Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome.

BACKGROUND: Intra-abdominal hypertension has been recognized as a source of morbidity and mortality in the traumatized patient following laparotomy. Multiple organ dysfunction attributable to intra-abdominal hypertension has been called the abdominal compartment syndrome. The epidemiology and characteristics of these processes remain poorly defined. METHODS: Intra-abdominal pressure was measured prospectively in all patients admitted to a trauma intensive care unit over 9 months. Data were gathered on all patients with intra-abdominal hypertension. RESULTS: Some 706 patients were evaluated. Fifteen (2 per cent) of 706 patients had intra-abdominal hypertension. Six of the 15 patients with intra-abdominal hypertension had abdominal compartment syndrome. Half of the patients with abdominal compartment syndrome died, as did two of the remaining nine patients with intra-abdominal hypertension. Patients with abdominal compartment syndrome had a mean intra-abdominal pressure of 42 mmHg compared with 26 mmHg in patients with intra-abdominal hypertension only (P < 0.05). CONCLUSION: The incidence of intra-abdominal hypertension and abdominal compartment syndrome was 2 and 1 per cent respectively. Intra-abdominal hypertension did not necessarily lead to abdominal compartment syndrome, and often resolved without clinical sequelae. Abdominal compartment syndrome did not occur in the absence of earlier laparotomy. Abdominal compartment syndrome was associated with a marked increase in intra-abdominal pressure (above 40 mmHg).

Splanchnic perfusion evaluation during hemorrhage and resuscitation with gastric near-infrared spectroscopy.

OBJECTIVE: The purpose of this study was to use a prototype side-illuminating near-infrared spectroscopy (NIRS) nasogastric probe to continuously measure changes in gastric tissue oxygen saturation (Sto2) in a pig hemorrhage model. METHODS: Swine (n = 12; 6 per group) underwent laparotomy and placement of a gastric NIRS probe, jejunal tonometer, superior mesenteric artery (SMA) flow probe, and a portal vein catheter. Animals underwent hemorrhage (28 mL/kg) t = 0 to 20 minutes (where t = time). Pigs in group I were resuscitated (t = 20-40 minutes) with lactated Ringer's solution (84 mL/kg), whereas group II had no resuscitation. RESULTS: A significant decrease in mean arterial pressure and SMA flow was observed after hemorrhage. SMA flow significantly correlated in group I with both NIRS Sto2 (r = 0.58, p = 0.0001) and regional CO2 (r = -0.54, p = 0.0001). In group II, superior mesenteric flow correlated with NIRS Sto2 (r = 0.30, p = 0.03), but not regional CO2 (r = -0.23, p = 0.09). CONCLUSION: Direct measurement of tissue oxygen saturation with a prototype side-illuminating near-infrared spectroscopy gastric probe appeared to rapidly reflect changes in splanchnic perfusion.

Near-infrared spectroscopy reflects changes in mesenteric and systemic perfusion during abdominal compartment syndrome.

BACKGROUND: Continuous and minimally invasive near-infrared spectroscopy (NIRS)-derived gastric tissue oxygen saturation (GStO(2)) and muscle tissue oxygen saturation (MStO(2)) were evaluated in a clinically relevant porcine model of hemorrhagic shock and abdominal compartment syndrome (ACS). METHODS: Phenobarbital-anesthetized swine underwent pulmonary artery catheter insertion for mixed venous oxygen saturation (SvO(2)) measurement and midline laparotomy to permit placement of a gastric NIRS probe, a jejunal (regional carbon dioxide [PrCO(2)]) tonometer, superior mesenteric artery (SMA) flow probe, and a portal vein oxygen saturation (SpvO(2)) catheter. A muscle NIRS probe was placed on the front limb. After randomization, Group 1 underwent hemorrhage and resuscitation. Group 2 had no hemorrhage or resuscitation. ACS was induced by peritoneal fluid infusion in both groups. A significant decrease in SMA flow, SpvO(2), GStO(2), SvO(2), and MStO(2) was observed after hemorrhage in Group 1 and with abdominal hypertension in both groups. RESULTS: GStO(2) significantly correlated with SMA flow (Group 1: r(2) = 0.90; Group 2: r(2) = 0.83) and mesenteric oxygen delivery (mesenteric oxygen delivery, Group 1: r(2) = 0.73; Group 2: r(2) = 0.89). MStO(2) significantly correlated with SvO(2) (Group 1: r(2) = 0.99; Group 2: r(2) = 0.65) and systemic oxygen delivery (SDO2, Group 1: r(2) = 0.60; Group 2: r(2) = 0.88). Tonometer-derived PrCO(2) values did not change at any time point in either group. CONCLUSIONS: NIRS measurement of GStO(2) and MStO(2) reflected changes in mesenteric and systemic perfusion respectively during hemorrhage and ACS.

2,576 ultrasounds for blunt abdominal trauma.

BACKGROUND: Determination of intra-abdominal injury following blunt abdominal trauma (BAT) continues to be a diagnostic challenge. Ultrasound (US) has been described as a potentially useful diagnostic tool in this setting and is being used with increasing frequency in trauma centers. We determined the diagnostic capability of US in the evaluation of BAT. METHODS: A retrospective analysis of our trauma US database was performed over a 30-month period. Computed tomographic scan, diagnostic peritoneal lavage, or exploratory laparotomy confirmed the presence of intra-abdominal injury. RESULTS: During the study period, 8,197 patients were evaluated at the Ryder Trauma Center. Of this group, 2,576 (31%) had US in the evaluation of BAT. Three hundred eleven (12%) US exams were considered positive. Forty-three patients (1.7%) had a false-negative US; of this group, 10 (33%) required exploratory laparotomy. US had a sensitivity of 86%, a specificity of 98%, and an accuracy of 97% for detection of intra-abdominal injuries. Positive predictive value was 87% and negative predictive value was 98%. CONCLUSION: Emergency US is highly reliable and may replace computed tomographic scan and diagnostic peritoneal lavage as the initial diagnostic modality in the evaluation of most patients with BAT.

Combined carotid artery injury and laryngeal fracture secondary to dog bite: case report.

Approximately 914 new dog bite injuries requiring emergency department visits occur daily in the United States. Attacks by dogs with training and strength to attack should be triaged cautiously because of the possibility of serious internal injury. A high index of suspicion is needed when treating patients with neck injuries secondary to dog bites. We report a case of successfully treated combined carotid artery and laryngeal injury produced by a dog bite.

Imaging of penetrating thoracic trauma.

The management of penetrating chest injuries has evolved significantly over the past few years, with an increasing emphasis on less invasive diagnostic and therapeutic modalities. Only 15% of patients need a therapeutic operative procedure. The challenge is to detect and treat these injuries rapidly while maximizing the use of noninvasive examinations and decreasing costs. The areas potentially at risk for injury include the heart, major vessels, thoracoabdomen, neck, spine, and aerodigestive tract. A review of injuries to these areas, including the use of new diagnostic modalities such as echocardiography and computed tomography (CT) scans, are discussed.