Injury to the Colon and RectumKarim Brohi, trauma.org 8:7, July 2003Case Presentation: Missed rectal injuryA 22 year old man presented to the trauma centre 3 days following a stab wound to the right buttock. He had initially been seen at another hospital where a 1.5cm wound to the outer aspect of the right buttock had been cleaned and stitched. He represented due to pain in the buttock and appearance of a 4cm black patch around the buttock wound. He had never complained of any rectal pain or bleeding.Examination at the trauma centre included digital rectal examination and rigid sigmoidoscopy/proctoscopy, revealing some blood and pus and an injury to the lateral rectal wall. The patient was transferred immediately to the operating room for debridement of the buttock wound and defunctioning colostomy. On the operating table the nectroci patch on the buttock had expanded to approximately 8cm in diameter. Debridement was commenced but could not keep pace with the rapidly spreading necrotizinf fasciitis.

The patient eventually died on the operating table when it became apparent the sepsis had spread to include his upper and lower limbs.

Guidelines for the management of Colon & Rectal TraumaHaemorrhagic Shock.Hypothermia - Coagulopathy - AcidosisDamage Control ProcedureControl HaemorrhageRapid primary suture of small wounds.Transect & close (stapler) more extensive injuries for later repair.Avoid colostomy.Colon:Primary repair.Consider colostomy if >24 hours post trauma.Rectum:Primary Repair if:Intra-peritoneal rectal injury.Extra-peritoneal rectal injury that can be mobilised intra-peritoneally or repaired trans-anally.No pre-sacral drainageNo distal washout.Proximal diverting loop colostomy if:More extensive rectal injury.Position makes repair impossible.Pre-sacral drainage if high-energy, blunt trauma or delayed surgeryNo distal washout.Hartmann's Procedure if:Severe extra-peritoneal rectal injury.

Penetrating Abdominal TraumaGuidelines for EvaluationImmediate Laparotomy if: Shock Peritonitis (clinical examination) Evisceration

else: FAST Ultrasound Scanor Diagnostic Peritoneal LavageIf either shows free intra-abdominal fluid proceed tolaparotomy.With no evidence of free intra-peritoneal fluid, admit for close haemodynamic monitoring and serial physical examination.Proceed to laparotomy if develops signs of shock or peritonitis.At 24 hours / the next morning: Clinical exam abnormal but no obvious peritonitis:Consider laparoscopy.Consider CT scan. Clinical exam normal:Allow to eat & drink. If subsequently well - discharge.Special scenarios1. Stab wound to flankProblems: Retroperitoneal colon injury Renal / ureteric injuryInvestigation of potential colon injury:There is no good radiological investigation for this injury.Serial physical examination is the most important.Consider CT scan with rectal contrast.Even if normal maintain a high index of suspicion. Continued management as for abdominal stab wound but will require longer period of observation, watching closely for signs of sepsis.Investigation of renal injury:In the presence of haematuria proceed to CT scan with intravenous contrast.Absence of haematuria does not exclude an injury to the urinary tract. Maintain a high index of suspicion during observation.2. Stab at Costal MarginIf shocked - use FAST to exclude haemopericardiumHaemothorax/pneumothorax and free fluid in abdomen implies a diaphragmatic injury.Consider next-day laparoscopy for all lower left chest stabs to exclude diaphragm injury.3. Tangential Gunshot WoundsIn general, most gunshot wounds will require laparotomy. However, if: Haemodynamically normal No clinical signs Possible tangential gunshot wound trackConsider CT scan or laparoscopy exclude/confirm peritoneal penetration.

Case Presentation32yr old man admitted post Motor Vehicle Crash.On admission :Primary surveyAirway : Maintaining own airway. Cervical collar & immobilisation in placeBreathing : Respiratory rate 20, right sided chest bruising, clinically multiple right sided rib fractures. O2sats 96%Circulation : Pulse 120/min, BP 80/40Disability : Glasgow Coma Score 14/15. Bilateral equal pupils. No gross peripheral motor or sensory deficit.Exposure : No other obvious injuries.IntroductionCase PresentationInitial EvaluationRadiologyGradingManagementSurgical TechniqueConclusions

Chest X-Ray showed multiple right sided rib fractures and pneumohaemothorax.Right intercostal chest drain insertedCervical spine and pelvis X-rays normal.Secondary SurveyShowed distended abdomen, with pain and tenderness in the right flank.Macroscopic haematuria following urethral catheterisation.No other injuries detected.Resuscitation room intravenous urography was performed:

Demonstrating extravasation of contrast from the right kidney, and a functioning left kidney.SurgeryPatient was taken for laparotomy, where he was found to have a 500mls of free blood in the peritoneum. There was no injury to intraperitoneal organs, but a large, expanding retroperitoneal haematoma was present, which was leaking into the peritoneal cavity.

The retroperitoneum was opened, revealing an large laceration to the lower pole of the right kidney:

Devitalised tissue was debrided, and the kidney repaired with pledgeted mattress sutures across both ends of the laceration.

A drain was placed to the retroperitoneum and the abdomen closed.The patient had an uneventful postoperative course and was discharged home on day 8.Intravenous Urography 90% accurracy under best of conditions Poor study in hypotensive patients Poor grading study Does not evaluate retroperitoneum One shot study may be important in unstable patients to identify a contralateral functioning kidney.IntroductionCase PresentationInitial EvaluationRadiologyGradingManagementSurgical TechniqueConclusions

Extravasation of contrastfrom right kidneyClot incollectingsystemNo filling of upper poleof right kidney

Computed Tomography Gold standard Delineates grade of injury Shows infarcted segments of kidney Images whole abdomen and retroperitoneum Not appropriate for haemodynamically unstable patients

Right perinephrichaematoma. Renalvessels visible. Pooruptake of contrast

Angiography Delineates vascular injury Where CT equivocal or unavailable InvasiveGradingClassified according to theOrgan Injury Scaling (OIS) Committee ScaleMinorIContusionMicroscopic or gross haematuria, Urological studies normal

HaematomaSubcapsular, nonexapnding without parenchymal laceration.

IIHaematomaNonexapnding perirenal haematoma confined to renal retroperitoneum.

Laceration1cm depth of renal cortex, without collecting system rupture or urinary extravasation

IVLacerationParenchymal laceration extending through the renal cortex, medulla and collecting system.

VascularMain renal artery or vein injury with contained haemorrhage.

VLacerationCompletely shattered kidney.

VascularAvulsion of renal hilum which devascularizes kidney.

IntroductionCase PresentationInitial EvaluationRadiologyGradingManagementSurgical TechniqueConclusions

ManagementGoals of management : minimize morbidity & mortality preserve renal functionSurgical vs Non-operative management:Most grade I - IV injuries can be treated conservatively, thus avoiding unnecessary surgery.Surgery is indicated for : Vascular (renal pedicle) injury Shattered kidney Expanding or pulsatile haematoma Shocked polytrauma patientIntroductionCase PresentationInitial EvaluationRadiologyGradingManagementSurgical TechniqueConclusions

Relative indications for surgery include : A devitalized renal segment in the presence of other abdominal injuries Persistent extravasation Loculated collections Incomplete grading (CT or angiography)9% of kidney injuries will require surgical exploration, and of these there is on average an 11% nephrectomy rate.Most nephrectomies are for haemorrhage, and 61% of nephrectomies are for renovascular injury.Patients underggoing nephrectomy tend to be more severely injured.Surgical Technique Midline laparotomy Gain proximal control Debride Ligate bleeding vessels Repair collecting system Close capsule or use omental graft Retroperitoneal drainageIntroductionCase PresentationInitial EvaluationRadiologyGradingManagementSurgical TechniqueConclusions

Proximal control of the renal artery and vein before mobilisation of the colon and opening of Gerota's fascia results in an increased rate of renal salvage and hence lower nephrectomy rate. On the left, the vessels can be exposed through the posterior peritoneum, by dividing it vertically between the inferior mesenteric vein and the fourth part of the duodenum. The renal vein and artery can then be identified an controlled with vessel loops. On the right side, it is often easier to control the renal vein and artery after mobilisation of the colon.If bleeding occurs on mobilisation of the colon or opening of perinephric fascia, atraumatic vascular clamps may be placed on the renal artery and vein. Warm ischaemia is poorly tolerated, and acute tubular necrosis develops after 20 minutes, though this is usually transient.Partial nephrectomy is often possible. Preserving the capsule of the kidney if possible, devitalised tissue is debrided and bleeders controlled with diathermy or suture. The collecting system is closed with a running absorbable suture. Alternatively, pledgeted matress sutures may be placed across the capsule. If possible the capsule is closed, or an omental flap closed over the defect.Nephrectomy is inidicated in the shattered kidney or renal pedicle injury in an unstable patient. The pedicle vessels are ligated separately, to avoid later arteriovenous fistula formation. The ureter is tied and kidney removed.Retroperitoneal drainage is necessary post partial or total nephrectomy. This should not be in contact with the renal collecting system. If the collecting system has been reparied, a nephrostomy tube and/or double-J stent should be placed. Injuries to other abdominal organs should be drained separately.ConclusionsBlunt Trauma and Penetrating Trauma are different injuriesCT scan gold standard for radiological investigationAlways preserve renal tissue when possible

Exsanguinating Pelvic TraumaCase One We recently had a case of a pedestrian run over by her own car and suffered major pelvic fractures (anterior and posterior), a liver laceration and major chest injuries. The Surgical team decided that there was no major thoracic or abdominal souce of bleeding although a FAST (Focussed Abdominal Sonography for Trauma) or DPL (Diagnostic Peritoneal Lavage) was not done.

The Orthopaedic team decided that pelvic angiography and embolisation was the way to go for control of the major pelvic bleeding. The patient was initially stable after intubation, fluid and blood resuscitation, but became very unstable in the Angio suite and had a hypovolaemic arrest in radiology. She was resuscitated with fluids, blood and adrenaline and the radiologist was then able to complete the angio ( after about an hour) and successfully embolise 2 major arterial bleeders.

She then went to the OT and had external fixation appllied and eventually had a laparotomy which revealed a liver laceration, which the surgeons tell me was not a major source of blood loss. Unfortunately she had a further cardiac arrest on the operating table and was not able to be resuscitated.Case Two25 year old motorcyclist was brought to our unit via our Helicopter Emergency Medical Service. She was persistently hypotensive throughout her prehospital course and on arrival in the emergency department had a blood pressure of 70/50 and pulse rate of 130/min. She was alert, orientated and conversing normally.Her airway was clear and examination of the chest was normal. Her abdomen was obviously distended and pelvis very unstable to clinical examination. Blood pressure improved to 90/50 with infusion of 2 litres of crystalloid and 4 units warmed O-egative blood through a rapid infusion system. She was log-rolled to examine her back but immediately lost her blood pressure and only had a palpable carotid pulse. Blood pressure returned to around 80/40 after further fluid and blood transfusion.

Pelvic X-ray showed pubic rami fractures and a left sacral fracture.

Ultrasound scan of her abdomen showed intraperitoneal free fluid in the hepatorenal space and pelvis.

She remained shocked and unresponsive to fluid resuscitation and was taken to the operating room. The decision was taken to place an external fixator prior to performing the laparotomy. Anaesthesia was induced and an incision made over the iliac crest. Unfortunately this entered the retroperitoneal haematoma and the patient began to haemorrhage from this wound. Packing was applied an the external fixator quickly completed.A laparotomy was carried out through a midline incision. The right lobe of the liver had a deep laceration not extending into the hepatic veins. There was a large pelvic retroperitoneal haematoma which was leaking into the intraperitoneal space. The haemorrhage from the liver laceration was controlled with ligation of bleeding arteries and packing. As the haematoma was expanding and leaking, attempts were made to control the retroperitoneal haemorrhage.The retroperitoneum was opened. This lead to significant haemorrhage from the general pelvic area. Both internal iliac arteries were identified and ligated. Further attempts were made to control venous haemorrhage by placing fogarty balloon catheters via the femoral veins. The patient became progressively cold, acidotic and coagulopathic despite administration of clotting factors and the use a rapid infuser go transfuse warmed fluids. All attempts to control haemorrhage were unsuccessful and the patient died on the table.Pelvic Injury Audit - 1994Following this case we reviewed our management of pelvic injuries. We looked at all patients arriving with unstable pelvic fractures. Overall mortality was 6%. When there was a significant concomittant intra-abdominal injury (Abbreviated Injury Scale 3 or more) mortality rose to 50% (median injury severity score - ISS - for this group was 56). For those patients who arrived in hypovolaemic shock with a systolic blood pressure below 90mmHg, with combined intraperitoneal injury and unstable pelvic fracture the mortality was 100% (median ISS 63).Management of these patients was altered, based on the principles of protecting the primary clot, prevention of the hypothermia-acidosis-coagulopathy syndrome and early control of haemorrhage using damage control techniques.

Case Three33yr old male driver of a car, lateral impact with another car and then head-on into a bus. At scene pulse 130, BP 80/40. GCS 14. Open pelvic fracture involving the rectum.At scene:Airway was clear, seat-belt mark to chest but lung fields appeared clear. No manual testing of pelvic stability. Pelvic splint applied. Minimal log-rolling. Scoop stretcher & vacuum mattress applied for transport. IV Access for analgesia. A total of 100 mls of warmed Ringer's lactate given in prehospital phase.Emergency Department:Arrived with pulse of 130, BP 70/50, cool peripheries.Chest X-ray showed a large diaphragmatic tear with haemothorax.

Pelvic X-ray showed a complex unstable pelvic injury.Intraperitoneal free fluid on abdominal ultrasound (FAST) .The pelvic splint was left on. A further 300 mls warmed RInger's given in emergency department. Right chest tube placed. 700 mls blood evacuated. Blood, platelets, fresh frozen plasma and cryoprecipitate was ordered.Operating Room:At laparotomy there was a large right diaphragmatic tear with liver herniation and a laceration to the right lobe of the liver extending into the retrohepatic inferior vena cava. There was a laceration to the upper pole of the spleen. There was a large retroperitoneal haematoma centrally in the upper abdomen and in the pelvis.The liver and vena cava were packed, a splenectomy performed and the pelvis packed (pelvic splint remains in place). The right diaphragm was repaired. The abdomen was closed and angiography was then performed on the table in the operating room. Obturator and internal pudendal arteries were embolized. Branches of the hepatic artery were also embolized.Once the major haemorrhage had been controlled, crystalloid, blood and clotting factors were administered to correct the base deficit. The patient was transferred to the intensive care unit and warmed. The following morning he developed an abdominal compartment syndrome and the abdomen was opened and the packs removed. The caval injury was re-packed.48 hours later all packs were removed and the abdomen closed primarily.

The Case PresentationAlgorithms

Prehospital

On Impact:A 28 year old male motorcyclist traveling approx 60 mph intercepts an automobile which ignores a stoplight.

On Scene:pulse 120, systolic blood pressure 90, Resp 16, GCS 8.PreHospital Questions: This patient is obviously in shock. How do you define haemodynamically instability?Adam StarrAge, fracture pattern, RTS, base deficit, GCS, systolic blood pressure and (according to Wolfgang Ertel) lactate - these are available quickly.How do you diagnose an unstable pelvic fracture in the street? Isclinical examinationvaluable? Is it harmful? Clinical Examination of the pelvis is used to assess for mechanical instability. However the sensitivity and specificity of this test have been called into question. In addition, opening and closing the pelvis may destabilise clot that has formed and provoke fresh haemorrhage:

Preserve clot - minimal movement, gentle handling, minimum of rolling. Punch anyone who tries to 'spring' the pelvis. Fit pelvic belt on basis of mechanism of injury. Minimal iv fluid to preserve systolic of 70 (90 mmHg if associated head injury). Take to a hospital that understands the condition! The Right iliac wing is mobile to exam. Do you stabilize this on scene?(e.g.London splint,Geneva belt,Dallas binder,Kendrick extrication device,PASG,etc) The nearest community hospital is 30 minutes away.The nearest Level II Trauma Center is 60 min.Level I Trauma Center is 90 min.To which hospital should this patient be transported?Both theKellamand theRouttalgorithms address thetransferquestion.

If the patient is taken first to a community hospital, what should be done there prior to transfer?Most algorithms (e.g.Agolini) call for fluid resuscitation. (NotBrohi)How much fluid should this patient receive?Ken MattoxWe are focusing on the WRONG thesis, the WRONG argument, and are bound to reach the WRONG conclusions. Remember the days of "flail" chest. The patients did not look bad until AFTER they arrived at the hospital and had a lot of fluids.The issue in pelvic fracture is similar. AGGRESSIVE cyclic hyperresuscitation results in a predictable coagulopathy and a rise in venous pressure. This leads to venous bleeding from the pelvic veins, requiring repeat cyclic hyperresuscitation and a viscous cycle requiring still other therapy.The studies of immediate external fixators are virtually ALL WAG [Wild Assed Guess] data and a lot of "expert opinion" expressed.

Emergency Room

On Arrival - Level I trauma centerIntubated and ventilated, saturations 99%Pulse 160, blood pressure 70/40,Patient immobilized to long backboard.2 large bore iv's running LR.Chest Xray- Left hemopneumothorax.Lt Chest tube placed. AP pelvic Xray obtained.

Emergency Room Questions:Is the AP pelvic X-rays as a priority? Do you order them on everybody?The American College of Surgeons Advanced Trauma Life Support advocates the routine use of the antero-posterior pelvic X-ray as an adjunct to the primary survey.Some authors suggest that this is not cost effective and that clinical criteria may be used to screen for the presence of a pelvic injury. Examination of the pelvis is notoriously unreliable, especially in obtunded, intoxicated or obese patients. In addition, repeated 'springing' of the pelvis may result in disruption of any clot that has formed and lead to further exsanguination.The antero-posterior pelvic X-ray should still be routinely used to determine the presence of pelvic injury in multiply injured trauma patients. Clinical examination, especially repeated 'springing' of the pelvis, should be kept to an absolute minimum. Is there anything wrong with this pelvic X-ray? Are the orthopaedic Tile and Burgess-Youngpelvic injury classificationsuseful in this situation?

A sheet was immediately wrapped around the pelvis in the emergency room.Blood pressure improved to 90/60 with tachycardia of 130/min. Can the haemodynamic response response to non-invasive stabilisation be used topredict the need for further interventions(external fixation / angiography etc.) Where is this patient bleeding from? How do you want to investigate this further and where?(EversandPohlemannhave already taken the patient to the OR.)

The patient has received 3L crystalloid, the 4 units of PRBC's and 4 units of FFP .Abdominal ultrasound shows hypoechoic stripe in the hepatorenal space.(positive for free intraperitoneal fluid).

FAST vs DPL Questions: Is this a positiveFAST? If so, do you trust it? IsFAST accuratein the presence of a pelvic fracture / retroperitoneal haematoma?'Ultrasonography has been shown to be as accurate as DPL and CT in the detection of hemoperitoneum following abdominal trauma.'Is there still a place forDiagnostic Peritoneal Lavage? 'Because of the high incidence of hemoperitoneum associated with retroperitoneal hematoma, peritoneal lavage is less useful in the setting of of pelvic fracture than in other settings of suspected intra-abdominal trauma.''Nine of 27 patients initially stable patients underwent laparotomy on the day of admission because of the development of hemodynamic instability, and all had retroperitoneal hematoma as the source of the increasing transfusion requirements.''It is likely that CT scanning of patients with pelvic fractures and suspected intra-abdominal injuries to solid organs will result in the lowering of the negative laparotomy rate and morbidity in that group.' What if this patient wereFAST Negative? - there's no intraperitoneal injury.What do you want to do now?Prior to laparotomy, the sheet & towel clip were replaced with apelvic clamp.Application time was 35 minutes.

Ex Fix Questions: Is there any point in applying an external fixation device over and above the non-invasive belts?The surgeons (e.g.Scalea,Brohi,Agolini) want to perform an immediate laparotomy. It appears that pelvic external fixation does not significantly tamponaderetroperitoneal hemorrhage, does not significantly reduce intrapelvic volume, and frequently increases posterior pelvic displacement- in the vicinity of major sources of venous and arterial hemorrhage.

Is there anyevidenceto support the use of the external fixator? Which methodof external stabilization is best? When should it be applied?

Operating Room

On OR Arrival:BP 90/50 pulse 140.At laparotomy - an extensive liver laceration is found and is controlled with packing. A large pelvic retroperitoneal haematoma is present.

Laparotomy Questions: Do you open the retroperitoneal haematoma?Is there are role for ligation of the internal iliacs? PohlemannandErtelrecommend extraperitoneal packing.Should you pack intra- or extra-peritoneally? Is internal fixation of the symphysis pubis indicated at laparotomy? Where do you want to send the patient now?A symphysis pubisplatewas used to close the anterior diastasis.Bilateralextraperitoneal paravesical pelvic packingis performed after the evacuation of approximately 3000ml of clot from this region.The abdomen is closed. The pelvic C-Clamp is removed.70 minute operative procedureBP 90/60, pulse 140, urine output 300 ml.The patient is transferred to the angiography suite.

Angiography Suite

Angiography:Haemorrhage from the left obturator artery is identified and embolized.BP 100/70, pulse 100

Angiography Questions: In retrospect shouldangiographyhave beenperformed first?Physicians are often reluctant, for no valid reason, to transport hemodynamically unstable patients to the angiography suite. We urge them to abandon this attitude. Patients in hemorrhagic shock, with surgically correctable injuries, should be transported to the operating theatre, regardless of shock. By the same token, patients in hemorrhagic shock, with unknown sources of hemorrhage - as well as those with hemorrhage best treated by embolization - should be transported to the angiographic suite, regardless of shock. Left where they are, be it the emergency department of intensive care unit, they may die of exsanguination.'

'Three basic principles should guide the angiographer in performing embolization. The purpose is to slow the bleeding to the extent that the body will control its own hemorrhage, rather than create large areas of ischemia or necrosis. If ischemia and necrosis must be created it should be limited to the smallest area possible. The procedure must be done expidetiously.'Overall 7-11% of pelvic fractures will require embolization. Only 2% of lateral compression fractures have demonstrable arterial haemorrhage, compared to 20% of anteroposterio compression, vertical shear or combined mechanism injuries. Can angiography control intraperitoneal haemorrhage avoiding the need for laparotomy? Should the operating room and angiography be the same place?

After sustained hemodynamic improvement in angiography,iliosacral screwsare placed under fluoroscopy to supplement the pelvic internal fixation.

Definitive Fixation Questions: How and when should definitive fixation be instituted? Would you do this without a CT scan?

Intensive Care Unit

The patient was transferred to the Intensive Care Unit where he was warmed and his acidosis and coagulopathy corrected.The patient subsequently underwent a CT scan of his head which revealed a small left subdural hematoma and diffuse brain injury with tight basal cisterns.Initial intracranial pressures of approximately 35 mm Hg increased relentlessly over the ensuing 48 hours despite aggressive management.Eventually ICP topped 100 mm Hg pressure.Pupils became fixed and dilated.A day later life support was withdrawn.

Traumatic Brain Injury Questions: Does management of the pelvic injuryaffect neurological outcome?Management of traumatic brain injury focuses on stabilisation of the patient andprevention of secondary neuronal injuryto avoid further loss of neurons. Fullneuromonitoringincludingintracranial pressuremeasurement are rarely available prior to the patients arrival in the intensive care unit. Significant neurological damage can occur between the time of injury and CT scanning, accurate measurement of ICP and other parameters. The acute management of these patients is therefore directed towards assuming there is significant intracranial pathology and instituting measures to protect living brain tissue.

Non-operative management of thoracic vascular InjuryCase PresentationThis was a 34 year old male who suffered a low velocity gunshot wound to the left upper chest, presenting with a 1cm wound just under the left midclavicle as a sucking chest wound. This wound was sutured close and a left tube thoracostomy placed, which initially put out 300cc blood. There was an apparent exit wound on the upper right back over the mid right scapula. Physical exam showed complete sensorimotor loss below the nipples and no rectal tone, consistent with a spinal cord injury at T4. Distal pulses were all present and equal in all 4 extremities.Patient's vital signs initially were BP 110/70, Pulse 120, RR 30, O2 sat 97% room air. CXR showed bullet fragments across the upper right chest posteriorly, and a left pulmonary contusion.

After the chest tube was placed, BP intermittently dropped into the 80's, and over the course of the next 4 hours a total of 1000cc blood came out the left chest tube. Patient was intubated.An arteriogram was performed showing a nonocclusive and non-extravasating intimal injury of the right innominate artery at the takeoff of the right subclavian and carotid arteries. Left great vessels were not injured. A flexible esophagoscopy showed no injury. It was decided to observe the patient nonoperatively. A right chest tube was placed which did not put out any blood. Over the next 5 days the blood from the left chest stopped, vital signs stabilized, and the patient was extubated. A repeat arteriogram showed complete resolution of the innominate artery intimal defect. The patient never required surgery. He was transferred to a spinal cord injury rehab center 10 days post injury.Initial AngiogramRepeat Angiogram

DiscussionIt was clear that the innominate artery injury was not responsible for the left chest bleeding (which was probably from the parenchymal injury of the lung), or the hemodynamic instability, and was an essentially incidental finding. Such nonocclusive "minimal" arterial injuries are well documented to have a benign natural history, and should be followed rather than being immediately operated upon when they are asymptomatic (i.e. no hard signs of vascular injury) with a vessel that is not occluded and has no gross extravasation, as the majority never require surgery. A patient such as this does not need unnecessary surgery, especially surgery as extensive as this procedure would have to have been. His bleeding from the left chest tube was borderline in terms of an indication to operate, which is generally suggested when output exceeds 200cc/hour for more than 4 hours. Fortunately it tapered off.CLASSIC CASESTension HaemothoraxCase PresentationA 31 year old man is transferred from another hospital following a kick to the left chest. Initial chest X-ray showed a large haemothorax.

The patient was taken to the CT scanner, by which time the whole chest had filled with blood and there was radiological evidence of tension.

CTs show a left hemithorax full of blood, with the lung compressed down to a very small volume. The heart, trachea and mediastinal structures are shifted to the right. By this time the patient was in respiratory distress with a respiratory rate of 40 with shallow, painful respiration. Pulse was 105 and blood pressure 110/60.A left sided chest drain was placed and the patient transferred to our institution. Over the next 12 hours the patient drained 4000mls of venous blood from the left chest, but the patient remained haemodynamically stable. The bleeding slowed and stopped. Thoracoscopic washout was performed to evacuate approximately 1000mls of retained clot on day 3 and the patient was discharged home on day 7.DiscussionMassive haemothorax is a well-recognised condition and may often produce radiological evidence of tension. Aprat from tracheal & mediastinal deviation, the other signs are not present. The affected hemithorax is dull to percussion and there is no distension of neck veins or raised jugular venous pressure due to the hypovolaemic state.This patient should have had a chest drain placed following the initial chest X-ray. While most venous bleeding will stop eventually there is no credence to the myth that the build-up of tension in the left chest will tamponade the bleeding - as evidenced by the dramatic collapse of the left lung and shift of the mediastinum visible on the CT scan. There is little indication for a CT scan in the emergent management of this patient, though a scan of the abdomen did rule out associated splenic trauma.CLASSIC CASESTension GastrothoraxCase PresentationA 40 year old man is the unrestrained driver in a front-impact motor vehicle collision. He arrives with a respiratory rate of approximately 20/minute but haemodynamically stable. Initial chest X-ray showed an elevtaed and slightly thickened left hemidiaphragm, suggesting a diaphragm injury. The patient was transferred, self-ventilating, to the CT scanner. He gradually became more and more dyspneoic, with rising respiratory rate.

CTs show a left hemithorax almost full of the stomach, with shift of mediastinal structures to the right. Towards the end of the scan the patient became progressively tachycardic and then hypotensive at 80/60. Further scanning was terminated and the patient anaesthetised, intubated and ventilated. Positive pressure ventilation caused re-expansion of the left lung and partial return of the stomach into the abdomen.The patient was transferred to the operating room for laparotomy, which identified a large circumferential laceration of the diaphragm approximately 2cm from the costal margin. The stomach and spleen were reduced into the abdomen and the diaphragm injury repaired primarily.DiscussionTension gastrothorax has previously been described. In the spontaneously ventilating patient the negative pressure generated in the thoracic cavity progressively sucks the stomach into the chest with each breath. Eventually, respiratory and haemodynamic compromise ensue, as with a classic tension pneumothorax.Various methods have been used to treat the condition acutely. Nasogastric trubes can be placed to decompress the stomach - although placement may be difficult due to kinking at the level of the diaphragm. Needle decompression of the stomach has also been suggested but this may theoretically lead to contamination of the thoracic cavity. Positive pressure ventilation allows immediate re-expansion of the lung and forces intraperitoneal contents back into the abdomen. As the patient will require operative repair, ventilation is already indicated.CLASSIC CASESLate presentation of diaphragm rupture following blunt thoracic traumaCase PresentationA 67 year old woman was admitted via the emergency department complaining of nausea, vomiting and abdominal pain after meals.Chest X-ray on admission:

The Chest X-ray showed rupture of the left hemi-diaphragm with associated collapse of the left lung.On questioning, the patient admitted to having fallen 3 months previously and having sustained two broken ribs on the left chest. She was seen in the emergency department of another hospital and discharged after an overnight stay with analgesia. A chest X-ray was taken at the time, which presumably showed no evidence of diaphragmatic rupture.A CT scan showed the stomach in the left thoracic cavity, and the rib fractures responsible for the diaphragmatic laceration:

The patient was prepared for operation and underwent a scheduled procedure the following day.Operating roomAt operation approximately two-thirds of the stomach and the spleen had herniated through a 10cm diaphragm laceration into the chest.The stomach and spleen were reduced into the abdomen by extending the laceration laterally.

A band-like constriction of the stomach by the diaphragm can be seen in the marks on the stomach:

The chest was washed out and the diaphragmatic laceration was repaired with a continuous nylon suture.Stay sutures on either side of the laceration allow the diaphragm to be tented downwards to aid closure.

The abdomen was closed and the patient made an uneventful post-operative recovery.DiscussionBlunt injury to the diaphragm occur in approximately 1% of all trauma adminssions. The diaphragm is most commonly injured by a direct blow to the abdomen, causing a sudden increase in intra-abdominal pressure, or by direct laceration from rib fractures. Rupture of the diaphragm rarely occurs in isolation, and associated injuries to the thoracic aorta, liver & spleen and pelvis are often present.Diagnosis is often difficult or missed, as the above case shows. A high index of suspicion is vital. Chest X-ray may reveal the injury if abdominal contents have herniated into the chest, may reveal a thickening or fuzziness of the diaphragmatic outline, an elevated hemidiaphragm or be completely normal - especially if the patient is intubated & ventilated. Haemopneumothoraces are a common associated finding. Overall the plain Chest X-ray has a 50% accurracy.Diaphragmatic injury may be detected on ultrasound - but rarely. CT scanning has a sensitivity of only around 70-80%. MRI may be the best non-invasive examination for blunt diaphragmatic injury.Laparoscopy or thoracoscopy have become the primary means of diagnosing diaphragmatic injury - though the are more frequently employed for penetrating trauma. As with CT and MRI scanning, the patient must be haemodynamically stable for these procedures.Delay in detecting and repairing diaphragmatic injury increased both morbidity and mortality. Operative repair is also technically more difficult, the longer the delay to surgery.Diaphragmatic injuries are usually repaired via a laparotomy incision.Abdominal contents are reduced and the diaphragm can usually be repaired simply with a large monofilament non-absorbably suture, placed as locked stitches or horizontal mattress sutures. Care should be taken if the laceration extends into the central tendon of the diaphragm, where the myocardium is easily caught in poorly placed sutures. It is important to adequately wash out the thoracic cavity prior to closure, to remove any clot or contamination. In cases where the diaphragmatic hernia has been present for a long time (years) simple closure may be difficult or impossible, and non-absorbably mesh may be required.

Transfusion for Massive Blood LossPresented below is a description of massive blood loss and the inherent problems associated with large volume blood transfusions. Following this is a suggested protocol for guiding management of the patient receiving a massive transfusion for haemorrhage.DefinitionMassive transfusion is arbitrarily definied as the replacement of a patient's total blood volume in less than 24 hours, or as the acute administration of more than half the patient's estimated blood volume per hour.Aim of TreatmentThe aim of treatment is the rapid and effective restoration of an adequate blood volume and to maintain blood composition within safe limits with regard to haemostasis, oxygen carrying capacity, oncotic pressure and biochemistry.Complications of Massive TransfusionThe complications of massive transfusion are those of any blood transfusion plus : Blood Volume ReplacementThe complications of massive transfusion are exacerbated by inadequate or excessive transfusion. Traditionally transfusion of hypovolaemic patients has been directed towards maintaining a haemoglobin concentration of 10g/dl. The use of haemoglobin as the only indicator (or 'transfusion trigger') may result in unnecessary administration of blood products, with their concommittant risks.Transfusion requirements should be based on the patient's physiologic needs, defined by their oxygen demand (consumption).Oxygen consumption is given by :

Where CO = Cardiac Output, CaO2 and CvO2 are arterial and venous oxygen content respectively.Oxygen delivery is :

The extraction ratio (ER) is the ratio of oxygen consumption to oxygen delivery, normally around 25%.

The most appropriate monitor of tissue oxygen supply is the tissue oxygen tension, reflected by the PvO2, or mixed venous partial pressure of oxygen (normally 6 kPa, 45mmHg). Patients with a low PvO2 can be classed as stable or unstable depending on haemodynamics, ventilation, acid base status and urine output. If they are stable, no therapy is indicated until a true critical level is reached (PvO2 around 3 kPa, 23mmHg). If unstable, treatment must be intituted.Thus transfusion should be guided by haemodynamic stability, PvO2 and ER. Obviously during trauma resuscitation, haemodynamic stability is the key indicator.In summary : If Hb > 10g/dl transfusion is rarely indicated. If Hb < 7g/dl transfusion is usually necessary. With Hbs between 7 and 10 g/dl, clinical status, PvO2 and ER are helpful in defining transfusion requirements. ThrombocytopeniaDilutional thrombocytopenia is inevitable following massive transfusion as platelet function declines to zero after only a few days of storage. It has been shown that at least 1.5 times blood volume must be replaced for this to become a clinical problem. However, thrombocytopenia can occur following smaller transfusions if disseminated intravascular coagulation (DIC) occurs or there is pre-existing thrombocytopenia. Coagulation Factor DepletionStored blood contains all coagulation factors except V and VIII. Production of these factos is increased by the stress response to trauma. Therefore only mild changes in coagulation are due to the transfusion per se, and supervening DIC is more likely to be responsible for disordered haemostasis. DIC is a consequence of delayed or inadequate resuscitation, and the usual explanation for abnormal coagulation indices out of proportion to the volume of blood transfused. Oxygen Affinity ChangesMassive transfusion of stored blood with high oxygen affinity adversely affects oxygen delivery to the tissues. Evidence for this is as yet not forthcoming, but it would seem wise to use fairly fresh red cell transfusions (293

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RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RRValues for the RTS are in the range 0 to 7.8408. The RTS is heavily weighted towards the Glasgow Coma Scale to compensate for major head injury without multisystem injury or major physiological changes. A threshold of RTS < 4 has been proposed to identify those patients who should be treated in a trauma centre, although this value may be somewhat low.The RTS correlates well with the probability of survival :

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