Core Topics in General and Emergency Surgery

Abdominal trauma

Kenneth D. Boffard

Introduction

In 1988, without organised trauma care, some 20–35% of patients who reached hospital alive in the UK died unnecessarily,1 and even in a recent study of the NHS, almost 60% of patients received a standard of care that was considered less than good practice.2 In the now classic study of trauma centres versus non-trauma centres in California published in 1979, West et al. demonstrated that the majority of preventable deaths resulted from unrecognised, and therefore untreated, intra-abdominal haemorrhage.3

Approximately 6% of all patients with blunt abdominal trauma will require laparotomy, primarily for haemorrhage from solid-organ injuries. Penetrating torso trauma poses its own problems, especially with regard to whether the peritoneal cavity has actually been penetrated, whether intra-abdominal injury has occurred and, in the presence of competing injuries, the decision-making required for best management.

Risk factors

Mackersie et al., in an evaluation of 3223 patients with blunt trauma, found that the risk of abdominal injury was significantly increased in the presence of an arterial base deficit of 3 mmol/L or more, the presence of major chest trauma, the presence of pelvic fractures or the presence of hypotension.4

The current ‘gold standard’ for assessment of perfusion following injury is measurement of the serum lactate. Elevated lactate levels indicate organ dysfunction and failure in severely injured trauma patients, and therefore reflect inadequate perfusion and oxygenation of ischaemic tissues.Several studies in critically ill intensive care patients have demonstrated that elevated initial or 24-hour lactate levels correlate significantly with mortality and appear to have a more superior predictive value than corresponding base deficit level changes.5,6Similarly, prolonged elevation of blood lactate levels has been correlated with increased organ failure and mortality after trauma.7

Criteria that identify patients at significant risk for abdominal injury, and therefore requiring objective evaluation, are:

Anatomy

  • major mechanism of injury;
  • associated major chest injury;
  • presence of pelvic fracture;
  • presence of haematuria;
  • objective physical findings (e.g. tenderness of the abdomen);
  • impaired sensorium and consequent inability for objective abdominal examination.

Physiology

  • significant rise in the serum lactate or significant base deficit;
  • unexplained haemodynamic instability;
  • unexplained hypovolaemic shock.

Transport

Helicopter Emergency Medical Services (HEMS) and its possible association with outcomes improvement continues to be a subject of debate. In an effort to facilitate the academic pursuit of assessment of HEMS utility, in late 2000 the National Association of EMS Physicians (NAEMSP) Air Medical Taskforce reviewed the use of HEMS in both trauma and non-trauma. A more recent literature analysis by Thomas8 showed, like most HEMS trauma studies, that the crude mortality was much higher in the HEMS patients; however, control for acuity reversed the association and outcomes point estimates favoured HEMS in nine of 10 analyses. Penetrating trauma was the only group for which the non-significant outcome impact was on the side of better outcome with ground EMS. For patients with severe head injuries HEMS response was associated with borderline significant outcome improvement. The authors concluded that HEMS was called for in patients of higher injury acuity with diminished (poorer) vital signs, and that HEMS response resulted in improved outcome for patients with blunt trauma and those with severe head injuries.

In a more recent study of 56 744 inured adults transported to US trauma centres by either ground transport or helicopter, the odds of death were 39% lower in those transported by HEMS, compared to those transported by road, especially in the 18- to 54-year-old age group.9 A second recent study of 223 475 patients transported by ground and air showed that certain patients transported to level I and II centres by helicopter had an improved odds of survival to hospital discharge.10

In summary, therefore, HEMS is associated with a reduction in mortality, particularly in patients under 55 years. However, overall survival, especially in those patients with torso or penetrating injury, and patients who are actively bleeding, is best achieved by early control of bleeding. This implies that the time between injury and successful surgical intervention is the single biggest factor in determining a favourable outcome, and in the urban environment this may imply rapid road transport with limited resuscitation en route. The right patient by the right transport to the right hospital in the right time.

Regional trauma systems

Dating from 1979,3 outcomes have been shown to be improved if a regional trauma system is present, and the importance of transporting a patient to an appropriate centre, capable of managing the injuries (actual and potential) in a timely and comprehensive fashion, is well established. The American College of Surgeons Committee on Trauma provides criteria for classification of trauma centres from level I to level IV and definitions for a level I patient.11 When one or more of the following criteria are present in the trauma patient, he or she is classified as a level I trauma patient and should be transported to the nearest appropriate centre:

  • confirmed blood pressure (BP) less than 90 mmHg at any time;
  • respiratory compromise, obstruction and/or intubation;
  • patients from other hospitals receiving blood to maintain vital signs;
  • emergency physicians' discretion, especially where there is unexplained hypotension, or the expected need for damage control may exist.

Assessment in the emergency department

The entire philosophy of the abdominal injury can be summed up by answering the following questions:

  • Is the abdomen involved in an injury process?
  • Is a surgical procedure necessary to correct it?
  • What additional support does the patient require?

In hypotensive patients, the goal is to stop the bleeding, and this includes the rapid determination of whether the abdomen is the cause of the hypotension. If intra-abdominal bleedingis the cause, then emergency measures will be needed to control that bleeding. These include emergency transfusion in order to ‘buy time’ or emergency thoracotomy in the emergency room to control the descending aorta and therefore control distal bleeding. Transfusion alone is only a means to an end, and for hypotensive patients with penetrating torso injuries, delay in aggressive fluid resuscitation until rapid operative intervention and control has occurred improves outcome.12 The often quoted paper by Bickell et al. states that this applies primarily to penetrating trauma of the chest and that other injuries, particularly those involving blunt abdominal trauma, should be assessed. Thromboelastography (TEG) has become a further dynamic point-of-care (POC) standard to optimise clotting ability for haemostasis.13,14

Haemodynamically stable patients without signs of abdominal irritation may undergo a more extended assessment in order to answer the above questions.

Most conventional texts emphasise the need for a careful history and physical examination of the abdomen. In trauma, it is extremely difficult to assess the abdomen, as the history may not be available and all the available physical signs are misleading. Fresh blood is not a peritoneal irritant! Positive clinical findings may be relevant. Negative ones are not!

The mechanism of injury is critically important in assessing the potential for abdominal injury. This information may be obtained from the patient, relatives, police or emergency care personnel. When assessing the patient who has sustained a penetrating injury, pertinent historical information includes the time of injury, type of weapon, number and direction of (especially) bullet wounds (was it an entrance and an exit wound, or two entry wounds with both bullets retained?).

It is unacceptable to withhold analgesia (see also Chapter 5). Judicious, properly titrated use of intravenous opiates will not significantly affect the clarity of the history, nor will it ‘mask’ pain, depress cerebration or respiration, or alter the blood pressure. What it will do is make the injury more comfortable for the patient and allow the clinician a much more accurate picture of both the history and the clinical presentation.

Diagnostic modalities in blunt abdominal trauma

The accuracy of physical examination of the abdomen in detecting intra-abdominal injuries is limited. There are many patient factors that contribute to the difficult physical examination, including the presence of other painful distracting injuries, especially if they occur both above and below the abdomen, and an altered level of consciousness as the result of drugs, alcohol or head injury. Recognising these limitations, most trauma surgeons advocate a more objective evaluation of the abdomen in patients at risk for intra-abdominal injury.

Routine Screening Radiographs

The routine radiographs as laid down by the Advanced Trauma Life Support Programme (ATLS®) of the American College of Surgeons are an anteroposterior (AP) chest film and a pelvic film.15 Abdominal films are not usually useful. If possible (and it is safe to do so), an erect chest radiograph will provide more information than an erect abdominal film in looking for infradiaphragmatic free air (see also Chapter 5).

In all cases of penetrating trauma, it is important to appreciate that in the unstable patient, the radiograph is unlikely to influence management and the patient requires an immediate laparotomy. However, in the stable patient, useful additional information regarding the track of the bullet can be obtained. It is essential in such a situation to make use of bullet markers to show the entry/exit wounds.16 These can be simply paper clips taped onto the skin. If there are wounds on both front and back, then one of the paper clips can be unfolded. After the clips are applied to all relevant torso wounds, the radiographs are taken and will give an indication of the track of the bullet, which wound is at the front and which is at the back, and also the presence of other fragments.

Special Diagnostic Studies

The advantages and disadvantages of each of the objective methods of examining the abdomen for injuries are summarised in Table 13.1.

Table 13.1

Comparison of diagnostic methods for abdominal injury

Method

Advantages

Disadvantages

Clinical

   

Clinical examination

Quick
Non-invasive

Unreliable

Diagnostic

   

Computed tomography
‘Gold standard’

Organ-specific retroperitoneal information

Patient must be stable
Expensive

Ultrasound

Quick
Non-invasive

User dependent
Unhelpful for hollow viscus injury

Diagnostic peritoneal lavage

Quick
Inexpensive

Invasive
Too sensitive
Limited specificity

Laparoscopy

Organ specific

Painful
Anaesthesia required
User dependent
Patient must be stable

Laparotomy

Highly specific

Complications
Expensive

Computed tomography (CT)

With contrast-enhanced CT (CECT), it is possible both to recognise the organ that is injured and to grade the severity of the injury. Intravascular contrast is essential. There is only limited evidence that enteral (via stomach or rectum) contrast is helpful, and its use may delay the examination. Both intraperitoneal and retroperitoneal injuries can be detected with CECT, and the amount of intra-abdominal blood loss can be estimated. Serial scanning can be used to follow the resolution (or progression) of an injury. The disadvantages of CECT include the need to move the patient to the radiology suite and the time required to perform the scan, although with the introduction of 64-slice spiral scanners, the latter factor has become less important. CT is expensive, there is the potential for allergic reaction to the injected contrast material, or for aspiration of oral contrast (a rare event), and the danger of the radiation dose administered should not be underestimated.17 It has been estimated that the danger of CT scan-induced cancer may be as high as 2%.18

Although CT is relatively insensitive in the detection of hollow viscus injuries, a bowel injury (and especially a duodenal injury) is suggested by finding a thickened bowel wall, extraluminal air and the presence of intraperitoneal fluid in the absence of a solid-organ injury.19,20 CT may also miss a pancreatic injury early in its course. The accuracy of CT is generally poor in the detection of diaphragmatic, hollow-organ and mesenteric injuries, and there have been reports of a high incidence of false-negative results.21 Despite these limitations, however, CT remains the method of choice for objective evaluation of the abdomen in stable trauma patients who are likely to have an intra-abdominal injury, and is currently the ‘gold standard’ of investigation.

Diagnostic ultrasound

The sensitivity of ultrasound for the detection of free intraperitoneal fluid in abdominal blunt trauma has been shown to be 81–99%.22 The disadvantage of ultrasound is its lack of sensitivity for injuries that do not produce blood or peritoneal fluid and the fact that its accuracy is directly related to the experience of the ultrasonographer. Nonetheless, surgeons can be taught to perform and interpret ultrasound examinations rapidly and accurately, with a sensitivity/specificity and accuracy each over 90%.23 This diagnostic method has particular appeal in paediatric trauma patients and in the injured gravid patient.

In most centres, ultrasound has replaced diagnostic peritoneal lavage (DPL) for evaluation of the unstable patient following blunt trauma. However, the role of ultrasound in the assessment of penetrating abdominal trauma is still controversial, since the examination will miss small amounts of intraperitoneal fluid.

Diagnostic peritoneal lavage (DPL)

Root et al. introduced DPL as a method of evaluation of the abdomen some 50 years ago,24 and while it has frequently been superseded by more sophisticated (and potentially more expensive) techniques, it remains the standard against which all other diagnostic examinations are judged. The main advantage of DPL is that it can be performed quickly and with few complications by relatively inexperienced clinicians. DPL is also reproducible, as well as highly sensitive and specific for the detection of abdominal blood (> 97%), but it does not identify the organ of injury.

Injuries of the retroperitoneum will be missed by DPL, and the presence of pelvic fractures may lead to a false-positive result.

A DPL is generally considered as positive if:

  • red cell count is > 100 000 cells/mm3;
  • white cell count is > 500/mm3;
  • there is amylase or bowel content in the lavage return.

However, if surgeons are committed to operating on all patients with positive DPL the ability to manage patients non-operatively may be lost.The lavage is therefore regarded as an indicator of the presence of abdominal pathology, but not necessarily an indication for surgery (see section on non-operative management below).

Diagnostic laparoscopy

Laparoscopy has yet to find its role in the evaluation of the patient with blunt abdominal trauma.25 With few exceptions, laparoscopy requires general anaesthesia, is expensive and has the potential to create a tension pneumothorax26 or air embolus during insufflation. Laparoscopy in penetrating injury has been reported with the successful repair of injuries of the diaphragm and stomach.27

An additional drawback of diagnostic laparoscopy currently is the relative cost compared with other modalities, especially those performed at the bedside, such as ultrasound. The technique should only be used on relatively stable patients, and laparoscopy is still limited in its ability to detect penetrating intestinal injury, especially in the hands of an operator unskilled in the specific techniques required for elucidation of intra-abdominal injury. Currently, laparoscopy is most useful in the patient with penetrating abdominal trauma when there is a question of peritoneal penetration or diaphragmatic injury. The diaphragm is also an area where delay or missed diagnosis dramatically increases the morbidity.28 Laparoscopy can identify not only clinically unsuspected diaphragm injuries but also other injuries that have been ‘missed’ by other diagnostic tests.

Diagnostic laparoscopy does not confer any advantages or improvements over other techniques when it comes to investigation of retroperitoneal injuries to organs such as the duodenum and pancreas, and CT remains more accurate in this regard.

Laparotomy

Mandatory Laparotomy: While laparotomy remains the most appropriate therapy for an unstable patient with obvious abdominal trauma, a non-therapeutic laparotomy is not necessarily benign. In a prospective study of unnecessary laparotomies performed in 254 trauma patients, complications occurred in 41% of patients, and included atelectasis, postoperative hypotension, pleural effusion, pneumothorax, prolonged ileus, pneumonia, surgical wound infection, small-bowel obstruction and urinary infection.29

Many centres still practise a policy of mandatory laparotomy for abdominal gunshot wounds because of the higher morbidity associated with delayed diagnosis. However, Ross et al.30reported a negative laparotomy rate (absence of injury) of 12% in gunshots, 23% in stab wounds and 6% in blunt trauma, suggesting that there is a more accurate investigation of the abdomen in blunt trauma.

Selective Laparotomy (I.E. Selective Conservatism) In Penetrating Injury: Several studies have considered the possibilities of selectively treating certain patients by observation only, even when a laparotomy seems to be required. Two South African studies reviewed selective conservatism in the management of abdominal gunshot wounds. Muckart et al. reported no delayed laparotomies or morbidity, with only a 7% negative laparotomy rate,31 and Demetriades et al. found a delayed laparotomy rate of 17%.32

It is obvious that the decision not to operate should be carefully considered and, if taken, meticulous and repeated re-examination of the patient for changing abdominal signs should be performed. A general dictum should be that the more there is uncertainty in the assessment, or the more inexperienced the assessor, the more aggressive should be the tendency towards laparotomy.

Operative management of abdominal trauma

Laparotomy For Trauma

In patients who, by any of the diagnostic criteria above, are judged to need a laparotomy for control of their injuries, the timing of laparotomy in relationship to the detection and/or repair of concomitant injuries requires input from an experienced trauma surgeon. Although open to debate, the following scenarios are offered along with a suggested algorithm (Fig. 13.1).

FIGURE 13.1 Management of abdominal injury.

The unstable patient with intra-abdominal bleeding

The unstable patient with obvious intra-abdominal haemorrhage should undergo immediate operative intervention. However, if other priorities are also pressing (e.g. major physiological derangement, severe closed head injury or associated pelvic haemorrhage), a ‘damage control’ procedure (abbreviated laparotomy) should be considered to allow management of the patient's physiology or of other life-threatening injuries.

During the laparotomy, however brief, if the patient had an initial Glasgow Coma Scale (GCS) of less than 8/15, it is recommended that intracranial pressure monitoring should take place. The most lethal secondary brain injury is induced by hypotension or hypoxia.

If a widened mediastinum is present, the situation must be assessed and priorities of care selected. In the patient who is unstable because of intra-abdominal pathology, the diagnostic processes for the mediastinum may have to take place after the therapeutic laparotomy. Consideration should be given to the use of beta-blockade, and hypotensive resuscitation, until the aorta/great vessels can be properly evaluated.

There are considerable data available to support medical treatment of contained thoracic aortic injuries and to delay repair or endovascular stenting until other injuries are stabilised.33

The unstable patient with intra-abdominal and pelvic haemorrhage

In a patient who is unstable with both intra-abdominal haemorrhage and pelvic bleeding, the surgeon must decide which injury is causing the hypotension. If the DPL is grossly positive, or an ultrasound demonstrates a large amount of fluid in Morrison's pouch, laparotomy should be performed promptly. As most fractures of the pelvis bleed extraperitoneally, this bleeding is unlikely to originate in the pelvis. An unstable patient who has signs of bleeding from both pelvis and abdomen should have compression stabilisation of the pelvis, with a knotted sheet (or proprietary device) or external fixation applied immediately, followed by laparotomy and extraperitoneal packing, then angiography of the pelvis and embolisation of bleeding arteries. Ultrasound is unreliable for quantifying blood loss in such circumstances and, if the patient is stable enough, CT of both pelvis and abdomen should be carried out. Not only will CT provide significant information regarding the pelvic fractures and source of bleeding (85% will be venous in origin), it will also give information as to possible injury to intra-abdominal organs. Furthermore it may exclude a diaphragmatic rupture, which has a significant association with pelvic fractures. Intrapelvic bleeding is best controlled by angio-embolisation (arterial) or by external fixation (venous), often in association with extraperitoneal pelvic packing.

The stable patient with combined head, chest and abdominal injuries

In stable patients with combined head/chest/abdominal injuries, CT with contrast can rapidly identify injuries that need operative intervention. A study by Wisner et al. described 800 patients who were thought to have potentially correctable injuries to both the head and the abdomen.34 Only 52 had a head injury requiring craniotomy, 40 required laparotomy, and only three needed both craniotomy and therapeutic laparotomy. These authors lend support to the concept that if patients with combined head/abdominal trauma are stable and have a negative ultrasound (or DPL), they can undergo CT of both the head and abdomen. Many patients with head trauma and stable liver/spleen injuries are now being treated non-operatively.35

The patient with abdominal injuries and limb fractures

With the exception of pelvic fractures, fracture/dislocations and in the presence of vascular impairment, most fractures can be simply splinted while other surgical procedures take place. Open fractures should be irrigated and debrided within 6 hours of the injury, and antibiotics administered. Although there is still considerable debate about the timing of fracture fixation in trauma patients with multiple priorities, those with head and/or pulmonary injuries still benefit from early fracture fixation, provided hypotension and hypoxia can be avoided during the surgery. There is a clear role for damage control orthopaedics as part of a damage control procedure.

Trauma Laparotomy: A Systematic Approach

If it is decided that the injured patient would benefit from laparotomy, the operation should be approached in an orderly fashion. It is important to recognise the components of the ‘trauma laparotomy’. The vital initial goals are to:

  • stop the bleeding;
  • limit contamination;
  • restore the physiology.

Preparation

An adequately stocked warm operating theatre is essential. Delay in surgery is the most common cause of unnecessary ongoing bleeding. In addition to routine equipment, the following should be considered as mandatory equipment:

  • rapid infusion devices with rapid warming capability (Alton Deane®, Mallincrodt® or Level One®);
  • patient warming blankets (e.g. Bair Hugger®);
  • autotransfusion if available.

Incision

A long midline abdominal incision is used, one that can be extended superiorly as a sternotomy. The ideal incision is always ‘too big rather than too small’ and should extend from the xiphisternum to the symphysis pubis.

Bleeding control

If, upon opening the abdomen, gross blood is encountered, as much as possible is scooped out, using a receiver such as a kidney dish. Suction is ineffective as it is too slow, and the apparatus blocks with clots.The abdomen is packed using layered dry abdominal swabs:

  • below the left hemidiaphragm;
  • lateral to the descending colon;
  • the pelvis;
  • lateral to the ascending colon;
  • lateral to the liver;
  • below the liver;
  • anterior to the dome of the liver, under the right subcostal margin;
  • central abdomen.

Additional packs are used to isolate bleeding areas as required.

With blunt injuries, the most likely sources of bleeding are the liver, spleen and mesentery. The solid organs are packed and bleeders in the mesentery are clamped using mosquito forceps. No attempt is made to tie off individual vessels (very time consuming) until all major bleeding has been controlled with clamps. If necessary, a soft bowel clamp can be used across the mesentery to control all mesenteric bleeding.

With penetrating injuries, the liver and retroperitoneal structures, vascular structures and mesentery are all examined.

If packing does not control the bleeding, the blood supply to the organ is isolated using proximal clamping or isolation techniques. If additional assistance is needed for blood pressure control, the abdominal aorta can be manually compressed at the hiatus. When the patient is reasonably stable, the packs are removed systematically, uncovering the most likely injurylast. Any bleeding sites are then rapidly controlled by clamps, sutures or re-packing as needed.

Contamination control

Gross contamination from the gastrointestinal tract is quickly controlled with sutures or staples.

Physiological control

No further definitive surgery is performed until the anaesthesia team has the patient stabilised and the patient is warm (> 35 °C). This may require a period of resuscitation in the intensive care unit (see ‘Damage control laparotomy’ below).

Full inspection for injury

Once there is control of haemorrhage and contamination, a systematic inspection is performed.

In addition to inspecting the liver and spleen, a full trauma laparotomy includes examination of the anterior/posterior stomach wall, the entire large and small bowel (including the duodenum), the diaphragm, the gastrohepatic ligament, the head, body and tail of the pancreas, and any central retroperitoneal haematomas. In order to achieve this, it will be necessary not only to perform a conventional reflection of the duodenum (the Kocher manoeuvre) and to enter the lesser sac, but also to reflect the right and left hemicolon to view the great vessels (right and left medial visceral rotation manoeuvres).

The abdomen is only closed when it is safe to do so (see ‘Damage control laparotomy’ and ‘Abdominal compartment syndrome’ below).

Damage Control Laparotomy

Since the mid-1980s, there has been a re-emergence of the concept of packing and closing for abdominal injuries with profuse haemorrhage. Further experience with this technique has resulted in its extension to patients with other vascular/intestinal injuries, and new terms such as ‘damage control’ surgery, ‘abbreviated laparotomy’, ‘staged laparotomy’ or ‘planned re-operation’ have emerged.36 The principle of damage control has been extended beyond the abdomen, to thoracic, extremity and orthopaedic damage control techniques.37

The concept of damage control has as its objective the avoidance of imposition of additional surgical stress at a moment of physiological frailty. The concept is not new – livers were not infrequently packed 100 years ago. However, the failure to understand the underlying rationale, or deal with the resulting disruption to physiological processes, led to disastrous results. The concept of packing was re-examined, and the technique establishment of intra-abdominal pack tamponade and then completion of the procedure once coagulation has returned to an acceptable level proved to be life-saving. This approach was initially advocated for patients with severe liver injuries, especially those with retrohepatic venous injuries. When properly applied, packs above/below the liver can compress and control venous injuries long enough for the patient's coagulopathy, acidosis and temperature to be corrected.

Often, when the patient is returned to the operating room after packing for liver injuries, the bleeding has already stopped, and irrigation, debridement and formal closure are all that are required. The concept of ‘staging’ applies both to routine and to emergency procedures, and it can apply equally well beyond the abdomen.

This approach has been used for patients with both penetrating and blunt injuries, and it generally includes clamping of major bleeding vessels, packing of bleeding solid-organ injuries and stapling/dividing bowel injuries but without initial reconstruction. A variety of temporary methods of closure of the abdomen have been developed (see ‘Temporary abdominal closure’ below), including mesh and other synthetic material, plastic intravenous bags and towel clips. Currently, the ‘vacuum sandwich’ technique is the simplest method of choice. However, it must be remembered that the type of closure is much less important than the recognition of the need to terminate the operation and save the patient.

Patient selection for damage control

Patients are selected for a damage control approach if there is:

  • inability to achieve haemostasis;
  • proven coagulopathy;
  • inaccessible major venous injury, e.g. retrohepatic vena cava injury;
  • anticipated need for a time-consuming procedure (> 90 min);
  • demand for non-operative control of other injuries, e.g. fractured pelvis;
  • desire to reassess the intra-abdominal contents (directed relook).

Irrespective of setting, a coagulopathy in the presence of hypothermia is the single most common reason for abortion of a planned procedure or the curtailment of definitive surgery. It is important to abort the surgery before the coagulopathy becomes obvious.

Hirshberg and Mattox described three distinct indications for planned re-operation in severely injured patients:38

  • avoidance of irreversible physiological insult in a hypothermic coagulopathic patient by rapid termination of the surgical procedure;
  • inability to obtain direct haemostasis (by ligation, suture or vascular repair), necessitating indirect control of bleeding by packing or balloon tamponade;
  • massive visceral oedema precluding formal closure of the abdomen or chest.

Garrison et al. described criteria that predicted the need to pack early for severe intra-abdominal haemorrhage:39

  • Injury Severity Score (ISS) > 35;
  • coagulopathy with a prothrombin time > 19 seconds;
  • hypotension with a systolic blood pressure < 70 mmHg for longer than 70 minutes;
  • pH < 7.2;
  • serum lactate > 5 mmol/L;
  • temperature < 34 °C.

More recently, thromboelastography (TEG) or rotary thromboelastometry (RoTEM) has been regarded as the ‘gold standard’ for assessment of coagulation status, and an r time > 12 minutes would mandate damage control surgery.13

Damage control procedures can be considered under the following stages.

Stage 1: Damage control procedure

In damage control, the technical aspects of the surgery are dictated by the injury pattern, with the primary objectives as follows.

Arrest Bleeding And The Resulting (Causative) Coagulopathy: Procedures for haemorrhage control include:

  • repair or ligation of accessible blood vessels;
  • occlusion of inflow into the bleeding organ (e.g. Pringle's manoeuvre for bleeding liver);
  • tamponade using wraps or packs;
  • intravascular shunting;
  • intraoperative or postoperative embolisation.

Limit Contamination And The Associated Sequelae: This is achieved by:

  • ligation or stapling of bowel;
  • isolation of pancreatic injury;
  • adequate suction drainage (e.g. with a Blake® drain).

Temporary Abdominal Closure: The abdomen is only closed to limit heat and fluid loss and to protect viscera. Closure is usually achieved using the ‘sandwich technique’, first described by Schein et al. in 198640 and subsequently popularised by Rotondo et al.36

A sheet of self-adhesive incise drape (Opsite®, Steridrape® or Ioban®) is placed flat, sticky side up, and an abdominal swab placed upon it. The plastic edges are trimmed, to produce a sheet with membrane on one side and abdominal swab on the other. If extra firmness is required, a surgical drape can be used instead of the swab. It is worth noting that it is unnecessary to make any perforations in the membrane, and to do so may increase subsequent fistula formation.

The membrane is utilised as an on-lay with the margins ‘tucked in’ under the edges of the open sheath, the membrane being in contact with the bowel.

The appreciable drainage of serosanguinous fluid that occurs is best dealt with by placing a pair of drainage tubes (e.g. sump-type nasogastric tubes or closed-system suction drains) through separate stab incisions onto the membrane and utilising continuous low-vacuum suction. This arrangement is covered by an occlusive incise drape applied to the skin, thus providing a closed system.

Other techniques, such as the use of towel clips or the so-called ‘Bogota bag’, are now generally regarded as obsolete. The use of proprietary vacuum suction devices at this stage is not only expensive, but the suction used is often above mean arterial pressure, which increases the risk of subsequent fistula. Such devices should generally only be used at the final stage of closure if definitive closure is not possible.

Stage 2: Transfer to the intensive care unit for ongoing resuscitation

The timing of the transfer of the patient from the operating theatre to the intensive care unit is critical. Early transfer is cost-effective; premature transfer is counter-productive. In addition, once haemostasis has been properly achieved, it may not be necessary to abort the procedure and it may be possible to proceed to definitive surgery. Conversely, there are some patients with severe head injuries where the coagulopathy is induced by severe irreversible cerebral damage, and further surgical energy is futile.

In the operating theatre, efforts must be started to reverse all the associated adjuncts, such as acidosis, hypothermia and hypoxia, and it may be possible to improve the coagulation status through these methods alone. Adequate time should still be allowed for this, following which reassessment of the abdominal injuries should take place, as it is not infrequent to discover further injuries or ongoing bleeding.

Stage 3: Resuscitation in the intensive care unit

Priorities on reaching the intensive care are:

  1. The restoration of body temperature using:
  2. passive rewarming with warming blankets, warmed fluids, etc.;
  3. active rewarming using lavage of chest or abdomen.
  4. Correction of clotting profiles by blood component repletion. This is best directed by the results of the TEG/RoTEM.13
  5. Optimisation of oxygen delivery:
  6. volume loading to achieve optimum preload;
  7. haemoglobin optimisation to a value of 9 g/dL;
  8. temperature optimisation (> 35 °C).
  9. Monitoring of intra-abdominal pressure (IAP) to prevent abdominal compartment syndrome (ACS).

Stage 4: Return to the operating theatre for definitive surgery

The patient is returned to the operating theatre as soon as stage 3 is achieved. The timing is determined by:

  • the indication for damage control in the first place;
  • the injury pattern;
  • the physiological response.

Patients with persistent bleeding despite correction of the other parameters merit early return to control the bleeding.

Every effort must be made to return all patients to the operating theatre within 24–48 hours of their initial surgery.

Stage 5: Definitive surgery and abdominal wall reconstruction if required

Once definitive surgery is complete, and no further operations are contemplated, then the abdominal wall can be closed. This is often difficult and methods involved include:

  • primary closure;
  • closure of the sheath, leaving the skin open;
  • grafts with Vicryl® mesh, or other synthetic sheets;
  • use of lateral relieving incisions to allow closure of sheath (component separation).

Abdominal compartment syndrome

There have been major developments in our understanding of intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH). Raised IAP has far-reaching consequences for the physiology of the patient.41 Clinically, the organ systems most affected include the cardiovascular, renal and pulmonary systems. A sustained IAP ≥ 20 mmHg associated with new organ dysfunction is known as abdominal compartment syndrome (ACS; see Table 13.2).With increasing awareness of the problem, reduced fluid resuscitation and more appropriate damage control, the incidence of ACS in trauma is decreasing. Failure to detect ACS in a timely fashion and treat it aggressively results in high mortality in such patients.

Table 13.2

Consensus definitions related to IAP, IAH and ACS

Reproduced with permission from the World Society for Abdominal Compartment Syndrome.

Definition

The first World Congress on ACS was held in 2005 and an internal consensus agreement relating to current definitions42 is shown in Table 13.2.

 

ACS is defined as a sustained IAP ≥ 20 mmHg (with or without an abdominal perfusion pressure < 60 mmHg) that is associated with new organ dysfunction/failure.

Pathophysiology

The incidence of increased IAP may be 30% of postoperative general surgery patients in intensive care and after emergency surgery the incidence is even higher. The causes of acutely increased IAP are usually multifactorial (see also Chapter 18). The first clinical reports of postoperative increased IAP were often after aortic surgery, with postoperative haemorrhage from the graft suture line. Peritonitis and intra-abdominal sepsis, tissue oedema and ileus are the predominant cause of increased IAP. Raised IAP in trauma patients is often caused by a combination of blood loss and tissue oedema. Causes of increased intra-abdominal pressure include:

  • tissue oedema secondary to insults such as ischaemia, trauma and sepsis;
  • paralytic ileus;
  • intraperitoneal or retroperitoneal haematoma;
  • ascites;
  • trauma with hypothermia, coagulopathy and acidosis.

Effect Of Raised IAP On Organ Function

Renal function

The most likely direct effect of increased IAP is an increase in the renal vascular resistance, coupled with a moderate reduction in cardiac output. The absolute value of IAP that is required to cause renal impairment is probably in the region of 20 mmHg. Maintaining adequate cardiovascular filling pressures in the presence of increased IAP also seems to be important.43

Cardiac function

Increased IAP reduces cardiac output as well as increasing central venous pressure, systemic vascular resistance, pulmonary artery pressure and pulmonary artery wedge pressure. Cardiac output is affected mainly by a reduction in stroke volume, secondary to a reduction in preload and an increase in afterload. This is further aggravated by hypovolaemia. Paradoxically, in the presence of hypovolaemia, an increase in IAP can be temporarily associated with an increase in cardiac output. Venous stasis occurs in the legs of patients with IAP values above 12 mmHg. In addition, recent studies of patients undergoing laparoscopic cholecystectomy show up to a fourfold increase in renin and aldosterone levels.

Respiratory function

In association with increased IAP, there is diaphragmatic splinting, exerting a restrictive effect on the lungs with reduction in ventilation, decreased lung compliance, increase in airway pressures and reduction in tidal volumes. The mechanism by which increased IAP impairs pulmonary function appears to be purely mechanical. As IAP increases, the diaphragm is forced higher into the chest, thereby compressing the lungs. Adequate ventilation can still be achieved, but only at the cost of increased airway pressures.

In critically ill, ventilated patients the effect on the respiratory system can be significant, resulting in reduced lung volumes, impaired gas exchange and high ventilatory pressures. Hypercarbia can occur and the resulting acidosis can be exacerbated by simultaneous cardiovascular depression as a result of the raised IAP. The effects of raised IAP on the respiratory system in the intensive care setting can sometimes be life threatening, requiring urgent abdominal decompression. Patients with true ACS demonstrate a remarkable improvement in their intraoperative vital signs following abdominal decompression.

Visceral perfusion

Interest in visceral perfusion has increased with increased awareness of gastric tonometry, and there is an association between IAP and visceral perfusion as measured by gastric pH. In a study of 73 patients after laparotomy, it was shown that IAP and gastric pH are strongly associated, suggesting that early decreases in visceral perfusion are related to IAP at levels as low as 12 mmHg.43 Visceral reperfusion injury is a major consideration after a period of raised IAP, and may of itself have fatal consequences.

Intracranial contents

Raised IAP can have a marked effect on intracranial pathophysiology and cause severe rises in intracranial pressure.

Measurement Of IAP

The most common method for measuring IAP uses a urinary catheter.44 The patient is positioned flat in the bed and a standard Foley catheter is used with a T-piece bladder pressure device attached between the urinary catheter and the drainage tubing. This piece is then connected to a pressure transducer, which is placed in the mid-axillary line and the urinary tubing clamped. Approximately 50 mL of isotonic saline is inserted into the bladder via a three-way stopcock. After zeroing, the pressure on the monitor is recorded.

Pitfalls of IAP pressure measurement

The following factors are important in achieving effective IAP measurements:

  • A strict protocol and staff education on the technique and interpretation of IAP is essential.
  • Very high pressures (especially unexpected ones) are usually caused by a blocked urinary catheter.
  • The size of the urinary catheter does not matter.
  • The volume of saline instilled into the bladder is not critical, but it should be enough to overcome the resistance of the contracted bladder; usually, not more than 50 mL is adequate.
  • A central venous pressure manometer system can be used but it is more cumbersome than online monitoring.
  • Elevation of the urine catheter and measuring the urine column provides a rough guide and is simple to perform.
  • If the patient is not lying flat, IAP can be measured from the pubic symphysis.
  • IAP is not a static measurement and should be measured continuously. In addition, whether IAP is measured intermittently or continuously, consideration of abdominal perfusion measurement should be given (see below). Real-time continuous monitoring of IAP is effective and shows trends as well as actual pressures.

 

Intra-abdominal hypertension (IAH) is defined by a sustained or repeated pathological elevation of IAP > 12 mmHg.

Abdominal Perfusion Pressure

Like the concept of cerebral perfusion pressure, calculation of the ‘abdominal perfusion pressure’ (APP), which is defined as mean arterial pressure (MAP) minus IAP, assesses not only the severity of IAP present, but also the adequacy of the patient's abdominal blood flow. A retrospective trial of surgical and trauma patients with IAH (mean IAP 22  ±  8 mmHg) concluded that an APP  > 50 mmHg optimised survival based upon receiver operating characteristic curve analysis.45 APP was also superior to global resuscitation end-points such as arterial pH, base deficit, arterial lactate and hourly urinary output in its ability to predict patient outcome.Three subsequent trials in mixed medical–surgical patients (mean IAP 10  ±  4 mmHg) suggested that 60 mmHg represented an appropriate resuscitation goal.4649 Persistence of IAH and failure to maintain an APP  ≥ 60 mmHg by day 3 following development of IAH-induced acute renal failure was found to discriminate between survivors and non-survivors.

Management Of Raised IAP

General support

In general, the best treatment is prevention, both by minimising the causative agents and early appreciation of the potential complications.

There are a number of key principles in the management of patients with potential ACS:

  • regular (< 8-hourly) monitoring of IAP;
  • optimisation of systemic perfusion and organ function in the patient with IAH;
  • institution of specific medical procedures to reduce IAP and the end-organ consequences of IAH/ACS;
  • early surgical decompression for refractory IAH.

Reversible factors

The second aspect of management is to correct any reversible cause of ACS, such as intra-abdominal bleeding. Maxwell et al. reported on secondary ACS, which can occur without abdominal injury, and stated that, again, early recognition could improve outcome.50

Massive retroperitoneal haemorrhage is often associated with a fractured pelvis, and consideration should be given to measures that would control haemorrhage, such as pelvic fixation or vessel embolisation. In some cases, severe gaseous distension or acute colonic pseudo-obstruction can occur in patients in intensive care. This may respond to drugs such as neostigmine but if it is severe, surgical decompression may be necessary (see also Chapter 10). Ileus is a common cause of raised IAP in patients in intensive care. There is little that can be actively done in these circumstances apart from optimising the patient's cardiorespiratory status and serum electrolytes.

Abdominal evaluation for sepsis is a priority and surgery is obviously the mainstay of treatment in patients whose rise in IAP is caused by postoperative bleeding.

Management of IAH and ACS is summarised in Figs 13.2 and 13.3.42,48,49

FIGURE 13.2 Intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) management algorithm. ACS, abdominal compartment syndrome; APP, abdominal perfusion pressure (MAP − IAP); IAH, intra-abdominal hypertension; IAP, intra-abdominal pressure; Primary ACS, a condition associated with injury or disease in the abdomino-pelvic region that frequently requires early surgical or interventional radiological intervention; Recurrent ACS, the condition in which ACS redevelops following previous surgical or medical treatment of primary ACS; Secondary ACS, ACS due to conditions that do not originate from the abdomino-pelvic region.

FIGURE 13.3 Medical management options to reduce intra-abdominal pressure (IAP). ACS, abdominal compartment syndrome; APP, abdominal perfusion pressure; IAH, intra-abdominal hypertension.

Surgery For Raised IAP

As yet, there are few guidelines for exactly when surgical decompression is required in the presence of raised IAP. The indications for abdominal decompression are related to correcting pathophysiological abnormalities as much as achieving a precise and optimum IAP. The abdomen is decompressed, and a temporary abdominal closure (TAC) is achieved. The simplest technique is the Opsite® sandwich technique described above.

Every effort must be made towards the reduction of intra-abdominal pressure, allowing early closure of the abdomen. Clinical infection is common in the open abdomen and the infection is usually polymicrobial. Prophylactic antibiotics are not routinely used.

Summary

Patients with raised IAP require close and careful monitoring, aggressive resuscitation and a low index of suspicion for requirement of surgical abdominal decompression.

 

The formation of the World Society on ACS has been a major advance, with production of consensus definitions, formation of a research policy with multicentre trials, and the publishing of the consensus guidelines on ACS.42,48,49

Organ injury scaling systems

The American Association for the Surgery of Trauma (AAST) has developed an organ injury scaling system for all major injuries in the body.5157 These scores not only allow a clear anatomical language when dealing with organ injury but also, since surgical policies are often dictated by the injuries sustained, a degree of consistency in both treatment and prognosis. The scaling system is outlined in the Appendix to this chapter and can be accessed at http://www.aast.org on the Internet.

Surgical decision-making in abdominal trauma

Experience in dealing with injury clearly leads to a better outcome:

Good judgment comes from experience.

Unfortunately, experience often comes from bad judgment!

There is limited evidence-based decision-making in trauma, although certain practice guidelines have been developed, primarily by groups working in the Eastern Association for the Surgery of Trauma (www.east.org).58 Examples of evidence-based practice management guidelines include the following.

Antibiotic Prophylaxis In Abdominal Trauma58,59

Guidelines for patient selection and specific antimicrobial regimens are based on good evidence (Box 13.1),59,60 those regarding high-risk patients and duration of therapy less so (Box 13.2). The trauma surgery setting is fundamentally different to that of elective surgery, especially with regard to prophylactic antibiotics. Antibiotics are given after the peritoneal insult and possible contamination has occurred (Boxes 13.3 and 13.4).

 

Box 13.1

Evidence-based guidelines for prophylactic antibiotic administration: summary of recommendations

Strong recommendation

  1. Patients with peritoneal contamination due to traumatic bowel injury repaired within 12 hours are not considered to have established intra-abdominal infections, and should be treated with prophylactic antimicrobials for 24 hours or less (Evidence level I)

Recommendation based on evidence of effectiveness

  1. Systemic antibiotics should be administered as soon as possible after injury for patients with penetrating trauma requiring surgical intervention (Evidence level II)
  2. A single broad-spectrum agent is at least as safe and effective as a double or triple antibiotic therapeutic regimen (Evidence level II)
  3. Patients with a fully removable focus of inflammation (e.g. bowel necrosis) should be treated with prophylactic antimicrobials for 24 hours or less (Evidence level II)

Recommendation made where there is no adequate evidence as to the most effective practice

  1. Patients with more extensive conditions should be treated as having more extensive infections, and given therapeuticantimicrobials for more than 24 hours (Evidence level III)

Reproduced from Mazuski JE, Sawyer RG, Nathens AB et al. The Surgical Infection Society Guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary. Surg Infect 2002; 3(3):161–73. Cornwell EE IIIrd, Campbell KA. Trauma. In: Gordon TA, Cameron JL (eds) Evidence-based surgery. Hamilton, Ontario: BC Decker, 2000; pp. 415–28. With permission from Mary Ann Liebert Inc./BC Decker Inc.

 

Box 13.2   Evidence-based guidelines for duration of antibiotic therapy: summary of recommendations

Recommendation based on evidence of effectiveness

  1. High postoperative septic complications can be expected in patients with gunshot injuries to the colon, high Penetrating Abdominal Trauma Index (PATI) scores, major blood loss, and common need for postoperative care.There is no evidence to date that extending prophylactic antibiotic therapy beyond 24 hours decreases that high risk (Evidence level II)
  2. Antimicrobial therapy of most established intra-abdominal infections should be limited to no more than 5 days (Evidence level II)
  3. Antimicrobial therapy can be discontinued in patients when they have no clinical evidence of infection such as fever or leucocytosis (Evidence level II)

Recommendation made where there is no adequate evidence as to the most effective practice

  1. Continued clinical evidence of infection at the end of the time period designated for antimicrobial therapy should prompt appropriate diagnostic investigations rather than prolongation of antimicrobial treatment (Evidence level III)
  2. If adequate source control cannot be achieved, a longer duration of antimicrobial therapy may be warranted (Evidence level III)

 

Box 13.3   Evidence-based guidelines for antimicrobial regimens: summary of recommendations

Strong recommendation

  1. Antimicrobial regimens for intra-abdominal infections should cover common aerobic and anaerobic enteric flora. No regimen has been demonstrated to be superior to another (Evidence level I)

Recommendation based on evidence of effectiveness

  1. Once-daily administration of aminoglycoside is the preferred dosing regimen for patients receiving these agents for intra-abdominal infections (Evidence level II)

Recommendation made where there is no adequate evidence as to the most effective practice

  1. Aminoglycosides should be avoided in the acute trauma patient due to difficulty in reaching adequate MIC levels without toxicity (Evidence level III)

For less severely ill patients with community-acquired infections, antimicrobial agents having a narrower spectrum of activity, such as antianaerobic cephalosporins, are preferable to more costly agents having broader coverage of Gram-negative organisms and/or a greater risk of toxicity (Evidence level III)

  1. The routine use of intraoperative cultures is controversial, and there is no evidence that altering the antimicrobial regimen on the basis of intraoperative culture results improves outcome (Evidence level III)

 

Box 13.4   Evidence-based guidelines for antimicrobial therapy in the high-risk patient: summary of recommendations

Strong recommendation

  1. In patients with intra-abdominal infections, treatment failure and death is associated with patient-related risk factors such as advanced age, poor nutritional status, low serum albumin concentration and pre-existing medical disease.A higher APACHE II score is the most consistently recognised risk factor for both death and treatment failure (Evidence level I)

Recommendation based on evidence of effectiveness

  1. Disease and treatment-related risk factors, including nosocomial origin of infection, the presence of resistant pathogens, and the lack of adequate source control are associated with treatment failure and death (Evidence level II)
  2. Routine addition of an aminoglycoside to other agents having broad-spectrum Gram-negative coverage provides no additional benefit (Evidence level II)
  3. Addition of empirical antifungal therapy with fluconazole is reasonable for patients with postoperative intra-abdominal infections at high risk of candidiasis (Evidence level II)

Recommendation made where there is no adequate evidence as to the most effective practice

  1. Patients at higher risk of failure (e.g. damage control) should be treated with an antimicrobial regimen having a broader spectrum of coverage of Gram-negative aerobic/facultative anaerobic organisms (de-escalation therapy) (Evidence level III)

Management of abdominal injury

Abdominal injury is of a blunt or penetrating nature.While it is hard to define precise parameters for the approach to management, the following guidelines are offered.

Hepatic Injury

Repair and resection for treatment of hepatic trauma demands a working knowledge of the anatomy of the liver. Segmental anatomical resection has been well documented but usually is not applicable to injury. The three main hepatic veins divide the liver into four sections: right posterior lateral, right anterior medial, left anterior and left posterior. Each of these sectors receives a portal pedicle.The liver is practically divided into eight Couinaud segments (Fig. 13.4).

FIGURE 13.4 Couinaud's segments of the liver.

Understanding the anatomy also helps to explain some of the patterns of injury following blunt trauma. There are also differences in tissue elasticity, which determine injury patterns. The forces from blunt injury are usually direct compressive forces or shear forces. The elastic tissue within arterial blood vessels makes them less susceptible to tearing than any other structures within the liver. Venous and biliary ductal tissues are moderately resistant to shear forces, whereas the liver parenchyma is the least resistant of all. Therefore, fractures within the liver parenchyma tend to occur along segmental fissures or directly into the parenchyma. This causes shearing of lateral branches to the major hepatic and portal veins. With severe deceleration injury, the origin of the hepatic veins may be ripped from the inferior vena cava, causing devastating haemorrhage. Similarly, the small branches from the caudate lobe entering directly into the cava are at high risk of shearing with linear tears on the caval surface.

Direct compressive forces usually cause tearing between segmental fissures in an anterior posterior sagittal orientation. Horizontal fracture lines into the parenchyma give the characteristic burst pattern to such liver injuries. If the fracture lines are parallel, these have been dubbed ‘bear claw’-type injuries and probably represent where the ribs have been compressed directly into the parenchyma. Occasionally, there will be a single fracture line across the horizontal plane of the liver, usually between the anterior and posterior segments. This can cause massive haemorrhage if there is direct extension or continuity with the peritoneal cavity.

The liver is at risk in any penetrating trauma to the right upper quadrant of the abdomen. CECT has enhanced the diagnosis of significant liver injury in the stable patient. Virtually all penetrating injuries to the abdomen should be explored promptly, especially when they occur in conjunction with hypotension. The surgeon should be aware that penetrating injuries to the right lower chest, presenting with haemothorax, may have penetrated the diaphragm, with the bleeding originating from the liver.

The treatment of severe liver injuries begins with temporary control of haemorrhage. Most catastrophic bleeding from hepatic injury is venous in nature and can therefore be controlled by liver packs. If there is bright red blood pouring from the parenchyma, it is then appropriate to apply a vascular clamp to the porta hepatis (Pringle's manoeuvre), via the gastrohepatic ligament. If this controls the bleeding, the surgeon should be suspicious of hepatic arterial or possible portal venous injury. While control is being obtained, it is important to establish more intravenous access lines and other monitoring devices as needed. (The treatment of bleeding is to stop the bleeding!) Hypothermia should be anticipated and corrective measures taken.

After haemostasis and haemodynamic resuscitation has been achieved, any packs in the two lower abdominal quadrants are removed. If there is abdominal contamination, it is appropriate to control this as rapidly as possible. The packs in the left upper quadrant are then removed. If there is an associated spleen injury a decision must be made either to remove it promptly or to clamp the hilum of the spleen temporarily with a vascular clamp to reduce further bleeding. Finally, the packs are removed in the right upper quadrant and the injury to the liver rapidly assessed.

If there is bleeding from the porta hepatis, careful exploration for a portal vein injury should be carried out, with repair or shunting. Traction on the dome of the liver, which produces a sudden gush of retrohepatic blood, should make the surgeon suspicious of injury to the posterior hepatic veins or inferior vena. The options for hepatic vein and cava injuries include direct compression (packing), extension of the laceration and direct control, atrial–caval shunt, non-shunt isolation (Heaney technique) and veno–veno bypass. Liver packs are increasingly used as definitive treatment, particularly when there is bilobar injury, or they can simply buy time if the patient develops a coagulopathy, hypothermia or there are no blood resources.

Pancreatic Trauma

Blunt pancreatic trauma can be subtle and presentation is often that of associated injuries. The pancreas is a retroperitoneal organ and there may be no intraperitoneal signs. History can be helpful, for example if there is a history of epigastric trauma. The physical examination is often misleading. Amylase and blood count are non-specific, and may be normal; CT is 85% accurate, but does not always help with the grading of the injury, and endoscopic retrograde cholangiopancreatography (ERCP) can be helpful in selected stable patients.

Penetrating pancreatic trauma is usually obvious since the patient will almost invariably have been explored for other injuries.61

Once the retroperitoneum has been violated it is imperative for the surgeon to do a thorough exploration in the central region. This includes:

  • an extended Kocher manoeuvre to examine the entire duodenum;
  • a right medial visceral rotation to examine the back of the head of the pancreas;
  • division of the ligament of Treitz to examine the front of the pancreas;
  • division of the gastrocolic omentum to examine the top of the pancreas;
  • a left medial visceral rotation to examine the anterior and posterior surfaces of the tail of the pancreas as it extends towards the splenic hilum.

Injury to the main pancreatic duct appears to increase the pancreatic-specific morbidity and mortality.62

Any parenchymal haematoma of the pancreatic head should be thoroughly explored and should include irrigation of the haematoma and adequate drainage with a suction drain (e.g. a Blake® drain).

Injuries to the tail and body of the pancreas can usually either be drained or, if a strong suspicion for major ductal injury is present (Grade III injury), resection can be carried out as a distal pancreatectomy. In young patients, the duct is not usually visualised following trauma and so cannot specifically be tied off.

The injuries that vex the surgeon most, however, are those to the head of the gland, particularly those with juxtaposed injuries or also involving the duodenum. Resection (Whipple's procedure) is usually reserved for those patients who have destructive injuries or those in whom the blood supply to the duodenum and pancreatic head has been embarrassed. This procedure should only be embarked upon as a planned procedure in the stable patient, with consideration being given to appropriate damage control procedures in all others. The remainder are usually treated with variations of drainage and pyloric exclusion. This would include tube duodenostomy and extensive closed drainage around the injury site. Common duct drainage is not indicated.63 There are limited guidelines for the management of major pancreatic trauma (Box 13.5).

 

Box 13.5   Evidence-based guidelines for diagnosis and management of pancreatic trauma: summary of recommendations

Recommendations made where there is no adequate evidence as to the most effective practice

  1. Delay in the recognition of main pancreatic duct injury causes increased morbidity (Evidence level III)
  2. CT scan is suggestive, but not diagnostic of, pancreatic injury (Evidence level III)
  3. Amylase/lipase levels are suggestive, but not diagnostic of, pancreatic injury (Evidence level III)
  4. Grade I and II injuries can be managed by drainage alone (Evidence level III)
  5. Grade III injuries can be managed with resection and drainage (Evidence level III)
  6. Closed suction is preferred to sump suction (Evidence level III)

Aorta And Inferior Vena Cava

Aortic and caval injuries are primarily a problem of access (rapid) and control of haemorrhage. If the surgeon opens the abdomen and there is extensive retroperitoneal bleeding centrally, there are two options. If the bleeding is primarily venous in nature, the right colon should be mobilised to the midline, including the duodenum and head of the pancreas, using a right medial visceral rotation. This will expose the infrarenal cava and infrarenal aorta. It will also facilitate access to the portal vein.

If the bleeding is primarily arterial in nature, it is best to approach the injury from the left. Initial control can be obtained by direct pressure at the oesophageal hiatus or via the lesser sac. Additional exposure can be obtained by simply dividing the left crus of the diaphragm. Exposure includes reflecting the left colon medially and mobilising the pancreas, kidney and spleen to the midline. By approaching the aorta from the left lateral position it is possible to identify the plane of Leriche more rapidly than by approaching it through the lesser sac. The problem is the coeliac and superior mesenteric ganglia, both of which can be quite dense and hinder dissection around the origins of the coeliac and superior mesenteric arteries.

Once isolation of the injury has been achieved, treatment of aortic or caval injuries is usually straightforward, either by direct suture or occasionally grafting. Caval injuries below the renal vein, if extensive, can be ligated, although repair is preferred. Injuries above the renal veins in the cava should be repaired if at all possible. If there is injury to the posterior wall of the vein, it is preferable to isolate the segment and repair it from within the vein using an anterior approach.

Colonic Injuries

Many studies have shown primary repair of colonic injuries to be safe in patients at low risk of postoperative complications; however, identification of the high-risk patient in whom avoidance of an intraperitoneal colonic suture line may be beneficial is still controversial. The significant morbidity and financial costs associated with the creation and reversals of colostomy, and the destructive effect of colostomy on the patient's quality of life, have been cited as evidence to support the primary repair of colonic wounds.60,6466

Stone and Fabian excluded patients from primary repair in the presence of shock, major blood loss, more than two organs injured, faecal contamination more than ‘minimal’, delay to repair of more than 8 hours and wounds of the colon or abdominal wall so destructive as to require resection.67 Murray et al. reviewed 140 patients with colonic injuries that required resection.68 They suggested that the majority of patients can safely undergo colonic resection with primary colo-colonic anastomosis, even for severe injuries; however, there is a subgroup of critically injured patients at higher risk of anastomotic leakage who may be best treated by colostomy.

In the ‘physiologically challenged’ patient, hypoperfusion of splanchnic tissues leads to local tissue hypoxia, and repair or anastomosis under those circumstances is more likely to fail. This high-risk group should be treated by damage control techniques with restoration of continuity of the bowel once the physiological insult has been corrected. Outcome is determined by the patient's physiological envelope and not by anatomical integrity69,70 (Box 13.6).

 

Box 13.6

Evidence-based guidelines for management of colon injuries: summary of recommendations

Strong recommendation

  1. Primary repair is supportedfor non-destructive(involvement of < 50% of the bowel wall without devascularisation) colon wounds in the absence of peritonitis. The risk is not obviated by colostomy, and intra-abdominal sepsis frequently occurs in the absence of suture line disruption. Accordingly, the majority of colon injuries in civilian practice may be managed by primary repair (Evidence level I)

Recommendations based on evidence of effectiveness

  1. Patients with penetrating colon wounds that are destructivecan undergo resection and primary anastomosis if they:
  • are haemodynamically stable without evidence of shock
  • have no significant underlying disease
  • have minimal associated injuries (PATI < 25, ISS < 25)
  • have no peritonitis

(Evidence level II)

  1. Given the small number of patients in high-risk categories with destructive colon injuries requiring resection who were randomised to primary repair, there is still room to consider colostomy in the management of these patients (Evidence level II)
  2. Patients with shock, underlying disease, significant associated injuries or peritonitis should have destructive wounds managed by resection and colostomy (Evidence level II)
  3. Colostomies performed following colon and rectal trauma can be closed within 2 weeks if contrast enema is performed to confirm distal healing. This recommendation pertains to patients who do not have non-healing bowel injury, unresolved wound sepsis or are unstable (Evidence level II)
  4. A barium enema should not be performed to rule out colon cancer or polyps prior to colostomy closure for trauma in patients who otherwise have no indications for being at risk (Evidence level II)
  5. Multiple blood transfusions, shock and a high PATI reliably identify patients at high risk of septic complications following penetrating colon injuries (Evidence level II)

Reproduced from Cayten CG, Fabian TC, Garcia VF et al. Patient Management Guidelines for penetrating intraperitoneal injuries. EAST Practice Parameter Working Group; http://www.east.org.

Complex Pelvic Fracture

Complex pelvic fractures can be some of the most difficult injuries to treat. Initially, they can cause devastating haemorrhage and subsequently may be associated with overwhelming pelvic sepsis and distant multiple organ failure.

For those patients who present with complex pelvic fractures and who are haemodynamically stable, diagnostic studies should be carried out as rapidly as possible, including plain films of the pelvis, CECT and arteriogram. All haemodynamically unstable patients with such pelvic fractures should be taken to the operating theatre as soon as possible, to allow continuing resuscitation including packing.71

The priorities facing the surgeon are to control the pelvic haemorrhage and rule out other intra-abdominal organ injuries with associated haemorrhage. Sometimes it is prudent to perform a rapid laparotomy to rule out additional haemorrhage, but if there is not a strong suspicion of abdominal bleeding, it is best to avoid laparotomy until the pelvic bleeding has been arrested (Box 13.7). Extrapelvic packing should be considered.

 

Box 13.7

Evidence-based guidelines for management of haemorrhage in pelvic fracture: summary of recommendations

Recommendations based on evidence of effectiveness

  1. Patients with evidence of unstable fractures of the pelvis associated with hypotension should be considered for some form of pelvic stabilisation (Evidence level II)
  2. Patients with evidence of unstable pelvic fractures who warrant laparotomy should receive external pelvic stabilisation prior to laparotomy incision (Evidence level II)
  3. Patients with a major pelvic fracture who have signs of ongoing bleeding after non-pelvic sources of blood loss have been ruled out should be considered for pelvic angiography and possible embolisation (Evidence level II)
  4. Patients with major pelvic fractures who are found to have bleeding in the pelvis, which cannot be adequately controlled at laparotomy, should be considered for pelvic angiography and possible embolisation (Evidence level II)
  5. Patients with evidence of arterial extravasation of intravenous contrast in the pelvis by computed tomography should be considered for pelvic angiography and possible embolisation (Evidence level II)
  6. Patients with hypotension and gross blood in the abdomen or evidence of intestinal perforation warrant emergency laparotomy (Evidence level II)
  7. The diagnostic peritoneal tap appears to be the most reliable diagnostic test for this purpose. Urgent laparotomy is warranted for patients who demonstrate signs of continued intra-abdominal bleeding after adequate resuscitation or evidence of intestinal perforation (Evidence level II)

Recommendation made where there is no adequate evidence as to the most effective practice

  1. Patients with evidence of unstable fractures of the pelvis not associated with hypotension but who do require a steady and ongoing resuscitation should be considered for some form of external pelvic stabilisation (Evidence level III)

Reproduced from DiGiacomo JC, Bonadies JA, Cole FJ et al. Practice Management Guidelines for haemorrhage in pelvic fracture. EAST Practice Management Guidelines Work Group; http://www.east.org.

Technique of extraperitoneal packing

The patient is positioned supine and, if necessary, an external fixator or C-clamp is applied. A 5-cm vertical midline suprapubic incision is made and the fascia anterior to the rectus muscle is exposed. The fascia is divided until the symphysis can be palpated directly (the pre-peritoneal plane has been reached). The fascia is divided in the midline, protecting against urinary bladder damage. From the symphysis the pelvic brim is followed laterally and posterior to the sacroiliac (SI) joint (first bony irregularity felt), first on the side of major bleeding (most often the side of SI joint disruption). The fascia is then dissected away from the pelvic brim as far posteriorly as possible at the level of the pelvic brim. The bladder and rectum are then held to the opposite side while the plane is opened bluntly down to the pelvic floor, avoiding injury to vascular and nerve structures in the area. The space is then packed with vascular or abdominal swabs, starting posteriorly and distal to the tip of the sacrum, and building the packs cranially and anteriorly.72 In an unbroken pelvis with intact pelvic floor, one should be able to accommodate three large abdominal swabs on each side. In severe pelvic fractures, efficient packing might require many more (> 10 packs is not unusual). The number of packs needed is defined by the available space and the appropriate force applied. The outer fascia is closed with a single running suture and the skin is closed. If laparotomy is required, it should follow the packing procedure.

After a damage control laparotomy with extraperitoneal pelvic packing, a temporary abdominal closure is appropriate. As in the abdomen, the packs should be removed after 24–48 hours.

Stabilisation of the pelvis is initially by compression (using a knotted sheet or external fixation). External fixation is used for stabilisation of the anterior pelvis but will fail if the posterior pelvis is unstable. These patients may require plating of the SI joint and are best managed by temporary stabilisation using a pelvic binder, and then assessed by CT and arteriography. Based on location of the injury, colostomy may be required in order to prevent contamination of a perineal wound in the post-injury period. In general, all compound injuries involving the perineum and perianal area should have a diverting colostomy (see also Chapter 11).

In patients with associated major perineal injuries, after the initial fixation of the pelvis has been obtained, daily wound examination, debridement and gradual removal of packs should take place. A caveat of pack removal is that the longer they are left in, the greater the risk of pelvic sepsis, and ideally they should be removed within 24–48 hours.

Non-Operative Approach To Abdominal Solid-Organ Injuries

There is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal injury, both blunt and penetrating in nature. Most surgeons who practice SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient, as a contraindication to attempting non-operative management.73 Almost all regard CT as essential, and their preparedness to consider SNOM was related to injury extent, as well as the experience of the surgeon concerned.

Liver

In 1990, it was suggested that a number of patients with blunt liver injuries might be candidates for expectant management,74 and in a multicentre study it was found that, in the hands of experienced trauma surgeons, the success with the non-operative approach to liver injuries was greater than 98%.75

Currently, all patients with liver injuries following blunt trauma should be considered candidates for non-operative management, provided that haemodynamic stability can be assured. Unlike the spleen, delayed haemorrhage from the liver is rare. The complications in those patients managed expectantly are frequently related to the biliary system and can usually be managed by endoscopic or interventional techniques. While non-operative management has most frequently been applied to patients with blunt injuries, stable patients with liver injuries as the result of penetrating trauma have also been managed expectantly.76

Spleen

In children, the success of non-operative management of the spleen is over 90%, but this has not been the experience in adults. Currently, most surgeons will attempt to manage the injured adult spleen with an AAST grade I–III injury non-operatively; the management of grade IV or V injuries remains controversial. Patients over 55 years of age generally do not do as well and splenectomy continues to be recommended (see Box 13.8).77

 

Box 13.8

Practice management guidelines for the non-operative management of blunt injury to the liver and spleen: summary of recommendations

Recommendations based on evidence of effectiveness

  1. There are class II and mostly class III data to suggest that non-operative management of blunt hepatic and/or splenic injury in a haemodynamically stable patient is reasonable (Evidence level II)
  2. The severity of hepatic or splenic injury (as suggested by CT grade or degree of haemoperitoneum), neurological status and/or the presence of associated injuries are not contraindications to non-operative management (Evidence level II)
  3. Abdominal CT is the most reliable method to identify and assess the severity of injury to the spleen or liver (Evidence level II)

Recommendations made where there is no adequate evidence as to the most effective practice

  1. The clinical status of the patient should dictate the frequency of follow-up scans (Evidence level III)
  2. Initial CT of the abdomen should be performed with oral and intravenous contrast to facilitate the diagnosis of hollow viscus injuries (Evidence level III)
  3. Medical clearance to resume normal activity status should be based on evidence of healing (Evidence level III)
  4. Angiographic embolisation is an adjunct in the non-operative management of the haemodynamically stable patient with hepatic and splenic injuries and evidence of ongoing bleeding (Evidence level III)

Reproduced from Alonso M, Brathwaite C, Garcia V et al. Practice Management Guidelines Work Group. Blunt liver and spleen injuries: non-operative management; http://www.east.org/tpg/livspleen.

Penetrating Injury

In those patients with penetrating injury to the abdomen, who are haemodynamically unstable, have peritonitis or clear signs of abdominal penetration, there is little debate regarding the need for urgent laparotomy. However, in those patients with penetrating injury where the wounds are tangential, it is clear that if these patients are stable, without peritonitis, some patients may not need surgery despite the penetrating nature of the wound.

In a recent study of gunshot wounds managed non-operatively, clinical examination was a key marker, and all failures occurred within 24 hours of admission, setting a minimum required observation period before discharge.78

Laparoscopy may play a role, particularly in the clarification of penetration of the abdominal cavity and of the diaphragm. Current evidence-based guidelines for the management of penetrating trauma are limited, and are perhaps more suited to high-volume centres than those only occasionally dealing with penetrating trauma79 (see Box 13.9).

 

Box 13.9

Selective non-operative management of penetrating injury of the abdomen: summary of recommendations

Strong recommendations

  1. Patients who are haemodynamically unstable or who have diffuse abdominal tenderness should be taken for laparotomy as an emergency (Evidence level I)
  2. Patients who are haemodynamically stable with an unreliable clinical examination (i.e. brain injury, spinal cord injury, intoxication or need for sedation or anaesthesia) should have further diagnostic investigations done for intraperitoneal injury or undergo exploratory laparotomy (Evidence level I)
  3. Routine laparotomy is not indicated in haemodynamically stable patients and abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centres with surgical expertise (Evidence level II)
  4. A routine laparotomy is not indicated in haemodynamically stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs (Evidence level II)
  5. Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (Evidence level II)
  6. In patients selected for initial non-operative management, abdomino-pelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (Evidence level II)
  7. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations as well as peritoneal penetration (Evidence level II)

Recommendations made where there is no adequate evidence as to the most effective practice

  1. Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness (Evidence level III)
  2. The vast majority of patients with penetrating abdominal trauma, managed non-operatively, may be discharged after 24 hours observation, in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (Evidence level III)

Reproduced from Como JJ, Bokhari F, Chiu WC et al. Practice Management Guidelines Working Group. Penetrating trauma: selective non-operative management. Eastern Association for the Surgery of Trauma. J Trauma 2010; 68(3):721–33. With permission from Lippincott, Williams & Wilkins.

Interventional radiology

In a significant number of patients, interventional radiology, with arterial embolisation (AE), stent or stentgraft placement, has become either the first line of treatment or an important adjunct to non-operative management of abdominal and other injuries.80 Clinical evaluation, however, determines the course of treatment. Patients who are haemodynamically stable should be evaluated with CECT.

Angio-Embolisation In Liver Injuries

Non-operative management (NOM) of blunt liver injuries in haemodynamically stable or stabilised patients has become standard practice. The introduction of AE has been reported to increase the success rate of NOM to well above 80%.81

Operative treatment of liver injuries, even in experienced hands, still carries a high mortality and morbidity risk. AE seems to be a valuable adjunct to operative management since most patients are haemodynamically abnormal at the end of a damage control laparotomy, and ongoing arterial bleeding is difficult to rule out clinically.

The indications for AE should include CT evidence of ongoing bleeding with contrast extravasation outside or within the liver, a drop in haemoglobin, tachycardia and haemoperitoneum, as well as formation of pseudoaneurysm. The risk of bleeding with NOM in OIS grade 4 and 5 liver injuries is significant, and operative intervention, with packing, followed by AE is preferable.82

Angio-Embolisation In Blunt Splenic Injuries

Indications for AE include CT evidence of ongoing bleeding with contrast extravasation outside or within the spleen, a drop in haemoglobin, tachycardia and haemoperitoneum, as well as formation of pseudoaneurysm. Selective catheterisation of the splenic artery is performed, followed by superselective catheterisation of the bleeding arteries or feeders to the pseudoaneurysm.83,84

Angio-Embolisation In Severe Pelvic Fractures

Severe pelvic fractures, particularly with disruption of the sacroiliac joints, are associated with a high risk of severe arterial and venous bleeding. The application of a sheet or external fixation may control the venous bleeding, which constitutes about 85% of all pelvic bleeding. However, arterial bleeding often requires AE, which has become the first line of treatment in patients stable enough to reach angiography.85 Established indications are CT evidence of ongoing bleeding such as contrast extravasation and pelvic haematoma with bladder compression and ongoing transfusion requirements without evidence of other extrapelvic bleeding sources.

There is also a possibility in this subgroup of patients of severe venous bleeding. The patient in shock refractory to resuscitation should be considered for damage control with (extraperitoneal) pelvic packing before AE.

AE is carried out after performing an abdominal aortography followed by selective catheterisation of the internal iliac arteries. When contrast extravasation is demonstrated, the bleeding vessels are catheterised superselectively and embolised with coils, or a combination of coils and gelfoam particles.

 

Key points

  • In order to avoid missed injuries and preventable deaths, trauma patients who have any of the risk factors for abdominal injury should undergo objective evaluation of the abdomen.
  • Delay in surgery is the most common cause of unnecessary ongoing bleeding.
  • In patients who are unstable, the preferred objective study is a bedside ultrasound. If an ultrasound examination is unavailable or equivocal, a DPL should be performed.
  • In stable patients, abdominal CT with intravenous contrast is the preferred method of objective examination of the abdomen.
  • When laparotomy is required, it should be approached in a systematic fashion and the treatment of injuries prioritised.
  • In patients who are cold, coagulopathic and acidotic, a damage control operation should be accomplished promptly.

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Recommended reading

Boffard K.D., ed. Manual of definitive surgical trauma care, 3rd ed, London: Hodder Arnold, 2011.

Committee on Trauma of the American College of Surgeons. Resources for optimal care of the trauma patient. Chicago, IL: Committee on Trauma of the American College of Surgeons; 2006.

Peitzman A., Rhodes M., Schwab C.W., eds. The trauma manual: Trauma and acute care surgery. Philadelphia, PA: Lippincott, Williams & Wilkins, 2008.

Websites

Organ Injury Scaling of the American Association for the Surgery of Trauma.

www.aast.org

Eastern Association for the Surgery of Trauma.

Practice Management Guidelines.

www.east.org

World Society of the Abdominal Compartment Syndrome (WSACS).

www.wsacs.org

Appendix: Scaling system for organ-specific injuries

Scaling System For Organ-Specific Injuries

Table A1 Cervical vascular organ injury scale

Table A2 Chest wall injury scale

Table A3 Heart injury scale

Table A4 Lung injury scale

Table A5 Thoracic vascular injury scale

Table A6 Diaphragm injury scale

Table A7 Spleen injury scale

Table A8 Liver injury scale

Table A9 Extrahepatic biliary tree injury scale

Table A10 Pancreas injury scale

Table A11 Oesophagus injury scale

Table A12 Stomach injury scale

Table A13 Duodenum injury scale

Table A14 Small-bowel injury scale

Table A15 Colon injury scale

Table A16 Rectum injury scale

Table A17 Abdominal vascular injury scale

Table A18 Adrenal organ injury scale

Table A19 Kidney injury scale

Table A20 Ureter injury scale

Table A21 Bladder injury scale

Table A22 Urethra injury scale

Table A23 Uterus (non-pregnant) injury scale

Table A24 Uterus (pregnant) injury scale

Table A25 Fallopian tube injury scale

Table A26 Ovary injury scale

Table A27 Vagina injury scale

Table A28 Vulva injury scale

Table A29 Testis injury scale

Table A30 Scrotum injury scale

Table A31 Penis injury scale

Table A32 Peripheral vascular organ injury scale

Table A1

Cervical vascular organ injury scale

*Increase one grade for multiple grade III or IV injuries involving more than 50% vessel circumference. Decrease one grade for less than 25% vessel circumference disruption for grade IV or V.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling VII: Cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum. J Trauma 1996; 41(3):523–4. With permission from Lippincott, Williams & Wilkins.

Table A2

Chest wall injury scale

*This scale is confined to the chest wall alone and does not reflect associated internal or abdominal injuries. Therefore, further delineation of upper versus lower or anterior versus posterior chest wall was not considered, and a grade VI was not warranted. Specifically, thoracic crush was not used as a descriptive term; instead, the geography and extent of fractures and soft tissue injury were used to define the grade. Upgrade by one grade for bilateral injuries.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ. Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 1992; 33:337–8. With permission from Lippincott, Williams & Wilkins.

Table A3

Heart injury scale

*Advance one grade for multiple wounds to a single chamber or multiple chamber involvement.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling IV: thoracic, vascular, lung, cardiac and diaphragm. J Trauma 1994; 36(3):299–300. With permission from Lippincott, Williams & Wilkins.

Table A4

Lung injury scale

*Advance one grade for bilateral injuries up to grade III. Haemothorax is scored under thoracic vascular injury scale.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling IV: thoracic, vascular, lung, cardiac and diaphragm. J Trauma 1994; 36(3):299–300. With permission from Lippincott, Williams & Wilkins.

Table A5

Thoracic vascular injury scale

*Increase one grade for multiple grade III or IV injuries if more than 50% circumference. Decrease one grade for grade IV injuries if less than 25% circumference.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling IV: thoracic, vascular, lung, cardiac and diaphragm. J Trauma 1994; 36(3):299–300. With permission from Lippincott, Williams & Wilkins.

Table A6

Diaphragm injury scale

*Advance one grade for bilateral injuries up to grade III.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling IV: thoracic, vascular, lung, cardiac and diaphragm. J Trauma 1994; 36(3):299–300. With permission from Lippincott, Williams & Wilkins.

Table A7

Spleen injury scale (1994 revision)

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ et al. Organ Injury Scaling: spleen and liver (1994 revision). J Trauma 1995; 38(3):323–4. With permission from Lippincott, Williams & Wilkins.

Table A8

Liver injury scale (1994 revision)

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ et al. Organ Injury Scaling: spleen and liver (1994 revision). J Trauma 1995; 38(3):323–4. With permission from Lippincott, Williams & Wilkins.

Table A9

Extrahepatic biliary tree injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A10

Pancreas injury scale

*Advance one grade for multiple injuries up to grade III. 863.51, 863.91 – head; 863.99, 862.92 – body; 863.83, 863.93 – tail. Proximal pancreas is to the patient's right of the superior mesenteric vein.

Reproduced from Moore EE, Cogbill TH, Malangoni MA et al. Organ Injury Scaling: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990; 30(11):1427–9. With permission from Lippincott, Williams & Wilkins.

Table A11

Oesophagus injury scale

*Advance one grade for multiple lesions up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A12

Stomach injury scale

*Advance one grade for multiple lesions up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A13

Duodenum injury scale

*Advance one grade for multiple injuries up to grade III.

D1, first position of duodenum; D2, second portion of duodenum; D3, third portion of duodenum; D4, fourth portion of duodenum.

Reproduced from Moore EE, Cogbill TH, Malangoni MA et al. Organ Injury Scaling: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990; 30(11):1427–9. With permission from Lippincott, Williams & Wilkins.

Table A14

Small-bowel injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Cogbill TH, Malangoni MA et al. Organ Injury Scaling: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990; 30(11):1427–9. With permission from Lippincott, Williams & Wilkins.

Table A15

Colon injury scale

*Advance one grade for multiple injuries up to grade III.

With ICD-9: 863.40/863.50, non-specific site in colon; 863.41/863.51, ascending; 863.42/863.52, transverse; 863.43/863.53, descending; 863.44/863.54, sigmoid.

Reproduced from Moore EE, Cogbill TH, Malangoni MA et al. Organ Injury Scaling: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990; 30(11):1427–9. With permission from Lippincott, Williams & Wilkins.

Table A16

Rectum injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Cogbill TH, Malangoni MA et al. Organ Injury Scaling: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990; 30(11):1427–9. With permission from Lippincott, Williams & Wilkins.

Table A17

Abdominal vascular injury scale

*This classification system is applicable to extraparenchymal vascular injuries. If the vessel injury is within 2 cm of the organ parenchyma, refer to specific organ injury scale. Increase one grade for multiple grade III or IV injuries involving > 50% vessel circumference. Downgrade one grade if < 25% vessel circumference laceration for grades IV or V.

NS, not scored.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ. Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 1992; 33:337–8. With permission from Lippincott, Williams & Wilkins.

Table A18

Adrenal organ injury scale

*Advance one grade for bilateral lesions up to grade V.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum. J Trauma 1996; 41(3):523–4. With permission from Lippincott, Williams & Wilkins.

Table A19

Kidney injury scale

*Advance one grade for bilateral injuries up to grade III.

Reproduced from Moore EE, Shackford SR, Pachter HL et al. Organ Injury Scaling: spleen, liver and kidney. J Trauma 1989; 29(12):1664–6. With permission from Lippincott, Williams & Wilkins.

Table A20

Ureter injury scale

*Advance one grade for bilateral up to grade III.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ. Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 1992; 33:337–8. With permission from Lippincott, Williams & Wilkins.

Table A21

Bladder injury scale

*Advance one grade for multiple lesions up to grade III.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ. Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 1992; 33:337–8. With permission from Lippincott, Williams & Wilkins.

Table A22

Urethra injury scale

*Advance one grade for bilateral injuries up to grade III.

Reproduced from Moore EE, Cogbill TH, Jurkovich GJ. Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 1992; 33:337–8. With permission from Lippincott, Williams & Wilkins.

Table A23

Uterus (non-pregnant) injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A24

Uterus (pregnant) injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A25

Fallopian tube injury scale

*Advance one grade for bilateral injuries up to grade III

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995: 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A26

Ovary injury scale

*Advance one grade for bilateral injuries up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A27

Vagina injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A28

Vulva injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Jurkovich GJ, Knudson MM et al. Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), uterus (pregnant), Fallopian tube, and ovary. J Trauma 1995; 39(6):1069–70. With permission from Lippincott, Williams & Wilkins.

Table A29

Testis injury scale

*Advance one grade for bilateral lesions up to grade V.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum. J Trauma 1996; 41(3):523–4. With permission from Lippincott, Williams & Wilkins.

Table A30

Scrotum injury scale

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum. J Trauma 1996; 41(3):523–4. With permission from Lippincott, Williams & Wilkins.

Table A31

Penis injury scale

*Advance one grade for multiple injuries up to grade III.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum. J Trauma 1996; 41(3):523–4. With permission from Lippincott, Williams & Wilkins.

Table A32

Peripheral vascular organ injury scale

*Increase one grade for multiple grade III or IV injuries involving > 50% vessel circumference. Decrease one grade for < 25% vessel circumference disruption for grades IV or V.

Reproduced from Moore EE, Malangoni MA, Cogbill TH et al. Organ Injury Scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum. J Trauma 1996; 41(3):523–4. With permission from Lippincott, Williams & Wilkins.