The complication rate after a negative or nontherapeutic laparotomy is reported to be substantial but most of this reported morbidity is because of associated injuries and is not related to the abdominal exploration. On the other hand, the morbidity and mortality associated with a delay in taking the injured patient to the operating room is well recognised. A retrospective study attempts to show that when injury severity (using TRISS) is controlled for, negative laparotomy did not significantly increase the complication burden compared with no laparotomy in blunt abdominal trauma patients.
“Never Be Wrong”: The Morbidity of Negative and Delayed Laparotomies After Blunt Trauma
J Trauma. 2010 Dec;69(6):1386-92
Tag Archives: surgical
Pre-hospital amputation
British trauma surgeon and pre-hospital pioneer Professor Keith Porter describes how to do a pre-hospital amputation in this months EMJ. Thankfully the procedure is only rarely necessary and often only requires cutting remaining skin bridges with scissors. The indications are:
- An immediate and real risk to the patient’s life due to a scene safety emergency
- A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
- A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation
- The patient is dead and their limbs are blocking access to potentially live casualties
The recommended procedure is:
- Ketamine anaesthesia
- Apply an effective proximal tourniquet
- Amputate as distally as possible
- Perform a guillotine amputation
- Apply haemostats to large blood vessels
- Leave the tourniquet in situ
- Apply a padded dressing and transport to hospital
Remember: the requirement for prehospital amputation other than cutting minimal soft tissue bridges is rare. However pre-hospital critical care physicians should be trained and equipped to amputate limbs in order to save life. Probably good to have a Gigli saw in your pack and to familiarise yourself with its use, as shown here:
Prehospital amputation
Emerg Med J 2010 27: 940-942
Small bowel obstruction
When assessed against CT as gold standard, ultrasound diagnosis of small bowel obstruction by emergency physicians compared favourably with abdominal radiographs.
US exams were performed using a phased array probe in the bilateral colic gutters, epigastric and suprapubic regions to assess for (1) the presence of fluid-filled, dilated bowel (defined as >25mm) proximal to normal or collapsed bowel, and (2) decreased or absent bowel peristalsis (defined as back and forth movements of spot echoes inside the fluid-filled bowel). Either finding was considered ‘positive’ for small bowel obstruction.
Bedside ultrasonography for the detection of small bowel obstruction in the emergency department
Emerg Med J. 2010 Aug 22. [Epub ahead of print]
Burr holes by emergency physicians
Emergency physicians at Hennepin County Medical Centre (HCMC) are trained in skull trephination (drilling a burr hole) for patients with coma, anisocoria and epidural (extradural) haematoma (EDH) who have not responded to osmotic agents and hyperventilation. This may be particularly applicable in centres remote from neurosurgical centres where delays caused by interfacility transfer are associated with increased morbidity and mortality.
Dr Smith and colleagues from HCMC describe a series of five talk-and-deteriorate patients with EDH who underwent skull trephination. 3 had complete recovery without disability, and 2 others had mild to moderate disability but with good to excellent cognitive function. None had complications from the procedure other than external bleeding from the already lacerated middle meningeal artery. In 4 of 5 cases, the times were recorded. Mean time from ED presentation to trephination was 55 min, and mean time from ED to craniotomy was 173 min. The mean time saved was 118 min, or approximately 2 h.
All trephinations were done by emergency physicians, who had received training in skull trephination as part of the HCMC Emergency Medicine Residency or as part of the Comprehensive Advanced Life Support (CALS) course. Training was very brief and involved discussion of the treatment of EDH, review of a CT scan of EDH, and hands-on practice on the skull of a dead sheep, using the Galt trephinator.
An excellent point made by the authors reminds us that patients with EDH who talk-and-deteriorate (those with the traditionally described “lucid interval”) have minimal primary brain injury and frequently have no brain parenchymal injury. Thus, if the EDH is rapidly decompressed, the outcome is significantly better than for deterioration due to other aetiologies. The authors recommend in EDH that the procedure should be done within 60–90 min of onset of anisocoria. A review of other studies on the procedure would suggest that case selection is critical in defining the appropriateness of the procedure: talk-and-deteriorate, coma, anisocoria, and a delay to neurosurgical decompression.
Emergency Department Skull Trephination for Epidural Hematoma in Patients Who Are Awake But Deteriorate Rapidly
J Emerg Med. 2010 Sep;39(3):377-83
Another pneumoperitoneum
This Video from Academic Emergency Medicine shows distinct hyperechoic foci with reverberation artifacts visualised within free fluid, suggesting associated free intraperitoneal air (in a patient with a gastric perforation)
The full article is available here
Pneumoperitoneum
This video from the Trauma Association of Canada shows sonographic detection of intraperitoneal free air
[quicktime]http://www.traumacanada.org/media/pneumoperitoneum_video.mov[/quicktime]
Decompressive craniectomy
Neuro-folks at LAC+USC Medical Centre describe outcomes for patients with traumatic brain injury without space-occupying haemorrhage who underwent decompressive craniectomy for intracranial hypertension refractory to maximal medical therapy. Of 43 included patients, 25.6% died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). More evidence will result from two ongoing randomised multicentre trials: the European RescueICP study and the Australian DECRA trial.
Decompressive craniectomy: Surgical control of traumatic intracranial hypertension may improve outcome
Injury. 2010 Jul;41(7):934-8
Guidelines on penetrating abdominal trauma
The Eastern Association for the Surgery of Trauma has published guidelines on the nonoperative management of penetrating abdominal trauma.
RECOMMENDATIONS
- Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1).
- Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1).
- A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds (SWs) without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2).
- A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds (GSWs) if the wounds are tangential and there are no peritoneal signs (level 2).
- Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2).
- In patients selected for initial nonoperative management, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2).
- Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3).
- The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3).
- Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2).
Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma
J Trauma. 2010 Mar;68(3):721-733
Chlorhexidine-alcohol surgical site prep
In contrast to the situation with skin preparation for intravascular catheters, there have been no recommendations for surgical practice. A randomised controlled trial compared chlorhexidine–alcohol (2% chlorhexidine gluconate and 70% isopropyl alcohol or ‘ChloraPrep’) with povidone–iodine in 849 patients undergoing surgery. The overall rate of surgical-site infection was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group (9.5% vs. 16.1%) and chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections (4.2% vs. 8.6%) and deep incisional infections (1% vs. 3%) but not against organ-space infections (4.4% vs. 4.5%)
Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis
N Engl J Med. 2010 Jan 7;362(1):18-26
Open Fractures of the Lower Limb
Two major British surgical associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have worked together to create updated multi-disciplinary standards for the treatment of open fractures of the lower limb
The recommendations are summarised as:
Standards for Practice Audit:
1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav (1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6 hourly if penicillin allergy
2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, particularly after reduction of fractures or the application of splints
3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within 3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia
4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions
5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heavily contaminated by marine, agricultural or sewage matter.
6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and orthopaedic surgical teams and clearly documented
7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-soaked gauze and an impermeable film to prevent desiccation
8. The limb, including the knee and ankle, is splinted
9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures have protocols in place for the early transfer of the patient to an appropriate specialist centre
10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only takes place in a non-specialist centre if the patient cannot be transferred safely
11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic surgeons working together on scheduled trauma operating lists within normal working hours and within 24 hours of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision and continued for 72 hours or definitive wound closure, which ever is sooner
12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum foam dressing or an antibiotic bead pouch is applied until definitive surgery.
13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days.
14. Vacuum foam dressings are not used for definitive wound management in open fractures.
15. The wound in open tibial fractures in children is treated in the same way as adults
The full guidelines are available here