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Pancreatic Injury Part 2 – Diagnosis

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Yesterday, I outlined the AAST organ injury scale for the pancreas. Today, I’ll go through diagnosis of the the injury in adults. 

First, there are two ways of detecting this injury. In stable patients, it is usually identified on CT. Hematoma around an area of the pancreas, combined with linear changes in the density of the gland are typical. It may be difficult to detect in very thin patients without a lot of contrasting fat (although this situation is becoming very uncommon). And obviously, CT is only to be used for stable patients.

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The other way this injury is discovered is in the OR during the trauma exploration. This is the most common situation in patients taken directly to OR due to hemodynamic status.

Even if the diagnosis has been made by CT, the diagnostic process continues in the OR. So in all cases, the usual approach to trauma laparotomy applies (large midline incision, control of hemorrhage, control of contamination in that order). Only then can a full inspection be carried out, and damage control principles should be followed. If a pancreatic injury is suspected but the laparotomy must be terminated for damage control reasons, a simple drain should be placed over the pancreas, and the injury addressed on the first takeback.

The two keys to deciding what to do in pancreatic injury are injury grade and duct status, which go hand in hand. Sometimes it is difficult to evaluate the duct and there are two ways to approach this in the OR: extra-ductal and intra-ductal. The former is the easiest, and involves direct inspection of the gland. Careful, gentle dissection coupled with close review with magnification will frequently show obvious leakage of clear fluid. The latter involves injecting contrast into the duct. This can be accomplished via either end of the pancreas (directly into the papilla via duodenotomy, into the distal end via distal pancreatectomy), or through on-table ERCP. Neither of the invasive methods are for the faint of heart, and will be discussed in future blog posts. And ERCP can be challenging because patient positioning with an open abdomen is difficult.

Once the grade and duct status have been identified, it’s time to think about fixing the problem. That’s the topic for tomorrow.

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General

Pancreatic Injury Part 1 – Grading

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The pancreas is a weird and mysterious organ. It’s considered a solid organ, but it doesn’t follow any of the usual rules. Today, I’ll review the grading system for injuries to this organ. Then over the next few days, I’ll review pancreatic injury management in adults and children.

The AAST has developed quite a few organ injury grading schemes over the years (32 to be exact). These are actually important to know, because they help us accomplish several things:

  • Objectively describe the degree of injury
  • Choose management strategies
  • Develop research cohorts so meaningful studies can be constructed

There are 5 grades that follow the usual AAST schema (numbered I-V). Unfortunately, I have not been able to find any quality diagrams, so you’ll just have to use your imagination.

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  • Grade I: Minor contusion or laceration of the parenchyma without duct involvement
  • Grade II: Major contusion or laceration of the parenchyma without duct involvement
  • Grade III: Distal duct laceration or transection. Distal means to the left of the superior mesenteric vein
  • Grade IV: Proximal transection or parenchymal injury not involving the ampulla (note that this was corrected after publication of the original scale in 1990, which omitted the word not)
  • Grade V: Massive disruption of the pancreatic head

Tomorrow I’ll delve into diagnosis and management options in adults.

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Reference: Pancreatic organ injury scale. J Trauma 30:1427–1429, 1990.

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Trauma Activation Patients Hanging Out In Your ED Too Long?

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One of the long-held beliefs in trauma care relates to the so-called “golden hour.” Patients who receive definitive care promptly do better, we are told. In most trauma centers, the bulk of this early care takes place in the emergency department. However, for a variety of reasons, throughput in the ED can be slow. Could extended periods of time spent in the ED after patient arrival have an impact on survival?

Wake Forest looked at their experience with nearly 4,000 trauma activation patients who were not taken to the OR immediately and who stayed in the ED for up to 5 hours. They looked at the impact of ED dwell time on in-hospital mortality, length of stay and ventilator days.

Overall mortality was 7%, and the average time in the ED was 3 hours and 15 minutes. The investigators set a reasonable but arbitrary threshold of 2 hours to try to get trauma activation patients out of the ED. When they looked at their numbers, they found that mortality increased (7.8% vs 4.3%) and that hospital and ICU lengths of stay were longer in the longer ED stay group. Hospital mortality increased with each hour spent in the ED, and 8.3% of patients staying between 4 and 5 hours dying. ED length of stay was an independent predictor for mortality even after correcting for ISS, RTS and age. The most common cause of death was late complications from infection.

Why is this happening? Patients staying longer in the ED between 2 and 5 hours were more badly injured but not more physiologically abnormal. This suggests that diagnostic studies or consultations were being performed. The authors speculated that the knowledge, experience and protocols used in the inpatient trauma unit were not in place in the ED, contributing to this effect.

Bottom line: This is an interesting retrospective study. It reflects the experience of only one hospital and the results could reflect specific issues found only at Wake Forest. However, shorter ED times are generally better for other reasons as well (throughput, patient satisfaction, etc). I would encourage all trauma centers to examine the flow and delivery of care for major trauma patients in the ED and to attempt to streamline those processes so the patients can move on to the inpatient trauma areas or ICU as efficiently as possible.

Reference: Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients. J Trauma 70(6):1317-1325, 2011.