year period. RESULTS: Fifty-six patients met the study criteria. Twenty-six (46%) were transferred primarily for management of the abdominal injury, and 14 of these patients (25% overall) underwent damage control procedures. Overall survival was 82%. Logistic regression demonstrated that transfer for treatment of the extra-abdominal injury was the only significant predictor of survival (odds ratio, 34.33; 95% confidence interval, 1.80-655.24). CONCLUSION: Although patients undergoing laparotomy who were subsequently transferred for management of abdominal injury have reasonable outcome, patients transferred primarily for management of extra-abdominal injury seem to have a survival advantage.

Abdominal Injuries↗
PubMed2001

Penetrating chest injuries in the firearm era.

BACKGROUND: firearm wounds of the chest are now common at our institution. The management algorithm for firearm wounds has not been evaluated for this mode of injury. METHODS: records of all patients with penetrating chest injuries admitted to an urban tertiary hospital over 1 year were retrieved and analysed. RESULTS: there were 473 stab and 116 firearm wounds. In comparison to stab injuries firearm wounds had significantly more normal X-rays (14 vs. 5%), fewer pneumothoraces (15 vs. 37%), and more contusions (43 vs. 2%). The frequency of haemothoraces (34 vs. 23%) and haemopneumothoraces (36 vs. 35%) was similar in both groups. Stabbing caused all the 18 cardiac injuries. Associated abdominal injuries occurred in 8% of stab and 34% of firearm injuries. Pneumothoraces due to firearms were uncommon and rarely required drainage. More pneumothoraces were treated nonoperatively among firearm injuries in contrast to stabbing injuries where the opposite applied. The management of haemothorax and haemopneumothorax was similar in both groups that fulfilled the criteria for drainage. The rate of ICU admission was higher and the hospital-stay longer following firearm injuries. Fifty-nine patients died (10% of the total), 33 (28%) from the firearm injuries and 26 (6%) from stab-wounds. Early deaths were 1 and 3% for stabs and firearms, respectively. CONCLUSIONS: patients with firearm injuries reaching hospital suffered three times higher mortality and a longer ICU and hospital stay than those with stab injuries. However, early mortality was similar for both modes of injury and validates the continued application of the stab wound derived management algorithm to all modes of injury.

Adolescent↗
PubMed1996

Craniomaxillofacial injuries: experience in Tehran.

This is a retrospective study of 1,608 patients (1,575 males and 33 females) who were treated in two university hospitals in Tehran, Iran from 1984 to 1990. The injuries were classified into three types: soft tissue injuries (132 patients), bony fractures (356 patients), and mixed injuries (1,120 patients). The craniofacial injuries were classified into seven anatomical levels: lower third; middle third; upper third; lower and middle third; lower and upper third; middle and upper third; and lower, middle, and upper third). The lower third craniofacial injuries were the most common (69%, n = 1,110) followed by the middle third (42%, n = 677). Injuries to the upper third were the least common (28%, n = 452). In the lower third injuries the mandible was the most common site; lateral midface injuries were the most common site in the middle third region; and frontal bone was the most common site in upper third injuries. Most of these injuries were caused by firearms (71%, n = 1,135) during the Iraq-Iran conflict; the least common cause was assault (0.80%, n = 13). There were many associated noncraniofacial injuries, such as head and ocular injuries and abdominal injuries. The head injuries were classified into five grades according to the clinical and computed tomography findings. Treatment of the craniofacial injuries ranged from minor repair or closed reduction to major soft tissue and bony reconstruction. The postinjury complication rate was very high, especially for firearm injuries. The follow-up period ranged from 3 months to 3 years.

Accidents, Traffic↗
PubMed1992

Prospective validation of criteria, including age, for safe, nonsurgical management of the ruptured spleen.

One hundred twelve cases of blunt splenic rupture were prospectively entered (October 1987-October 1991) into surgical or nonsurgical management groups using these criteria for the nonsurgical group: hemodynamic stability+age less than 55 years+CT scan appearance of grade I, II, or III injury+absence of concomitant injuries precluding abdominal assessment+absence of other documented abdominal injuries. All ages were included and AAST injury scaling was used. Patients were grouped from the trauma room. The surgical treatment group included 66 patients (49 splenectomies, 17 splenorraphies). These patients were generally older and more severely injured, required more transfused blood, and a longer ICU stay. The nonsurgical group included 46 patients with 33 older than 14 years. There were 3 patients over the age of 55 years inappropriately included in this group, and nonsurgical therapy failed in all three. Statistical analysis (chi 2) showed that more splenic injuries were observed and more spleens were saved with these criteria applied prospectively compared with a previous retrospective series in the same institution. Our series had a success rate of 93%, and validates the criteria used for safe, nonsurgical management of the ruptured spleen and adds a new criterion: a maximum age of 55 years.

Abbreviated Injury Scale↗
PubMed2000

Imaging in thoracic trauma: the trauma surgeon's perspective.

Thoracic trauma is a common cause of significant disability and mortality. Most thoracic injury in developed countries results from motor vehicle crashes (MVC). Imaging of patients with thoracic trauma must be accurate and timely to avoid preventable death. Trauma surgeons prioritize imaging options based on the patient's hemodynamic status, associated injuries, and age. The screening test for the detection of life-threatening thoracic injury is the supine anteroposterior (AP) chest radiograph. Rib fractures are a marker for serious associated injuries, including abdominal injuries. Rib fractures are especially ominous in children and the elderly. Thoracic aortic injury is associated with high-speed mechanisms of injury and can occur in the absence of radiographic signs. Chest computed tomography (CT) can be used as a screening and diagnostic tool for suspected aortic injury. Aortography is reserved for patients with high suspicion of aortic injury or for confirmation of CT scan diagnosis.

Aortography↗
PubMed2002

Concomitant injuries in 531 patients with maxillofacial fractures.

A ten-year review of five hundred and thirty one patients with facial fractures who sustained six hundred and forty eight associated injuries was presented. The male to female ratio was 2.7:1 and the highest incidence was in the 21-30 years age group. Road traffic accident was the commonest aetiology while the most frequently associated injury was soft tissue lacerations (71.0%). Neurological injuries constituted 9.9% of the total number of concomitant injuries. Other associated injuries seen were orthopaedic injuries 9.5%, ophthalmologic injuries 6.6%, chest injuries 1.9%, abdominal injuries 0.6% and urological injuries 0.5%. It is mandatory that the surgical team should be organised in the treatment of patients with concomitant injuries coexisting with maxillofacial fractures.

Accidental Falls↗