Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre.

AIMS: The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs). METHODS: This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records. RESULTS: Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24h (P=0.036) and tachycardia on presentation (P=0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality. DISCUSSION: Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.

Legg-Calvé-Perthes disease: MR imaging evaluation during manual positioning of the hip--comparison with conventional arthrography.

PURPOSE: To evaluate the use of magnetic resonance (MR) imaging during manual positioning of the hip, or multipositional MR imaging, in an open-magnet configuration to study femoral head containment, articular congruency, and femoral head deformity in Legg-Calvé-Perthes disease. MATERIALS AND METHODS: In 12 children with advanced Legg-Calvé-Perthes disease, multipositional MR imaging and conventional arthrography were compared in the assessment of containment, femoroacetabular congruency, and femoral head deformity. Images of the hips in several positions were compared subjectively and objectively. RESULTS: MR imging correlated well with arthrography for overall subjective assessment of severity of disease (r = 0.71, P = .01), with good interobserver agreement (kappa = 0.65, P < .001). MR images demonstrated all cases of hinge abduction shown arthrographically. However, MR imaging failed to depict one case of femoral head flattening. MR imaging correlated well with arthrography in the objective evaluation of joint fluid and lateral subluxation (r = 0.80, P < .01). MR imaging correlated poorly with arthrography in the measurement of sphericity of the femoral head. CONCLUSION: Multipositional MR imaging with an open-magnet configuration was comparable to arthrography for demonstration of femoral head containment and congruency of the articular surfaces of the hip. In the evaluation of deformity, it performed less well.

Implementation of a two-tier trauma response.

OBJECTIVE: To apply a triage tool to patients on their arrival in the emergency department and determine the efficacy and safety of a two-tier trauma response. DESIGN: Descriptive prospective audit. SETTING: Principal urban referral hospital that provides a major trauma service. MATERIALS AND METHODS: The triage tool designated a major trauma or stable trauma response. A major trauma designation mobilised a multidisciplinary team and a stable trauma designation an expedited evaluation by emergency department staff. Chi-square test and Mann-Whitney U test were used to compare major and stable trauma designations. Triage accuracy was evaluated using outcome variables. MAIN RESULTS: 78% of 58 major trauma responses and 30% of 180 stable trauma responses were admitted. The median injury severity score (and interquartile range) of admitted patients was 9.0 (5.0-19.5) for major responses and 5.0 (2.0-9.0) for stable responses. The triage tool had a sensitivity of 65%, specificity of 87%, accuracy (appropriate triage rate) of 82%, undertriage rate of 8% and overtriage rate of 10%. CONCLUSION: The triage tool adequately distinguished between patients with and without major trauma. Undertriaged patients had timely and appropriate referral for definitive surgical care and had no adverse outcomes.

Traumatic thoracic aortic rupture: investigation determines outcome.

Blunt thoracic aortic rupture (TAR) initially presents with subtle signs but is usually fatal if not diagnosed and treated early. Does the diagnostic process affect outcome? The definitive test most widely promoted is thoracic (arch) aortography but is usually only available in major teaching hospitals. Thoracic computerized tomography (CT) scanning is more readily available but its role in diagnosis of TAR is unproven. A retrospective review of trauma databases and medical record indexes over a 7 year period identified 38 patients presenting with TAR at Westmead and Royal North Shore Hospitals in the period 1984-91. Thirteen patients (34%) were dead on arrival or died within 15 min of arrival at either hospital. Five patients (13%) who arrived in cardiac arrest (with suspected TAR) died after immediate thoracotomy (two in the Emergency Department and three in the operating room). Two patients (5%) died from severe head injuries and were not investigated for TAR. Eighteen patients (47%) remained alive long enough for investigation and were considered potentially salvageable. Nine of these survived. Only 13 patients had arch aortography. No patient survived without an aortogram. Five patients had a chest CT scan; aortography followed in four patients. Computerized tomography scans delayed aortography or were misinterpreted. Review of all trauma thoracic (arch) aortograms for the same period at Westmead Hospital revealed a diagnosis of TAR in 7.4%. Blind thoracotomy did not result in survival. Computerized tomography scanning of the chest was of no value in the management of this injury. Early suspicion of possible thoracic aortic rupture demands urgent arch aortography and this remains the diagnostic 'gold standard'.