Evaluation of the patient with blunt abdominal trauma: an evidence based approach

The Complex Consequences of Severe Polytrauma with Traumatic Brain Injuries Caused by a Traffic Accident in a Child: A Case Report

BACKGROUND

Polytrauma is one of the three leading causes of mortality worldwide and a major contributor to psychosocial morbidity and disability. Concomitant traumatic brain injuries further increase this risk.

METHODS

We present the case of a 6-year-old child who sustained significant trauma in a road accident, resulting in injuries to multiple anatomical regions, including the central nervous system.

RESULTS

Two years after the accident, the child experiences brief episodes of decreased visual acuity, dizziness, nausea, pallor, and headaches, along with occasional migraines that resolve spontaneously. Additionally, the child struggles with school adjustment. Brain injuries associated with polytrauma are crucial prognostic factors in both the short and long term, influenced by the brain's reactivity and recovery capacity. There is also an increased risk of developing syncopal episodes, seizures, and other neurological manifestations.

CONCLUSIONS

The direct and secondary effects of the trauma have contributed to psychosocial disabilities, necessitating complex medical care and family-centered interventions.

Thoracoabdominal Injuries

Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described.

In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.

Diagnostic Accuracy of Focused Assessment With Sonography for Trauma in the Emergency Department

Background

Trauma is currently the fourth leading cause of death in developed countries. One of the main objectives in abdominal trauma patients is to develop a rapid and accurate diagnosis. There is a tendency to use emergency abdominal ultrasound with abdominal trauma, therefore, it is recommended in some centers as a diagnostic tool and as a primary choice in abdominal trauma.

Objectives

The aim of this study was to determine the diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents

Patients and Methods

This was a descriptive and analytical study performed on patients with abdominal blunt trauma who referred to the emergency ward. The diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents was evaluated.

Results

Of the 380 patients, 296 were males and 84 were females. The mean ages of male and female patients were 34.52 ± 16.38 years and 41.19 ± 21.38 years, respectively (P = 0.009). The sonographies performed by emergency residents were positive in 46 patients, with 22 of these confirmed by CT scans. The sensitivity and specificity of the sonography by emergency residents, as confirmed by CT scans, were 78.5% and 93.2%, respectively. The sonographies performed by radiology residents were positive in 38 patients, with 24 being confirmed by CT scans.

Conclusions

The sensitivity and specificity of the sonography by radiology residents, as confirmed by CT scans, were 85.7% and 96%, respectively. Sonographies performed by emergency residents were positive in 46 patients with 34 of these being confirmed by sonographies by radiology residents. The sensitivity and specificity of the sonographies by emergency residents, as confirmed by sonographies by radiology residents, were 89.5% and 96.5%, respectively

An abdominal computed tomography may be safe in selected hypotensive trauma patients with positive Focused Assessment with Sonography in Trauma examination

BACKGROUND

Positive Focused Assessment with Sonography in Trauma examination and hypotension often indicate urgent surgery. An abdomen/pelvis computed tomography (apCT) may allow less invasive management but the delay may be associated with adverse outcomes.

METHODS

Patients in the Prospective Observational Multicenter Major Trauma Transfusion study with hypotension and a positive Focused Assessment with Sonography in Trauma (HF+) examination who underwent a CT (apCT+) were compared with those who did not.

RESULTS

Of the 92 HF+ identified, 32 (35%) underwent apCT during initial evaluation and apCT was associated with decreased odds of an emergency operation (odds ratio .11, 95% confidence interval .001 to .116) and increased odds of angiographic intervention (odds ratio 14.3, 95% confidence interval 1.5 to 135). There was no significant difference in 30-day mortality or need for dialysis.

CONCLUSIONS

An apCT in HF+ patients is associated with reduced odds of emergency surgery, but not mortality. Select HF+ patients can safely undergo apCT to obtain clinically useful information.

Return to play after liver and spleen trauma

CONTEXT

Sport-related spleen and liver injuries pose a challenge for the physician. Although rare, these injuries can have serious and even life-threatening outcomes if not accurately diagnosed and managed in a timely fashion. Currently, there are no evidence-based guidelines on duration and intensity of restricted activity and return to play after spleen and liver injury. In addition, there is controversy on follow-up imaging after injury.

EVIDENCE ACQUISITION

PubMed was searched using the terms splenic or spleen and trauma and hepatic or liver and trauma from 1980 to 2013. The citations from sentinel papers were also reviewed.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Ultrasound is ideal in the unstable athlete. Nonoperative management of blunt splenic and hepatic injuries is recommended for hemodynamically stable patients regardless of injury grade, patient age, or presence of associated injuries. Follow-up imaging is not routinely recommended unless clinically indicated. Athletes may engage in light activity for the first 3 months after injury and then gradual return to unrestricted activity as tolerated. High-level athletes may choose splenectomy or serial imaging for faster return to play.

CONCLUSION

Intravenous contrast-enhanced computed tomography is the diagnostic imaging modality of choice in stable athletes with blunt abdominal trauma.

STRENGTH-OF-RECOMMENDATION TAXONOMY

C.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs.

OBJECTIVES

To assess the effects of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma.

SEARCH METHODS

We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EBSCO), publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and conference abstracts were searched for further elligible studies. Trial authors were contacted for further information and individual patient data. The searches were updated in February 2013.

STUDIES

randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs).

PARTICIPANTS

patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury.

INTERVENTIONS

diagnostic algorithms comprising emergency ultrasonography (US).

CONTROLS

diagnostic algorithms without ultrasound examinations (for example, primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]).

OUTCOME MEASURES

mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate.

MAIN RESULTS

We identified four studies meeting our inclusion criteria. Overall, trials were of moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We pooled mortality data from three trials involving 1254 patients; relative risk in favour of the US arm was 1.00 (95% CI 0.50 to 2.00). US-based pathways significantly reduced the number of CT scans (random-effects RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result is unclear. Given the low sensitivity of ultrasound, the reduction in CT scans may either translate to a number needed to treat or number needed to harm of two.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

Development and evaluation of a novel, real time mobile telesonography system in management of patients with abdominal trauma: study protocol

BACKGROUND

Despite the use of e-FAST in management of patients with abdominal trauma, its utility in prehospital setting is not widely adopted. The goal of this study is to develop a novel portable telesonography (TS) system and evaluate the comparability of the quality of images obtained via this system among healthy volunteers who undergo e-FAST abdominal examination in a moving ambulance and at the ED. We hypothesize that: (1) real-time ultrasound images of acute trauma patients in the pre-hospital setting can be obtained and transmitted to the ED via the novel TS system; and (2) Ultrasound images transmitted to the hospital from the real-time TS system will be comparable in quality to those obtained in the ED.

METHODS

Study participants are three healthy volunteers (one each with normal, overweight and obese BMI category). The ultrasound images will be obtained by two ultrasound-trained physicians The TS is a portable sonogram (by Sonosite) interfaced with a portable broadcast unit (by Live-U). Two UTPs will conduct e-FAST examinations on healthy volunteers in moving ambulances and transmit the images via cellular network to the hospital server, where they are stored. Upon arrival in the ED, the same UTPs will obtain another set of images from the volunteers, which are then compared to those obtained in the moving ambulances by another set of blinded UTPs (evaluators) using a validated image quality scale, the Questionnaire for User Interaction Satisfaction (QUIS).

DISCUSSION

Findings from this study will provide needed data on the validity of the novel TS in transmitting live images from moving ambulances to images obtained in the ED thus providing opportunity to facilitate medical care of a patient located in a remote or austere setting.

Determining the accuracy of base deficit in diagnosis of intra-abdominal injury in patients with blunt abdominal trauma

BACKGROUND

Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. A multiplicity of diagnostic modalities exists to evaluate the abdomen. We sought to assess the diagnostic performance of base deficit (BD) in identifying intra-abdominal injury in patients with blunt abdominal trauma.

METHODS

A prospective, nonrandomized series of patients with blunt abdominal trauma admitted into the 2 emergency departments was investigated from September 2007 to September 2008. Arterial blood samples were analyzed. According to BD, the patients were divided into 2 groups: group 1 who had a BD of -6 or lower and group 2 who had a BD more than -6. Ultrasonography, computed tomographic scan, or laparotomy was performed to find intra-abdominal injury. Follow-up at 7 days by telephone interview was obtained on patients who were discharged.

RESULTS

A total of 400 patients were enrolled, with a mean (SD) age of 34.8 ± 17.1 years. Two hundred sixty-eight (67%) of them were male. Seventy-six (19%) of patients had a BD of -6 or lower. Sixty-eight (17%) of them showed to have intra-abdominal injury with a BD of approximately -8.7 ± 3.2, compared with patients without intra-abdominal injury, -0.4 ± 0.1. Patients with a BD of -6 or lower achieved more laparotomy and blood transfusion compared with patients with a BD more than -6. On receiver operating characteristic curve analysis, the cutoff point of -6 was obtained with sensitivity and specificity of 88.2% and 95.2% and with positive and negative predictive values of 79% and 97.5%, respectively. None of outpatients had abdominal problem in telephone follow-up.

CONCLUSIONS

These data show that the BD is an early available important indicator to identify intra-abdominal injury in patients with blunt abdominal trauma, as well as a high transfusion requirement.

Radiographic evaluation of the patient with sport-related abdominal trauma

Abdominal injuries are rare in sports, but they can be very serious, even life threatening when they occur. With the increasing popularity of snowboarding and extreme skiing, the rate of abdominal injuries is beginning to rise slightly. It is imperative that physicians be able to recognize signs of injury to the liver, spleen, kidney, and hollow abdominal viscera and order appropriate diagnostic tests to investigate these injuries. This article focuses on the imaging modalities physicians can use to assist in diagnosis of sport-related abdominal trauma. Although the sports medicine physician will likely not provide definitive care and treatment of these injuries, because a team approach works best, it is important to know how to diagnose them through the proper studies.

Evaluation of the abdomen in the critically ill patient: opening the black box

PURPOSE OF REVIEW

Evaluation of the abdomen in critically ill patients can be challenging. This article reviews the available data and proposes evidence-based guidelines for evaluation of the abdomen in the critically ill patient.

RECENT FINDINGS

The critically ill are often clinically unevaluable due to distracting injuries, respiratory failure, obtundation, or other conditions. Even when patients can be examined, the clinical exam can be unreliable and misleading. Critically ill patients who are sufficiently stable to undergo imaging benefit from computerized tomography unless biliary sepsis is suspected, when ultrasound is preferred. There is an important role for endoscopy and angiography in the setting of gastrointestinal hemorrhage, as well as magnetic resonance imaging for mesenteric ischemia. Critically ill patients who are too unstable for imaging may require bedside laparoscopy or diagnostic peritoneal lavage. Abdominal compartment syndrome should be considered in the differential diagnosis of the unstable critically ill patient. Empiric laparotomy may still need to be employed in diagnosis and management of unstable patients.

SUMMARY

Timely and accurate diagnosis of life-threatening intraabdominal pathology is essential to care for critically ill patients. A multitude of laboratory, radiologic, and interventional modalities are available to evaluate the abdomen in the critically ill.

Blunt abdominal trauma: back to clinical judgement in the era of modern technology

BACKGROUND AND METHODS

Abdominal trauma poses a diagnostic challenge to most trauma surgeons. This study evaluates a clinical scoring system in 476 blunt abdominal trauma patients treated by the author over a period of 92 months. Patients were sorted into three groups according to the score results. Priority I group (160 patients) was subjected to an immediate laparotomy. Priority II group (200 patients) was treated according to the results of auxiliary investigations. Priority III group (116 patients) was kept under observation. The treatment outcome was used as a gold standard for the evaluation of the results.

RESULTS

In priority I and III groups (276 cases) the management was only dependent on the proposed clinical score with a 100% specificity, 88% sensitivity, 90% positive predictive value, 100% negative predictive value and an overall accuracy of 94%.

CONCLUSIONS

This scoring system (CASS) is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality that may result from improper and/or delayed diagnosis.

[Medical imaging in the management of abdominal trauma]

There is a marked trend toward nonoperative management of abdominal trauma. This has been possible thanks to the advances in imaging and interventional techniques. Computed tomography (CT), angiography, and endoscopic retrograde cholangiopancreatography (ERCP) can guide the nonoperative management of abdominal trauma.

Usefulness of Multidetector Computed Tomography for the Initial Assessment of Blunt Abdominal Trauma Patients

BACKGROUND

The prompt detection and accurate localization of abdominal injuries are difficult. Some diagnostic modalities, including laboratory tests, ultrasound, and diagnostic peritoneal lavage (DPL) were used to evaluate patients with blunt abdominal trauma, with various advantages and pitfalls. We aimed to evaluate the risk and benefit of using multidetector computed tomography (MDCT) as an initial assessment tool for proper diagnosis and treatment planning of patients with blunt abdominal trauma.

METHODS

Two hundred fifty-two patients with blunt abdominal trauma were prospectively enrolled. Multidetector computed tomography was performed during resuscitation. The risk and benefit of using MDCT in the diagnosis and planning of treatment were analyzed.

RESULTS

The time required for a MDCT examination averaged 10.2 minutes. Of the studies done, 224 revealed abdominal injuries. Of those, 34 were performed in patients with unstable hemodynamic status without adverse effect. Prompt diagnosis and proper treatment were given according to the MDCT findings. A total of 43 (17.1%) MDCTs showed contrast extravasation. Active bleeding was confirmed in all and treated with transarterial embolization (30) or surgery (13). Another 58 patients sustained bowel, mesenteric, or pancreatic injuries (BMPI) necessitating laparotomy. The sensitivity, specificity, and accuracy of MDCT in identifying patients with active bleeding or BMPI were all 100%.

CONCLUSIONS

Multidetector computed tomography was useful as a second line initial assessment tool to identify injuries and determine treatment planning in blunt abdominal trauma patients. No increased risk was found if the facility is readily available, the protocol is well designed, and the patient is well prepared.

The fast is positive, now what? Derivation of a clinical decision rule to determine the need for therapeutic laparotomy in adults with blunt torso trauma and a positive trauma ultrasound

INTRODUCTION

The object of this study was to derive a clinical decision rule for therapeutic laparotomy among adult blunt trauma patients with a positive abdominal ultrasound for trauma (FAST) examination.

METHODS

We retrospectively reviewed the trauma registry and medical records of all critical trauma patients who underwent a FAST examination in the emergency department (ED) in a university Level I trauma center over a 3-year period. Blunt trauma patients aged >16 years who had a positive FAST examination (defined as the presence of intraperitoneal fluid) were eligible. We selected seven clinical and ultrasound variables available during ED resuscitation for analysis: age, presence of an episode of hypotension (systolic blood pressure <90 torr in the ED), presence of abdominal tenderness, chest injury, pelvic fracture, femur fracture, and FAST fluid location (right upper quadrant [RUQ] only; RUQ plus other location; other location only). The primary outcome variable was whether a laparotomy was performed and whether this laparotomy was needed to provide the definitive surgical intervention ("therapeutic laparotomy"). We analyzed the variables using binary recursive partitioning analysis to create a decision rule.

RESULTS

There were 2336 FAST examinations performed during the study period, resulting in 230 (9.8%) positive examinations in patients meeting inclusion criteria. There were 135 patients who had therapeutic laparotomies and 95 who did not need laparotomy. The groups were similar in baseline characteristics. In the recursive partitioning analysis, the first node in the decision tree was the presence of fluid in the RUQ. Of the 144 patients with RUQ fluid, 105 (73%, 95% confidence interval [CI] 64%-80%) required therapeutic laparotomy. Of the 86 patients without RUQ fluid, 30 (35%, 95% CI 25%-46%) nevertheless required therapeutic laparotomies, and the variables blood pressure, femur fracture, abdominal tenderness, and age further divided these patient into high- and low-risk groups. Of the 12 patients without RUQ fluid who had normal blood pressures, no femur fractures, no abdominal tenderness, and were aged 60 years and younger, none (95% CI 0%-22%) required therapeutic laparotomy. In conclusion, given a positive FAST examination, the presence of fluid in the RUQ is an important predictor of the need for therapeutic laparotomy.

CONCLUSION

In the absence of fluid in the RUQ, there are other clinical variables that may allow for the development of a clinical decision rule regarding the need for therapeutic laparotomy.

The halo sign and peripancreatic fluid: useful CT signs of hypovolaemic shock complex in adults

AIM

To report two new, useful computed tomography (CT) signs of the hypovolaemic shock complex (HSC) in adults admitted after blunt abdominal trauma: the halo sign (ring of fluid around a collapsed intra-hepatic inferior vena cava (IVC)), and peripancreatic retroperitoneal fluid.

MATERIALS AND METHODS

CT images of 498 consecutive patients admitted after blunt abdominal trauma were reviewed, of which 27 had CT signs of the HSC. The CT images of these 27 patients were analysed. A control group of 101 patients examined using CT for suspected blunt abdominal trauma who did not have the HSC were chosen for comparison.

RESULTS

The most common features involved the vascular compartment: diminished IVC diameter n = 27 a positive halo sign n = 21 diminished anteroposterior diameter of the aorta n = 13 and abnormal vascular enhancement n = 10. Peripancreatic retroperitoneal fluid in the absence of pancreatic injury, pancreatitis or pancreatic disease was observed in eight patients. Hollow visceral abnormalities included: diffuse increased mucosal enhancement of both the small and large bowel n = 19 diffuse thickening of the small bowel wall n =11 and small bowel dilatation n = 7. Solid visceral abnormalities included both decreased and or increased enhancement. Several concomitant intra- and extra-abdominal injuries were also identified.

CONCLUSION

In the setting of blunt abdominal trauma, early abdominal CT can show diffuse abnormalities due to the HSC, which occasionally may alert clinicians of unsuspected shock. Recognition of these signs as distinguished from injured viscera is important in order to avoid unnecessary laparotomy. Two new signs are described: the halo sign and peripancreatic retroperitoneal fluid.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs.

OBJECTIVES

To assess the efficiency and effectiveness of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CENTRAL, CCMED, publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and congress abstracts were handsearched. Trials were obtained from the Cochrane Injuries Group's trials register. Authors were contacted for further information and individual patient data.

PARTICIPANTS

patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury.

INTERVENTIONS

diagnostic algorithms comprising emergency ultrasonography (US).

CONTROLS

diagnostic algorithms without US ultrasound examinations (e.g. primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]).

OUTCOME MEASURES

mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life.

STUDIES

randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs).

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate.

MAIN RESULTS

We identified two RCTs with US in the experimental arm and another with US in the control group. We also considered two qRCTs. Overall, trials were of moderate methodological quality. Few authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We were able to pool data from two trials comprising 1037 patients for primary endpoint analysis (i.e. mortality). The relative risk in favour of the no-US arm was 1.4 (95% CI 0.94 to 2.08). Because of a lack of details, the meaning of this observation remains unclear. There was a marginal benefit with US-based pathways in reducing CT scans (random-effects RD -0.46; 95% CI -1.00 to 0.13), offset by trials of higher methodological rigour. No differences were observed in DPL and laparotomy rates.

AUTHORS' CONCLUSIONS

There is insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

Emergency department spirometric volume and base deficit delineate risk for torso injury in stable patients

Background

We sought to determine torso injury rates and sensitivities associated with fluid-positive abdominal ultrasound, metabolic acidosis (increased base deficit and lactate), and impaired pulmonary physiology (decreased spirometric volume and PaO₂/FiO₂).

Methods

Level I trauma center prospective pilot and post-pilot study (2000–2001) of stable patients. Increased base deficit was < 0.0 in ethanol-negative and ≤ -3.0 in ethanol-positive patients. Increased lactate was > 2.5 mmol/L in ethanol-negative and ≥ 3.0 mmol/L in ethanol-positive patients. Decreased PaO₂/FiO₂ was < 350 and decreased spirometric volume was < 1.8 L.

Results

Of 215 patients, 66 (30.7%) had a torso injury (abdominal/pelvic injury n = 35 and/or thoracic injury n = 43). Glasgow Coma Scale score was 14.8 ± 0.5 (13–15). Torso injury rates and sensitivities were: abdominal ultrasound negative and normal base deficit, lactate, PaO₂/FiO₂, and spirometric volume – 0.0% & 0.0%; normal base deficit and normal spirometric volume – 4.2% & 4.5%; chest/abdominal soft tissue injury – 37.8% & 47.0%; increased lactate – 39.7% & 47.0%; increased base deficit – 41.3% & 75.8%; increased base deficit and/or decreased spirometric volume – 43.8% & 95.5%; decreased PaO₂/FiO₂ – 48.9% & 33.3%; positive abdominal ultrasound – 62.5% & 7.6%; decreased spirometric volume – 73.4% & 71.2%; increased base deficit and decreased spirometric volume – 82.9% & 51.5%.

Conclusions

Trauma patients with normal base deficit and spirometric volume are unlikely to have a torso injury. Patients with increased base deficit or lactate, decreased spirometric volume, decreased PaO₂/FiO₂, or positive FAST have substantial risk for torso injury. Increased base deficit and/or decreased spirometric volume are highly sensitive for torso injury. Base deficit and spirometric volume values are readily available and increase or decrease the suspicion for torso injury.

Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture

Two patients who presented to the Emergency Department (ED) in shock with severe pelvic fractures were evaluated for intra-abdominal injury with a focused assessment with sonography in trauma (FAST) examination. Free intraperitoneal fluid was identified in the hepato-renal recess of both patients. At laparotomy both patients were found to have extensive uroperitoneum resulting from intraperitoneal bladder rupture and no other intra-abdominal injuries. The source of shock in both cases was ultimately determined to be arterial hemorrhage from pelvic vessels. The utility of FAST examinations in the setting of major pelvic injury is relatively unstudied. Coincident injuries make the evaluation for source of hemorrhage in this subset of patients challenging. This is a report of sonographic intraperitoneal fluid in the setting of major pelvic injury and hemodynamic instability found to be uroperitoneum and not hemoperitoneum.

Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography

The estimated prevalence of liver injury in patients with blunt multiple trauma ranges from 1% to 8%. The objective of this study was to investigate the profile of accompanying liver injury in a cohort of polytraumatized patients who had regularly undergone contrast-enhanced, whole-body helical computed tomography (CT). We enrolled consecutive patients admitted between September 1997 and January 2001 to a level I trauma center. Clinical baseline data were compiled as part of a nationwide trauma registry. Morphologic features were evaluated descriptively, whereas prognostic variables were assessed by logistic regression analysis. We identified 218 patients [149 men, mean age 35 +/- 18 years, mean injury severity score (ISS) 35 +/- 10], 55 of whom had sustained blunt liver trauma [25.2%, 95% confidence interval (CI) 19.6-31.5%]. The prevalence of Moore III to V lesions was 10.1%. There were 99 parenchymal contusions, 15 capsular tears, and 2 liver fractures. Surgery was required in 15 patients and was best predicted by the classification of the American Association for the Surgery of Trauma [odds ratio (OR) 3.91, 95% CI 1.59-9.61]. The mortality rate was 0.0035/person/day. Patients requiring surgical repair had fourfold increased relative odds of case fatality (OR 4.50, 95% CI 1.01-19.96). Sevenfold increased relative odds were observed if liver laceration was considered the leading injury (OR 7.17, 95% CI 1.17-43.97). The prevalence of liver lacerations among multiple-trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT. High-grade hepatic injuries and the need for surgical repair are associated with poorer survival prognosis.

Management of traumatically injured patients in the emergency department observation unit

An EDOU may be an ideal setting for the short-term monitoring and treatment of certain acutely injured patients. The patients choosen for observation, and the diagnostic studies used, will be specific to a particular institution's availability and expertise. Pathways should be developed in conjunction with all services caring for these patients.