ABSTRACT

CORRESPONDING AUTHOR:
Dr. Katta Srinivasa Rao,
Door No: 4-22-85/3A,
1 st Lane, Balaji Nagar,
Mutyala Reddy Nagar Extn,
Guntur – 522007,
Andhra Pradesh.
E-mail: kattasrinivas2070@yahoo.com

ABSTRACT: Blunt Abdominal trauma is one of the most common causes among injuries caused mainly due to road traffic accidents.¹The rapid increase in number of motor vehicles and its aftermath has caused rapid increase in number of victims to blunt abdominal trauma. Motor vehicle accidents account for 75 to 80% of blunt abdominal trauma.²Blunt injury of abdomen is also a result of fall from height, assault with blunt objects, industrial mishaps, sport injuries, bomb blast and fall from riding bicycle.²In view of increasing number of vehicles and consequently road traffic accidents, this topic is chosen to study the cases of blunt abdominal trauma with reference to the patients presenting at Govt. General Hospital, attached to Guntur Medical College, Guntur. OBJECTIVES: The objectives of the study are: 1. To evaluate the impact of blunt abdominal trauma on solid viscera. 2. To evaluate etiology and various modes of presentation. 3. To evaluate various available investigations for the detection of solid organ injuries. 4. To evaluate various modalities of treatment available with aim to reduce the mortality and morbidity. 5. To evaluate common complications of solid organ injury in blunt trauma abdomen. MATERIALS AND METHODS: Patients admitted in Government General Hospital, Guntur, from November 2012 to October 2014 and studied 50cases. This is a prospective study conducted over 2 years. RESULTS: Male patients were commonly affected (80%), Peak age group being 21–30 years (48%). The commonest mode of injury was road traffic accident (58%). The common organ injured was spleen (54%) followed by liver. 70% of the patients were treated by surgery, 30% conservatively. The mortality in this study was 14%. CONCLUSIONS: Blunt injury abdomen forms considerable load and health care system, most common age group is youngsters in road traffic accidents , so efforts should be made to formulate and execute road traffic regulations. Well established trauma care centers should be established. High index of suspicion and prompt management reduces the mortality and morbidity.

KEYWORDS: Blunt abdominal trauma; Solid organs; Road traffic accidents; Splenic injury.

INTRODUCTION: Blunt abdominal trauma is usually not obvious. Hence, often missed, unless, repeatedly looked for. Several pathophysiological processes take place in case of blunt injury abdomen. In general injuries are classified as high energy or low energy.^2,3,4Focussed assessment sonography for trauma has emerged as a useful diagnostic test in the evaluation of blunt injury abdomen.^5,6,7  There are four categories of injuries depending on the seriousness of injury.⁸Exigent, emergency, urgent, deferrable. Thorough investigation, timely treatment saves many victims of abdominal trauma.

METHODS OF COLLECTION OF DATA: Direct interview with the patient or patient relatives accompanying the patient and obtaining a detailed history. Thorough clinical examination. Clinical findings and relevant diagnostic investigations performed over the patient.

After initial resuscitation of the patients, thorough assessments for injuries were carried out in all the patients. Documentation of patients, which included, identification, history, clinical findings, diagnostic test, operative findings, operative procedures, complications during the stay in the hospital and during subsequent follow-up period, were all recorded on a Proforma specially prepared. Demographic data collected included the age, sex, occupation and nature and time of accident leading to the injury.

After initial resuscitation and hemodynamic stability, all patients were subjected to careful examination, depending on the clinical findings; decision was taken for further investigations such as four-quadrant aspiration, x ray abdomen and FAST.

The decision for operative or non-operative management depended on the outcome of the clinical examination, hemodynamic stability and CECT abdomen.

Patients selected for non-operative or conservative management were placed on strict bed rest, were subjected to serial clinical examination which included hourly pulse rate, blood pressure, respiratory rate and repeated examination of abdomen and other systems. Appropriate diagnostic tests especially ultrasound of abdomen was repeated as and when required.

CT scan was done in 36 patients in our study. FAST was done in all patients and results and observations are as follows.

RESULTS: From November 2012to October 2014, 50 numbers of cases were studied which belonged to surgical units in Government General Hospital, Guntur.

In this study majority belongs to 21-30 years of age accounting for 48%followed by 31-40years of age.

In 58%cases road traffic was the mode of injury followed by fall from height in 24%. Least was injury with blunt object in 18%

It is the time interval between time of injury to time of presentation to our hospital.

40% of cases presented to hospital between 7-12 hours of incident. 1 patient presented after a day.

Investigations: USG abdomen was done in all 50 cases. Organ injury in USG abdomen:

CECT was performed in 36 cases.

Those patients who did not undergo CECT were taken for laparotomy as they were hemodynamically unstable.

70% (35) of the patients underwent emergency laparotomy because of pneumoperitoneum or hemodynamic instability. 15 patients were managed non-operatively because they had no signs of peritonitis and they were hemodynamically stable.

The below table shows various operative procedures carried out during exploratory laparotomy:

In our study, spleen was the most commonly injured organ.

Majority of the times multiple organs are involved in our study as shown above.

Complications:

Mortality: Total 7 patients died in the present study. 3 belonged to operative group and died within 2-3days of post-operative period mainly due to hypovolemia or sepsis. 3 patients died during resuscitation. 1 died due to severe head injury. Therefore mortality is 14%.

DISCUSSION:

From the above table it is clear that males are more common victims of blunt trauma abdomen when compared to Davis et al study⁹. The incidence is slightly more in males involved in RTA and Assaults.

Age group - in our study majority of our study population belonged to 21-30yrs of age.

Followed by 31-40yrs of age as young people are involved in RTA which is compared to Daviset al study.⁹

From above table it clearly states that RTA is the most common mode of injury because of increased number of vehicles recently. The young people also give priority to speed rather than safety.

Clinical Presentation: In our series abdominal pain was the most common presenting complaint accounting 90%.Abdominal distention was next most common presentation in 56% of cases. The signs and symptoms are misleading in case of blunt trauma abdomen and are masked by concomitant head injury, chest injury and alcohol consumption. Retroperitoneal organ injury was missed in USG abdomen.

In Davis et al study⁹43% had no specific complaints. So this emphasizes the importance of careful and continuing observation and repeated clinical examination of individuals with blunt trauma abdomen.

Latent Period: Latent period is the interval between the times of injury to presentation to our hospital.40%of our patients presented between 7-12hrs after injury. 30% presented within 6hrs after injury. This time lag is due to lack of facility for transport. Many belonged to rural area.

Associated injury was present in 37 cases. The most extra abdominal injury was thoracic accounting for 32% followed by extremity fracture, head injury, pelvic fracture and soft tissue injury in descending order. There was no association in 13 patients. The above table shows comparison to present study.

Haemoglobin: Haemoglobin percentage was done in all cases out of which 26% of our study population had hemoglobin less than 8grams.

Hematocrit: Hematocrit value was done in 45 patients. It was<30% in 40% of our study population. In 5cases there was decreasing hematocrit on serial measurement and were taken for emergency laparotomy.

Urine microscopy: Urine microscopy was done in all cases. There was hematuria either macro/micro in 10 cases. All the cases showed renal injury on CT scan.

Plain X-ray Erect Abdomen: Plain erect X ray of abdomen was done in 45 cases. Gas under diaphragm was found in 5 cases. In

Davis et al.,⁹ study abdominal X ray was abnormal in 21% cases. In our study it is abnormal in 22% of cases of BIA (Blunt Injury Abdomen).

USG abdomen (Focussed Assessment with Sonography for Trauma) was done in all cases out of which 45 cases had solid organ injury. Therefore USG abdomen is more reliable in detecting solid organ injury and free fluid in the abdomen.

From above table, spleen is the most common organ injured in BIA as compared to international series, accounting to 54%, followed by liver in 30% cases and kidney in 12% cases.

Imaging is essential in early decision making. Focussed Assessment with Sonography in Trauma (FAST) examination of pericardial, perihepatic, perisplenic and pelvic areas help in early detection of clinically significant abdominal injury. FAST examination can be performed repeatedly and is an excellent adjuvant to physical examination.

CT Scan Abdomen: CECT was done in 36 cases. Rest of the patients which were managed conservatively, patients were not affordable and some were hemodynamically unstable and were taken for exploratory laparotomy.

Computed tomography (CT) can provide reliable information on haemoperitoneum, extent of solid organ injuries, retroperitoneal organ injuries, most cases of hollow viscus perforation and ongoing bleeding by means of radiographic blush.

There is an increase in trend towards conservative management if the patient is hemodynamically stable. The grade of injury was assessed by CECT. Minor lacerations and capsular tears which are difficult to diagnose clinically can be easily demonstrated in CECT scan and were selected for nonoperative management. However the disadvantage of non-operative management is missed injuries resulting in increased morbidity and mortality.

Above table shows incidence of multiple organ injuries in our study. In 24% of cases there was multiple organ injury in the abdomen.

Operative Procedure: In the present study, closure of bowel which was associated with solid organ injury was done in 5cases. Splenectomy was done in 25 cases because of hemodynamic instability and severity of injury. Splenorraphy was done in 2 cases and most of liver injuries were managed conservatively. Hepatorraphy was done in 4 cases. All renal injury cases were managed conservatively. Drainage procedure was done in 2 patients of pancreatic injury.

Mortality: Total 7 patients died in our study. 3 patients belonged to operative group. They died in postoperative period, majority of them died due to septicemia, 3 patients died during resuscitation. 1 patient died due to severe head injury. Therefore mortality in the present study is 14% which is on par with the other published studies in our country (Khannaetal¹⁰). The mortality rate in Di Vincenti et al,¹²  study was 23%. Cox et al,¹¹ study reports mortality of 10% and in Davis et al,⁹study it was 13.3%.

CONCLUSIONS: Most common age group involved is 21-30 years. Predominantly males are affected in large proportions. Road traffic accident forms the most common mode of injury. So efforts should be made to bring road traffic regulations into strict action and traffic norms regulated. Well established trauma care centres should be established at every Taluka hospital. Measures for early transport of the patients from the accident site to the trauma centres should be undertaken. Clinical presentation is varied, sometimes confusing. Falling titres in serial hematocrit value indicates ongoing bleeding. With the advent of high resolution ultrasonography (FAST) and FQA (Four Quadrant Aspiration) investigations are becoming less opted. CECT forms the core investigation of choice in dealing with blunt injury abdomen patients, and becomes more important in deciding operative versus conservative management. Early diagnosis and repeated clinical examination and use of appropriate investigations forms the key in managing BIA injuries.

REFERENCES:

1.    CusheriA, George Hanna A. R: Essential Surgical Practice; Butter worth International 4thEd. 2013:p263-304.
2.    Sabiston’s Text book ofsurgery: 19 edition: vol 1: 2012: p455-459.
3.    Skandalakis Surgical anatomy 3rd Ed.
4.    Surgery of the liver and biliary tract: L. H. Blumgart: vol 1: 5 edition: 2013: 1277-1318 p.
5.    Joe Jack Davis, Isidore Cohn, Francis C. Nance; Diagnosis and management of Blunt abdominal trauma. Ann, Surg, June 1976: vol 183: No 6; p672-678.
6.    SchwabCW.Selectionofnonoperativemanagementcandidates.WorldJSurg2001;25:1389-1392
7.    Scalea TM, Rodriguez A, et al. Focussed assessment with Sonography for Trauma (FAST): result from an international consensus conference. J Trauma 1999; 46: 466-472.
8.    FA Moore, J Nelson, BA MC Kinley massive transfusion in trauma patients tissue haemoglobin, oxygen saturation predicts poor outcome, journal of trauma 2008.
9.    JoeJackDavis, Isidore Cohn, Francis C. Nance; Diagnosis and management of Blunt abdominal trauma. Ann, Surg, June 1976: vol 183: No 6; p672-678.
10.    R.Khanna,SKhanna,PSingh,PuneetandAKKhanna;Spectrumofbluntabdominal trauma in Varanasi; Quart J; vol 35, No 1&2, Mar&Jun 1999; p25-28.
11.    Cox, Everard F; Blunt abdominal trauma: A 5 year Analysis of 870 patients requiring Celiotomy; Ann, Surg; April 1984 vol199; p467-474.
12.    DiVincenti F C, River JD, Laborde EJ, etal: Blunt abdominal trauma. J Trauma 8:1004, 1968.