In the current issue of the Archives of Surgery by Berg et al, through the JAMA network, highlighted in the ACEP news , “To our knowledge, the current study is the most complete examination of injury patterns and outcomes in the largest series of blunt thoracoabdominal trauma patients to date,” wrote study investigators Dr. Regan J. Berg and colleagues in the division of trauma surgery and surgical critical care, Los Angeles County + University of Southern California Medical Center in Los Angeles. Blunt trauma was defined as an Abbreviated Injury Score of 2 or more in both the chest and abdomen) who were admitted to the LAC+USC Medical Center between January 1996 and December 2010. They investigated trauma patterns, resulting injuries, need for operative care, and clinical outcomes – - and found that ”In cases of blunt thoracoabdominal trauma, the abdomen should be the initial cavity of exploration in patients requiring emergent surgery without direct radiologic data, based on the results of a trauma registry and medical record review of 1,661 patients.”
Laparotomy alone was required in 281 (24.8%), while only 24 patients (2.1%) had both a laparotomy and a thoracotomy; 7 patients (0.6%) had a laparotomy following RT.
Independent risk factors of mortality included an Injury Severity Score of 25 or more, a Glasgow Coma Scale score of 8 or less, the need for massive transfusions, age of 55 years or older, and the need for dual-cavity intervention. Among injury patterns, liver, abdominal vascular, and cardiac injury were independently associated with mortality which includes evaluation through bedside ultrasound and diagnostic peritoneal aspirates.
“The most frequent causes of injury in the remaining 1,661 patients were motor vehicle collision (68.1%), falls (15.6%), and motorcycle collisions (10.4%), with assault accounting for only 1.8% of patients”
“Conclusions Most patients with blunt thoracoabdominal trauma are managed nonoperatively. The need for nonresuscitative 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. In patients with thoracoabdominal trauma, the potential for concurrent injury in 2 body cavities can present challenges to both diagnosis and surgical management. In these complex patients, rapid diagnostic assessment and surgical planning may be hampered by multiple factors. Clinical urgency may limit time for critical evaluation, and patient instability often precludes radiologic investigation away from the resuscitation bay. Thoracic trauma may decrease abdominal examination sensitivity and diaphragmatic injury may result in misinterpretation of tube thoracostomy drainage and diagnostic peritoneal aspirates. In patients requiring surgery, determination of the cavity with the most significant injury is paramount to prevent delayed treatment and increased morbidity and mortality.