Adam Brooks

Missed injury in major trauma patients

OBJECTIVES To determine the incidence, aetiology and contributing factors to injuries being missed during the primary and secondary surveys in patients with major trauma managed on a general Adult Intensive Care Unit (AICU). METHODS The records for patients admitted to the AICU following severe injury (defined as injury severity score (ISS) >16) over a 1-year period were reviewed. Diagnostic imaging performed during the resuscitation was reviewed in cases where missed injuries were discovered. RESULTS Forty-five patients with a median injury severity score of 26 were included in the study. Twelve missed injuries were discovered in 10 patients during the intensive care admission; three required an additional surgical procedure. There was no significant difference in Glasgow Coma Score, revised trauma score, ISS or admission systolic blood pressure between patients with missed injuries and those patients where all injures were found at resuscitation (P > 0.05). Three quarters of the undetected injuries were orthopaedic. CONCLUSIONS Significant injuries can be missed during the primary and secondary surveys in severely injured patients. A tertiary survey should be completed in all trauma patients admitted to an intensive care unit.

Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum

Objectives: To evaluate non-radiologist performed emergency ultrasound for the detection of haemoperitoneum after abdominal trauma in a British accident and emergency department. Methods: Focused assessment with sonography for trauma (FAST) was performed during the primary survey on adult patients triaged to the resuscitation room with suspected abdominal injury over a 12 month period. All investigations were performed by one of three non-radiologists trained in FAST. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident and emergency physician. The patients were followed up for clinically significant events until hospital discharge or death. Results: One hundred patients who had sustained blunt abdominal trauma, were evaluated by FAST. Nine true positive scans were detected and confirmed by computed tomography, diagnostic peritoneal lavage, or laparotomy. There was one false positive in this group, giving a sensitivity of 100%, specificity 99%, and positive predictive value of 90%. Ten patients with penetrating injuries were evaluated with a sensitivity and specificity for FAST of 33% and 86% respectively. Conclusions: Emergency torso ultrasound for the detection of haemoperitoneum can be successfully performed by trained non-radiologists within a British accident and emergency system. It is an accurate and rapid investigation for blunt trauma, but the results should be interpreted with caution in penetrating injury.

Prospective Evaluation of Handheld Ultrasound in the Diagnosis of Blunt Abdominal Trauma

Objectives To evaluate the Sonosite 180 handheld ultrasound in the diagnosis of haemoperitoneum in blunt abdominal trauma. Methods Trauma ultrasound using the Focused Assessment with Sonar for Trauma (FAST) technique was performed using the Sonosite 180 handheld ultrasound during the primary survey of adult patients triaged to the resuscitation room with multiple trauma or suspected abdominal injury. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident & emergency physician - CT, DPL, laparotomy or clinical observation. Results 50 patients who had sustained blunt abdominal trauma were evaluated using FAST. Satisfactory images were obtained in 96%. There were 5 true positive scans confirmed by CT, DPL or laparotomy. There were no false negative or false investigations. The sensitivity and specificity of handheld FAST was 100%. Conclusions Handheld ultrasound using the Sonosite 180 system can be successfully used by appropriately trained doctors as the primary investigation in the acute evaluation of blunt abdominal trauma.

Outcomes in patients with indeterminate pulmonary nodules undergoing resection for colorectal liver metastases

OBJECTIVES This study aimed to assess outcomes in patients who underwent hepatic resection for colorectal liver metastases (CRLM) with subcentimetre indeterminate pulmonary nodules (IPN) and to devise a management pathway for these patients. METHODS Patients undergoing CRLM resection from January 2006 to December 2010 were included. Survival differences following liver resection in patients with and without IPN were determined. RESULTS A total of 184 patients were included, 30 of whom had IPN. There were no significant differences between the IPN and non-IPN groups in terms of demographics, surgery and pathological factors. There were no significant differences between patients with and without IPN with respect to disease-free (P= 0.190) and overall (P= 0.710) survival. Fifteen patients with IPN progressed to metastatic lung disease over a median period of 10 months (range: 3-18 months); six of these patients underwent lung resection. Of the remaining 15 patients with IPN, eight showed no IPN progression and subsequent CT scans did not identify IPN in the remaining seven. CONCLUSIONS Colorectal liver metastases patients with IPN who have resectable disease should be treated with liver resection and should be subject to intensive surveillance post-resection. Although 50% of these patients will progress to develop lung metastases, this does not appear to influence survival following liver resection.

Education and imaging. Gastrointestinal: Duodenal duplication cyst causing recurrent acute pancreatitis.

A 17-year-old male student presented with recurrent attacks of acute pancreatitis over a 3-month period. There was no history of alcohol consumption. His liver function tests, lipid profile and serum calcium concentrations were normal. An abdominal ultrasound did not reveal gallstones or biliary dilatation. Abdominal CT (Fig. 1A) revealed a 3 ¥ 2 cm thin-walled cyst (arrow) projecting into the contrast-filled lumen of the second part of the duodenum. A coronal MRCP reconstruction (Fig. 1B) confirmed the presence of the cyst (arrow) and its relationship to the medial wall of the duodenum, with an absence of pancreaticobiliary ductal dilatation or choledocholithiasis. Side viewing endoscopy showed an intraluminal bulge arising from the periampullary region. Ductal cannunaltion was not possible as the papilla could not be located. These appearances are consistent with a diagnosis of a duodenal duplication cyst arising at the level of the ampulla of Vater. A type III choledochal cyst (choledochocele) or a Wirsungocele were unlikely as the cyst was confined to the duodenum and did not involve the intrapancreatic portion of the common bile duct or the pancreatic duct. This patient underwent a laparotomy and transduodenal excision of the cyst following identification of the major papilla (Fig. 2Aand B). A transduodenal sphincteroplasty of both the biliary and pancreatic orifices was also performed to ensure ductal patency. Histological examination of the resected specimen stained with haematoxylin and eosin confirmed the absence of malignancy and the presence of smooth muscle between layers of duodenal mucosa (Fig. 2C). The muscle layer within the duplication cyst can be clearly visualised following immunostaining with antibody to alpha smooth muscle actin (Fig. 2D). The patient has not had another episode of pancreatitis for over six months after the operation. Congenital duodenal duplication cysts are a rare cause of recurrent pancreatitis. Abdominal pain and distension are typical features but gastrointestinal bleeding can occur due to the presence of ectopic gastric mucosa, allowing subsequent diagnosis during endoscopy. Pancreatitis, secondary to pancreatic ductal outflow obstruction is usually the result of pancreatic duct compression involving the cyst, or stone disease if there is direct communication with the pancreaticobiliary tract. Although endoscopic drainage and snare resection is considered safe, surgical excision is accepted as the treatment of choice with the intention to alleviate symptoms, prevent pancreatitis and eliminate the risk of malignant transformation, a development reported in only a small number of cases.

Trauma and Surgery

Touch MEdical MEdia 135 In the US, approximately 3 % of all emergency department visits are related to eye trauma. Many of these cases unfortunately lead to permanent visual impairment as ocular injury accounts for the leading cause of irreversible vision loss in teenagers and young adults. When penetrating or openglobe injuries occur, an estimated 10 to 41 % involve an intraocular foreign body (IOFB). The IOFB may be overtly recognizable, but it may also be obscured by hemorrhage (as hyphema and/or in the vitreous), traumatic cataract, marked inflammation, or retinal detachment. At times, it could be inconspicuously lodged in the angle, in the sulcus, or in the far retinal periphery. Up to 20 % of patients with IOFB present with no pain or decreased vision. Therefore, a full and detailed ophthalmic examination including slit-lamp biomicroscopy and dilated examination is critical. Important information to be gained from tonometry, gonioscopy, ultrasonography, and scleral depression may not be feasible in the setting of globe penetration or perforation and if other concurrent systemic injuries warrant immediate medical attention. Overall, in the acute setting of eye trauma, the examiner must maintain a high index of suspicion for possible retained IOFBs.

Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies

AIM To investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up. METHODS Neoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed. RESULTS Twenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively). CONCLUSION PPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Gastrointestinal: Duodenal duplication cyst causing recurrent acute pancreatitis: Images of Interest

A 17-year-old male student presented with recurrent attacks of acute pancreatitis over a 3-month period. There was no history of alcohol consumption. His liver function tests, lipid profile and serum calcium concentrations were normal. An abdominal ultrasound did not reveal gallstones or biliary dilatation. Abdominal CT (Fig. 1A) revealed a 3 ¥ 2 cm thin-walled cyst (arrow) projecting into the contrast-filled lumen of the second part of the duodenum. A coronal MRCP reconstruction (Fig. 1B) confirmed the presence of the cyst (arrow) and its relationship to the medial wall of the duodenum, with an absence of pancreaticobiliary ductal dilatation or choledocholithiasis. Side viewing endoscopy showed an intraluminal bulge arising from the periampullary region. Ductal cannunaltion was not possible as the papilla could not be located. These appearances are consistent with a diagnosis of a duodenal duplication cyst arising at the level of the ampulla of Vater. A type III choledochal cyst (choledochocele) or a Wirsungocele were unlikely as the cyst was confined to the duodenum and did not involve the intrapancreatic portion of the common bile duct or the pancreatic duct. This patient underwent a laparotomy and transduodenal excision of the cyst following identification of the major papilla (Fig. 2Aand B). A transduodenal sphincteroplasty of both the biliary and pancreatic orifices was also performed to ensure ductal patency. Histological examination of the resected specimen stained with haematoxylin and eosin confirmed the absence of malignancy and the presence of smooth muscle between layers of duodenal mucosa (Fig. 2C). The muscle layer within the duplication cyst can be clearly visualised following immunostaining with antibody to alpha smooth muscle actin (Fig. 2D). The patient has not had another episode of pancreatitis for over six months after the operation. Congenital duodenal duplication cysts are a rare cause of recurrent pancreatitis. Abdominal pain and distension are typical features but gastrointestinal bleeding can occur due to the presence of ectopic gastric mucosa, allowing subsequent diagnosis during endoscopy. Pancreatitis, secondary to pancreatic ductal outflow obstruction is usually the result of pancreatic duct compression involving the cyst, or stone disease if there is direct communication with the pancreaticobiliary tract. Although endoscopic drainage and snare resection is considered safe, surgical excision is accepted as the treatment of choice with the intention to alleviate symptoms, prevent pancreatitis and eliminate the risk of malignant transformation, a development reported in only a small number of cases.

Gastrointestinal: Duodenal duplication cyst causing recurrent acute pancreatitis

A 17-year-old male student presented with recurrent attacks of acute pancreatitis over a 3-month period. There was no history of alcohol consumption. His liver function tests, lipid profile and serum calcium concentrations were normal. An abdominal ultrasound did not reveal gallstones or biliary dilatation. Abdominal CT (Fig. 1A) revealed a 3 ¥ 2 cm thin-walled cyst (arrow) projecting into the contrast-filled lumen of the second part of the duodenum. A coronal MRCP reconstruction (Fig. 1B) confirmed the presence of the cyst (arrow) and its relationship to the medial wall of the duodenum, with an absence of pancreaticobiliary ductal dilatation or choledocholithiasis. Side viewing endoscopy showed an intraluminal bulge arising from the periampullary region. Ductal cannunaltion was not possible as the papilla could not be located. These appearances are consistent with a diagnosis of a duodenal duplication cyst arising at the level of the ampulla of Vater. A type III choledochal cyst (choledochocele) or a Wirsungocele were unlikely as the cyst was confined to the duodenum and did not involve the intrapancreatic portion of the common bile duct or the pancreatic duct. This patient underwent a laparotomy and transduodenal excision of the cyst following identification of the major papilla (Fig. 2Aand B). A transduodenal sphincteroplasty of both the biliary and pancreatic orifices was also performed to ensure ductal patency. Histological examination of the resected specimen stained with haematoxylin and eosin confirmed the absence of malignancy and the presence of smooth muscle between layers of duodenal mucosa (Fig. 2C). The muscle layer within the duplication cyst can be clearly visualised following immunostaining with antibody to alpha smooth muscle actin (Fig. 2D). The patient has not had another episode of pancreatitis for over six months after the operation. Congenital duodenal duplication cysts are a rare cause of recurrent pancreatitis. Abdominal pain and distension are typical features but gastrointestinal bleeding can occur due to the presence of ectopic gastric mucosa, allowing subsequent diagnosis during endoscopy. Pancreatitis, secondary to pancreatic ductal outflow obstruction is usually the result of pancreatic duct compression involving the cyst, or stone disease if there is direct communication with the pancreaticobiliary tract. Although endoscopic drainage and snare resection is considered safe, surgical excision is accepted as the treatment of choice with the intention to alleviate symptoms, prevent pancreatitis and eliminate the risk of malignant transformation, a development reported in only a small number of cases.

Trauma: Surgical and Related Conditions

The authors of this chapter include emergency physicians, surgical specialists and anaesthetists with experience of working in a wide variety of hostile environments. As with earlier chapters, the aim is not to “teach grandmothers to suck eggs”. Senior surgeons with deployment experience will have their own tried and trusted methods for managing patients under austere circumstances, and some will belong to that dying breed the “general surgeon”. This chapter is not aimed at the senior and experienced old hands. Rather, the purpose is to illustrate the range and complexity of conditions covered by our chapter headings for the more junior and often specialised health professional with a surgical interest in the widest sense