PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study.

BACKGROUND: The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma. METHODS: For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury). FINDINGS: 7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery. INTERPRETATION: The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma. FUNDING: The Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The prevalence of early contained vascular injury of spleen.

Contained vascular injuries (CVI) of spleen include pseudoaneurysms (PSA) and arterio-venous fistulae (AV-fistulae), and their reported prevalence varies. Our purpose was to assess the prevalence of early splenic CVI seen on admission CT in patients with splenic trauma admitted to a single level 1 trauma center in 2013-2021, and its detection in different CT protocols. A retrospective, single-center longitudinal cohort study. Nine-year data (2013-2021) of all patients with suspected or manifest abdominal trauma were retrieved. All patients, > 15 years with an ICD code for splenic trauma (S36.0XX) were included. CT and angiographic examinations were identified. Reports and images were reviewed. Splenic CVI CT criterion was a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Number of CVIs and treatment was based on medical records and/or available angioembolization data. Of 2805 patients with abdominal trauma, 313 patients (313/2805; 11.2%) fulfilled the study entry criteria. 256 patients (256/313; 81.8%) had a CT examination. Sixteen patients had splenectomy before CT, and the final study group included 240 patients (240/313; 76.7%). Median New Injury Severity Score (NISS) was 27 and 87.5% of patients had NISS > 15. Splenic CVI was found in 20 patients, which yields a prevalence of 8.3% (20/240; 95% CI 5.2-12.6%). In those cases with both late arterial and venous phase images available, CVI was seen in 14.5% of cases (18/124, 95% CI 8.6-22.0%). None of the patients with CVI died within 30 days of the injury. The prevalence of early splenic CVI in patients with a splenic trauma was 8.3-14.5% (95% CI 5.2-22.0%). Our data suggests that both arterial and venous phase are needed for CT diagnosis. The 30-day outcome in terms of mortality was good.

Repeat imaging increases detection of delayed pseudoaneurysms in patients with high-grade solid organ injury following abdominal trauma.

BACKGROUND: Nonoperative management of abdominal trauma can be complicated by the development of delayed pseudoaneurysms. Early intervention reduces the risk of rupture and decreases mortality. The objective of this study is to determine the utility of repeat computed tomography (CT) imaging in detecting delayed pseudoaneurysms in patients with abdominal solid organ injury. METHODS: A retrospective cohort study reviewing Montreal General Hospital registry between 2013 and 2019. Patients with The American Association for the Surgery of Trauma (AAST) grade 3 or higher solid organ injury following abdominal trauma were identified. A chart review was completed, and demographics, mechanism of injury, Injury Severity Score (ISS) score, AAST injury grade, CT imaging reports, and interventions were collected. Descriptive analysis and logistic regression model were completed. RESULTS: We identified 195 patients with 214 solid organ injuries. The average age was 38.6 years; 28.2% were female, 90.3% had blunt trauma, and 9.7% had penetrating trauma. The average ISS score was 25.4 (SD 12.8) in patients without pseudoaneurysms and 19.5 (SD 8.6) in those who subsequently developed pseudoaneurysms. The initial management was nonoperative in 57.0% of the patients; 30.4% had initial angioembolization, and 12.6% went to the operating room. Of the cohort, 11.7% had pseudoaneurysms detected on repeat CT imaging within 72 h. Grade 3 represents the majority of the injuries at 68.0%. The majority of these patients underwent angioembolization. CONCLUSIONS: In patients with high-grade solid organ injury following abdominal trauma, repeat CT imaging within 72 h enabled the detection of delayed development of pseudoaneurysms in 11.7% of injuries. The majority of the patients were asymptomatic.

Hollow viscus injury due to blunt abdominal trauma: a tertiary trauma center experience.

BACKGROUND: Hollow viscus injuries (HVIs) present less frequently than solid organ injuries in patients with blunt abdominal trauma, potentially leading to significantly increased morbidity and mortality rates. Modern imaging equipment, confidently used for diagnosing solid organ injuries, may fail to identify hollow viscus injuries. In this study, we aim to present our tertiary center's experience with this entity. METHODS: Patients treated in our clinic from April 2011 to December 2021 for hollow viscus injury following blunt abdominal trauma were included in this study. We recorded and retrospectively evaluated patients' demographic data, injury site and mechanism, preoperative and perioperative findings, and mortality rates in a prospective database. RESULTS: Of the 607 blunt trauma patients, 35 (5.8%) had hollow viscus injuries, with 88.6% being male. Motor vehicle accidents were the leading cause of injury (80%). The mean duration between admission and surgical exploration was 26±21.2 hours. The mean Injury Severity Score was 21.8±13.6. Rigidity was the most frequent clinical finding (60%). The jejunum and ileum were the most frequently injured organs (54.1%). Mortality and morbidity rates were 11.4% and 17.1%, respectively. CONCLUSION: Nondeclining white blood cell (WBC) counts within 24 hours of admission, alongside any physical or radiological finding indicating an HVI, should prompt immediate surgical exploration.

Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine.

PURPOSE OF REVIEW: There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS: POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY: POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury.

PURPOSE: Blunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI. METHODS: We conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI. RESULTS: One hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67-0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64-0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75-0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55). CONCLUSION: Radiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist's impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Evaluation of Focused Assessment With Sonography for Trauma Completeness of Children in the Clinical Setting.

OBJECTIVES: We evaluated the completeness of real-world Focused Assessment with Sonography for Trauma (FAST) in children after blunt abdominal trauma by benchmarking against established expert guidelines. METHODS: We conducted a retrospective cohort study, analyzing a random sample of FASTs from two urban pediatric emergency departments. Two experts reviewed and labeled all FASTs for completeness using a predefined guideline of 5 anatomic views and 30 landmarks. We compared frequencies of views and landmarks as medians with interquartile ranges. RESULTS: We analyzed 200 FASTs, consisting of 1636 video clips, performed by 31 clinicians representing 198 children with a median age of 10 years (IQR 5,14). Over half of FASTs (52%) had all 5 views. The right upper quadrant view was most commonly visualized (96.5%), and suprapubic sagittal was least (65%). None of the FASTs included all 30 landmarks, ranging from 0 to 28 and median of 19 (IQR 15,23). The least visualized landmark of the right and left upper quadrants was caudal liver edge (60%) and splenic tip (64%), respectively. In the pericardial view, it was left atrium (45%). In both transverse and sagittal pelvic views, retro-uterine space was least visualized in girls, 21 and 29% respectively. CONCLUSIONS: In our study, most FAST views and landmarks were visualized. However, the pelvic sagittal view was the least frequently visualized view, and caudal liver edge was the least visualized landmark. Future research should evaluate if variability in visualizing FAST views and landmarks correlates with inconsistencies in diagnostic test performance.

Validation of the predictive model for operative intervention after blunt abdominal trauma in children with equivocal computed tomography findings: a multi-institutional study.

BACKGROUND: We recently developed a preliminary predictive model identifying clinical and radiologic factors associated with the need for surgery following blunt abdominal trauma (BAT) in children. Our aim in this study was to further validate the factors in this predictive model in a multi-institutional study. METHODS: A retrospective chart review of pediatric patients from five pediatric trauma centers who experienced BAT between 2011 and 2020 was performed. Patients under 18 years of age who had BAT and computed tomography (CT) abdomen imaging were included. Children with evidence of pneumoperitoneum, and hemodynamic instability were excluded. Fisher's exact test was used for statistical analysis of the association between the following risk factors and need for laparotomy: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture (TLF), presence of free fluid (FF), presence of solid organ injury (SOI). A predictive logistic regression model was then estimated employing these factors. FINDINGS: Seven hundred thirty-four patients were identified in this multi-institutional dataset with BAT and abdominal CT imaging, and 726 were included. Of those, 59 underwent surgical intervention (8.8%). Univariate analysis of association between the studied factors and need for surgical management showed that the presence of TLF (p < 0.01), APT (p < 0.01), FF (p < 0.01), and SOI (p < 0.01) were significantly associated. A predictive model was created using the 5 factors resulting in an area under the curve (AUC) of 0.80. For the motor vehicle collisions (MVC) group, only FF, SOI, and TLF are significantly associated with the need for surgical intervention. The AUC for the MVC group was 0.87. CONCLUSIONS: A clinical and radiologic prediction rule was validated using a large multi-institutional dataset of pediatric BAT patients, demonstrating a high degree of accuracy in identifying children who underwent surgery. FF, SOI, and TLF are the most important factors associated with the need for surgical intervention. LEVEL OF EVIDENCE: Level III.

Pediatric Traumatic Lumbar Hernias and Associated Injuries: A Case Series.

OBJECTIVE: Traumatic lumbar hernias are a rare entity mostly seen with high-impact, blunt abdominal trauma. This injury occurs when there is disruption of the posterior musculature along with bony structures, allowing for herniation of abdominal contents. There are minimal cases of this entity reported in adults, but even fewer in the pediatric population. METHODS: We describe 3 cases of traumatic lumbar hernia at our institution as well as provide a review of the literature to elucidate the most common mechanisms, severity of injury, and associated injuries. RESULTS: Traumatic lumbar hernia is most commonly seen in restrained passengers involved in motor vehicle collisions. A majority of cases are diagnosed using computed tomography imaging and less frequently during primary surgical exploration. The most common associated injuries were mesenteric and bowel injuries, followed by spinal and chest trauma. Traumatic lumbar hernia often leads to prolonged hospital stays and increased need for posthospital rehabilitation because of associated traumatic comorbidities. CONCLUSIONS: Traumatic lumbar hernia is a rare entity in children, and early suspicion and identification of associated injuries is necessary in the management of these patients.

Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa.

INTRODUCTION: The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade. MATERIALS AND METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022. RESULTS: Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed. CONCLUSIONS: Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.

Should surgeon-performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases?

BACKGROUND: The diagnostic performance of multiple tests for detecting the presence of a main pancreatic duct injury remains poor. Given the central importance of main duct integrity for both subsequent treatment algorithms and patient outcomes, poor test reliability is problematic. The primary aim was to evaluate the comparative test performance of computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative ultrasound (IOUS) for detecting main pancreatic duct injuries. METHODS: All severely injured adult patients with pancreatic trauma (2010-2021) were evaluated. Patients who received an IOUS pancreas-focused evaluation, with Grades III, IV, and V injuries (main duct injury) were compared with those with Grade I and Grade II trauma (no main duct injury). Test performances were analyzed. RESULTS: Of 248 pancreatic injuries, 74 underwent an IOUS. The additional mix of diagnostic studies (CT, MRCP, ERCP) was variable across grade of injury. Of these 74 IOUS cases for pancreatic injuries, 48 (64.8%) were confirmed as Grades III, IV, or V main duct injuries. The patients were predominantly young (median age = 33, IQR:21-45) blunt injured (70%) males (74%) with severe injury demographics (injury severity score = 28, (IQR:19-36); 30% hemodynamic instability; 91% synchronous intra-abdominal injuries). Thirty-five percent of patients required damage-control surgery. Patient outcomes included a median 13-day hospital length of stay and 1% mortality rate. Test performance was variable across groups (CT = 58% sensitive/77% specific; MRCP = 71% sensitive/100% specific; ERCP = 100% sensitive; IOUS = 98% sensitive/100% specific). CONCLUSION: Intraoperative ultrasound is a highly sensitive and specific test for detecting main pancreatic duct injuries. This technology is simple to learn, readily available, and should be considered in patients who require concurrent non-damage-control abdominal operations. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study.

BACKGROUND: Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS). METHODS: A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance. RESULTS: The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively. CONCLUSION: The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Paradigms in trauma laparoscopy for anterior abdominal stab wounds: A scoping review.

INTRODUCTION: Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW. METHODOLOGY: Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure. RESULTS: Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury. CONCLUSION: This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/hospital experience, patient factors, and resource availability.

Echinococcal Cyst Rupture in a 3-Year-Old Boy With a Minor Abdominal Trauma Identified by a Point-of-Care Ultrasound E-Fast Examination: A Case Report and Literature Review.

ABSTRACT: Point-of-care ultrasound is now widely used in adult and pediatric emergency departments as part of the rapid evaluation and treatment of patients in urgent care settings. It has been shown to be a powerful tool to aid in decision making in both trauma and acute medical situations. We describe a case of a 3-year-old boy who presented with abdominal pain and fever after a minor abdominal trauma, highlighting the use of point-of-care ultrasound to arrive at the diagnosis of a ruptured echinococcal cyst.

Omental infarction in an overweight child: conservative treatment is a safe approach.

A previously healthy but overweight (body mass index (BMI) of 24.4) adolescent boy presented with fever and significant right-sided abdominal pain. An abdominal ultrasound scan revealed an omental infarction (OI), which was treated conservatively. OI has been described in overweight teenage children with abdominal trauma but can be missed if not considered. A missed diagnosis could result in an unnecessary laparotomy or laparoscopic surgery. Although CT is the gold standard for diagnosis, ultrasonography is an effective approach to identifying OI in children. The benefits of early diagnosis of OI by abdominal ultrasound include a shorter hospital stay and a reduction in unnecessary investigations and surgery.

Seat belt syndrome with caecal perforation and Chance fracture in an adolescent.

Seat belt syndrome describes a combination of injuries a person restrained by a seat belt may have after a high-velocity motor vehicle crash. A seat belt-shaped bruise may be present across the torso. A Chance fracture is a horizontal vertebral fracture, resulting from spinal hyperflexion, and in disruption of the three columns of the vertebral bodies. Its association with intra-abdominal injury is rare in children. A male, in early adolescence, was involved in a high-energy car crash. A total-body CT scan highlighted lacerations of the anterolateral abdominal wall and an acute L4 Chance fracture. Another CT scan performed because of clinical deterioration, showed cecal perforation, caused by a mesenteric tear and non-displaced fracture of the left sacral ala. He underwent a right hemicolectomy with ileocolic anastomosis and protective ileostomy and was immobilised in a body jacket orthosis for 3 months. The ileostomy was closed 3 months later. At 2-year follow-up, he is well.

Blunt abdominal trauma: watch and wait.

PURPOSE OF REVIEW: This review examines recent advancements in nonoperative management (NOM) of hemodynamically stable blunt abdominal trauma, focusing on expanding patient selection for observation-first strategies, particularly for high-grade solid organ injuries. RECENT FINDINGS: Advances include a more deliberate nonoperative approach, allowing for broader patient inclusion in diagnostic and interventional angiography. Strict clinical monitoring and appropriate follow-up strategies are crucial to identify early signs of clinical progression and complications. Repeated contrast-enhanced CT (CECT) scan can be used for close observation of high-risk injuries, while the repetition of CECTs may be avoided for lower-risk cases, such as specific high-grade kidney injuries. The role of contrast-enhanced ultrasound (CEUS) in detecting sequelae of nonoperative approaches is still debated and has lot of potential, with ongoing trials exploring possible advantages. SUMMARY: Multidisciplinary trauma teams play a crucial role in nonoperative management, particularly for high-grade injuries. A careful selection of patients is essential to minimize failure rates. Complications of nonoperative and angiographic approaches should be managed according to local expertise.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.