Blunt and penetrating injuries to the abdomen

Abstract

Over the past twenty years there has been a shift towards non-operative management (NOM) for haemodynamically stable patients with abdominal trauma. Embolisation can achieve haemostasis and salvage organs without the morbidity of surgery, and the development and refinement of embolisation techniques has widened the indications for NOM in the management of solid organ injury. Advances in computed tomography (CT) technology allow faster scanning times with improved image quality. These improvements mean that whilst surgery is still usually recommended for patients with penetrating injuries, multiple bleeding sites or haemodynamic instability, the indications for NOM are expanding.

We present a current perspective on angiography and embolisation in adults with blunt and penetrating abdominal trauma with illustrative examples from our practice including technical advice.

Introduction

Trauma is a leading cause of death and over 5 million people per year die from their injuries [1]. Patients often have abdominal injuries which require prompt assessment and triage. A recent study of over 1000 patients following abdominal trauma identified over 300 injuries on abdominal CT [2] and a study of 224 patients following abdominal trauma whom received CT regardless of haemodynamic stability identified 35 splenic injuries, 24 hepatic injuries and 13 renal injuries [3].

Emergency laparotomy is the standard treatment for patients with abdominal injury and haemodynamic instability. Over the past twenty years there has been a shift towards non-operative management (NOM) for haemodynamically stable patients without evidence of hollow viscus injury and, more recently for selected unstable patients [4]. The availability of rapid CT and the development and refinement of embolisation techniques has widened the indications for NOM in the management of trauma.

Optimal trauma management requires a multidisciplinary team, including surgeons and interventional radiologists, coupled with modern facilities and equipment. The emerging standard for trauma centres is the provision of multi-detector computed tomography (MDCT) within the emergency department [5] allowing rapid and complete CT diagnosis and improved clinical outcomes including reduction in ICU and hospital bed stays [6]. In addition there should be adequate provision of interventional radiology expertise - in practice this is not always the case.

Rapid assessment and treatment is vital in the management of patients with significant abdominal injury. Multiple bleeding sites or severe haemodynamic instability remain indications for surgery, and ATLS guidelines for the management of haemodynamically unstable patients advocate surgery without CT [7]. Patients who are stable or rapidly become stable with fluid resuscitation are suitable for CT, which will allow appropriate treatment decisions to be made. Traditionally a lot of time is spent on plain films but all of this information and more will be obtained by a CT. Embolisation aims to achieve haemostasis and salvage organs without the need for surgery, reducing the resuscitation period and transfusion requirements [8]. Super-selective embolisation is performed whenever possible.

This review gives a current perspective on the role of embolisation in adults with vascular complications arising from blunt and penetrating abdominal trauma, and includes illustrative examples from our practice and technical advice on 'how to do it'.

Blunt and penetrating injuries to the abdomen

Protocols defining the role of transarterial embolisation in the management of the abdominal trauma victim vary among trauma centres, and many now advocate routine angiography [9]. There is substantial experience of embolisation in the management of blunt abdominal trauma, first described following hepatic injury in 1977 [10]. Splenic embolisation was initially described for haematological indications in the 1970s [11,12] and its use in the management of splenic injury was first reported in the early 1980s [13].

Angiography enables the identification and assessment of sites of haemorrhage. Angiographic embolisation of injured vessels has become a valuable adjunct in the management of trauma patients. It may provide life-saving haemostasis to areas that may be difficult to access surgically, prevent the need for re-operation in cases of rebleeding, or assist in the NOM of solid visceral injuries. Principles allowing the safe use of embolisation and NOM in blunt abdominal trauma include the absence of associated hollow visceral injuries and other injuries requiring operative intervention and lack of peritoneal signs on abdominal examination [14]. As experience increases, in the correct environment even haemodynamically unstable patients may be considered suitable for NOM [15].

The haemodynamic stability of the patient is key to management yet it is not easy to define. Shocked, unstable patients can be quickly identified and need rapid transfusion while urgent assessment and then treatment of the injury takes place. Stability implies repeated assessments over a period of time but it is usually abbreviated in patients with major abdominal trauma to initial response to fluid infusion. Haemodynamic stability may be defined as hemorrhagic shock not worse than Class 2, i.e. patients are normotensive, have elevated or normal pulse rate, respiratory rate <30/min, normal or decreased pulse pressure (arterial pulse amplitude), and have a rapid response to the initial fluid therapy of 2 L crystalloid [16]. The opinions of experienced clinicians should not be discounted in identifying quickly those patients which are most likely to deteriorate.

Experience with embolisation following penetrating truncal injuries is expanding. Velmahos demonstrated a success rate of 91% with embolisation used as a first line treatment, after operative failure to control bleeding or because of post-operative vascular complications [17]. The efficacy of embolisation at a number of sites within the abdomen was demonstrated, including the hepatic, internal iliac, renal, superior mesenteric and also gluteal vessels. Penetrating abdominal or pelvic trauma may also be associated with significant haemorrhage from non-visceral arteries as shown in figure 1.

Figure 1. a) Axial arterial phase contrast enhanced CT in a 23 year old man following a stab wound to the left buttock demonstrates haematoma within the gluteus muscles. Contrast enhancement medially (arrow) represents active haemorrhage from the superior gluteal artery (Somatom sensation, 24 slice,Siemens, Erlangen, Germany). b)A Cobra catheter was negotiated into the posterior (somatic) left internal iliac artery from an ipsilateral approach. Active haemorrhage from a branch of the superior gluteal artery was demonstrated. c)A microcatheter system (Progreat) was negotiated into the bleeding vessel and 2 microcoils (Boston Scientific vortex fibred) were deployed (arrows). This completely abolished the bleeding with good perfusion of the buttock post procedure.

The first large study of the use of embolisation in both blunt and penetrating abdominal trauma demonstrated a similar success rate of over 90% [18]. There was no difference between the success rates of embolisation for both. In over half the patients with penetrating trauma embolisation was used successfully after operative management failed to achieve haemostasis. The use of angiographic embolisation as a first-line treatment modality or as an adjunct to difficult surgery is supported by other studies [19].

Date: 2015-12-24; view: 771