CT scan is an invaluable tool for evaluating blunt abdominal trauma. Although it is very good at detecting solid organ injury, it is not so great with intestinal and mesenteric injuries. Older studies have suggested that CT can detect mesenteric injuries if done right, but a newly published study has shown good accuracy with a few imaging tweaks.
A Taiwanese study looked at a series of prospectively studied victims of blunt abdominal trauma. Patients with abdominal pain or a positive FAST were entrolled (total 106). IV contrast was given, and scans during the arterial, portal, and equilibrium contrast phases were performed using a multidetector scanner. Images were read in a blinded fashion.
A total of 13 of 23 patients who underwent laparotomy were found to have a bowel or mesenteric injury. Five had bowel injury, 4 had mesenteric hemorrhage, and 4 had both. Mesenteric contrast extravasation was seen in 7 patients, and this correlated with mesenteric bleeding at laparotomy.
The authors found that the following signs on CT scan indicated injury:
- Full or partial thickness change in bowel wall appearance
- Increased mesenteric density
- Free fluid without solid organ injury
Bottom line: This study shows that CT scan can detect bowel and mesenteric injury reliably if you scan the patient 3 times! This seems like over-radiation and overkill. A more intelligent way to approach this would be to perform a normal trauma abdominal scan. If a suspicious area of mesenteric or bowel thickening is seen, then a limited rescan through the affected area only for equilibrium phase images may be warranted. If actual contrast extrvasation is seen, no further scanning is needed. A quick trip to the OR is in order. And higher risk patients (e.g. seat belt sign) should have a lower threshold for diagnosis!
Reference: Contrast-enhanced multiphasic computed tomography for identifying life-threatening mesenteric hemorrhage and transmural bowel injuries. J Trauma 71(3):543-548, 2011.
The June newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is orthopedics.
In this issue you’ll find articles on:
- Pelvic trauma radiographs demystified
- Bleeding and pelvic fractures
- Predicting pelvic fracture bleeding
- Posterior hip dislocation
- Captain Morgan hip reduction technique
- The fading 8-hour open fracture rule
- Smoking is bad for fractures, really!
Subscribers had the newsletter emailed to them over the weekend. If you want to subscribe (and download back issues), click here.
Download the newsletter here!
There has been a slow shift toward nonoperative management of many injuries that used to demand a quick trip to the operating room. Liver and spleen injury is one of the best examples, with extremely good success rates (95%). Kidneys fall into this category, too.
The pancreas is another solid organ. Perhaps we can do the same thing? A number of pediatric surgeons have been attempting to manage children with pancreatic injury. Low grade injuries (principally contusions) have been managed expectantly for some time. Could higher grade injuries (duct injury) be managed this way as well? How about using repeat imaging, percutaneous drainage, stenting via ERCP, and TPN to avoid the OR in hemodynamically stable kids?
A recent paper looks at this practice critically. Nine years of registry data at two Level I pediatric centers was reviewed to identify all high grade (III-IV) pancreatic injuries. They isolated 39 children with this injury (which is quite a few!). They were separated into two groups based on initial management plan, operative (15) or nonoperative (24). Here are the results of interest (all statistically significant):
- Average ISS was higher in the nonop group (23 vs 15)
- Hospital length of stay was longer in the nonop group (28 vs 15 days)
- TPN was required for a longer period in the nonop group (22 vs 8 days)
- There were more complications in the nonop group (17 vs 4 children), with 13 developing a pseudocyst (none in the op group)
Bottom line: Nonoperative management of high grade pancreatic injury in kids is just not ready for prime time. It may seem that avoiding a big abdominal operation would be a good thing. Distal pancreatectomy usually keeps children in the hospital for 5-7 days, and then they are done unless they have other serious injuries. Nonoperative management results in a lengthy stay in the hospital, multiple imaging studies (radiation), getting stuck with big drainage needles, and TPN with its attendant infection risks. The old fashioned way, going to the OR, is still the best!
Reference: Non-operative management of high-grade pancreatic trauma: is it worth it? J Ped Surg 48:1060-1064, 2013.
Coming Technology: Stop Abdominal Bleeding With Foam
Foam is used for everything. Firefighting. Impact resistance. Law enforcement. Now a company working with DARPA has developed a foam to slow intra-abdominal bleeding until the patient can get to a definitive care hospital. This concept has been used successfully in pigs and slows uncontrolled liver hemorrhage, increasing survival from 7% to 72%.
It is hoped that the foam can be used in the battlefield, and is simple enough to be administered by a combat medic. A small plastic trochar is introduced into the abdominal cavity and two liquids are injected, like epoxy. They react and fill the abdomen with foam, which slows active bleeding.
Like so many military innovations, this may ultimately work its way down to urban EMS units for use in penetrating trauma. Keep an eye on this interesting technology.
Alcohol and fireworks again?