A patient with penetrating injury to the chest should undergo thoracotomy if:
The most common injuries from both blunt and penetrating thoracic trauma are hemothorax and pneumothorax. More than 85% of patients can be definitively treated with a chest tube. The indications for thoracotomy include significant initial or ongoing hemorrhage from the tube thoracostomy and specific imaging-identified diagnoses. One caveat concerns the patient who presents after a delay. Even when the initial chest tube output is 1 .5 L, if the output ceases and the lung is re-expanded, the patient may be managed nonoperatively, if hemodynamically stable (Table below)
Indications for operative treatment of thoracic injuries:
After sustaining a gunshot wound to the right upper quadrant of the abdomen, the patient has no signs of peritonitis. Her vital signs are stable, and CT scan shows a grade III liver injury.
What is the next step in management?
The liver's large size makes it the organ most susceptible to blunt trauma, and it is frequently involved in upper torso penetrating wounds. Nonoperative management of solid organ injuries is pursued in hemodynamically stable patients who do not have overt peritonitis or other indications for laparotomy. Patients with more than grade II injuries should be admitted to the SICU with frequent hemodynamic monitoring, determination of hemoglobin, and abdominal examination. The only absolute contraindication to nonoperative management is hemodynamic instability. Factors such as high injury grade, large hemoperitoneum, contrast extravasation, or pseudoaneurysms may predict complications or failure of non operative management. Angioembolization and endoscopic retrograde cholangiopancreatography (ERCP) are useful adjuncts that can improve the success rate of nonoperative management. The indication for angiography to control hepatic hemorrhage is transfusion of 4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours without hemodynamic instability.
A 25-year-old man has multiple intra-abdominal injuries after a gunshot wound. Celiotomy reveals multiple injuries to small and large bowel and major bleeding from the liver. After repair of the bowel injuries, the abdomen is closed with towel clips, leaving a large pack in the injured liver. Within 12 hours, there is massive abdominal swelling with edema fluid, and intra-abdominal pressure exceeds 35 mm Hg. The immediate step in managing this problem is to:
Cardiac, pulmonary, and renal problems develop when invasive ascites compresses the diaphragm and the inferior vena cava. Dialysis, diuresis, and increasing serum oncotic pressure will not correct this problem rapidly enough to save the patient's life. Opening the incision relieves the intra-abdominal pressure. There are few reports of sudden hypotension after this maneuver, but volume loading has largely eliminated this problem.
Which of the following statements is correct regarding traumatic spleen injury?
Unlike hepatic injuries, which usually rebleed within 48 hours, delayed hemorrhage or rupture of the spleen can occur up to weeks after injury. Indications for early intervention include initiation of blood transfusion within the first 12 hours and hemodynamic instability. After splenectomy or splenorrhaphy, postoperative hemorrhage may be due to loosening of a tie around the splenic vessels, an improperly ligated or unrecognized short gastric artery, or recurrent bleeding from the spleen if splenic repair was used. An immediate postsplenectomy increase in platelets and WBCs is normal; however, beyond postoperative day 5, a WBC count above 15,000/mm3 and a platelet/WBC ratio of <20 are strongly associated with sepsis and should prompt a thorough search for underlying infection. A common infectious complication after splenectomy is a subphrenic abscess, which should be managed with percutaneous drainage. Additional sources of morbidity include a concurrent but unrecognized iatrogenic injury to the pancreatic tail during rapid splenectomy resulting in pancreatic ascites or fistula, and a gastric perforation during short gastric ligation. Enthusiasm for splenic salvage was driven by the rare, but often fatal, complication of overwhelming postsplenectomy sepsis. Overwhelming postsplenectomy sepsis is caused by encapsulated bacteria, Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, which are resistant to antimicrobial treatment. In patients undergoing splenectomy, prophylaxis against these bacteria is provided via vaccines administered optimally at 14 days.
The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is:
Duodenal hematomas are caused by a direct blow to the abdomen and occur more often in children than adults. Blood accumulates between the seromuscular and submucosal layers, eventually causing obstruction. The diagnosis is suspected by the onset of vomiting following blunt abdominal trauma; barium examination of the duodenum reveals either the coiled spring sign or obstruction. Most duodenal hematomas in children can be managed nonoperatively with nasogastric suction and parenteral nutrition. Resolution of the obstruction occurs in the majority of patients if this therapy is continued for 7 to 14 days. If surgical intervention becomes necessary, evacuation of the hematoma is associated with equal success but fewer complications than bypass procedures. Despite few existing data on adults, there is no reason to believe that their hematomas should be treated differently from those of children. A new approach is laparoscopic evacuation if the obstruction persists more than 7 days.