Thoracoabdominal trauma outcomes

In what the authors describe as ‘the largest and most rigorous description of blunt thoracoabdominal injury to date’, we learn some interesting things and are reminded of some others:

Most solid organ injuries in the abdomen are managed non-operatively

Thoracotomy – especially non-resuscitative thoracotomy – is rare

In patients with thoracoabdominal trauma, the overwhelming majority of injuries requiring operative intervention were found in the abdomen, therefore..

…excluding those patients in extremis requiring a resuscitative thoracotomy, the initial incision, without directive radiological information, belongs in the abdomen

Concomitant thoracic injury did not preclude nonoperative management of abdominal solid organ injury

This is a really interesting paper providing important data on the outcomes and management of a patient group that frequently produces management dilemmas in trauma centres.

The double jeopardy of blunt thoracoabdominal trauma
Arch Surg. 2012 Jun;147(6):498-504


OBJECTIVES: To examine the specific injuries, need for operative intervention, and clinical outcomes of patients with blunt thoracoabdominal trauma.

DESIGN: Trauma registry and medical record review.

SETTING: Level I trauma center in Los Angeles, California.

PATIENTS: All patients with thoracoabdominal injuries from January 1996 to December 2010.

MAIN OUTCOME MEASURES: Injuries, incidence and type of operative intervention, clinical outcomes, and risk factors for mortality.

RESULTS: Blunt thoracoabdominal injury occurred in 1661 patients. Overall, 474 (28.5%) required laparotomy, 31 (1.9%) required thoracotomy (excluding resuscitative thoracotomy), and 1146 (69.0%) required no thoracic or abdominal operation. Overall incidence of intraabdominal solid organ injury was 59.7% and hollow viscus injury, 6.0%. Blunt cardiac trauma occurred in 6.3%; major thoracic vessel injury, in 4.6%; and diaphragmatic trauma, in 6.0%. The majority of solid organ injuries were managed nonoperatively (liver, 83.9%; spleen, 68.3%; and kidney, 91.2%). Excluding patients with severe head trauma, mortality ranged from 4.5% with nonoperative management to 18.1% and 66.7% in those requiring laparotomy and dual cavitary exploration, respectively. Age 55 years or older, Injury Severity Score of 25 or more, Glasgow Coma Scale score of 8 or less, initial hypotension, massive transfusion, and liver, cardiac, or abdominal vascular trauma were all independent risk factors for mortality.

CONCLUSIONS: Most patients with blunt thoracoabdominal trauma are managed nonoperatively. The need for non-resuscitative thoracotomy or combined thoracoabdominal operation is rare. The abdomen contains the overwhelming majority of injuries requiring operative intervention and should be the initial cavity of exploration in the patient requiring emergent surgery without directive radiologic data.