This may be the car accidents, sports injury, domestic fall, accidents due to falling from great height or work accident. Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however its role in resuscitation of patients with abdominal exsanguination is uncertain. Vascular surgery involves surgery of one of the major arteries. Damage control surgery is defined as the rapid initial control of hemorrhage and contamination with packing and temporary closure, followed by resuscitation in the icu, and subsequent reexploration and. Penetrating injuries include gunshot and shrapnel injuries, impalements, and knifings. Abdominal penetrating trauma an overview sciencedirect topics.
The pressure within the abdominal cavity, or intraabdominal pressure in a normal person is 05 mmhg. Bowel contusion remains a difficult problem both with regard to diagnoses as well as treatment, and. Jan 22, 2015 management of vascular injuries, especially when they occur in combination with fractures, soft tissue loss, and nerve damage, is extremely challenging. Predictably, exsanguinating hemorrhage is the most important. Management of penetrating trauma to the major abdominal. Damage control dc, defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid. Control and exposure of intraabdominal vascular trauma. The impact of shorter prehospital transport times on.
Although literature regarding emergency department thoracotomy edt outcome after abdominal exsanguination is limited, numerous reports have documented poor edt survival in patients with anatomic injuries other than cardiac wounds. Fortunately, injury related deaths have declined over the last twenty years however, they continue to be a significant burden on health resources. Trauma is the leading cause of death worldwide in patients younger than 45 years and the sixth leading cause of all death, accounting for 10% of all mortality. The patients who suffered an isolated arterial injury made up 1. This is a basic article for medical students and other nonradiologists. Abdominal penetrating trauma an overview sciencedirect. Penetrating injuries often result in injury to hollow organs, such as the intestines. Blunt pediatric vascular trauma journal of vascular surgery. Management guidelines for penetrating abdominal trauma.
Be cause exsanguination from venous injury, rather than. Management of intraabdominal vascular injury in trauma. This is the largest reported civilian or military experience with this specific injury. Initial assessment and management of major trauma trauma in australia and new zealand is the leading cause of death in the first four decades of life. Curr trauma rep management of penetrating trauma to the major abdominal vessels peep talving 0 1 2 5 sten saar 0 1 2 5 lydia lam 0 1 2 5 0 department of surgery, tartu university hospital, tartu, estonia 1 department of surgery, school of medicine, university of tartu, tartu, estonia 2 division of acute care surgery, department of surgery, north estonia medical center, j. Trauma exsanguination protocol improves survival and blood. Definitive laparotomy dl for penetrating abdominal wounding with combined vascular and visceral injury is a difficult surgical challenge. Research open access the impact of shorter prehospital. Management of penetrating trauma to the major abdominal vessels. Vascular injuries remain among the most challenging entities encountered in the. Abdominal vascular injuries have a very high mortality and morbidity rates among trauma patients.
Our primary study objective was to prove that prelaparotomy edt is beneficial to patients with exsanguinating abdominal hemorrhage. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life. Shownotes pdf link rosens in perspective principles to consider with any trauma patient. Trauma one of the most serious causes for exsanguinations is an accident.
Abdominal vascular trauma is fairly common in modern civilian life and is a highly lethal injury. Vascular imaging in the setting of trauma endovascular today. Penetrating abdominal vascular injuries result in significant mortality. Most deaths in patients with abdominal vascular injuries abvi are caused by exsanguination and irreversible shock. Severity and outcome analysis of abdominal vascular injuries at a. It is imperative that the primary threat to the patient be rapidly analyzed and managed. Abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. Oct 06, 2016 intra abdominal vascular injuries are associated with extremely rapid rates of blood loss and pose challenges of exposure during celiotomy, 1, 2, 3 given the posterior position of the major abdominal vascular structures except for the portal vein and the hepatic artery. Abdominal vascular injuries refer to the disruption of major midline, mesenteric, retroperitoneal, andor portal blood vessels. Blunt abdominal trauma in a european trauma setting. View pdf world journal of emergency surgery biomed central. Trauma, vascular injuries, vascular control, ruptured abdominal aorta aneurism. Secondary fecal contamination was found in six patients, either after secondary extension of bowel contusion over time 494 judgements.
The mortality rate varies widely and may reach 90% 3, 4. Frequently, these patients reach the hospital in severe hypovolaemic shock and exsanguination accounts for their high mortality. Management guidelines for penetrating abdominal trauma walter l. Exsanguinating hemorrhage upon elevation of the over lying lobe mandates. Open abdomen in trauma and emergency general surgery. The evaluation and management of patients with abdominal vascular trauma or injury requires rapid and effective decisionmaking in these unfavorable circumstances. A strategy combining the techniques of permissive hypotension, haemostatic resuscitation, and damage control surgery to prompt control of. Major abdominal vascular injuries are usually a result of penetrating trauma and associated with a high mortality rate. Multidetector ct in vascular injuries resulting from. Successful approach requires setting clear priorities, a logical plan of interventions, and close coordination between various subspecialty services.
A ct abdomen in its simplest form is a ct from diaphragm to symphysis pubis performed 60 seconds after pumpinjection of iodinated contrast into a peripheral vein. Civilian vascular trauma munich vascular conference. Jul 04, 2016 the severe traumatic brain injury in austria. The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decisionmaking in these unfavorable circumstances. Exsanguination from iliac vessel injuries is common and associated with high mortality resulting from refractory hemorrhage and associated injuries. Management of lower extremity vascular trauma springerlink. Laceration of the pancreas within the proximal body arrowheads.
However, if the projectile is small enough, if its energy is diminished when passing through the tissue and if the arterial system is elastic enough, the entry wound into the artery may close without exsanguination and therefore may not be fatal. Injuries to the abdominal aorta are rare and remain one of the most lethal causes of early death in trauma. As a result, many trauma surgeons consider prelaparotomy edt futile for patients dying from intraabdominal hemorrhage. In the literature, the management of acute traumatic vascular injuries is. Abdominal vascular trauma, primarily due to penetrating. Abdominal vascular injuries, blunt, penetrating abdominal trauma. If an aortic injury is not the source of hemorrhage, manual compression is. Although trauma surgeons recognize exsanguination as a syndrome 119, its multifactorial effects on the. All abdominal vascular injuries were graded with the american association for the surgery of trauma organ injury scale aastois for abdominal vascular injury 9 table 1. Jan 21, 2019 surgical complication patient often bleed following surgery because of surgical trauma of the major artery resulting in laceration or tear. Sep 14, 2019 api will miss nonobstructing vascular injuries and will give false positive results in patients with shock or elderly patients with significant peripheral vascular disease. Exsanguination awaits better definition, not only clinically but also physiologically and biochemically. Outcome of traumarelated emergency laparotomies, in an. Major vascular injuries following trauma in the civilian settings are relatively rare.
Asensio 14 has described it as the most extreme form of hemorrhage, with an initial blood loss of 40% and ongoing bleeding that, if not surgically controlled, will lead to death. Physiologic derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. This episode of crackcast covers chapters 46 of rosens emergency medicine, abdominal trauma. Emergent abdominal exploration if exsanguinating haemorrhage is. In most non trauma centers, blunt abdominal trauma bat following abdominal organ injuries is managed by elective surgeryoriented visceral and vascular surgeons and not by more broadly trained general surgeons as in the past 4. The purposes of this study were to identify primary predictors of mortality and to examine the impact of a wellestablished operating room resuscitation protocol on survival in patients with traumatic aortic injury. Patient factors and operating room resuscitation predict. Frontiers contemporary strategies in the management of.
Exsanguination accounts for more than 80% of operating room deaths, with 50% of the deaths occurring in the first 24 hours, but transfusion strategies for trauma related coagulopathy remain poorly. Outcomes following resuscitative thoracotomy for abdominal. Various factors, including blunt trauma can lead to increased abdominal pressure or intraabdominal hypertension which is defined as sustained pressures over 12 mmhg lee, 2012. The impact of damage control surgery on major abdominal. Identifying children at very low risk of clinically important. Bleeding introduction major vascular injuries following trauma in the civilian settings are relatively rare. Abdominal trauma may involve penetrating or blunt injuries. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting.
Abdominal vascular injuries are among the most lethal injuries sustained by trauma. Injury caused by car accident and work accident often results in severe blood loss, which if ignored results in exsanguination. The management of the periarrest or arrested patient following major trauma is controversial with poor outcomes in both civilian and military practice 1, 2. Ct abdomen is an increasingly common investigation that is used to help make diagnoses of a broad range of pathologies. The double jeopardy of blunt thoracoabdominal trauma.
Pdf abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. Abdominal trauma is responsible for about 10% of all deaths related to trama. This chapter highlights the basic principles of vascular injury management that can be used. Injury to the major arteries and veins in the abdomen are technical challenge to the. The most commonly injured abdominal vessels are the aorta, superior mesenteric artery sma, iliac arteries, inferior vena cava ivc, portal vein pv, and iliac veins. Civilian vascular trauma american college of surgeon. Abdominal vascular trauma is rare, lethal, and primarily associated with penetrating mechanisms. Only three patients had major abdominal arterial injuries in this series. Rarely injury missed and presents later as pseudoaneurysm or avfistula.
Increased early mortality has been associated with shock, acidosis, hypothermia, coagulopathy, free intraperitoneal bleeding and advanced american association for the surgery of trauma organ injury scale grade. Recognition of a traumatic vascular injury begins in the field by the firstresponse emergency medical team. Management of abdominal vascular trauma western trauma. Scrotal trauma testicular rupture rare in blunt trauma, more common in penetrating trauma. In the cases of severe abdominal trauma because of penetrating or blunt injury involving hepatic, nonhepatic, or vascular injuries with intraabdominal packing, the use of the oa technique should be considered, and an early decision to truncate a definitive operation should be. Other data collected included any concomitant solidorgan injury, duration of hospital stay, admission to. The lower extremities are involved in two thirds of all patients with vascular injuries. The impact of shorter prehospital transport times on outcomes.
The profuse internal bleeding resulting in exsanguination is occasionally seen following vascular surgery. Contemporary strategies in the management of civilian. Az of abdominal radiology gabriel conder, john rendle, sarah kidd and rakesh r. The purposes of this study were to identify primary predictors of mortality and to examine the impact of a wellestablished operating room resuscitation protocol on. Current guidelines advocate initiating cardiopulmonary resuscitation, intubation and bilateral thoracostomies followed by rapid transfer to theatre and if available, a range of advanced procedures including a thoracotomy for specific. Therefore, time to definitive hemorrhage control is an important factor affecting survival. Major venous injuries accompany 51% of significant arterial injuries. However, when it does occur, it can be quite lethal, with mortality ranging from 20% to 60%. Penetrating abdominal trauma is by far the most common and accounts for about 90% of the cases 1, 2.