Survival Secrets: Unmasking the Factors Predicting Failure of Non-operative Management (NOM) in Splenic Injuries.

BACKGROUND: Splenic injuries are common solid organ injuries resulting from blunt abdominal trauma in road traffic accidents. Very often, splenic injuries can be life-threatening. Earlier, splenic injuries were often dealt with surgical intervention, such as splenectomy. With the recognition of the immunological function of the spleen and possible complications of splenectomy surgery, such as overwhelming post-splenectomy infections (OPSI), there has been a recent trend for non-operative management (NOM). OBJECTIVE: To study the variables predicting failure of NOM in blunt abdominal trauma patients with splenic injury. METHODS: This is a retrospective study that includes 235 patients who presented to the Safdarjung Hospital emergency room (New Delhi, India) with blunt trauma abdomen and splenic injuries with or without associated injuries between January 2019 and December 2021. The data was entered in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Categorical variables were expressed as frequencies and percentages. Pearson's chi-square test of association was used to determine if there is a relationship between two variables. A p-value of <0.05 was considered statistically significant. RESULTS: Out of 235 patients with blunt abdominal trauma and splenic injuries, 82 were hemodynamically unstable despite resuscitation and were taken up for emergency laparotomy. The remaining 153 patients, who were either hemodynamically stable or stabilized after adequate resuscitation, were managed on the lines of NOM. The number of patients with splenic injury in AAST grades 1, 2, 3, 4, and 5 was 36, 50, 40, 24, and three, respectively. Out of 153 patients, 130 (85%) were successfully managed by NOM, while eight (5%) had to discontinue NOM as they required surgical intervention. The failure of NOM (fNOM) is seen mostly with grade 5 injuries (2/2, 100%, p<0.01), followed by grade 4 (4/20, 20%) and grade 3 (2/37, 5.7%). The mean age in fNOM was 58.3 years, as compared to 42.2 years in the success of NOM (sNOM). All eight patients had multiple concomitant injuries, with femur fracture being the most common association in up to six patients (p<0.01), followed by liver injury in four patients. There were 15 mortalities, irrespective of AAST severity grade. All of these patients had associated concomitant injuries, with intracranial bleeding (n = 10, 32%, p<0.01) being the most common association, followed by femur fracture (n = 6, 20%) and liver injury (n = 5, 16%). Also, the cause of death was unrelated to splenic trauma (p = 0.67), with pulmonary embolism (n = 6, 40%, p<0.01) being the most common cause, followed by brain stem herniation (n = 5, 34%). CONCLUSION: Non-operative management is a safe and efficient method for treating patients with splenic injuries who are hemodynamically stable or stabilized. The factors associated with fNOM include elderly age, a higher American Association for the Surgery of Trauma (AAST) grade of splenic injury, and associated concomitant injuries. Femur fracture was the most common concomitant injury present in cases where NOM failed, followed by liver injury. The presence of intracranial bleeds in these patients was a common association with mortality, irrespective of the grade of splenic injury.

Access, Safety, and Barriers in Adoption of Emergency Laparoscopy Surgery for Trauma Patients in a Low-Resource Setting.

Introduction This study analyzes barriers to the adoption of emergency laparoscopy (EL), safety, and accessibility in a low-resource setting of a low- and middle-income country (LMIC). Methods In this prospective observational study, patients with blunt trauma abdomen (BTA) who required exploration were included and divided into two groups-open exploration (open surgery [OSx]) and laparoscopic exploration (laparoscopic surgery [LSx]). Data were compiled and analyzed. Results Out of 94 BTA patients, 66 required exploration, and the rest were managed conservatively. Out of 66 patients, 42 were in OSx and 24 were in LSx, reason for not selecting LSx was the surgeon's preference for OSx in 26 patients and the lack of availability of operation theater (OT) slots in 16 patients. LSx even after indication was less likely if patients had preoperative evidence of perforation peritonitis. Conclusion Lack of resources (OT availability and trained personnel) are barriers to the adoption of emergency LSx in low-resource settings.

Triple Diversion Technique in Complete Duodenal Transaction Following Blunt Trauma Abdomen: A Time-Tested Method in a Very Rare Injury.

Duodenal injury following blunt abdominal trauma is extremely rare in children and many times, it has delayed presentation, leading to increased morbidity and mortality. A patient with complete duodenal transaction is a surgical challenge and management involves the time of presentation and extent of visceral damage. A 10-year-old boy was brought with features of bowel perforation after road traffic accident and underwent emergency laparotomy which revealed complete transaction of duodenum at D1 and D2 and pyloroduodenal junction extending toward lesser curvature. Primary closure of pyloroduodenal junction and D1-D2 was done with omental patch along with triple tube decompression (cholecystostomy, gastrostomy, and jejunostomy). The patient had an uneventful recovery. Primary closure of disturbed ends with triple diversion is a safe approach in young children with complete duodenal transaction in absence of gross peritoneal contamination and early presentation.

Delayed Presentation of Post-traumatic Multiorgan Left Diaphragmatic Hernia: A Case Report and Literature Review.

Post-traumatic diaphragmatic injuries can present as diaphragmatic hernia with herniation of abdominal viscera into the thoracic cavity. It is challenging for trauma surgeons to identify the delayed presentation of post-traumatic diaphragmatic injuries which require a high index of suspicion in patients who are at risk. We report a rare case of delayed diagnosis and management of post-traumatic diaphragmatic hernia in a polytrauma patient with a concise review of the literature. The patient presented after two years of post-traumatic thoracoabdominal injury due to a road traffic accident with breathing difficulty. On investigations, it was a large diaphragmatic hernia with herniation of abdominal contents into the left thoracic cavity. Laparotomy was performed with a reduction of abdominal contents from the left side of the chest along with mesh repair of the large diaphragmatic hernia. Postoperatively, the patient recovered well. The literature suggests that there should be a high level of suspicion of diaphragmatic injuries, especially when dealing with thoracoabdominal trauma or polytrauma patients. Post-traumatic diaphragmatic injuries, though rare, can lead to high morbidity or mortality if not treated on time.

Spectrum of hollow visceral injury due to isolated blunt trauma abdomen presented to a tertiary care trauma hospital of Pakistan.

OBJECTIVE: To evaluate the spectrum of isolated hollow visceral perforations in patients presenting with abdominal blunt trauma. METHODS: The observational, analytical, cross-sectional study was conducted at the surgical ward of Mayo Hospital, Lahore, Pakistan from July 1, 2020, to June 31, 2021, and comprised patients who presented in the emergency department after blunt trauma to abdomen without any open wound. Findings of hollow visceral injury were confirmed on exploration laparotomy. Data was analysed using SPSS 26. RESULTS: Of the 216 patients, 173(80.9%) were male and 43(19.9%) were female. The overall mean age was 42±9.7 years. Most of the blunt trauma abdomen cases were caused by motor vehicle accidents 59(27.3%). The most common hollow viscus affected was jejunum 42(19.4%), followed by transverse colon 29(13.4%). The most common type of injury observed was single complete disruption of hollow viscus 74(34.2%). CONCLUSIONS: The most common hollow organ affected by blunt trauma to the abdomen was jejunum, followed by transverse colon, and motor vehicle accidents were the major cause of these injuries.

Evaluation of ISS, RTS, CASS and TRISS scoring systems for predicting outcomes of blunt trauma abdomen.

PURPOSE: Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation. The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen. MATERIALS AND METHODS: A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative complications and mortality. RESULTS: The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative complications. All scores except CASS significantly predicted mortality. CONCLUSIONS: Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and TRISS predicted mortality with good accuracy but the superiority of one score over the other couldn't be proved.

Perforation of the Meckel's Diverticulum Following Blunt Trauma to the Abdomen.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Most of the patients are asymptomatic and very few develop symptoms. Hemorrhage, obstruction, perforation, and inflammation are the complications that can occur in an MD. Even though hollow viscus perforation is common, perforation of the MD following blunt abdominal trauma is rare. We report a case of perforation of the MD in a 60-year-old man following a blunt abdominal trauma due to a fall from a bike, which was diagnosed promptly and managed successfully by timely operative intervention.

Missed pancreatic injury in patients undergoing conservative management of blunt abdominal trauma: Causes, sequelae and management.

OBJECTIVES: Pancreas is a less commonly injured organ in blunt abdominal trauma. This study aimed to analyze the management and outcomes of patients in whom the pancreatic injury was missed during the initial evaluation of blunt abdominal trauma. MATERIAL AND METHODS: We retrospectively (2009-2019) analyzed the details and outcome of patients who underwent conservative management of blunt abdominal trauma, where the diagnosis of pancreatic injury was missed for at least 72 hours following trauma. RESULTS: A total of 31 patients with missed pancreatic injury were identified. All patients were hemodynamically stable following trauma and most (21) were initially assessed only by an ultrasound. A delayed diagnosis of pancreatic injury was made at a mean of 28 (4 to 60) days after trauma when patients developed abdominal pain (31), distension (18), fever (10) or vomiting (8). On repeat imaging, 18 (58.1%) patients had high grade pancreatic injuries including complete transection or pancreatic duct injury. Seven (22.5%) patients were managed conservatively, seventeen (54.8%) underwent percutaneous drainage of intra-abdominal collections, seven (22.5%) underwent endoscopic or surgical drainage procedure for symptomatic pseudocyst. Eleven (35.4%) patients needed readmissions to manage recurrent pancreatitis, intra-abdominal abscess and pancreatic fistula. Three patients required pancreatic duct stenting for pancreatic fistula. There was no mortality. CONCLUSION: Pancreatic injury may be missed in patients who remain hemodynamically stable with minimal clinical symptoms after abdominal trauma, especially if screened only by an ultrasound. In our series, there was significant morbidity of missed pancreatic injury.

Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial.

BACKGROUND: Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial. MATERIALS AND METHODS: After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge. RESULTS: Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits. CONCLUSION: Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.

Post-traumatic diaphragmatic hernia: Diagnostic dilemma in primary care.

Diaphragmatic hernia (DH) is a common condition following blunt trauma to upper abdomen and is also a commonly missed diagnosis. Its early anticipation in post-traumatic setting is very important to avoid any further life-threatening sequelae. X-ray chest with a nasogastric tube is a simpler way to diagnose this condition. CT scan is a gold standard tool to confirm diagnosis. Due to wide availability of ultrasound (US) in emergency room (ER), this tool will decide the correct way of further evaluation avoiding unnecessary delays in management. We present a case of a diaphragmatic hernia followed by blunt injury abdomen with multiple herniated abdominal contents successfully managed by early intervention.

Delayed Presentation of Complete Ileal Transection Following Blunt Trauma Abdomen: A Condition to Cognize.

Isolated small bowel perforation is a rare presentation of blunt abdominal trauma, and most cases present immediately following the trauma. Delayed presentation of such cases beyond one week of trauma is extremely rare, and various pathophysiological mechanisms were described for the same. We present a 20-year-old male patient who sustained blunt abdominal and pelvic trauma, underwent open reduction and internal fixation for right acetabular fracture, and later developed features of acute peritonitis after one month. On laparotomy, complete terminal ileal transection was found and an ileostomy was done. Delayed perforation of the intestine following trauma occurs due to ischemic necrosis, either through direct trauma to the intestinal wall or indirectly by injury to the mesenteric vessels. Direct trauma to the bowel can result in large hematomas on the bowel wall, which can later perforate due to ischemia. Surgeons should be aware of this rare presentation as the management is challenging and it poses significant medico-legal sequel. Close monitoring of the patient's vitals and examination for the development of abdominal signs along with repeat imaging at the onset of abdominal signs are cornerstones for successful management of these patients.

Emergency Focused Assessment with Sonography in Blunt Trauma Abdomen.

BACKGROUND: Focused assessment with sonography in trauma (FAST) being a rapid noninvasive examination is used primarily to evaluate for the evidence of traumatic free fluid suggestive of injury in the peritoneal, pericardial, and pleural cavities. It is widely recognized as a mainstream emergency skill in the management of trauma. AIM: The aim of the study is to evaluate the accuracy of FAST in patients presenting with blunt abdominal trauma. METHODS: Data were collected prospectively from FAST scans conducted in blunt trauma abdomen (BTA) patients. Positive and negative FAST scans were confirmed either with contrast-enhanced computed tomography (CECT) abdomen or with exploratory laparotomy, thus dividing it further into four groups, i.e., true-positive, false-positive, true-negative, and false-negative scans. After collecting the data, accuracy of FAST was calculated. RESULTS: In this study, a total of 104 patients were included. The mean age was 38.17 years. Most common cause of BTA was road traffic accident. The overall sensitivity, specificity, and accuracy of FAST were 69.8%, 92.1%, and 80.8%, respectively. CONCLUSION: This study showed that FAST is of paramount importance in patients who are hemodynamically unstable as it has a high positive predictive value. However, a FAST-negative result should always be confirmed by other modalities.

Traumatic Rupture of Jejunal Burkitt's Lymphoma with Intestinal Transection.

Burkitt's lymphoma (BL) is an aggressive non-Hodgkin lymphoma.[1] BL of the small intestine, presenting as a surgical emergency needing emergency laparotomy, is an uncommon presentation of this tumor. We present a case of BL presenting as perforation peritonitis after blunt trauma abdomen.

Handlebar Hernia with Triple Herniation and Perforation: A Case Report and Literature Review.

Blunt trauma abdomen is a very common entity but traumatic abdominal wall hernia is not that common. Herniation through abdominal wall usually occurs following trauma with seat belt, motor cycle, bicycle handle bar etc. Handlebar hernia is a less known variety of traumatic abdominal wall hernia as a consequence of injury with handlebar of a bicycle. It is difficult to diagnose and one should have high index of suspicion. Management in traumatic abdominal wall hernia is individualized based on various factors. We herein present an interesting case of a14-year-old boy, who sustained blunt trauma abdomen from bicycle handlebar leading to triple herniation and perforation of the small bowel and hematoma of the mesentery. Patient was resuscitated and operated with a favorable outcome. Blunt trauma abdomen is a very common and the possibility of traumatic abdominal wall hernia should always be borne in mind.

Pancreatic injury in children: a case report and review of the literature.

BACKGROUND: Trauma is the main cause of morbidity and mortality in the pediatric population. Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury, although uncommon (2 to 9%), is the fourth most common solid organ injury. Unlike other solid organ injuries, pancreatic trauma may be subtle and difficult to diagnose. Computed tomography currently is the imaging modality of choice. As the incidence of pancreatic injury in children sustaining blunt abdominal trauma is low, management remains a challenge. CASE PRESENTATION: We present a 7-year-old Bahraini boy who sustained blunt trauma to his abdomen. He presented with abdominal pain and vomiting. His examination revealed abdominal distension and an epigastric bruise. Contrast-enhanced computed tomography reported grade III liver injury, grade I bilateral renal injury, a suspicion of splenic injury, and a grade III to IV pancreatic injury. He was admitted to Pediatric Intensive Care Unit and was treated conservatively. Because he was stable, he was discharged to the surgical ward at day 3. At day 18 he developed a pancreatic pseudocyst that was aspirated and recurred at day 25 when a pigtail catheter was inserted. He was kept on total parenteral nutrition through a peripherally inserted central catheter. The pigtail catheter was removed on day 36 and a low fat diet was started by day 44. He was discharged home at day 55 in good health. Out-patient follow-up and serial abdominal ultrasound showed resolution of the cyst and normalization of blood tests. CONCLUSION: Non-operative management of pancreatic injury is effective and safe in hemodynamically stable patients with no other indication for surgery.

Management and Outcome of Patients with Pancreatic Trauma.

INTRODUCTION: Pancreatic trauma is a rare entity occurring in 0.2% of patients with blunt trauma abdomen. Once the diagnosis is made, the management of patients is dependent on multiple variables. Conservative management, suture repair, drainage, and resection have been utilized with varying degree of success. This study is aimed to evaluate the management of patients with pancreatic trauma. MATERIALS AND METHODS: This was a prospective study done in the Department of Surgery in Dayanand Medical College and Hospital where forty hemodynamically stable patients diagnosed to have pancreatic trauma on contrast-enhanced computed tomography abdomen were included in the study. RESULTS: Out of forty patients taken in this study, 38 were male and two were female with age ranging from 3 to 50 years. Road traffic accident was the most common cause of pancreatic injury. Pancreatic injuries were graded according to the American Association for Surgery in Trauma scale. Twelve patients had Grade I and II injuries. Grade III was the most common injury occurring in 14 patients. Twenty-four patients underwent surgical management. Mortality rate was 45% and it was in direct correlation with the severity of injury. CONCLUSION: Grade I and II pancreatic injury can be managed conservatively depending upon the hemodynamic status of the patient. Grade III and IV injuries have a better prognosis if managed surgically.

Arterial ammonia levels: Prognostic marker in traumatic hemorrhage.

BACKGROUND: In blunt trauma, extent of hemorrhage cannot be determined by physical examination, and vital signs may also not give clear picture in all the patients, especially young healthy ones. Hemorrhagic shock has been reported to increase blood ammonia levels. Arterial ammonia was analyzed in blunt trauma abdomen patients and correlated with shock index (SI). Its predictive value was determined for timely decision of intervention. MATERIALS AND METHODS: Hundred blunt trauma abdomen patients presented in the emergency ward of tertiary care hospital were included in the study. Group I comprised 62 patients requiring either blood transfusion ≥2 units and/or intervention to control bleeding within 24 h following admission. Group II had 38 patients: Not requiring transfusion/intervention during hospital stay. Arterial blood sample was taken immediately after admission; ammonia was analyzed within 20 min of sampling on Cobas 6000 (Roche). SI was calculated. Predictive value of ammonia was determined using receiver operating characteristic curve. RESULTS: Ammonia levels and SI were significantly (P < 0.001) higher in Group I compared to Group II patients (68.55 ± 14.36 umol/L vs. 37.55 ± 7.41 umol/L and 1.28 ± 0.5 vs. 0.74 ± 0.12, respectively). Significantly higher number of patients in Group I (88.7% vs. 13%) had SI > 0.9. Ammonia levels were significantly higher in patients with complications and in those expired. CONCLUSIONS: Ammonia levels were significantly higher in patients requiring blood transfusion/intervention in 24 h of admission. The best cutoff value to maximize sensitivity and specificity was ammonia >58.85 µmol/L. Ammonia estimation at admission can be clinically significant indicator of traumatic hemorrhage needing intervention.

Asymptomatic Traumatic Hepatothorax, Symptomatic Gall Stone Disease - A Rare Coincidence.

Traumatic diaphragmatic hernia rarely affects right side due to protective effect of liver. In adult it is mainly caused by blunt abdominal trauma. Acute presentations are often life threatening and usually clinch the diagnosis early. It may remain asymptomatic for many years unless being detected incidentally during investigations for some unrelated reason or getting complicated by some pathology of herniated viscera. High degree of suspicion is required to detect this delayed presentation particularly in a post-trauma patient as this condition may require modifications in management. We report a case of acute cholecystitis which revealed a rare association of traumatic right diaphragmatic hernia and hepatothorax.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales.

INTRODUCTION: Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown. METHODS: We conducted a population based analysis of 2012-2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded. RESULTS: During 2012-2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type. CONCLUSIONS: This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals.