|Year : 2020 | Volume
| Issue : 4 | Page : 270-274
Thoraco-abdominal injuries among patients presenting with trauma
Rakesh Mohanty1, Rebecca George2, Kundavaram Paul Prabhakar Abhilash3
1 Division of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Obstetrics and Gynecology, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||16-Mar-2020|
|Date of Decision||12-Apr-2020|
|Date of Acceptance||15-May-2020|
|Date of Web Publication||19-Oct-2020|
Dr. Rakesh Mohanty
Division of Critical Care, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Globally, injuries contribute to around 10% of total deaths, and in India, to 13%–18%. Among all injury-related deaths, thoraco-abdominal trauma is the second most common cause of death. The aim of the study was to determine the outcomes of patients with thoraco-abdominal injuries presenting to a tertiary-level emergency department (ED) in South India. The study also aimed to verify the impact of extended-focused assessment with sonography in trauma (e-FAST) positivity on outcomes. Materials and Methods: A prospective observational study was conducted over 3 months. A cohort of patients presenting to the ED with abdomino-thoracic trauma were studied. Results: During the study period, we received 1216 trauma patients to our ED. 241 (19.8%) of them had thoraco-abdominal trauma. 158 (65.6%) patients had thoracic injuries and 183 (75.9%) patients had abdominal injuries. Among patients with thoracic injuries, 55 (34.8%) had hemothorax, 33 (20.9%) had pneumothorax, 30 (19%) had lung contusions, 64 (40.5%) had rib fractures, and 2 (1.2%) had pericardial effusions. Among patients with abdominal injuries, 33 (18%) had solid organ injuries, 68 (37.2%) had free fluid being present, and 3 (1.6%) had bowel injuries. 209 (86.7%) patients underwent e-FAST examination, of which 68 (32.5%) were e-FAST positive and 141 (67.5%) were e-FAST negative. Among e-FAST-positive patients, 54 (79.8%) needed admission, 3 (4.4%) were discharged from ED, and 4 (7.3%) died. Among e-FAST-negative patients, 80 (56.7%) needed admission, 54 (38.3%) were discharged from ED, and 1 (0.7%) patient died. 7 (10.2%) patients in the e-FAST-positive group and 15 (10.6%) in the e-FAST-negative group were discharged against medical advice. Systolic blood pressure <90, heart rate <60 and >100, Glasgow coma score ≤8, blood transfusion in the ED, and positive e-FAST were associated with increased risk of mortality. Conclusion: The study showed that abdominal trauma is more in two-wheeler riders and among adult males. e-FAST is a simple tool that can be used in the ED to timely recognize thoraco-abdominal trauma. Patients with e-FAST being positive are at an increased risk of adverse outcomes.
Keywords: Blunt injury, extended-focused assessment with sonography in trauma, thoraco-abdominal trauma, thoracotomy
|How to cite this article:|
Mohanty R, George R, Abhilash KP. Thoraco-abdominal injuries among patients presenting with trauma. Curr Med Issues 2020;18:270-4
| Introduction|| |
Trauma is the sixth leading cause of mortality and morbidity, worldwide. Under the age of 35, trauma is the leading cause of death and disability. Road traffic accidents (RTAs) account for 35% of the worldwide fatalities with 1.3 million deaths and 45 million disabilities each year. In India, RTAs were the leading cause of trauma (65%). Worldwide, blunt abdominal trauma accounted for 8%–17% and thoracic trauma accounted for 18%–35% as compared to 4.6% and 4.3% in India.
Diagnosis and surgical management are challenging in patients with thoraco-abdominal trauma as there is a chance of concurrent injury in two body cavities. Although radiological investigation such as computed tomography (CT) is very essential, very often co-existing airway, hemodynamic instability, as well as urgency of management precludes the transfer of patient away from resuscitation room.
The focused assessment with sonography in trauma (FAST) is an ultrasound protocol developed to assess for hemoperitoneum and hemopericardium. Numerous studies have demonstrated sensitivities between 85% and 96% and specificities exceeding 98%. FAST examination evaluates the pericardium and three potential spaces within the peritoneal cavity for pathologic fluid. The right upper quadrant visualizes the hepatorenal recess, also known as Morrison's pouch, the right paracolic gutter, the hepatodiaphragmatic area, and the caudal edge of the left liver lobe. The subxiphoid (or subcostal) view evaluates the pericardial space for any effusion. The left upper quadrant is used to check the splenorenal recess, the subphrenic space, and the left paracolic gutter for any free fluid. The suprapubic view inspects for free fluid in the rectovesical pouch in males and the rectouterine (pouch of Douglas) and vesicouterine pouches in females.
The extended-FAST or e-Fast includes the assessment of the thorax for both pneumothorax and hemothorax.
Ninety-six percent of all level-1 trauma centers along with Advance Trauma Life Support (ATLS) have incorporated e-FAST in their trauma algorithms.
This prospective study was done to determine the prevalence and different modes of injuries of patients with thoraco-abdominal trauma. The percentage of thoraco-abdominal trauma with e-FAST positive was noted, and the clinical outcomes among e-FAST-positive and e-FAST-negative patients were assessed.
| Materials and Methods|| |
This is a cross-sectional study to determine the prevalence of thoraco-abdominal trauma and effectiveness of e-FAST among patients in the emergency department (ED).
The study was conducted in the ED of Christian Medical College (CMC) Hospital, Vellore, which is a large tertiary care hospital in South India. The ED is a 47-bed department and tends to about 200 patients per day including trauma and nontrauma patients.
A consecutive sampling strategy was employed for this study, wherein all patients presenting with suspected thoraco-abdominal trauma based on history and physical examination to the ED CMC Hospital, Vellore, were considered for enrollment in the study.
Relevant details regarding history, clinical findings, laboratory investigations, and imaging were documented prospectively in the study questionnaire. The management in ED either nonoperative or operative intervention was noted. The outcomes of the patients from the ED with regard to admission, discharged against medical advice (DAMA), and leaving against medical advice were documented.
The outcomes of interest were surgical intervention involving thorax and/or abdomen, ICU admission ward admission, discharge from ED, death, and DAMA.
This study is a prospective, observational study based on history, and therefore, informer bias is unavoidable. Clinician bias occurs due to interobserver variation in the findings of e-Fast.
All patients suffering from thoraco-abdominal injuries over a span of 3 months (March 2016–May 2016) were recruited. Based on the study by Costa et al., assuming a prevalence of 6% precision and 95% confidence interval, the required sample size for the study was calculated to be 278 thoraco-abdominal trauma patients.
All patients had relevant radiological and blood investigations done based on the primary, secondary, and tertiary surveys.
The data were analyzed using Statistical Package for the Social Sciences (IBM Corp. Released 2015. IBM SPSS, Version 23.0, Armonk, NY, USA). All categorical variables were expressed as frequencies and percentages. Data were summarized using mean along with standard deviation for continuous variables, and frequencies along with percentages were calculated and given.
This study was approved by the institutional review board before the commencement of the study (IRB Min no: 9776 dated December 3, 2015). Patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.
| Results|| |
During this prospective study, a total of 1216 patients with trauma presented to the ED of CMC, Vellore, over a span of 3 months (March 2016–May 2016). Among them, 241 (19.8%) were found to have thoraco-abdominal injuries [Figure 1].
Majority of the patients, i.e., 160 (66.6%), with thoraco-abdominal trauma were found to be from the productive age group of 20–50 years with a mean of 34.3 ± 16.1. Gender predominance, assigned priority based on triage, time from incident to presentation to ED, place of incidence (Vellore district or outside), baseline hemodynamic parameters, and associated injuries are described in [Table 1]. Two-wheeler accidents were found to be the most common mode of injury (57.7%), followed by fall from height (15.4%) and travelers in four-wheeler (9.1%) [Figure 2].
Of the 241 patients with thoraco-abdominal injuries, 42 (17.6%) had hypotension (<90 mmHg systolic blood pressure [SBP]). Among these 42 patients, 25 required ICU care. There were 8 (19%) deaths seen in the patients with hypotension, of which 5 (62.5%) patients died in the ED and 3 (37.5%) patients died during their hospital admission.
90 (37.3%) patients had associated head injury, and among them, 33 (13.7%) patients were found to have Glasgow coma scale (GCS) ≤8.
At index presentation, 156 patients had thoracic injuries, of which 101 had clinical findings such as abrasions, laceration, hematoma, tenderness, and crepitus and decreased breath sounds. Among patients with thoracic injuries, 55 (34.8%) had hemothorax, 33 (20.9%) had pneumothorax, 30 (19%) had lung contusions, 64 (40.5%) had rib fractures, and 2 (1.2%) had pericardial effusion. On arrival to ED, 183 had abdominal injuries, 81 patients out of them were found to have clinical evidence such as abrasion, laceration, hematoma, tenderness, and absent bowel sounds. Among patients with abdominal injuries, 33 (18%) had solid organ injuries, 68 (37.2%) had free fluid in the peritoneal cavity, and 3 (1.6%) had bowel injuries.
Interventions such as laparotomy, needle/tube thoracostomy, thoracotomy, or pericardiocentesis needed for the management of thoraco-abdominal injuries are described in [Table 2].
e-FAST was performed on 209 (86.7%) patients. Of these 209 patients, 68 (32.5%) were found to be e-FAST positive [Figure 3]. Among the patients who were found to be e-FAST positive, 33 (48.5%) were e-FAST positive for chest and 49 (72%) were e-FAST positive for abdomen. Among e-FAST-positive patients, 54 (79.8%) needed admission, 3 (4.4%) were discharged from ED, and 4 (5.9%) died. Among e-FAST-negative patients, 80 (56.7%) needed admission, 54 (38.3%) were discharged from ED, and 1 (0.7%) patient died. 7 (10.2%) patients in the e-FAST-positive group and 15 (10.6%) in the e-FAST-negative group were DAMA. Laparotomy was done for 6 (8.8%) of the e-FAST-positive patients. The mortality rate of e-FAST-positive patients was 7.3% (4/68).
|Figure 3: Distribution of extended-focused assessment with sonography in trauma.|
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Among the patients with thoraco-abdominal injuries, 38 (15.8%) required blood transfusion. Of these 38 patients, 26 (68.4%) were admitted and 17 (44.7%) of them required ICU care. Among the patients who received blood transfusion, three required laparotomy and two patients required ICD insertion for hemothorax. ED outcome of the patients with thoraco-abdominal trauma is shown in [Figure 4].
| Discussion|| |
Trauma remains an important cause for mortality worldwide and is a major public issue as it affects the productive age group of people. Almost 10%–30% of hospital admissions are related to RTAs. Rapid economic growth and urbanization with changing lifestyles has led to increasing use of high-speed automobiles.
The abdomen is commonly injured in blunt injuries and often requires operative intervention. Early intervention has been known to reduce mortality in these patients. According to Clement et al., less than one-third of the patients presented to the ED within 3 h of the time of injury, which is consistent with our study. In this study, two-third of the patients with thoraco-abdominal trauma were found to be from the productive age group of 20–50 years which was consistent with the study done by Arumugam et al., where the mean age in trauma patients was found to be 30. Our study showed a male predominance which was similar to the studies done by Aldemir et al., where it was 89.4%, and Amuthan et al., where it was 84%., We observed that age had no positive correlation to outcome though other studies such as Haddad et al. proved that advanced age group is associated with mortality.
The key prognostic factors in determining outcome of patients presenting to the ED with severe trauma were studied by González-Robledo et al. Clinical variables assessed in the ED such as pulse rate, SBP <90, GCS ≤8, anisocoria, and mydriasis were found to be the significant predictors of in hospital outcome. In our study, many patients with low GCS had a high mortality which was congruous with the study done by Abhilash et al.
Revised trauma score (RTS) is an excellent predictor of mortality. According to Agbroko et al.'s study on determinants of outcome of abdominal trauma, RTS of survivors was significantly higher than nonsurvivors (P = 0.021). Our study showed that RTA was the most common mode of thoraco-abdominal injury, which is consistent with the studies done by Arumugam et al. (61%) and Amuthan et al. (68%).,
e-FAST is a good diagnostic tool in trauma patients, especially in those who are hemodynamically unstable and who cannot be shifted for contrast-enhanced CT. There is a good correlation in the assessment of e-FAST done by ED physicians (80.4%) and radiologist (84.3%) as found by Abhilash et al. In another study by Tayal et al., FAST was found to be 100% sensitive and specific for diagnosis of pericardial effusion and intraperitoneal fluid in patients with trauma.
Our study has certain limitations; small sample size and absence of severity scoring systems being some of them. Hence, we could not compare the outcomes of surgical and nonoperative management of patients with blunt injury of the abdomen. Future prospective studies on the outcomes of the two modes of management of patients are required to shed light on this enigma.
| Conclusion|| |
Thoraco-abdominal trauma is one of the important causes of morbidity and mortality in relatively young individuals. Most common mode of injury is RTAs, with two-wheeler being predominantly implicated.
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Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min No: 9776 dated December 3, 2015. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]