Development and testing of a decision tree for blunt trauma.

The aim of the present study was to examine the essential problems in a retrospective study of 381 organ injuries in 260 patients, to identify problems, to define criteria, to describe decision rules, and to organize these rules into branch-chain decision trees or clinical algorithms. The basic hypothesis of this study is that criteria organized into a prioritized decision tree can provide objective standards to evaluate the quality of trauma care and to compare alternative approaches. The algorithm was designed to provide prompt therapy for the most life-threatening problems: respiratory and cardiac arrest, shock, head injury, tamponade, lacerations of the great vessels, cardiac contusion, ruptured parenchymal organs, lacerated viscera, and injury to other intraperitoneal organs. Resuscitation from shock, correction of circulatory problems, and monitoring of physiologic variables were prioritized to evaluate the presence of circulatory deficits and the adequacy of specific therapy to correct them. Concomitantly, diagnosis of the underlying problems was approached using peritoneal lavage, abdominal and chest x-rays, iv urograms, cystograms, endoscopy, upper and lower GI barium or hypaque studies, ultrasound, scintograms, and CT scans. In emergency conditions these are limited to a large extent by time factors. The diagnostic accuracy, priorities, and limitations of each of these were evaluated in emergency conditions. The algorithm was used to track management decisions in a prospective series; the mortality of 51 patients with satisfactory compliance was 4% and 44% in nine patients with major deviations from the algorithm.

Determinants of morbidity and mortality in blunt abdominal trauma.

We reviewed retrospectively 260 consecutive patients operated upon for blunt abdominal trauma in a 7-year period; there were 318 injured organs and 40 deaths, giving a mortality of 15%. The injuries with the highest mortality were duodenal, vascular, hepatic, pancreatic, and gastrointestinal perforations; splenic, small bowel and gallbladder trauma had the lowest mortality. Almost half of the fatal cases but less than a quarter of the survivors had two or more non-abdominal injuries and 72% of the survivors but only 32% of the non-survivors had two or more injured abdominal organs. Diagnostic procedures were obtained preoperatively in 98% of the patients; about half of these were positive but only 12% were specifically diagnostic of a particular organ injury. Using the correct organ and the correct injury as the criteria, half of the cases were correctly diagnosed preoperatively, although all of the patients were judged to have some form of significant abdominal trauma. Delays from attempts to establish a precise preoperative diagnosis contributed to increased morbidity and mortality, particularly in patients who were haemodynamically unstable. After a Trauma Unit was established, the time from admission of patients to hospital until operation and the overall mortality were significantly reduced, particularly for those with hypotension.

Traumatic injuries to the duodenum: a report of 98 patients.

Data of 98 patients who had sustained traumatic injuries to the duodenum during a recent 7-year period is reviewed. The overall mortality was 23.5%; that of the blunt injury group was 35%, that of the penetrating injury group was 20%. However, after the establishment of a trauma unit, the mortality for duodenal injuries fell from 32% to 12%. Death from duodenal wounds may be reduced by earlier hospitalization, earlier diagnosis and consequently earlier surgical repair. Vigorous treatment of shock is essential. A specialized trauma unit with personnel experienced in the management of shock and trauma problems provides a better environment to carry out the preoperative and postoperative care of the acutely injured patient. Adequate surgical treatment of the blunt injury and missile injury of the duodenum should consist of the following procedures: 1) repair of the duodenal wall utilizing conventional techniques; 2) internal decompression of the repair by afferent jejunostomy; 3) efferent jejunostomy for postoperative feeding; 4) temporary gastrostomy; and 5) external drainage of the repair. In certain selected instances, the simple stab wound of the duodenum may be treated by conventional repair without decompression, but a loop of jujunum should be sutured over the repair to prevent delayed disruption. The majority of patients with injuries to the duodenum have associated organs injured which also require considered surgical judgment and action.