Erwin R. Thal

Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma

Three hundred one hemodynamically stable patients with equivocal abdominal examinations following blunt abdominal trauma had a CT scan followed by DPL. Both studies were negative in 194 patients (71.6%) and positive in 51 patients (27.1%). Seven of the 51 patients (13.7%) had an additional significant injury at operation that was not seen on the CT scan. Nineteen patients had a negative CT scan, a positive DPL, and a significant injury confirmed at celiotomy. In this group of 19 patients, the CT failed to identify seven splenic, three hepatic, and three small bowel injuries. There were two complications attributed to DPL. Three patients had a false negative DPL. Diagnostic peritoneal lavage continues to be a reliable study (sensitivity--95.9%, specificity--99%, accuracy--98.2%). The CT scan is not as sensitive (sensitivity--74.3%, p less than 0.001; specificity--99.5%, accuracy--92.6%). It is concluded that selective use of both procedures is appropriate as long as one recognizes the inherent limitations of each.

Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds.

One hundred twenty-three patients with lower chest and abdominal stab wounds were evaluated. If chest wounds were located between the two anterior axillary lines and abdominal examination was negative, peritoneal lavage was performed. If abdominal wounds were located between the two anterior axillary lines and physical examination was negative, local exploration was performed followed by lavage if local exploration was positive. Patients with negative lavage were observed and those with positive lavage were operated upon. Of the patients in this selected series 69.9% were spared an operative procedure. The incidence of negative laparotomy was 4.1%. It is concluded that the combination of local exploration and peritoneal lavage will increase diagnostic accuracy, eliminate unnecessary hospitalization, and reduce the number of negative laparotomies.

COMPLEX PROBLEMS IN PENETRATING NECK TRAUMA

This article discusses the problems and controversies in the assessment of penetrating injuries of the neck. The role of physical examination and color-flow Doppler imaging in the initial assessment is highlighted. Complex injuries of major vessels, the aerodigestive tract, and the parotid are discussed and therapeutic options are presented.

Role of laparoscopy in the evaluation of abdominal trauma

This prospective study was designed to determine if laparoscopy is a safe and accurate method for abdominal evaluation in the trauma patient. Thirty-two patients who presented with blunt or penetrating trauma and who were scheduled for celiotomy based on clinical evaluation constituted the study group. The patients underwent diagnostic laparoscopy prior to exploratory celiotomy. One of 6 (16%) patients with blunt abdominal trauma and 5 of 26 (19%) patients with penetrating abdominal trauma had significant injuries that were found at the time of operation but not visualized during laparoscopy. The missed injuries involved the liver, pancreas, stomach, duodenum, small bowel, small bowel mesentery, ureter, and urinary bladder. The correlation between the laparoscopist and the trauma surgeon as to the need to perform a celiotomy was 97%. Complications occurred in 2 of 32 patients. Eleven patients with anterior abdominal penetrating injuries had no evidence of penetration of the abdominal cavity at laparoscopy, and had no evidence of injury at celiotomy. We concluded that (1) there are areas within the abdominal cavity that cannot be accurately visualized with laparoscopy; (2) the evaluation of penetration of the peritoneal cavity from anterior penetrating injury appears to be accurate; (3) a number of injuries were not identified; and (4) further investigation of this procedure for the evaluation of abdominal trauma is required to assess its safety and accuracy.

Diagnosis of penetrating cervical esophageal injuries

Arterial injuries pose the greatest early threat to the patient with penetrating neck trauma and esophageal injuries, the greatest late threat. Clinical evaluation reliably identifies 80 percent of esophageal injuries, which, in our opinion, is not adequate. In 118 minimally symptomatic or asymptomatic patients with penetrating neck trauma, the combination of esophagography with esophagoscopy identified all 10 esophageal injuries in 118 patients with penetrating neck trauma. These data suggest that patients with penetrating neck trauma and minimal clinical findings should be initially evaluated with arteriography and esophagography. If the results of arteriography or esophagography are positive, then neck exploration should be performed. If the results of esophagography are equivocal, then rigid esophagoscopy should be performed. If all test results are negative, then observation is justified.

Peritoneal lavage in blunt abdominal trauma

Diagnosis of blunt abdominal trauma is frequently complicated by the presence of associated multiple system injuries. Diagnostic needle paracentesis has been advocated by numerous authors for many years. If nonclotting blood is recovered from the peritoneal cavity after taps in two or four quadrants, the accuracy of this adjunctive procedure has been reported as high as 95 per cent in predicting intraabdominal injury. The chance of obtaining positive results of the tap seems to be directly related to the amount of blood in the peritoneal cavity. Paracentesis is a simple quick procedure that has relatively few complications. Although abdominal paracentesis is accurate if results are positive, no information is gained if the result is negative. The major objection to the use of this test is the high percentage of falsenegative results. Because of the lack of reliability attached to negative results on paracentesis, other procedures have been sought to detect intra-abdominal injury. Canizaro, Fitts, and Sawyer [I] described the use of intraperitoneal saline infusions in animals in 1964. They consistently recovered blood-stained fluid in those animals which previously had blood injected into the peritoneal cavity and subsequently had negative results on abdominal paracentesis. In 1965 Root et al [2] described the technic of peritoneal lavage in patients. A follow-up study published in 1970 reported 304 patients in whom a 96 per cent accuracy rate was obtained [3]. This stimulated the intro-

Morbidity of colostomy closure following colon trauma

Recent reports have suggested alternative procedures to temporary colostomy because of the high morbidity associated with its closure. The charts of 137 patients, who had colostomy closure following colostomies for trauma, were reviewed. Barium enema was helpful in the preoperative evaluation in selected patients. Early closure in uncomplicated cases was not associated with greater problems. Fourteen patients had postoperative complications for an overall morbidity of 10.2%. There were no deaths in the series. Colostomy closure in the trauma patient appears to be safer than in patients whose colostomy is constructed for nontraumatic reasons. Meticulous technique, including leaving the skin and subcutaneous tissue open, is essential. It is concluded that the principle of diverting or exteriorized colostomy in the trauma patient should not be abandoned because of hazards of subsequent closure.

Abdominal surgical wound infection is lowered with improved perioperative enterococcus and bacteroides therapy.

Perioperative antibiotics decrease surgical wound infection (SWI) in trauma patients requiring abdominal exploration. This investigation evaluated 24 hours of cefoxitin or ampicillin/sulbactam used for early therapy in such patients. Patients were randomly assigned to one of two treatment groups. The primary endpoint evaluated was SWI, which was defined as purulent drainage or active wound treatment. Five hundred ninety-two patients were evaluated: 283 received ampicillin/sulbactam and 309 received cefoxitin. The incidence of wound infection among the ampicillin/sulbactam patients was 2% and among cefoxitin patients it was 7% (p < 0.004). The cefoxitin patients with colon injuries were analyzed (p < 0.007). The major difference between the two groups was an increased incidence of enterococcal infections in the cefoxitin-treated patients. A single broad-spectrum antibiotic given for 24 hour perioperatively effectively controls SWI. Use of ampicillin/sulbactam results in a significantly lower SWI rate than use of cefoxitin, which may be a result of improved enterococcal and Bacteroides coverage.

Vascular proximity : is it a valid indication for arteriography in asymptomatic patients ?

The role of arteriography in asymptomatic patients with penetrating extremity wounds in proximity to major vessels is controversial. This prospective study was designed to evaluate a precise definition of proximity, determine the incidence of positive arteriograms, and correlate angiographic interpretation with operative findings. Proximity was defined as any wound located within 1 cm of a major vessel. Excluded were patients with a pulse deficit, bruit, thrill, history of arterial hemorrhage, expanding hematoma, nerve deficit, fracture, or significant soft-tissue injury. One hundred sixty arteriograms were performed in 146 patients. One hundred forty-three (89.4%) were true-negatives. Seventeen (10.6%) were suggestive of injury. These included seven (4.4%) true-positive arteriograms, six (3.8%) false-positive studies, and four (2.5%) positive arteriograms in patients who were not operated upon. The angiographic report correlated with operative findings in five (38.5%) of 13 patients. These data confirm the low incidence (4.4%) of vascular injury in asymptomatic patients. The use of extremity angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination must be questioned.

The role of abdominal CT in the evaluation of stab wounds to the back

Two hundred five patients with stab wounds to the back were evaluated with CT scans using both oral and IV contrast material. One hundred sixty-nine patients had a negative scan. Thirty (17.8%) of the 169 patients were operated upon because of clinical concern. Injuries were found in two of these patients: a diaphragmatic injury in one and a combined diaphragmatic and liver injury in the other. None of the 139 patients observed developed any sequelae. Twenty of the 33 patients with a positive CT were taken to the operating room where 16 were found to have a significant injury. Seven of these 16 patients had additional injuries not identified on CT. There were four false positive scans. Thirteen patients with a positive scan and two patients with an equivocal scan were observed based upon clinical judgment. Ten of these 15 patients had minor isolated renal or hepatic injuries seen on scan. None of these developed complications. It is concluded that abdominal computed tomography, with a sensitivity of 89%, specificity of 98%, and accuracy of 97% is a reliable study in the evaluation of patients with stab wounds to the back.