Associated injuries in blunt solid organ trauma: Implications for missed injury in nonoperative management

Preston R. Miller, Martin Croce, Tiffany K. Bee, Ajai K. Malhotra, Timothy C. Fabian

Research output: Contribution to journalArticle

93 Citations (Scopus)

Abstract

Background During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or supleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and supleen injuries, and missed injuries were reviewed in patients undergoing NOM. Methods Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsusupected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or supleen injury. Results Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or supleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. Conclusion Damage to the pancreas and bowel is significantly associated with liver as opposed to supleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with supleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We supeculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the supleen accounts for the greater rate of associated injuries to the pancreas/small bowel.

Original languageEnglish (US)
Pages (from-to)238-244
Number of pages7
JournalJournal of Trauma
Volume53
Issue number2
DOIs
StatePublished - Jan 1 2002

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Nonpenetrating Wounds
Wounds and Injuries
Abdominal Injuries
Liver
Pancreas
Diaphragm
Incidence

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Associated injuries in blunt solid organ trauma : Implications for missed injury in nonoperative management. / Miller, Preston R.; Croce, Martin; Bee, Tiffany K.; Malhotra, Ajai K.; Fabian, Timothy C.

In: Journal of Trauma, Vol. 53, No. 2, 01.01.2002, p. 238-244.

Research output: Contribution to journalArticle

Miller, Preston R. ; Croce, Martin ; Bee, Tiffany K. ; Malhotra, Ajai K. ; Fabian, Timothy C. / Associated injuries in blunt solid organ trauma : Implications for missed injury in nonoperative management. In: Journal of Trauma. 2002 ; Vol. 53, No. 2. pp. 238-244.
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abstract = "Background During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or supleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and supleen injuries, and missed injuries were reviewed in patients undergoing NOM. Methods Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsusupected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or supleen injury. Results Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89{\%} (L group), 78{\%} (S group), and 75{\%} (L + S group). On examination of all patients with blunt liver or supleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5{\%} as compared with 1.7{\%} in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2{\%}. Although in the L and S groups, rates of diaphragm (0.5{\%} vs. 1{\%}, p = 0.45) and intra-abdominal bladder injury (0.3{\%} vs. 0.3{\%}, p = 0.99) were similar, bowel injury was more common in the L group (11{\%} vs. 0{\%}, p = 0.0004), as was pancreatic injury (7{\%} vs. 0{\%}, p = 0.007). In NOM patients, missed injury occurred in seven (2.3{\%}) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. Conclusion Damage to the pancreas and bowel is significantly associated with liver as opposed to supleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with supleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We supeculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the supleen accounts for the greater rate of associated injuries to the pancreas/small bowel.",
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AU - Fabian, Timothy C.

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N2 - Background During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or supleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and supleen injuries, and missed injuries were reviewed in patients undergoing NOM. Methods Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsusupected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or supleen injury. Results Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or supleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. Conclusion Damage to the pancreas and bowel is significantly associated with liver as opposed to supleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with supleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We supeculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the supleen accounts for the greater rate of associated injuries to the pancreas/small bowel.

AB - Background During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or supleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and supleen injuries, and missed injuries were reviewed in patients undergoing NOM. Methods Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsusupected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or supleen injury. Results Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or supleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. Conclusion Damage to the pancreas and bowel is significantly associated with liver as opposed to supleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with supleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We supeculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the supleen accounts for the greater rate of associated injuries to the pancreas/small bowel.

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