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PubMed1992

The effects of hypothermia and injury severity on blood loss during trauma laparotomy.

To assess the relationships between core temperature (T) and other factors relating to operating room (OR) blood loss and mortality following abdominal injury, the records of 122 patients undergoing laparotomy for trauma at Detroit Receiving Hospital over a 1-year period (1989) were reviewed. Most injuries were penetrating (86%) and the mortality rate was 8.2%. Overall, 57 of 122 (47%) had hypothermia (T < or = 35 degrees C) upon arrival in the OR. There was a significant correlation between admission blood pressure and lowest intraoperative temperature (r = 0.60; p < 0.001). Multiple regression analysis revealed that the patient's lowest temperature (p < 0.001) and Trauma Score (TS); p < 0.0015), but not Abdominal Injury Severity Score (AISS) (p = 0.25) correlated with OR blood loss. The 28 patients with high TS (15 or 16) and AISS > or = 9 had significantly less blood loss when the OR temperature was maintained above 35 degrees C versus 33 degrees-35 degrees C (540 +/- 580 mL vs. 1820 +/- 1160 mL; p < 0.003). This suggests that hypothermia may exacerbate OR blood loss independent of degree of physiologic or anatomic injury. Thus hypothermia is common in patients undergoing a laparotomy for trauma. Trauma scores and the presence of shock preoperatively correlate with the development of intraoperative hypothermia. Hypothermic patients with similar injury severity have greater blood loss. Prevention and rapid correction of hypothermia during resuscitation and surgery appear to be extremely important in reducing blood loss in this patient population.

Abdominal Injuries↗
PubMed1990

Bayesian analysis of the reliability of peritoneal lavage.

The popular methods of reporting the reliability of a test--sensitivity and specificity--do not tell the practicing physician what the chance is that a patient has the disease if the results from the particular test for that disease are positive or negative. Bayesian analysis, however, does answer this question. In this study, the data from 29 studies of peritoneal lavage were analyzed using the Bayesian method. The probability of an intra-abdominal injury being present if findings from lavage were positive ranged from 0.448 to 1.0. The probability of an intra-abdominal injury being present if findings from lavage were negative ranged from zero to 0.286. These probabilities varied with the criteria for positivity, technique used and type of trauma. In general, results of Bayesian analysis showed that findings from peritoneal lavage were most reliable in diagnosing the patient with blunt trauma when the standard positive criteria and open technique were used.

Abdominal Injuries↗
PubMed1980

Pitfalls of peritoneal lavage in blunt abdominal trauma.

Peritoneal lavage is a sensitive detector of intra-abdominal injury following blunt trauma. The open method of diagnostic lavage is advocated, because it is associated with less morbidity. Although quantitative and qualitative methods are available to interpret lavage returns, the results, in some patients, do not correlate with the severity of injury found at laparotomy. Diaphragmatic and extraperitoneal injury are illusive to detection by peritoneal lavage. Despite the pitfalls of peritoneal lavage, we still recommend its use for all patients suspected of having an intra-abdominal injury.

Abdominal Injuries↗
PubMed2005

Abdominal war wounds--experiences from Red Cross field hospitals.

The traditional approach to abdominal war wounds consists of triage, eche-loned care, and mandatory laparotomy for penetrating abdominal injuries, and it remains valid in modern conventional wars with well-organized evacuation and surgical services. Expectant management of abdominal casualties can be considered under difficult circumstances with a high influx of patients exhausting the available resources. This can occur in regional conflicts associated with mass movements of people and with collapsed infrastructure. While always combined with adequate fluid resuscitation, antibiotic treatment, and other supportive care, the expectant approach in patients with penetrating abdominal injuries could be indicated for asymptomatic patients with multiple fragment wounds or for patients presenting several days post-injury in good condition. The focus of surgical resources and competence should be on the majority of patients with intestinal perforation only, who need surgery to save life--but not necessarily on an urgent basis--and who have a good chance of survival. The limited availability of blood products to correct blood loss and coagulation factor deficiencies, and the lack of sophisticated monitoring of hemodynamic variables that call into question the value of a damage-control approach for the most severely injured. Even if the bleeding could be temporarily controlled, the subsequent need for adequate resuscitation before returning the patient to the operating room could be difficult to achieve and would result in incompletely resuscitated patients being reoperated while acidotic, coagulopathic, and even hypothermic. Perhaps, in mass casualty situations these patients should be recognized during triage or at least early during operation, and aggressive surgery should be replaced with adequate expectant management with sedation and analgesics.

Abdominal Injuries↗
PubMed1990

Intra-abdominal abscess after blunt abdominal trauma.

The relationship between blunt abdominal trauma and intra-abdominal abscess (IAA) is discussed infrequently; therefore we conducted a retrospective review of 4050 multiple blunt trauma admissions from January 1986 to July 1988. Of 325 patients who had a laparotomy for blunt abdominal trauma, we identified 15 (4.6%) who had 40 IAAs. The most common intra-abdominal injuries involved the spleen and liver. Splenectomy increased the risk for IAA in contrast to splenic salvage. Blunt injuries to the kidney and pancreas, when occurring in multiple trauma patients, carried a significant risk of IAA. Associated multiple extra-abdominal injuries and high transfusion requirements increased the risk for IAA formation. Most of the IAAs were located in the upper quadrants. There was a 46% incidence of multiple IAA, which in turn had an 80% chance of recurrence after initial drainage. Enterobacter species played an important role in the formation of IAA in our trauma patients. Three patients (20%) died. Poor prognostic indicators included a high injury severity score, high transfusion requirements, the presence of pelvic fracture, positive blood cultures, multiple organisms per abscess, and multiple-organ system failure.

Abdominal Injuries↗
PubMed1998

Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population.

BACKGROUND: Although computed tomography has been considered the diagnostic modality of choice for pediatric patients with blunt abdominal trauma (BAT), it is costly, time-consuming, requires sedation, and may be associated with complications in young children. Abdominal ultrasonography (US) is a promising modality in the evaluation of BAT that is quick, noninvasive, repeatable, and cost-effective. We hypothesized that emergency department US, performed by trauma surgeons, is a useful triage tool for pediatric BAT that reduces the need for computed tomography. METHODS: The 230 children (<18 years old) with suspected BAT were initially evaluated with US in the emergency department by surgeons. Subsequent computed tomographic scan or exploratory laparotomy was performed as indicated by the key clinical pathway. RESULTS: Twelve children (5.2%) had documented intra-abdominal injuries. All five injured children with significant intraperitoneal fluid were identified by US. Of the seven patients who had intra-abdominal injury not detected by US, six sustained solid organ injuries that were managed nonoperatively. Extrapolated reductions in hospital charges due to the decreased number of computed tomographic scans total $130,000. CONCLUSIONS: Using US as a triage tool may dramatically reduce the cost of pediatric BAT evaluation while being able to quickly identify significant intraperitoneal fluid that requires further evaluation and possible laparotomy.

Abdominal Injuries↗
PubMed1976

Gunshot wounds of the abdomen. A review of 277 cases.

During a five-year period from July 1968 throuhgh June 1973, 277 abdominal gunshot wounds (GSWs) occurred, the overall fatality of which was 10%. Abdominal exploration was done in all patients. No intra-abdominal injury was found in 40 patients (14%) and no death occurred in this group. There were 28 fatalities (12%) in 237 patients (86%) who had intra-abdominal injuries. Morbidity and mortality were related not only to the number of organs injured, but also to specific organs injured. The leading cause of early death was hypovolemia due to major vessel injuries. Septicemia was the most common cause of death if the patient survived the first 24 hours of hospitalization. Penetrating abdominal stab wounds and gunshot wounds must be considered separately, and mandatory routine abdominal exploration for all penetrating gunshot wounds is advised. In stab wounds to the abdomen, conservative management may be preferable.

Abdominal Injuries↗
PubMed1976

Splenic injury during abdominal surgery.

Of 237 splenectomies performed over a six-year period, 39 were necessitated by intraoperative injury. Capsular and hilar tears were predominant. All injuries were recognized at the time they occurred. The incidence of pulmonary complications and wound infections exceeded those for other categories of splenectomy and for these other abdominal operations without splenectomy. Although these complications were not fatal and the mortality was not increased, measures for avoidance of intraoperative splenic injury are indicated. These include knowledge of anatomic relationships and exercising cautious traction in operations on the upper part of the stomach and the splenic flexure of the colon, in reoperation in elderly people, or where there is suspicion of intrinsic splenic abnormality.

Abdomen↗
PubMed1991

Serum amylase determination and blunt abdominal trauma.

To determine the value of serum amylase sampling as an indicator of intra-abdominal injury, the records of 940 consecutive victims of blunt trauma were retrospectively reviewed. The sensitivity, specificity, and predictive value were poor in the determination of intra-abdominal injury, whether accompanied by craniofacial injury or not. It was concluded that routine serum amylase determination is of no value in the clinical management of the patient suffering blunt injury.

Abdominal Injuries↗
PubMed2001

A prospective evaluation of surgeon performed sonography as a screening test in blunt abdominal trauma.

INTRODUCTION: Sonography has found a role in the evaluation of patients with abdominal injury. However, the accuracy of sonography as performed by non-radiologists remains controversial. This study aims to determine the accuracy of focused abdominal sonography for trauma when performed by surgeons. MATERIALS AND METHOD: Over a 1-year period, 48 patients with abdominal injury were initially evaluated for free intraperitoneal fluid by sonography. These tests were performed by 2 surgeons who had received instructions and performed a minimum of 30 examinations. Sonographic findings were then compared with other diagnostic modalities including computed tomography (CT) scan, diagnostic peritoneal lavage and exploratory laparotomy. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for sonography were found to be 0.86, 0.92, 0.89, 0.90 and 0.89, respectively. Although not specifically sought for, 2 cases of solid organ injury and 1 haemothorax, which were missed in initial examinations and X-rays, were detected on sonography. CONCLUSION: In conclusion, our initial experience suggests that local surgeons can perform a focused sonographic examination for trauma with acceptable accuracy. Although sonography lacks the sensitivity of diagnostic peritoneal lavage and the accuracy of CT scan, the diagnostic algorithm for abdominal trauma should include sonography as a screening test.

Abdominal Injuries↗
PubMed1997

Conservative management of pancreatic trauma in children.

Many adults and most children with a solid-organ abdominal injury can be managed nonoperatively. To date, however, little is known about the outcome of nonoperative management of pancreatic injury. To analyze current treatment patterns of pancreatic injury in children, all children (age < 19 years) identified in the National Pediatric Trauma Registry (49,540 patients) and admitted to two level I pediatric trauma centers with a diagnosis of injury to the pancreas (International Classification of Disease-9 codes 863.81-863.84 and 863.91-863.94) were reviewed. Over a 7-year period, 154 children were identified with pancreatic injury. Thirty-one (20%) sustained severe injuries (grades III, IV, or V) and 123 (80%) sustained lower-grade injuries (grades I and II). Sixteen (52%) of the children sustaining grades III, IV, or V injury required pancreatic procedures (9 distal resections, 3 simple repairs, 2 enteric anastomoses, 2 others). Only 26 (21%) of the grades I and II injuries required surgical intervention specific to the pancreas (11 resections, 9 catheter drainage of pseudocysts, 2 enteric anastomoses, 4 others). Ninety-seven (79%) grades I and II injuries were successfully managed conservatively. Overall, 15 (10%) children required drainage procedures for pseudocyst. The frequency of operative intervention decreased during the last 4 years of the study (18 vs. 26%, p > 0.05), coinciding with a decrease in the frequency of drainage procedures for pseudocysts. The need for surgical intervention was not influenced by age, Injury Severity Score, or Pediatric Trauma Score (p > 0.05). Associated abdominal injuries were common but did not influence operations on the pancreas (p > 0.05). No deaths were attributed to the pancreatic injury. These data indicate that early intervention for pancreatic injury, in the absence of clinical deterioration or major ductal injury (grades III, IV, or V), is unwarranted, and careful observation may supplant the conventional surgical therapy recommended for adults.

Adolescent↗
PubMedDate not supplied

[Potential of current physical investigative methods in the diagnosis of injuries to organs of the abdominal cavity].

Injuries to the proximal region of the gastrointestinal tract in 594 patients at different ages (from 19 to 56 years old) are investigated. Four groups of patients were identified depending on the prevalence and duration of the gastroenterological anamnesis: the main group of patients with chronic glomerulonephritis (CGN) presenting with secondary (nephrogenic) gastroduodenopathy; the control group I (CGN with concomitant primary injury to the gastroduodenal zone); the control group II (similar injuries to the proximal portion of the alimentary canal but with no renal lesion, group III was essentially healthy subjects. With the aid of the outlined physical express-methods a comparative incidence of injuries to the gastroduodenal zone has been estimated in patients with primary and secondary (nephrogenic) gastroduodenopathy.

Abdominal Injuries↗
PubMed2001

N-acetyl-cysteine reduces neointimal thickening and procoagulant activity after balloon-induced injury in abdominal aortae of New Zealand white rabbits.

BACKGROUND: Procoagulant activity and oxidative stress generated by balloon injury to normal vessels promote the migration of medial smooth muscle cells and their proliferation in the intima. We hypothesised that administering levo N-acetyl-cysteine (NAC) i.v. at the time of injury, and s.c. before and after injury would reduce neointimal formation 4 weeks later and would regulate procoagulant activity in vessels with neointima undergoing ballooning a second time. METHODS AND RESULTS: at the time of injury rabbits received: NAC, unfractionated heparin (HEP) or both (NAC + HEP). Neointimal thickening at 28 days, calculated as the ratio between the intimal and medial area, was attenuated after NAC, HEP and NAC+HEP by 39%, 30% and 47% respectively when compared to untreated injured animals (CONTROLS) (p <0.05). At 28 days, bound thrombin activity and platelet adhesion 1 h after a repeated balloon injury decreased in animals receiving NAC, HEP and NAC+HEP bv 54%, 63% and 64% for thrombin activity (p <0.05 vs CONTROLS), and by 56%, 66% and 75% respectively for 111Indium-platelet deposition (p <0.05 vs CONTROLS). CONCLUSIONS: NAC in-vivo was effective in reducing neointimal thickening and procoagulant response after balloon injury.

Acetylcysteine↗
PubMed2002

Intra-abdominal free fluid without solid organ injury in blunt abdominal trauma: an indication for laparotomy.

BACKGROUND: The optimal management of patients sustaining blunt abdominal trauma (BAT), in whom intra-abdominal free fluid but no solid organ injury is found on imaging, remains unclear. The purpose of this study was to determine the incidence and significance of this finding. METHODS: All patients presenting with suspected BAT to a provincial trauma center over a 30-month period were reviewed. A screening focused abdominal sonogram for trauma scan was obtained in every case. Stable patients with positive or indeterminate scans underwent computed tomographic scanning. Those with free fluid but without visible solid organ injury were studied. Radiologic interpretation, clinical management, and operative findings were analyzed. RESULTS: Twenty-eight of 1,367 patients (2%) met inclusion criteria. Twenty-one patients (75%) underwent exploratory laparotomy, which for 16 (76%) was therapeutic: bowel injuries were found in 10 patients, mesentery injuries in 6, and injuries to solid organs in 3. In five patients, laparotomy was nontherapeutic. Those with more than a trace of free fluid were significantly more likely to have a therapeutic procedure. Seven patients (25%) were observed, of whom two failed nonoperative management and underwent therapeutic laparotomies within 24 hours of admission for missed colon, splenic, and hepatic injuries. The presence of abdominal seat belt bruising or a Chance-type fracture in the study patients was associated with a 90% and 100% therapeutic laparotomy rate, respectively. Computed tomographic scan findings were variable and were not able to predict injury severity or need for surgery. CONCLUSION: The finding of more than trace amounts of free fluid in the absence of solid organ injury in BAT is often associated with clinically significant visceral injury. Early laparotomy is recommended for these patients.

Abdominal Injuries↗
PubMed2003

[Initial diagnosis of intra-abdominal hemorrhage caused by isolated splenic injury in blunt abdominal trauma].

Diagnosis of intraabdominal bleeding caused by spleen injury must be performed in the shortest possible period of time, with little risk for the patient, and with high preciseness. By its simple performance, high preciseness and little risk for the patient, DPL imposes as the predominant method in initial diagnostic of intraabdominal bleeding. Control and monitoring of lavage may duly signalize degree of bleeding. Preciseness of this diagnostic in our series ranges up to 93.3%. DPL method is especially important in a combined neurotrauma. Ultrasonography is a sovereign method in diagnostic of bleeding source as well as in monitoring of bleeding that from the very beginning does not require urgent surgical intervention. Its importance is in monitoring both intrasplenic and subcapsulary hematomas. It is not appliable in disturbed and haemodynamically unstable patients. It is in particular important in children where a maximum conservative attitude with respect to operative treatment has been assumed. CT takes the leading place with respect to preciseness of bleeding area, and the combined thoracoabdominal trauma. Preciseness of CT in our series comes up to 96.6%, but can be applied only in haemodynamically stable patients. Same as US of abdomen so the CT of abdomen represents a prominent method in monitoring of both intrasplenic and subcapsular hematomas, which do not require urgent surgical intervention.

Abdominal Injuries↗
PubMed1995

Influence of low dose allopurinol on ischaemia--reperfusion injury during abdominal aortic surgery.

OBJECTIVES: To ascertain whether surgery causes ischaemia-reperfusion (I-R) related injury, if this injury is augmented by preoperative shock, and reduced with low dose allopurinol. DESIGN: Randomised blind placebo controlled trial. SETTING: Surgical laboratory. MATERIAL AND METHODS: 22 pigs were randomly allocated to four groups; OP = operation/placebo, OA = operation/ allopurinol, SOP = shock + operation/placebo, SOA = shock + operation/allopurinol. An aortic tube prosthesis was inserted in all. In groups SOP and SOA preoperative shock was induced by exsanguination. Allopurinol was administered in group OA on the preoperative day and peroperatively, in group SOA during shock and peroperatively. CHIEF OUTCOME MEASURES: Perioperative blood concentrations of thiobarbituric acid reactive species (TBARS), ascorbic acid (AA), albumin, 99mTc-albumin and creatine phosphokinase (CPK) as indicators of oxidative membrane damage, antioxidant activity, microvascular permeability changes and muscular cell damage respectively. MAIN RESULTS: In the OP and OA groups TBARS gradually increased, while AA, 99mTc-albumin and CPK remained unchanged and albumin decreased. No effect of allopurinol was observed in these groups. In the SOP group TBARS and AA were not significantly different from groups OP and OA. Yet, albumin, 99mTc-albumin and CPK decreased significantly more in the SOP group. Compared with the SOP group, allopurinol treatment (SOA) produced lower TBARS and higher AA levels, and reduced the effect of shock on albumin, 99mTc-albumin and CPK concentrations. CONCLUSIONS: Aortic surgery causes no I-R related damage. Pre-operative shock produces I-R related damage, which is reduced by allopurinol.

Allopurinol↗