Original Article
European Journal of Trauma and Emergency Surgery
A Prospective Study of Blunt Abdominal Trauma at the University of Calabar Teaching Hospital, Nigeria Maurice E. Asuquo1, Anietimfon U. Etiuma1, Okon O. Bassey1, Gabriel Ugare1, Ogbu Ngim1, Cyril Agbor1, Anthonia Ikpeme2, Wilfred Ndifon3
Abstract Background: Blunt abdominal trauma (BAT) usually results from motor vehicle accidents, assaults, and recreational accidents or falls. This communication is a 3-year report of an ongoing study aimed at providing the current BAT prevalence in our center. It is hoped that this would assist in a better design of prevention and emergency trauma response systems to cope with this epidemic. Methods: All of the patients admitted to the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria, from February 2005 to January 2008 were prospectively studied based on a questionnaire. Hemodynamic stability and sonography formed the basis for selecting patients for non-operative management (NOM); others were offered laparotomy. Results: In total, 4,391 emergencies were seen during the study period, of which 1,654 (38%) were due to trauma. Seventy-nine patients with abdominal trauma accounted for 4.8% of trauma cases. Forty-two (53%) patients suffered BAT and their ages ranged from 14 and 56 years (mean 28.4 years), with a male:female ratio of 2.5:1. Road traffic accidents accounted for 13 (87%) and 26 (96%) patients in the NOM and laparotomy groups, respectively. The most commonly injured organ was the spleen in both groups: 8 (50%) and 15 (56%) in the NOM and laparotomy groups, respectively. Fifteen (36%) patients were managed successfully in the NOM group. Conclusion: Trauma was mainly due to road traffic injuries. Hemodynamic stability and ultrasonography
effectively selected patients for NOM. The establishment of trauma systems, provision of ancillary diagnostic and monitoring facilities, well-designed roads and traffic infrastructure, and health education on road safety would reduce injury, morbidity, and mortality. Key Words Blunt abdominal trauma Æ Non-operative management Eur J Trauma Emerg Surg 2010;36:164–8 DOI 10.1007/s00068-009-9104-2
Introduction Abdominal injuries are on the increase in both the developed and the developing countries and remain a major source of morbidity and mortality [1, 2]. Blunt abdominal trauma (BAT) usually results from motor vehicle accidents, assaults, and recreational accidents or falls [3]. Road traffic injuries remain a major source of BAT, men tend to be affected slightly more often than women, and the spleen is the most commonly injured organ [3–6]. Vehicular trauma is by far the leading cause of BAT in the civilian population; autoto-auto and auto-to-pedestrian collision have been cited as causes in 50–75% of cases [3]. The morbidity and mortality associated with BAT results from bleeding due to the disruption of solid organs, vascular structures, and infection from the perforation of hollow
1
Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria, 2 Department of Radiology, University of Calabar Teaching Hospital, Calabar, Nigeria, 3 Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria. Received: May 31, 2009; revision accepted: July 9, 2009; Published Online: September 11, 2009
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Asuquo ME, et al. A Prospective Study of Blunt Abdominal Trauma
viscus [2]. The management of patients with BAT has evolved over the past two decades, with increasing reliance on a non-operative approach and this has become the standard of care [3, 7, 8]. Sonography is now considered as the screening modality of choice, as it has the ability to demonstrate the amount of intraperitoneal hemoperitoneum within minutes of the patient’s arrival [9, 10]. Sonography for trauma has been shown to be comparable with diagnostic peritoneal lavage (DPL) and computed tomography (CT) for the detection of hemoperitoneum. It is superior to both because of its rapidity, non-invasiveness, portability, and low cost [10]. From February 2005, we undertook a prospective study of abdominal trauma at the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria, as part of a wider prospective study of the UCTH Trauma Research Group, headed by Professor O.O. Bassey. This communication is a 3-year report (from February 2005 to January 2008) of this ongoing prospective study. It is hoped that this would provide the current BAT prevalence and this would engender better designs of prevention and emergency trauma systems suitable for our region.
Patients and Methods In Calabar, there is no ambulance/paramedic service. Pre-hospital intervention is not in place and there is no proper trauma system. Doctors and nurses trained in accident and emergency receive the injured at the reception, where primary survey/resuscitation is performed. Patients are, thereafter, referred to the surgical unit on call based on the specialty required. Hemodynamic stability was defined as stable quarter-hourly serial blood pressure and heart rate appropriate for age with adequate end-organ perfusion urinary output > 30 mL per hour measured on admission or after fluid resuscitation with crystalloids (Ringer’s lactate/normal saline). Clinical evaluation was carried out by a registrar/senior registrar and confirmed by a consultant when there is failure of non-operative management (NOM). Failure of NOM was determined by clinical and laboratory evidence of ongoing hemorrhage or by the development of peritonitis. Ongoing hemorrhage was defined clinically by progressive abdominal distension measured hourly initially and/or tachycardia pulse > 100/ min or hypotension systemic pressure < 90 mmHg refractory to fluid resuscitation or progressive fall in packed cell volume (PCV) and ongoing hemorrhage confirmed by ultrasound. The first on call is the registrar, followed by the senior registrar (mostly pre-fellowship) and the consultant surgeon. Anesthesiology and radiol-
Eur J Trauma Emerg Surg 2010 Æ No. 2
ogy are organized in a similar pattern. A theater is dedicated for emergencies, with a three-bed intensive care unit. The ultrasonography evaluations were done by senior registrars and confirmed by the consultant. All of the patients admitted into the UCTH with BAT from February 2005 to January 2008 were prospectively studied based on a questionnaire. This included biographic data, mechanism and pattern of injuries, as well as associated injuries. Other data included investigations on ultrasonography findings, initial and definitive management, and outcome. Hemodynamic stability and ultrasonography findings in the absence of CT in our facility formed the basis for the selection of patients for either NOM or laparotomy. On admission, patients were evaluated for evidence of intraperitoneal hemorrhage with ultrasound scan, and those who were stable initially or after resuscitation were enrolled for NOM. The amount of hemoperitoneum was quantified as follows: mild (minimal) – blood in the subphrenic or perihepatic space (approximately 500 mL); moderate – perihepatic and blood along the paracolic gutter (less than 1 L); and large (severe) – perihepatic and blood along the paracolic gutter and accumulation in the pelvic cavity (more than 1 L) [9]. On admission, patients were offered bed rest in the NOM group and on post admission day three, they were allowed to start quiet activity. Patients with associated fractures were offered deep venous thrombosis prophylaxis. Diagnosis was established by ultrasound scan on admission. The next scan was done prior to discharge to ensure the absence of ongoing bleeding and 4 weeks post injury to monitor healing and the absorption of hemoperitoneum. The patients were evaluated on an outpatients basis weekly for 4 weeks, and then monthly for 2 months. The total number of patients with abdominal trauma was compared with the total number of emergencies and traumatic injuries seen during the same period to determine their relative frequencies.
Results A total of 4,391 emergencies were seen at the accident and emergency unit of UCTH during the study period, of which 1,654 (38%) were due to trauma. Seventynine patients which accounted for 4.8% of trauma cases were admitted and treated for abdominal trauma. There were 42 (53%) patients who suffered BAT, while 37 (47%) patients had penetrating abdominal trauma.
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Table 1. Age/sex distribution. Age range
1–10 11–20 21–30 31–40 41–50 51–60
Gender
Total (%)
M
F
– 4 18 3 4 1 30
– 3 7 2 – – 12
– 7 (17) 25 (60) 5 (12) 4 (9) 1 (2) 42 (100)
Age range: 14–56 years (mean 28.4 years), male:female ratio 2.5:1
Table 1 shows the age/sex distribution. The ages ranged from 14 and 56 years (mean 28.4 years). The male:female ratio was 2.5:1. Based on the management modality, patients were categorized into two groups: NOM and laparotomy. Fifteen (36%) patients were enrolled successfully for NOM (Table 2), while 27 (64%) had laparotomy (Table 3). The mechanism of injury, organ injury, and associated injury in the NOM group were as shown in Table 2. Road traffic accidents involved 13 (87%) patients, while two (13%) had a kick in the abdomen while playing football. The spleen was the most com-
mon organ injured (8, 50%), while the liver ranked second (5, 31%). Two patients (13%) sustained associated injuries (both fractured left femur). The findings were mild to moderate intraperitoneal fluid collection, likely hemoperitoneum, and a sentinel clot sign adjacent to small bowel loops suggestive of a mesenteric tear (Table 2). Five (33.3%) patients had mild hemoperitoneum, 7 (46.7%) moderate, and 3 (20%) severe hemoperitoneum. Table 3 shows the mechanism of injury, organ injury, and associated injury in the laparotomy group. Road traffic accidents were recorded in 26 (96%) patients and the most common form was motorcycle– pedestrian collision in 15 (56%) patients. The most common organ injured was the spleen, which was recorded in 25 (82%) patients. Associated injuries were recorded in 14 (52%) patients, of which head injury was the most common (43%); other injuries were fractures that involved various bones. Sixteen patients with BAT were enrolled for NOM. This was discontinued in a patient on account of signs of peritonism. Table 4 shows the clinical characteristics of those who were enrolled for NOM and laparotomy. The mean duration of admission for the NOM group was 6.7 days, while that of the laparotomy group was 12.3 days. Two patients were discharged on
Table 2. Non-operative management (NOM; 15). Mechanism of injury
No. (%)
Organ injury
1. Road traffic injuries Motor vehicle (MV) (occupants) MV/pedestrian Motorcycle (MC) (cyclist) MC/pedestrian 2. Kick in the abdomen (football)
4 1 3 5 2 15
No. (%)
Spleen Liver Renal contusion Mesenteric vascular injury
(27) (7) (20) (33) (13) (100)
8 5 2 1
(50) (31) (13) (6)
Associated injury
No. (%)
# (L) Femur
2 (13)
16 (100)
Table 3. Blunt abdominal trauma (BAT; laparotomy). Mechanism of injury
No. (%)
1. Road traffic injuries MV (occupants) MV/pedestrian MC (cyclist) MC/pedestrian 2. Kick (football)
166
5 (18) 3 3 15 1 27
(11) (11) (56) (4) (100)
Organ injury
No. (%)
Associated injury
Spleen Renal Pancreas
25 (82) 1 (3) 1 (3)
Ruptured diaphragm Jejunal perforation Ascending colon Transverse colon
1 1 1 1 31
Head injury # (R) Clavicle # Ribs # (L) Radius/ulnar # (L) Humerus Spinal injury (cervical)
(3) (3) (3) (3) (100)
No. (%) 6 1 1 3 2 1
(43) (7) (7) (22) (14) (7)
14 (100)
Eur J Trauma Emerg Surg 2010 Æ No. 2
Asuquo ME, et al. A Prospective Study of Blunt Abdominal Trauma
Table 4. BAT. Clinical characteristics. GCS: Glasgow Coma Scale; ISS: Injury Severity Score. NOM (15)
Age (years) GCS ISS Duration of admission (days)
Laparotomy (27)
Mean
SD
Mean
SD
28.3 15.0 – 6.7
9.7 0 – 0.9
28.4 14.2 11.5 12.3
9.1 1.9 5.4 4.9
request earlier than 7 days but were seen at the outpatient clinic for follow-up with satisfactory ultrasound scan report. The p-value was statistically significant (0.000) for < 0.05 (Table 4). The average hematocrit of the NOM group on presentation was 34% compared to 22% for patients in the laparotomy group with hemodynamic instability. None of the patients in the NOM group required blood transfusion. Ten (37%) patients in the laparotomy group had auto transfusion, while 5 (19%) required cross-matched blood transfusion. Two patients (7%) in the laparotomy group developed surgical site infection. There was a fatal outcome in a patient (laparotomy group) with an Injury Severity Score (ISS) of 22. The average ISS in this study for the laparotomy group was 11.5, standard deviation (SD) 5.4, table 4.
Discussion BAT affected mainly young patients in the third decade of life in this study, with a mean age of 28.4 years. This is in keeping with an earlier report from this center and other centers [1, 2, 4, 5]. They constitute an active, aggressive, and productive segment of the population, with greater mobility and increased risk of accidents. There was a male (male:female ratio 2.5:1); men tend to be affected slightly more than women [3]. BAT accounted for 53% of patients with abdominal trauma. Similar experiences were reported in Benin, Nigeria (62.2%) [1] and Maiduguri (54%) [5]. However, in Kano [2], Lagos [11], and Uganda [12], the reports showed a higher incidence of penetrating abdominal trauma (PAT) in keeping with urban violence. Trauma accounted for 38% of emergencies seen in the study period, with abdominal trauma accounting for 4.8% of cases. When compared with an earlier study in this center (BAT cases = 55 in 5 years), it shows an increasing trend in the incidence of BAT. Road traffic injuries accounted for 87% of patients in the NOM group and 96% in the laparotomy group. Inexperience, impatience, and drunkenness are well recognized risk factors among drivers and cyclists. The
Eur J Trauma Emerg Surg 2010 Æ No. 2
p-value
0.96 (not significant) – – 0.000 (significant)
most common form of injury was motorcycle–pedestrian collision. Motorcycles are distributed as reward for political patronage and as part of poverty alleviation to inexperienced cyclists. Motorcycle taxi has become a common form of transportation, as most roads are too poorly maintained for vehicular traffic. Good road construction with measures to separate automobiles from pedestrian traffic and less use of motorcycles would reduce incidence. NOM of blunt hepatic and splenic trauma has become an accepted treatment option [9, 13]. The primary admission criteria are hemodynamic stability with or without resuscitation and monitoring until continued bleeding can be ruled out and the absence of demonstrable signs of peritonism [14]. Fifteen (36%) patients with BAT were successfully managed in the NOM group. Some solid-organ injuries may be missed in the absence of demonstrable hemoperitoneum on ultrasound [15]. However, hemodynamic stability and ultrasonography effectively selected patients for conservative management in the absence of a CT scan. This translated to reduced hospitalization, lower cost of treatment, and avoidance of added morbidity attributable to laparotomy and the hazards of blood transfusion. The spleen was the most commonly injured organ in patients in the NOM (50%) and laparotomy (82%) groups. This is in keeping with other studies [2–5]. All of the patients in the laparotomy group had total splenectomy on account of the severity of injury (Types IV and V) [16] and diseased spleen adjudged not suitable for conservation. This study is at variance with an earlier study in this hospital where most splenic injuries were common in the pediatric age group [4]. This may be due to less automobile–pedestrian accidents involving children from the separation of automobile–pedestrian traffic by the construction of walkways along major roads and the regulation of automobile speed, along with the introduction of bumps across the road at strategic locations. BAT was largely due to road traffic injuries. Welldesigned roads and traffic infrastructure, and health
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education on road safety measures are advocated. Hemodynamic stability and focused ultrasound for solid-organ injury effectively selected patients for NOM with its attendant benefits. The establishment of trauma systems and the provision of ancillary diagnostic and monitoring facilities in our hospitals would improve outcome.
Conflict of interest statement The authors declare that there is no actual or potential conflict of interest in relation to this article.
References 1. 2. 3.
4. 5. 6. 7.
Okobia MN, Osime U. Abdominal trauma in Benin City, Nigeria. Nig J Surg 1998;5:49–54. Edino ST. Pattern of abdominal injuries in Aminu Kano Teaching Hospital, Kano. Niger Postgrad Med J 2003;10:56–9. Udeani J, Steinberg SR. Abdominal trauma, blunt. eMedicine. Available online at: http://emedicine.medscape.com/article/ 433404-overview. Overview updated 22 Aug 2008. Asuquo ME, Nwagbara V, Inyang A, Ugare G. Blunt abdominal trauma in Calabar. Nig J Surg Sci 2006;16:12–5. Dogo D, Yawe T, Hassan AW, Tahir B. Pattern of abdominal trauma in North Eastern Nigeria. Nig J Surg Res 2000;2:48–51. Andrew G, Williams S. Abdomen. In: ABC of trauma, 2nd edn. 1996;46–53. Gibson DE, Canfield CM, Levy PD. Selective nonoperative management of blunt abdominal trauma. J Emerg Med 2006;31:215–21.
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Notash AY, Amoli HA, Nikandish A, Kenari AY, Jahangiri F, Khashayar P. Non-operative management in blunt splenic trauma. Emerg Med J 2008;25:210–12. 9. Goan YG, Huang MS, Lin J. Non-operative management for extensive hepatic and splenic injuries with significant haemoperitoneum in adults. J Trauma 1998;45:360–5. 10. McKenney KL. Ultrasound of blunt abdominal trauma. Radiol Clin North Am 1999;37:879–93. 11. Adesanya AA, Afolabi IR, da Rocha-Afodu JT. Civilian abdominal gunshot wounds in Lagos. J Roy Coll Surg Edinb 1998;43:230–4. 12. Carswell JW. Small gut injuries in blunt abdominal trauma: 18 cases from Uganda. Injury 1974;5:233–6. 13. Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB, Richardson JD. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619–24. 14. Ochsner MG. Factors of failure for nonoperative management of blunt liver and splenic injuries. World J Surg 2001;25:1393–6. 15. Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez A. Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 1999;212:423–30. 16. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995;38:323–4.
Address for Correspondence Dr. Maurice E. Asuquo Department of Surgery University of Calabar Teaching Hospital P.O. Box 1891 Calabar Nigeria e-mail: [email protected]
Eur J Trauma Emerg Surg 2010 Æ No. 2
European Journal of Trauma and Emergency Surgery
A Prospective Study of Blunt Abdominal Trauma at the University of Calabar Teaching Hospital, Nigeria Maurice E. Asuquo1, Anietimfon U. Etiuma1, Okon O. Bassey1, Gabriel Ugare1, Ogbu Ngim1, Cyril Agbor1, Anthonia Ikpeme2, Wilfred Ndifon3
Abstract Background: Blunt abdominal trauma (BAT) usually results from motor vehicle accidents, assaults, and recreational accidents or falls. This communication is a 3-year report of an ongoing study aimed at providing the current BAT prevalence in our center. It is hoped that this would assist in a better design of prevention and emergency trauma response systems to cope with this epidemic. Methods: All of the patients admitted to the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria, from February 2005 to January 2008 were prospectively studied based on a questionnaire. Hemodynamic stability and sonography formed the basis for selecting patients for non-operative management (NOM); others were offered laparotomy. Results: In total, 4,391 emergencies were seen during the study period, of which 1,654 (38%) were due to trauma. Seventy-nine patients with abdominal trauma accounted for 4.8% of trauma cases. Forty-two (53%) patients suffered BAT and their ages ranged from 14 and 56 years (mean 28.4 years), with a male:female ratio of 2.5:1. Road traffic accidents accounted for 13 (87%) and 26 (96%) patients in the NOM and laparotomy groups, respectively. The most commonly injured organ was the spleen in both groups: 8 (50%) and 15 (56%) in the NOM and laparotomy groups, respectively. Fifteen (36%) patients were managed successfully in the NOM group. Conclusion: Trauma was mainly due to road traffic injuries. Hemodynamic stability and ultrasonography
effectively selected patients for NOM. The establishment of trauma systems, provision of ancillary diagnostic and monitoring facilities, well-designed roads and traffic infrastructure, and health education on road safety would reduce injury, morbidity, and mortality. Key Words Blunt abdominal trauma Æ Non-operative management Eur J Trauma Emerg Surg 2010;36:164–8 DOI 10.1007/s00068-009-9104-2
Introduction Abdominal injuries are on the increase in both the developed and the developing countries and remain a major source of morbidity and mortality [1, 2]. Blunt abdominal trauma (BAT) usually results from motor vehicle accidents, assaults, and recreational accidents or falls [3]. Road traffic injuries remain a major source of BAT, men tend to be affected slightly more often than women, and the spleen is the most commonly injured organ [3–6]. Vehicular trauma is by far the leading cause of BAT in the civilian population; autoto-auto and auto-to-pedestrian collision have been cited as causes in 50–75% of cases [3]. The morbidity and mortality associated with BAT results from bleeding due to the disruption of solid organs, vascular structures, and infection from the perforation of hollow
1
Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria, 2 Department of Radiology, University of Calabar Teaching Hospital, Calabar, Nigeria, 3 Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria. Received: May 31, 2009; revision accepted: July 9, 2009; Published Online: September 11, 2009
164
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Asuquo ME, et al. A Prospective Study of Blunt Abdominal Trauma
viscus [2]. The management of patients with BAT has evolved over the past two decades, with increasing reliance on a non-operative approach and this has become the standard of care [3, 7, 8]. Sonography is now considered as the screening modality of choice, as it has the ability to demonstrate the amount of intraperitoneal hemoperitoneum within minutes of the patient’s arrival [9, 10]. Sonography for trauma has been shown to be comparable with diagnostic peritoneal lavage (DPL) and computed tomography (CT) for the detection of hemoperitoneum. It is superior to both because of its rapidity, non-invasiveness, portability, and low cost [10]. From February 2005, we undertook a prospective study of abdominal trauma at the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria, as part of a wider prospective study of the UCTH Trauma Research Group, headed by Professor O.O. Bassey. This communication is a 3-year report (from February 2005 to January 2008) of this ongoing prospective study. It is hoped that this would provide the current BAT prevalence and this would engender better designs of prevention and emergency trauma systems suitable for our region.
Patients and Methods In Calabar, there is no ambulance/paramedic service. Pre-hospital intervention is not in place and there is no proper trauma system. Doctors and nurses trained in accident and emergency receive the injured at the reception, where primary survey/resuscitation is performed. Patients are, thereafter, referred to the surgical unit on call based on the specialty required. Hemodynamic stability was defined as stable quarter-hourly serial blood pressure and heart rate appropriate for age with adequate end-organ perfusion urinary output > 30 mL per hour measured on admission or after fluid resuscitation with crystalloids (Ringer’s lactate/normal saline). Clinical evaluation was carried out by a registrar/senior registrar and confirmed by a consultant when there is failure of non-operative management (NOM). Failure of NOM was determined by clinical and laboratory evidence of ongoing hemorrhage or by the development of peritonitis. Ongoing hemorrhage was defined clinically by progressive abdominal distension measured hourly initially and/or tachycardia pulse > 100/ min or hypotension systemic pressure < 90 mmHg refractory to fluid resuscitation or progressive fall in packed cell volume (PCV) and ongoing hemorrhage confirmed by ultrasound. The first on call is the registrar, followed by the senior registrar (mostly pre-fellowship) and the consultant surgeon. Anesthesiology and radiol-
Eur J Trauma Emerg Surg 2010 Æ No. 2
ogy are organized in a similar pattern. A theater is dedicated for emergencies, with a three-bed intensive care unit. The ultrasonography evaluations were done by senior registrars and confirmed by the consultant. All of the patients admitted into the UCTH with BAT from February 2005 to January 2008 were prospectively studied based on a questionnaire. This included biographic data, mechanism and pattern of injuries, as well as associated injuries. Other data included investigations on ultrasonography findings, initial and definitive management, and outcome. Hemodynamic stability and ultrasonography findings in the absence of CT in our facility formed the basis for the selection of patients for either NOM or laparotomy. On admission, patients were evaluated for evidence of intraperitoneal hemorrhage with ultrasound scan, and those who were stable initially or after resuscitation were enrolled for NOM. The amount of hemoperitoneum was quantified as follows: mild (minimal) – blood in the subphrenic or perihepatic space (approximately 500 mL); moderate – perihepatic and blood along the paracolic gutter (less than 1 L); and large (severe) – perihepatic and blood along the paracolic gutter and accumulation in the pelvic cavity (more than 1 L) [9]. On admission, patients were offered bed rest in the NOM group and on post admission day three, they were allowed to start quiet activity. Patients with associated fractures were offered deep venous thrombosis prophylaxis. Diagnosis was established by ultrasound scan on admission. The next scan was done prior to discharge to ensure the absence of ongoing bleeding and 4 weeks post injury to monitor healing and the absorption of hemoperitoneum. The patients were evaluated on an outpatients basis weekly for 4 weeks, and then monthly for 2 months. The total number of patients with abdominal trauma was compared with the total number of emergencies and traumatic injuries seen during the same period to determine their relative frequencies.
Results A total of 4,391 emergencies were seen at the accident and emergency unit of UCTH during the study period, of which 1,654 (38%) were due to trauma. Seventynine patients which accounted for 4.8% of trauma cases were admitted and treated for abdominal trauma. There were 42 (53%) patients who suffered BAT, while 37 (47%) patients had penetrating abdominal trauma.
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Asuquo ME, et al. A Prospective Study of Blunt Abdominal Trauma
Table 1. Age/sex distribution. Age range
1–10 11–20 21–30 31–40 41–50 51–60
Gender
Total (%)
M
F
– 4 18 3 4 1 30
– 3 7 2 – – 12
– 7 (17) 25 (60) 5 (12) 4 (9) 1 (2) 42 (100)
Age range: 14–56 years (mean 28.4 years), male:female ratio 2.5:1
Table 1 shows the age/sex distribution. The ages ranged from 14 and 56 years (mean 28.4 years). The male:female ratio was 2.5:1. Based on the management modality, patients were categorized into two groups: NOM and laparotomy. Fifteen (36%) patients were enrolled successfully for NOM (Table 2), while 27 (64%) had laparotomy (Table 3). The mechanism of injury, organ injury, and associated injury in the NOM group were as shown in Table 2. Road traffic accidents involved 13 (87%) patients, while two (13%) had a kick in the abdomen while playing football. The spleen was the most com-
mon organ injured (8, 50%), while the liver ranked second (5, 31%). Two patients (13%) sustained associated injuries (both fractured left femur). The findings were mild to moderate intraperitoneal fluid collection, likely hemoperitoneum, and a sentinel clot sign adjacent to small bowel loops suggestive of a mesenteric tear (Table 2). Five (33.3%) patients had mild hemoperitoneum, 7 (46.7%) moderate, and 3 (20%) severe hemoperitoneum. Table 3 shows the mechanism of injury, organ injury, and associated injury in the laparotomy group. Road traffic accidents were recorded in 26 (96%) patients and the most common form was motorcycle– pedestrian collision in 15 (56%) patients. The most common organ injured was the spleen, which was recorded in 25 (82%) patients. Associated injuries were recorded in 14 (52%) patients, of which head injury was the most common (43%); other injuries were fractures that involved various bones. Sixteen patients with BAT were enrolled for NOM. This was discontinued in a patient on account of signs of peritonism. Table 4 shows the clinical characteristics of those who were enrolled for NOM and laparotomy. The mean duration of admission for the NOM group was 6.7 days, while that of the laparotomy group was 12.3 days. Two patients were discharged on
Table 2. Non-operative management (NOM; 15). Mechanism of injury
No. (%)
Organ injury
1. Road traffic injuries Motor vehicle (MV) (occupants) MV/pedestrian Motorcycle (MC) (cyclist) MC/pedestrian 2. Kick in the abdomen (football)
4 1 3 5 2 15
No. (%)
Spleen Liver Renal contusion Mesenteric vascular injury
(27) (7) (20) (33) (13) (100)
8 5 2 1
(50) (31) (13) (6)
Associated injury
No. (%)
# (L) Femur
2 (13)
16 (100)
Table 3. Blunt abdominal trauma (BAT; laparotomy). Mechanism of injury
No. (%)
1. Road traffic injuries MV (occupants) MV/pedestrian MC (cyclist) MC/pedestrian 2. Kick (football)
166
5 (18) 3 3 15 1 27
(11) (11) (56) (4) (100)
Organ injury
No. (%)
Associated injury
Spleen Renal Pancreas
25 (82) 1 (3) 1 (3)
Ruptured diaphragm Jejunal perforation Ascending colon Transverse colon
1 1 1 1 31
Head injury # (R) Clavicle # Ribs # (L) Radius/ulnar # (L) Humerus Spinal injury (cervical)
(3) (3) (3) (3) (100)
No. (%) 6 1 1 3 2 1
(43) (7) (7) (22) (14) (7)
14 (100)
Eur J Trauma Emerg Surg 2010 Æ No. 2
Asuquo ME, et al. A Prospective Study of Blunt Abdominal Trauma
Table 4. BAT. Clinical characteristics. GCS: Glasgow Coma Scale; ISS: Injury Severity Score. NOM (15)
Age (years) GCS ISS Duration of admission (days)
Laparotomy (27)
Mean
SD
Mean
SD
28.3 15.0 – 6.7
9.7 0 – 0.9
28.4 14.2 11.5 12.3
9.1 1.9 5.4 4.9
request earlier than 7 days but were seen at the outpatient clinic for follow-up with satisfactory ultrasound scan report. The p-value was statistically significant (0.000) for < 0.05 (Table 4). The average hematocrit of the NOM group on presentation was 34% compared to 22% for patients in the laparotomy group with hemodynamic instability. None of the patients in the NOM group required blood transfusion. Ten (37%) patients in the laparotomy group had auto transfusion, while 5 (19%) required cross-matched blood transfusion. Two patients (7%) in the laparotomy group developed surgical site infection. There was a fatal outcome in a patient (laparotomy group) with an Injury Severity Score (ISS) of 22. The average ISS in this study for the laparotomy group was 11.5, standard deviation (SD) 5.4, table 4.
Discussion BAT affected mainly young patients in the third decade of life in this study, with a mean age of 28.4 years. This is in keeping with an earlier report from this center and other centers [1, 2, 4, 5]. They constitute an active, aggressive, and productive segment of the population, with greater mobility and increased risk of accidents. There was a male (male:female ratio 2.5:1); men tend to be affected slightly more than women [3]. BAT accounted for 53% of patients with abdominal trauma. Similar experiences were reported in Benin, Nigeria (62.2%) [1] and Maiduguri (54%) [5]. However, in Kano [2], Lagos [11], and Uganda [12], the reports showed a higher incidence of penetrating abdominal trauma (PAT) in keeping with urban violence. Trauma accounted for 38% of emergencies seen in the study period, with abdominal trauma accounting for 4.8% of cases. When compared with an earlier study in this center (BAT cases = 55 in 5 years), it shows an increasing trend in the incidence of BAT. Road traffic injuries accounted for 87% of patients in the NOM group and 96% in the laparotomy group. Inexperience, impatience, and drunkenness are well recognized risk factors among drivers and cyclists. The
Eur J Trauma Emerg Surg 2010 Æ No. 2
p-value
0.96 (not significant) – – 0.000 (significant)
most common form of injury was motorcycle–pedestrian collision. Motorcycles are distributed as reward for political patronage and as part of poverty alleviation to inexperienced cyclists. Motorcycle taxi has become a common form of transportation, as most roads are too poorly maintained for vehicular traffic. Good road construction with measures to separate automobiles from pedestrian traffic and less use of motorcycles would reduce incidence. NOM of blunt hepatic and splenic trauma has become an accepted treatment option [9, 13]. The primary admission criteria are hemodynamic stability with or without resuscitation and monitoring until continued bleeding can be ruled out and the absence of demonstrable signs of peritonism [14]. Fifteen (36%) patients with BAT were successfully managed in the NOM group. Some solid-organ injuries may be missed in the absence of demonstrable hemoperitoneum on ultrasound [15]. However, hemodynamic stability and ultrasonography effectively selected patients for conservative management in the absence of a CT scan. This translated to reduced hospitalization, lower cost of treatment, and avoidance of added morbidity attributable to laparotomy and the hazards of blood transfusion. The spleen was the most commonly injured organ in patients in the NOM (50%) and laparotomy (82%) groups. This is in keeping with other studies [2–5]. All of the patients in the laparotomy group had total splenectomy on account of the severity of injury (Types IV and V) [16] and diseased spleen adjudged not suitable for conservation. This study is at variance with an earlier study in this hospital where most splenic injuries were common in the pediatric age group [4]. This may be due to less automobile–pedestrian accidents involving children from the separation of automobile–pedestrian traffic by the construction of walkways along major roads and the regulation of automobile speed, along with the introduction of bumps across the road at strategic locations. BAT was largely due to road traffic injuries. Welldesigned roads and traffic infrastructure, and health
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education on road safety measures are advocated. Hemodynamic stability and focused ultrasound for solid-organ injury effectively selected patients for NOM with its attendant benefits. The establishment of trauma systems and the provision of ancillary diagnostic and monitoring facilities in our hospitals would improve outcome.
Conflict of interest statement The authors declare that there is no actual or potential conflict of interest in relation to this article.
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Address for Correspondence Dr. Maurice E. Asuquo Department of Surgery University of Calabar Teaching Hospital P.O. Box 1891 Calabar Nigeria e-mail: [email protected]
Eur J Trauma Emerg Surg 2010 Æ No. 2
