Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma.

BACKGROUND: Occult diaphragm injury after penetrating thoracoabdominal injury can be difficult to diagnose and can remain occult for months to years. Delayed diagnosis is associated with the risk of hernia formation, strangulation, and high morbidity and mortality. Although laparoscopy has been proposed as a means of evaluating the diaphragm in these patients, prior studies did not include a confirmatory procedure or did not report long-term follow-up. Thus, true sensitivity and specificity remain unknown. The purpose of this study was to determine the sensitivity and specificity of laparoscopy for the detection of diaphragm injury after penetrating thoracoabdominal trauma. We hypothesized that laparoscopy alone is sufficient to exclude diaphragm injury after penetrating thoracoabdominal trauma. METHODS: We conducted a prospective case series of 34 hemodynamically normal asymptomatic patients with thoracoabdominal penetrating injuries. All patients underwent diagnostic laparoscopy to evaluate the diaphragm for the presence of injury. All patients then underwent confirmatory celiotomy (n = 30) or video-assisted thoracoscopy (n = 4). RESULTS: All patients were men between the ages of 18 and 54 years. There were 37 stab wounds and 1 gunshot wound. The mean lowest preoperative systolic blood pressure recorded was 120 +/- 18 mm Hg. Penetrating injuries were stratified by anatomic location (anterior, 18; posterior, 8; flank, 9; not specified, 3). There were 7 true-positive, 30 true-negative, no false-positive, and 1 false-negative result. Specificity, sensitivity, and negative predictive value were 100%, 87.5%, and 96.8%, respectively. The single missed injury occurred in a patient with hemoperitoneum from associated splenic injury that obscured the diaphragm and warranted celiotomy. CONCLUSION: In asymptomatic hemodynamically normal patients with penetrating thoracoabdominal injury, laparoscopy alone is sufficient to exclude diaphragmatic injury.

The utility of routine trauma laboratories in pediatric trauma resuscitations.

BACKGROUND: Because of the difficulties in evaluating injured children, screening blood tests are recommended. METHODS: Resuscitation blood tests (complete blood count, chem12, coagulation panel, urinalysis) were reviewed for abnormality frequency, injury correlation, managements, and outcome. RESULTS: Panels were obtained on 240 children (age < 16 years) meeting trauma system criteria. Abnormalities were identified as follows: white blood cell/hematocrit/platelets (41%, 27%, 1%), Na/K/Cl/CO(2) (3%, 30%, 23%, 14%), blood ureal nitrogen/creatinine (6%, 0%), prothrombin time/international normalized ratio/partial thromboplastin time (22%, 16%, 6%), aspartate aminotransferase/alanine transferase (43%, 35%), amylase (2%), glucose (77%), and urinalysis (31%). Organ-specific chemistries predicted injury poorly. Transaminasemia correlated with liver injury when levels exceeded 400 U/L. Two children (1%) with hyperamylasemia had abdominal injuries. Coagulation abnormalities correlated with intracranial injury (43%) and Glasgow Coma Scale (GCS 3 to 8; 56%, GCS 9 to 14; 20%, GCS 15; 14%, P <0.05). Only 25 (10%) had interventions for test abnormalities (11 transfusions, 8 fresh frozen plasma, 3 tests repeated, 3 KCl). CONCLUSIONS: Routine laboratory panels are little value in the management of injured children.