Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma.

OBJECTIVE: To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts. BACKGROUND: FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan. METHODS: Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management. RESULTS: A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%. CONCLUSIONS: FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

A prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy is associated with high survivability and low rates of fecal diversion.

OBJECTIVE: This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization. BACKGROUND: Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial. METHODS: We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality. RESULTS: Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%). CONCLUSIONS: Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.

Role of CT colonography in symptomatic assessment, surveillance and screening.

INTRODUCTION: When 'whole colonic imaging' is indicated, clinicians must decide between optical colonoscopy, barium enema and CT colonography (CTC). CTC is a relatively new technique which has become increasingly accessible in the UK over the past 5 years. As radiologists have gained experience and scanning parameters have standardised, there have been substantial improvements in both the accuracy and safety of CTC. METHODS: We review evidence from observational studies and randomised trials, and draw on expert opinion, to provide a comprehensive discussion of the current role of CTC in both symptomatic and asymptomatic individuals. CONCLUSIONS: The emergence of CTC could soon entirely obviate the need for barium enema. CTC now has a complementary role alongside colonoscopy in symptomatic patients and a possible future role in colorectal cancer screening in the UK.

Intraoperative blood salvage in penetrating abdominal trauma: a randomised, controlled trial.

BACKGROUND: Blood is a scarce and costly resource. Transfusion is often required after major trauma but blood may not be readily available, and concerns remain over the potential adverse consequences of allogeneic blood transfusion. Intraoperative blood salvage (IBS) is used extensively after blunt abdominal trauma, but when blood is contaminated by enteric contents its use has been considered contraindicated. METHODS: This was a randomised, controlled trial conducted with Ethical Review Board approval in an inner city trauma unit. Patients with penetrating torso injury requiring a laparotomy and who had exhibited hypotension either pre-hospital or on arrival and in whom there was considered to be significant blood loss were randomly assigned to 2 groups. The control group was given allogeneic blood transfusion at the discretion of the attending medical staff. The cell save (CS) group underwent IBS with transfusion of both allogeneic and autologous blood. All patients received prophylactic antibiotics. The primary outcome was exposure to allogeneic blood up to the first 24 hours postinjury. RESULTS: Twenty-three patients were entered into the control group and 21 into the CS group. The groups were equivalent in demographic details, injury patterns and injury severity. The mean volume of salvaged blood re-infused in the CS group was 1,493 ml (range 0-2,690 ml). The mean number of units of allogeneic blood transfused in the first 24 hours in the control group was 11.17 compared to 6.47 in the CS group (P=0.008). Enteric injury had been sustained in 17/23 (75%) of the control group and 18/21 (85%) of the CS group (P=NS). Survival in the control group was 8/23 (35%) compared to 7/21 (33.3%) in the CS arm (P=NS). Patients with documented postoperative sepsis were significantly more likely to die compared to those without sepsis (P=0.04); however, those patients in the CS arm were no more likely to develop sepsis compared to those who received allogeneic blood alone. CONCLUSION: In this randomised, controlled trial for patients with penetrating abdominal injuries, IBS led to a significant reduction in allogeneic blood usage with no discernable effect on rates of postoperative infection or mortality.

Minimally invasive surgery in trauma: technology looking for an application.

BACKGROUND: Minimally invasive surgery has achieved pre-eminence for certain operations in general surgery over the last two decades, as the reduction in surgical insult has produced faster recovery with enhanced patient satisfaction and favourable health economics. Minimally invasive techniques have been less enthusiastically adopted by the trauma surgical community, despite some evidence of efficacy for nearly 40 years. METHODS: The literature on minimally invasive techniques in trauma was reviewed. RESULTS AND CONCLUSIONS: To date, minimally invasive surgery has played only a small role in trauma surgery. As clearer indications emerge and technology improves, surgeons should be encouraged to incorporate laparoscopy and video-assisted thoracoscopy (VATS) into their protocols and gain familiarity and expertise with their use.

The malignant epidemic--changing patterns of trauma.

OBJECTIVES AND SETTING: The worldwide burden of trauma is increasing, but is unequally distributed between nations. Trauma in South Africa targets the young and productive in society and imposes a major burden on the health infrastructure. We undertook a review of injury trends among patients attending the Johannesburg Hospital Trauma Unit (JHTU) and the Johannesburg Medicolegal Laboratory (JMLL) in order to document the evolution in patterns of trauma over a 17-year period of great social and political change. DESIGN, SUBJECTS AND OUTCOME MEASURES: This was a retrospective review of all priority-one patients attending the JHTU from January 1985 to December 2001. The JHTU trauma database was used to retrieve information on patient demographics, wound mechanism and injury severity. The database at the JMLL, maintained since 1996, was examined and the manner and place of death were analysed. RESULTS: The JHTU has seen an unprecedented increase in the number of trauma patients over the last 17 years. The patients' demographic profiles have altered and injury is now predominantly due to interpersonal violence. Unnatural deaths examined at the JMLL have declined by 19% since 1996; however, the proportion of those deaths due to gunshot wounds has risen. CONCLUSIONS: The social and political changes in South Africa in recent years have led to changes in the injury profiles seen at the JHTU. Part of the increase can be explained by desegregation and a reduction in the provision of local hospital services; however, the impact of urbanisation within South Africa, cross-border migration and the high incidence of substance abuse are recognised. Evidence supports the implementation of legislative, environmental, social and behavioural interventions to contain and reduce the incidence and impact of violence and injury. Concerted efforts must be made at all levels to curb South Africa's trauma epidemic.