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Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Background This study examined the feasibility of transabdominal intestinal ultrasonography in evaluating acute gastrointestinal injury (AGI). Methods A total of 116 patients were included. Intestinal ultrasonography was conducted daily within 1 week after admission to the intensive care unit. Ultrasonography indicators including intestinal diameter, changes in the intestinal folds, thickness of the intestinal wall, stratification of the intestinal wall, and intestinal peristalsis (movement of the intestinal contents) were observed to determine the acute gastrointestinal injury ultrasonography (AGIUS) score. The gastrointestinal and urinary tract sonography ultrasound (GUTS) protocol score was also calculated. During the first week of the study, the gastrointestinal failure (GIF) score was determined daily. The correlations between transabdominal intestinal scores (AGIUS and GUTS) and the GIF score were analyzed to clarify the feasibility of evaluating AGI through observation of the intestine. The utility of intestinal ultrasonography indicators in predicting feeding intolerance was investigated to improve the ability of clinicians to manage AGI. Results A total of 751 ultrasonic examinations were performed with 511 images (68%) considered to be of “good quality.” AGIUS and GUTS scores differed significantly between AGI patients (GIF score 0–2) and non-AGI patients (GIF score 3–4) ( p  < 0.001). Both scores correlated positively with GIF score ( r  = 0.54, p  < 0.001; r  = 0.66, p  < 0.001). These ultrasonography indicators could predict feeding intolerance, with an area under the receiver operating characteristic curve of 0.60 (0.48–0.71; intestinal diameter), 0.76 (0.67–0.85; intestinal folds), 0.71 (0.62–0.80; wall thickness), 0.77 (0.69–0.86; wall stratification), and 0.78 (0.68–0.88; intestinal peristalsis). Compared to patients with a normal rate of peristalsis (5–10/min), patients with abnormal peristalsis rates (< 5/min or > 10/min) have increased risk for feeding intolerance (16/83 vs. 25/33, p  < 0.001). Conclusions The transabdominal intestinal ultrasonography represents an effective means for assessing gastrointestinal injury in critically ill patients. Intestinal ultrasonography indicators, especially the degree of intestinal peristalsis, may be used to predict feeding intolerance. Trial registration ClinicalTrial.gov, NCT03589248 . Registered 04 July 2018—retrospectively registered.

Diagnostic laparoscopy (DL) has decreased the rate of nontherapeutic laparotomy for patients suffering from penetrating injuries. We evaluated whether DL similarly lowers the rate of nontherapeutic laparotomy for patients with blunt injuries. All patients undergoing DL over a 10-year period (ie, 2001–2010) in a single level 1 trauma center were classified by the mechanism of injury. Demographic and perioperative data were compared using the Student t and Fisher exact tests. There were 131 patients included, 22 of whom sustained blunt injuries. Patients suffering from blunt injuries were more severely injured (Injury Severity Score 18.0 vs 7.3, P = .0001). The most common indication for DL after blunt injury was a computed tomographic scan concerning for bowel injury (59.1%). The rate of nontherapeutic laparotomy for patients sustaining penetrating vs blunt injury was 1.8% and nil, respectively. DL, when coupled with computed tomographic findings, is an effective tool for the initial management of patients with blunt injuries.

Background Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems. Methods A literature review was undertaken to determine the current consensus on investigation and management strategies. Results The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing. Conclusions Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury. All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry. Of 1549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery. AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.

Abdominopelvic trauma has been for decades classified with the AAST-OIS (American Association for the Surgery of Trauma—Organ Injury Scale) classification. It has represented a milestone. At present, the medical evolutions in trauma management allowed an incredible progress in trauma decision-making and treatment. Non-operative trauma management has been widely applied. The interventional radiological procedures and the modern conception of Hybrid and Endovascular Trauma and Bleeding Management (EVTM) led to good results in increasing the rate of patients managed non-operatively, opening new scenarios and options. Even severe anatomical lesions in hemodynamically stable patients can be safely managed non-operatively. The driving issue in deciding for the best treatment is anatomy, as well as physiology, for the patient physiological derangement grade is even more important. The emergency general surgeon must be prepared in those pathophysiological issues that play the pivotal role in the team management of trauma patients. Moreover, the classification of trauma patients cannot only remain anchored to anatomical lesions. The necessity to follow the modern possibilities of treatment imposes addressing trauma using a classification based on anatomical lesions and on the physiological status of the patient.

The objective of this study was to determine the incidence and interobserver agreement of individual CT findings as well as the bowel injury prediction score (BIPS) in surgically proven bowel injury after blunt abdominal trauma. This HIPAA-compliant retrospective study was IRB approved and consent was waived. All patients 14 years or older who sustained surgically proven bowel injury after blunt abdominal trauma between 1/1/2004 and 6/30/2015 were included. Admission trauma MDCT scans were independently interpreted by two abdominal fellowship-trained radiologists who recorded the following CT findings: intraperitoneal fluid, mesenteric hematoma/fat stranding, bowel wall thickening/hematoma, active intravenous contrast extravasation, free intraperitoneal air, bowel wall discontinuity, and focal bowel hypoenhancement. Subsequently, the electronic medical records of the included patients, admission abdominal physical exam results, admission white blood cell count, and findings at exploratory laparotomy of the included patients were recorded. Thirty-three patients met the inclusion criteria. The incidence and interobserver agreement of the CT findings were as follows: intraperitoneal fluid 93.9 %, kappa = 0.784 (good); mesenteric hematoma/fat stranding 84.8 %, kappa = 0.718 (good); bowel wall thickening/hematoma 42.4 %, kappa = 0.491 (moderate); active IV contrast extravasation 36.3 %, kappa = 1.00 (perfect); free intraperitoneal air 21.2 %, kappa = 0.904 (very good), bowel wall discontinuity 6.1 %, kappa = 1.00 (perfect); and focal bowel hypoenhancement 6.1 %, kappa = 0.468 (moderate). An absence of the specified CT findings was encountered in 9.1 % with surgically proven bowel injuries (kappa = 1.00, perfect). In our study, 9/16 patients or 56.3 % had a bowel injury prediction score (BIPS) of 2 or more as defined by McNutt et al. (J Trauma Acute Care Surg 78(1):105–111, 2014 ). The presence of intraperitoneal fluid and mesenteric hematoma/fat stranding are the most common CT findings in bowel injuries proven at laparotomy. A small percentage of patients have no abnormal CT findings. This grading system did not prove to be useful in our study likely due to our inherently small patient population; however, the use of BIPS deserves further investigation as it may help in identifying blunt bowel and mesenteric injury patients with often subtle or nonspecific CT findings.

Blunt abdominal aortic injury (BAAI) accounts for only 5 per cent of all blunt aortic injury with other blunt aortic injuries occurring in the chest.1, 2 Abdominal aortic and iliac injury from blunt trauma has often been associated with the ''seat belt syndrome'' including abdominal wall contusion, hollow viscus, and spinal column injury.3 The trauma registry for the Oklahoma University Medical Center was queried from 2000 to 2014 using International Classification of Diseases, 9th Revision (ICD-9) codes for abdominal aortic injury (902.0) and procedural codes for vascular repair to find patients who qualified (Table 1).4 Also, current Oklahoma University Medical Center trauma staff surgeons were questioned about this type of injury. Multiple publications have reported the need to suspect BAAI in patients presenting with a seat belt sign, abdominal wall disruption, lumbar spine fracture, and hollow viscus injury.1-4 We believe it is important to add abnormal peripheral pulses, either grossly or by ankle/brachial index, to this list of suspicious signs.

Objective To analyse the correlation between contrast-enhanced ultrasound (CEUS)-based classification of the severity of abdominal parenchymal organ trauma and clinical outcomes, and to explore CEUS in classifying patients with such trauma, expecting that the use of CEUS will potentially enhance the quality and speed of the emergency management of abdominal trauma. Methods Three hundred six consecutive patients with blunt abdominal parenchymal organ trauma who received CEUS examination were retrospectively analysed. Two CEUS radiologists (identified as Reader A and Reader B in this study) who were not involved in the CEUS examinations of the patients were then asked to classify the patients independently according to their CEUS results. The classification results were later compared with patients’ clinical outcomes using Spearman’s rank correlation. Results The final clinical outcomes showed that 25.5 % (78/306) of patients received conservative treatment, 52.0 % (159/306) received minimally invasive treatment, and 22.5 % (69/306) received surgery. Spearman's rank correlation coefficients between the CEUS-based classification and clinical outcome were 0.952 from Reader A and 0.960 from Reader B. Conclusions CEUS can play an important role in the emergency management of abdominal trauma through the classification of patients for different treatment methods. Key points • The severity of abdominal trauma was classified by contrast-enhanced ultrasound (CEUS) • There was a high correlation between CEUS-based classification and clinical outcomes • CEUS-based classification is helpful for surgeons in the emergency management of abdominal trauma

American Association for the Surgery of Trauma (AAST) abdominopelvic organ laceration grading is used to determine which patients can be managed non-operatively. We assess a change in the use of AAST grading system by radiologists at a single, large, academic institution before and after a one-time departmental intervention and reviewed non-graded reports evaluating if grading could be inferred. After IRB approval, a keyword search for “laceration” identified traumatic abdominopelvic CT reports in a 2-year period before and after the one-time intervention. Reports were reviewed to determine if an organ laceration was seen, if it was graded by AAST criteria, and if grading could be inferred for non-graded reports. T test was performed to assess statistical significance. Before the intervention, 348 reports contained the keyword “laceration,” 81 with lacerations, 31 graded (38 %). After the intervention, 302 reports were found, 79 with lacerations, 59 graded (75 %). The increase was statistically significant ( p  < 0.0001). A decreasing trend in grading was seen over time following the intervention. Two out of 50 (4 %) pre-intervention and four out of 20 (20 %) post-intervention reports gave enough detailed descriptions for the grading to be inferred when it was not explicitly stated. Non-graded reports did not describe laceration parenchymal depth and subcapsular hematoma surface area percentage; however, the presence/absence of active extravasation, omitted in the 20-year-old AAST grading scheme, was described in every report. One-time departmental intervention yielded a significant increase in adherence to AAST laceration grading. Lack of perfect compliance, which diminished over time, suggests a need for further reinforcement.