Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
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.
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
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
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
1.
Anderson, I.D., Woodford, M., de Dombal, T., et al. A retrospective study of 1000 deaths from injury in England and Wales.
Br Med J
. 1988;296:1305–1308.
2.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Trauma: Who cares?
www.ncepod.org/2007b.htm
; [accessed January 2008].
3.
West, J.C., Trunkey, D.D., Lim, R.C., System of trauma care: a study of two counties.
Arch Surg
1979;114:455–460.
435058
4.
Mackersie, R.C., Tiwary, A.D., Shackford, S.R., et al, Intra-abdominal injury following blunt trauma: identifying the high-risk factors.
Arch Surg
1989;124:809–813.
2742481
5.
Nguyen, H.B., Banta, J.E., Cho, T.W., et al. Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.
Shock
. 2008;30(1):23–28.
6.
Husain, F.A., Martin, M.J., Mullenix, P.S., et al, Serum lactate and base deficit as predictors of mortality and morbidity.
Am J Surg
. 2003;185(5):485–491.
12727572
7.
Manikis, P., Jankowski, S., Zhang, H., et al, Correlation of serial blood lactate levels to organ failure and mortality after trauma.
Am J Emerg Med
. 1995;13(6):619–622.
7575797
8.
Thomas, S.H., Helicopter EMS transport outcomes literature: annotated review of articles published 2004–2006.
PreHosp Emerg Care
. 2007;11(4):477–488.
17907037
9.
Sullivent, E.E., Faul, M., Wald, M.M., Reduced mortality in injured adults transported by helicopter emergency medical services.
PreHosp Emerg Care
. 2011;15(3):295–302.
21524205
10.
Galvagno, S.M., Jr., Haut, E.R., Zafar, S.N., et al, Association between helicopter vs ground emergency medical services and survival for adults with major trauma.
JAMA
. 2012;307(15):1602–1610.
22511688
11.
Resources for optimal care of the trauma patient. Committee on Trauma of the American College of Surgeons, 2006.
The definitive manual of standards by which trauma and trauma services are set up and judged.
12.
Bickell, W.H., Wall, M.J., Pepe, P.E., et al, Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.
N Engl J Med
1994;331:1105–1109.
7935634
13.
Johansson, P.I., Ostrowski, S.R., Secher, N.H., Management of major blood loss: an update.
Acta Anaesthesiol Scand
. 2010;54(9):1039–1049.
20626354
An outstanding review of the current state of knowledge regarding blood administration, massive blood transfusion and goal-directed transfusion therapy.
14.
Johannson, P.I., Emerging treatment strategies for trauma-induced coagulopathy.
Br J Surg
. 2012;99(Suppl. 1):40–50.
22441855
15.
American College of Surgeons. Advanced Trauma Life Support Programme: Abdominal trauma. Chicago, IL: American College of Surgeons, 2008.
16.
Brooks, A., Bowley, D.M., Boffard, K.D., Bullet markers – a simple technique to assist in the evaluation of penetrating trauma.
J R Army Med Corps
. 2002;148(3):259–261.
12469427
17.
Smith-Bindman, R., Lipson, J., Marcus, R., et al, Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.
Arch Intern Med
. 2009;169(22):2078–2086.
20008690
18.
Brenner, D.J., Hall, E.J., Computed tomography: an increasing source of radiation exposure.
N Engl J Med
2007;357:2277–2284.
18046031
19.
Donohue, J.H., Federle, M.P., Griffiths, B.G., et al. Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries.
J Trauma
. 1987;27:11–17.
20.
Brasel, K.J., Olson, C.H., Stafford, R., et al, Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma.
J Trauma
1998;44:889–892.
9603094
21.
Sherck, J.P., Oakes, D.D. Intestinal injuries missed by computed tomography.
J Trauma
. 1990;30:1–7.
22.
McKenney, M.G., Martin, L., Lopez, C., 1000 consecutive ultrasounds for blunt abdominal trauma.
J Trauma
1996;40:607–612.
8614041
23.
Rozycki, G.S., Ochsner, M.G., Schmidt, J.A., et al, A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment.
J Trauma
1995;39:492–497.
7473914
24.
Root, H.D., Hauser, C.W., McKinley, C.R., et al, Diagnostic peritoneal lavage.
Surgery
1965;57:633–637.
14295771
25.
Brooks, A.J., Boffard, K.D. Current technology: laparoscopic surgery in trauma.
Trauma
. 1999;1:53–60.
26.
Fabian, T.C., McCord, S. Therapeutic laparoscopy in trauma.
Trauma Quart
. 1993;34:313–315.
27.
Zantut, L.F., Ivatury, R.R., Smith, S., Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicentre experience.
J Trauma
1997;42:825–831.
9191663
28.
Degiannis, E., Levy, R., Sofianos, C., et al, Diaphragmatic herniation after penetrating trauma.
Br J Surg
1996;83:88–91.
8653376
29.
Renz, B.M., Feliciano, D.V., Unnecessary laparotomies for trauma: a prospective study of morbidity.
J Trauma
1995;38:350–356.
7897713
30.
Ross, S.E., Dragon, G.M., O'Malley, K.F., et al, Morbidity of negative celiotomy in trauma.
Injury
1995;26:393–394.
7558260
31.
Muckart, D.J., Abdool-Carim, A.T., King, B., Selective conservative management of abdominal gunshot wounds: a prospective study.
Br J Surg
1990;77:652–655.
2383733
32.
Demetriades, D., Charalambides, D., Lakhoo, M., et al, Gunshot wound of the abdomen: role of selective conservative management.
Br J Surg
1991;78:220–222.
2015480
33.
Maggisano, R., Nathens, A., Alexandrova, N.A., et al. Traumatic rupture of the thoracic aorta: should one always operate immediately?
Ann Vasc Surg
. 1995;9:44–46.
34.
Wisner, D.H., Victor, N.S., Holcroft, J.W., The priorities in the management of multiple trauma: intracranial versus intra-abdominal injury.
J Trauma
1993;35:271–278.
8355308
35.
Archer, L.P., Rogers, R.B., Shackford, S.R., Selective nonoperative management of liver and splenic injuries in neurologically impaired adult patients.
Arch Surg
1996;131:309–315.
8611097
36.
Rotondo, M.F., Schwab, C.W., McGonigal, M.D., et al, ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury.
J Trauma
1993;35:375–382.
8371295
37.
Loveland, J.A., Boffard, K.D., Damage control in the abdomen and beyond.
Br J Surg
. 2004;91(9):1095–1101.
15449259
38.
Hirshberg, A., Mattox, K.L. Planned re-operation for severe trauma.
Ann Surg
. 1995;222:3–8.
39.
Garrison, J.R., Richardson, J.D., Hilakos, A., et al, Predicting the need to pack early for severe intra-abdominal haemorrhage.
J Trauma
1996;40:923–929.
8656478
40.
Schein, M., Saadia, R., Jamieson, J.R., et al, The “sandwich technique” in the management of the open abdomen.
Br J Surg
. 1986;73(5):369–370.
3708284
41.
Burch, J., Moore, E., Moore, F., et al, The abdominal compartment syndrome.
Surg Clin North Am
1996;76:833–842.
8782476
42.
World Society for Abdominal Compartment Syndrome,
www.wsacs.org
; [accessed February 2012].
43.
Sugrue, M., Buist, M.D., Hourihan, F., et al, Prospective study of intra-abdominal hypertension and renal function after laparotomy.
Br J Surg
1995;82:235–238.
7749700
44.
Kron, I.L., Harman, P.K., Nolan, S.P. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration.
Ann Surg
. 1984;199:28–30.
45.
Cheatham, M.L., White, M.W., Sagraves, S.G., et al, Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension.
J Trauma
2000;49:621–626.
11038078
46.
Malbrain, M.L., Chiumello, D., Pelosi, P., et al, Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-centre epidemiological study.
Crit Care Med
2005;33:315–322.
15699833
47.
Malbrain, M.L., Chiumello, D., Pelosi, P., et al, Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study.
Intensive Care Med
2004;30:822–829.
14758472
48.
Malbrain, M.L., Cheatham, M.L., Kirkpatrick, A., et al, Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome.
I. Definitions. Intensive Care Med
. 2006;32(11):1722–1732.
16967294
49.
Cheatham, M.L., Malbrain, M.L., Kirkpatrick, A., et al, Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome.
II. Definitions. Intensive Care Med
. 2007;33(6):951–962.
17377769
50.
Maxwell, R.A., Fabian, T.C., Croce, M.A., et al, Secondary abdominal compartment syndrome: an underappreciated manifestation of severe haemorrhagic shock.
J Trauma
2000;47:995–999.
10608523
51.
Moore, E.E., Shackford, S.R., Pachter, H.L., et al, Organ Injury Scaling: spleen, liver and kidney.
J Trauma
1989;29:1664–1666.
2593197
52.
Moore, E.E., Cogbill, T.H., Malangoni, M.A., et al, Organ Injury Scaling: pancreas, duodenum, small bowel, colon and rectum.
J Trauma
1990;30:1427–1429.
2231822
53.
Moore, E.E., Cogbill, T.H., Jurkovich, G.J., et al, Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra.
J Trauma
1992;33:337–338.
1404499
54.
Moore, E.E., Malangoni, M.A., Cogbill, T.H., et al, Organ Injury Scaling IV: thoracic, vascular, lung, cardiac and diaphragm.
J Trauma
1994;36:299–300.
8145307
55.
Moore, E.E., Cogbill, T.H., Jurkovich, G.J., et al, Organ Injury Scaling: spleen and liver (1994 revision).
J Trauma
1995;38:323–324.
7897707
56.
Moore, E.E., Jurkovich, G.J., Knudson, M.M., et al, Organ Injury Scaling VI: extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary.
J Trauma
1995;39:1069–1070.
7500395
57.
Moore, E.E., Malangoni, M.A., Cogbill, T.H., et al, Organ Injury Scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis and scrotum.
J Trauma
1996;41:523–524.
8810974
58.
Hoff, W.S., Holevar, M., Nagy, K.K., et al, Practice Management Guidelines for the evaluation of blunt abdominal trauma. Available at. EAST Practice Management Guidelines Work Group; 2001.
http://www.east.org
[[accessed February 2012]].
59.
Mazuski, J.E., Sawyer, R.G., Nathens, A.B., et al, The Surgical Infection Society Guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary.
Surg Infect
. 2002;3(3):161–173.
12542923
60.
Cornwell IIIrd, E.E., Campbell, K.A. Trauma. In: Gordon T.A., Cameron J.L., eds.
Evidence-based surgery
. BC Decker: Hamilton, Ontario; 2000:415–428.
61.
Boffard, K.D., Brooks, A.J. Pancreatic trauma.
Eur J Surg
. 2000;166:4–12.
62.
Bradley, E.L., 3rd., Young, P.R., Jr., Chang, M.C., et al, Diagnosis and intial management of blunt pancreatic trauma: guidelines from a multi-institutional review.
Ann Surg
. 1998;227(6):861–869.
9637549
63.
Bokhari F, Phelan H, Holevar M, et al. EAST Guidelines for the diagnosis and management of pancreatic trauma. Eastern Association for the Surgery of Trauma: Practice Management Guidelines,
http://www.east.org/tpg/pancreas
; [accessed February 2012].
64.
Brasel, K.J., Borgstrom, D.C., Weigelt, J.A., Management of penetrating colon trauma: a cost utility analysis.
Surgery
1999;125:471–479.
10330934
65.
Bern, J.D., Velmahos, G.C., Chan, L.S., et al, The high morbidity of colostomy closure after trauma: further support for the primary repair of colon injuries.
Surgery
1998;123:157–164.
9481401
66.
Pachter, H.L., Hoballah, J.J., Corcoran, T.A., et al, The morbidity and financial impact of colostomy closure in trauma patients.
J Trauma
1990;30:1510–1514.
2258963
67.
Stone, H.H., Fabian, T.C., Management of perforating colon trauma: randomisation between primary colon closure and exteriorisation.
Ann Surg
1979;190:430–436.
384941
68.
Murray, J.A., Demetriades, D., Colson, M., et al, Colonic resection in trauma, colostomy versus anastomosis.
J Trauma
1999;46:250–254.
10029029
69.
Hirschberg, A., Walden, R., Damage control for abdominal trauma.
Surg Clin North Am
1997;77:813–821.
9291983
70.
Cayten CG, Fabian TC, Garcia VF, et al. Patient Management Guidelines for penetrating intraperitoneal injuries. EAST Practice Parameter Working Group,
http://www.east.org
; [accessed February 2012].
71.
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
; [accessed February 2012].