delay | The Trauma Pro

Yesterday, I wrote about using ultrasound in place of CT for initial diagnosis of blunt abdominal injury in children. Although it looks good for identification of solid organ injury and free fluid, it may miss injury to the intestine. Is that bad?

Lets look at a recent study that examined the consequences of delayed laparotomy for blunt intestinal injury. The American Pediatric Surgical Association conducted an 18-center study of the management of intestinal injuries in children less than 16 years of age. They were stratified by time to treatment. There were 214 patients with complete data records for review.

The majority of the patients were involved in a motor vehicle crash or a bicycle accident. Demographics were similar in all time to treatment groups. Half were resuscitated at a referring hospital and then transferred to a pediatric trauma center, on average after 6 hours.

Key points:

The only deaths occurred in the 0-6hr and 6-12hr groups. The average Injury Severity Score of the children who died was significantly higher than survivors.
Children operated on in the 0-6hr group had significantly higher ISS as well.
There was no difference in early or late complications across all groups.
Time to beginning oral intake and time in hospital were the same in all groups.

The authors concluded that observation and serial exam rather than urgent exploration or repeated CT scans is appropriate.

Bottom line: If you combine this study with the ultrasound study I reviewed yesterday, it seems appropriate to modify the usual (read: adult) way of evaluating blunt trauma to the abdomen. In place of automatically getting a CT scan of the abdomen in children, obtain a complete abdominal ultrasound to detect solid organ injury or free fluid. This will determine the degree of monitoring needed (e.g. ICU for higher grade liver or spleen injuries). Follow this with serial abdominal exam. If the child becomes symptomatic, it’s probably time to proceed to the OR. Note: I generally do not make children npo during the observation phase. They need to eat, and if they don’t want to, that tells you something.

Reference: Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric patient. J Pediatric Surg 45(1):161-166, 2010.

Trauma surgeons generally dread the negative laparotomy for trauma. Previous work has shown that complications occur in anywhere from 22% to 53% of cases. Those studies were usually retrospective and included patients with penetrating trauma, which may have skewed the results.

A newly published study tries to throw this common wisdom in doubt. It was a retrospective review of a prospectively maintained database of trauma admissions after blunt trauma . Patients were separated into groups who underwent immediate, delayed or no laparotomy, as well as whether they had or did not have associated injuries. Complications were tracked using an accurate and validated tracking system. The complications tracked included death, DVT, PE, infections, pulmonary issues, as well as other organ system problems.

The authors found that a negative laparotomy did not increase the complication rate, but that a delayed laparotomy did. They also noted that a Complication Impact Score (that they made up) was higher in the delay to laparotomy patients. So they believe that when clinical and imaging findings are equivocal, doing an operation to establish a diagnosis is justifiable.

My Bottom Line: This study does not look at really delayed complications like small bowel obstruction, which we see with some regularity in old trauma patients. Also, other studies have also shown that brief observation, even in patients with a bowel injury, does not increase complications significantly. Unless the potential injury that you are observing is known to have significant complications, my practice is to observe equivocal cases in order to avoid more complications down the road.

Reference: “Never be wrong”: the morbidity of negative and delayed laparotomies after blunt trauma. J Trauma 69(6): 1386-1392, 2010.

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Delayed Diagnosis of Blunt Intestinal Injury in Children

Less Morbidity From Negative Trauma Laparotomies?

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