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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 32-36

Nonoperative management of blunt abdominal trauma cases at a tertiary care center in India – An effective strategy


1 Department of General Surgery, Himalayan Institute of Medical Sciences, SRHU, Dehradun, Uttarakhand, India
2 Department of Emergency Medicine, Himalayan Institute of Medical Sciences, SRHU, Dehradun, Uttarakhand, India

Date of Submission09-Jul-2021
Date of Decision16-Mar-2022
Date of Acceptance17-Mar-2022
Date of Web Publication31-Jul-2022

Correspondence Address:
Karamjot Bedi
Department of General Surgery, Himalayan Institute of Medical Sciences, SRHU, Jolly Grant, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/atr.atr_54_21

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  Abstract 


Background and Objectives: An emerging paradigm is observed toward the application of nonoperative management for blunt abdominal trauma (BAT) over invasive surgery. It is postulated that the nonoperative approach is more effective financially, is safe and has a higher success rate. To evaluate the success of the shift from an aggressive operative approach to nonoperative management in solid organ injuries due to BAT at a tertiary care center in North India. Materials and Methods: An observational study was undertaken to evaluate the management of 95 cases of BAT presenting to the emergency department at a tertiary care center in North India, over 12 months. Operative and nonoperative managements were recorded, and the outcome was assessed at 72 h. Categorical variables were analyzed using the Chi-square test; P < 0.05 was taken to indicate a significant difference. Results: Out of the 95 patients, 46% were between 20 and 40 years and 84% were males. The most common mechanism of trauma was road traffic accidents (67%), followed by falls. Specific organ injuries were found in 59% of cases; of these, 38% were injuries to the liver and 34% to the spleen. Overall, 21% of all the cases underwent operative management, whereas 79% were managed nonoperatively. Nonoperative management showed satisfactory outcomes in 89% of cases overall. Furthermore, 88.90% of solid organ injuries with computed tomography American Association for the Surgery of Trauma (CT-AAST) Grades of III or above were successfully managed with nonoperative management. Conclusions: Nonoperative management shows successful results while allowing us to avoid surgical stress, complications, and financial burdens along with an acceptable morbidity rate and low mortality rate. A high CT-AAST grade of injuries does not warrant surgery, and operative management should be used judiciously.

Keywords: Abdominal trauma, blunt trauma, computed tomography American Association for Surgery of Trauma Score, nonoperative management


How to cite this article:
Luthra T, Bedi K, Sahu S, Banerjee S. Nonoperative management of blunt abdominal trauma cases at a tertiary care center in India – An effective strategy. Arch Trauma Res 2022;11:32-6

How to cite this URL:
Luthra T, Bedi K, Sahu S, Banerjee S. Nonoperative management of blunt abdominal trauma cases at a tertiary care center in India – An effective strategy. Arch Trauma Res [serial online] 2022 [cited 2022 Aug 10];11:32-6. Available from: https://www.archtrauma.com/text.asp?2022/11/1/32/353058




  Introduction Top


Trauma-related injury is one of the major causes of death in India and worldwide. According to the World Health Organization, more than 5 million people die annually as a result of injury due to incidents, such as road traffic accidents (RTAs) and falls.[1] Developing nations, like India, are most affected due to injury-related deaths, and these are found to be 1.7 times more than those caused by infectious diseases.[2] With the exponential increase in vehicular density on Indian roads, the number of deaths due to RTAs is on the rise. The Ministry of Road Transport and Highways reported 464,910 RTAs in the year 2017 and recorded 147,913 fatalities because of the same.[3] The primary factors for mortality in cases of blunt abdominal trauma (BAT) are hemorrhage and sepsis.[4] Most deaths in early cases of BAT are due to hemorrhage. Blood in the abdomen can be clinically inconspicuous due to sequestration within the peritoneal cavity.[5] It is therefore essential to carry out thorough serial clinical examinations accompanied by radiological investigations in those patients who are likely to have intra-abdominal injuries to further guide therapy. Plain radiographs with evidence of lower rib fractures, diaphragmatic hernia, free air under diaphragm, and a fracture involving the pelvic rim suggest intra-abdominal injury. “Focused assessment with sonography for trauma (FAST)” has an important role in the detection of free intraperitoneal blood after blunt trauma in the hepatorenal space (Morrison's pouch), splenorenal recess, inferior part of the pelvic cavity, and the pericardium which aids in guiding the management of trauma cases.[6] However, due to a low sensitivity (82%), we cannot exclude intra-abdominal injury based on a normal ultrasound alone despite its benefits such as being economical, noninvasive, rapid, and repeatable. To date, computed tomography (CT) scan is the gold standard for assessing BAT[7] and due to its high sensitivity (97%–98%) and specificity (97%–99%).[8],[9] Multidetector CT aids in the exact identification of the severity and extent of injury as per the American Association for the Surgery of Trauma (AAST) organ injury scale. Over the past two decades, there has been a significant shift in the application of nonoperative management for BAT rather than a more aggressive surgical approach.[10] It is postulated that the nonoperative approach is more effective financially, is safe and has a higher success rate.[11] This new opinion has laid strain on the importance of being very selective while choosing patients of trauma for exploratory laparotomy. The present study was undertaken at our center to study solid organ injury patients with a high CT-AAST injury score who were nonoperatively managed.


  Materials and Methods Top


This observational prospective study was conducted by recruiting all patients of BAT visiting the emergency department of a tertiary care center in North India, over a period of 12 months (January 2018–December 2018) after taking written informed consent. The study was approved by the institutional ethics committee.

Cases of penetrating abdominal trauma, pregnant women with gestational age more than 3 months, age <18 years, and patients on warfarin or those with Glasgow Coma Scale <13 were excluded from the study.

All recruited patients underwent primary and secondary surveys with robust concomitant resuscitation as per Advanced Trauma Life Support guidelines. As adjuncts to clinical examination, FAST was done in all patients, while X-rays of chest, cervical spine, and pelvis were done for all hemodynamically stable patients. CT scan with iv contrast were done for all hemodynamically stable patients selected for the nonoperative arm of management to grade the severity of organ injury. The nonoperatively managed patients were serially reassessed and closely monitored. The outcome of all patients was recorded at 72 h as satisfactory, morbidity, or mortality. Satisfactory outcomes meant hemodynamic stability and no need for intensive care. Morbidity included the need for repeated interventions, intensive care unit (ICU) care, and ventilator support with or without inotropic support. Mortality outcome included demise at or within 72 h of presentation.

[Figure 1] gives a summary of the protocol followed for the recruited patients.
Figure 1: Protocol of the study

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Statistical analysis was performed by the SPSS program for Windows, version 17.0. Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentages. Data were checked for normality before statistical analysis, and categorical variables were analyzed using the Chi-square test. For all statistical tests, P < 0.05 was taken to indicate a significant difference.


  Results Top


Among the total of 95 subjects recruited in this study to evaluate the success of nonoperative management in solid organ injuries due to BAT, the majority (46%) were found in the age group of 20–40 years and were predominantly males (84%). The mean age was 40.57 years. Most cases (67%) were due to RTAs. In addition, recorded causes included fall from height, assault, and other accidents (including animal mauling, electrocution, or fall of a heavy object over the abdomen).

Specific organ injuries were found in 56 instances, and these were categorized based on the injured organ [Figure 2].
Figure 2: Injured organ (n = 56)

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All 12 bowel injury cases, diagnosed as pneumoperitoneum on radiographs, were taken up for surgery without further radiological investigations.

The 44 cases with solid organ injury underwent abdominal CT scans and were graded based on the AAST score [Table 1].
Table 1: American Association for the Surgery of Trauma scores of various solid organ injuries recorded in the study based on computed tomography scan results (n=44)

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Persistent hemodynamic instability in solid organ injuries despite resuscitation (8 subjects), hollow viscus injury (12 subjects) and a high clinical suspicion remained the deciding factors for operative intervention which was done in 20 patients [Table 2].
Table 2: Surgical procedures performed on subjects in the study distributed based on the injured organ (n=20)

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All the eight subjects with solid organ injuries who showed persistent hemodynamic instability were found to have CT-AAST scores of III or more than III. These CT findings were also confirmed based on the intraoperative findings.

Satisfactory outcome was seen in 13 out of 20 operated patients while morbidity (four cases showed wound infection and one patient showed controlled biliary fistula from the surgical wound) was noted in five cases and mortality in two.

Nonoperative management was done for 75 subjects comprising 39 cases of blunt abdominal injuries without any specific organ injuries and 36 cases (out of 44) who had proven solid organ injuries based on their CT scans.

A satisfactory outcome was seen in 67 out of 75 subjects managed nonoperatively.

Morbidity was observed in seven patients (five cases needed mechanical ventilation and two cases needed continued inotropic support under ICU care even after 72 h). Mortality was recorded in one patient whose death occurred within the first 24 h of admission.

The correlation between management options and outcome was calculated, and it was observed that nonoperative management showed a higher proportion of satisfactory outcomes and a lower morbidity and mortality proportion when compared to operative management (P = 0.019) [Table 3].
Table 3: Comparison of management and outcome of subjects in the study (n=95)

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Out of the 36 patients with solid organ injuries under the nonoperative management arm, 75% (27 cases) had high CT-AAST scores (score of III or above). Majority of these patients (88.90%) showed satisfactory outcomes with nonoperative management at 72 h [Table 4].
Table 4: Outcome of patients with high-grade injuries at 72 h, computed tomography-American Association for the Surgery of Trauma scores of III or more (n=27)

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Failure of nonoperative management was noted in 2 cases out of 75 (0.03%). One was of a 38-year-old male with Grade IV liver injury who presented with biliary peritonitis on posttrauma day 7 for which he underwent a laparotomy and successful repair of the liver laceration. The other case was of a 28-year-old male who presented with shock on posttrauma day 6 after nonoperative management due to delayed splenic rupture for which emergency splenectomy was done. Both patients had an uneventful postoperative phase.


  Discussion Top


Trauma is a subject gaining tremendous attention in the present day in developing as well as developed nations. BAT is an entity which is difficult to diagnose and manage because of its conspicuous nature when compared with penetrating injuries. The 95 subjects of BAT recruited herein were mostly males, between the age group of 20–40 years. Most of the cases were due to RTAs. Similar demographic patterns have earlier been noted in Indian[7] and international studies.[8]

Spleen and liver were found to be the most commonly injured organs in the abdominal trauma patients in our study and almost 80% (35 out of 44) of the solid organ injuries had AAST scores of III or above. Similar trends were found in the study by Tinkoff et al. done based on the National Trauma Data Bank in the USA[12] and in the study by Nishijima et al.[13] high-grade solid organ injuries, with AAST scores of III and above were assessed separately and it was found that 27 out of 35 cases (77%) were managed with nonoperative management. Satisfactory outcome at 72 h was noted in 24 out of 27 such cases (88.90%) [Table 4]. Nonoperative management was thus justified as the treatment of choice even in patients with high-grade solid organ injuries in the setting of hemodynamic stability. Similar conclusions were made by Ruscelli et al.,[14] Brillantino et al.[15] and Sisodiya and Malpani.[16] who documented the overall success of nonoperative management with an acceptable rate of morbidity irrespective of the grade of injury.

Persistent hemodynamic instability despite adequate resuscitation and the evidence of hollow viscus injury leading to peritonitis were the only reasons which warranted operative management herein this study. Nonoperative management showed satisfactory outcomes in 89% of cases and was the preferred choice for managing patients with blunt abdominal injuries. This shift in management trend toward the nonoperative approach is supported by the findings of various studies including the likes of a study by Okuş et al.[17] which found a similar success rate of 86.3% with nonoperative management.

In this study, we monitored BAT patients from the time of presentation until 72 h and recorded the details of two cases that were classified as failures of nonoperative management. Literature published for blunt splenic injuries by Peitzman et al. in their multi-institutional study of the Eastern Association for the Surgery of Trauma,[18] McCray et al.[19] and Smith et al.;[20] and those for blunt hepatic injuries by Parks et al.[21] support that most failures of nonoperative management occur within 48–72 h. Although this period of observation has proven adequate for most patients, we must not ignore the need to assess the causes and preventive measures needed for late failures of nonoperative management who can present even a week after the original trauma without any associated inciting factors.

The limitations of our study are that due to its observational design, a precise comparison between groups managed operatively and nonoperatively could not be done; and the posttrauma and postoperative complications in the patients could not be adequately assessed due to lack of a follow-up design due to time constraints. Osler et al.[22] identified a list of 82 different complications which contributed significantly to mortality in trauma patients and suggested that if all complications were eliminated, then two-thirds of deaths could be prevented. A study conducted by Chaudhry et al.[23] showed that postcomplications in trauma in Indian patients included a high wound infection rate (50%–500%), intra-abdominal abscess (25%–8%), enterocutaneous fistula (20%–25%), and abdominal hypertension (20%).

Despite the drawbacks, our study identified very low rates of morbidity and mortality in the study subjects which indicates a good trauma protocol at our center. The study concurs with the rationale behind the major shift from mandatory to a selective surgical approach for solid organ injuries over the years, studied in detail by Lepp&#xs228;niemi.[24] and is in accordance with the evidence-based guidelines developed by the International Consensus Conference held in Milan in December 2016.[25]

Summary

Based on the findings of this observational study, nonoperative management emerged to be successful overall. Further, nonoperative management was also effective in patients who had high-grade injuries, with AAST scores of III or above. Morbidity and mortality could not solely be assessed based on the AAST grade of solid organ injuries. Operative intervention was justified only in cases of hollow viscus injuries and in patients who remained hemodynamically unstable despite resuscitation.


  Conclusion Top


The golden rule of management of BAT injuries is nonoperative management when it is done for hemodynamically stable patients with careful monitoring and good patient selection. A high CT-AAST grade of injuries does not warrant surgery, and operative management should be used judiciously. Nonoperative management shows successful results while allowing us to avoid surgical stress, complications, and financial burdens along with an acceptable morbidity rate and low mortality rate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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